1. Skills Days Winter 2007 Competency Review/Discussion

2. BiPAP Guidelines c. 2004 Critical Care: 5E, 5SE, 8NE Med-Surg Units: 4NE,5NE,6NE (Competency Trained) ALL Med- Surg Units  Decreased LOC  Patient meets ICU admission criteria  Unstable / severe respiratory failure  Presence of relative contraindications  Patient requires nearly continuous direct monitoring.  Interruption of ventilatory support could lead to significant deterioration in oxygenation or ventilation.  Ventilation via invasive airway (ETT,Tracheostomy)  Non-invasive support has been established and stabilized in ICU 24 hour prior to transfer.  Patient has ability to manage own secretions.  Patient demonstrates ability to remove mask independently.  PH > 7.30  Interruption of ventilatory support is non-life threatening  Stable / improving respiratory status  Request Pulmonary Medicine consult if complications are present.  Alert, cooperative  Patient demonstrates ability to remove mask independently.  Patients experienced with full face mask at home. PACU: Patients may fall within and/or move through each of the above categories.

3. BiPAP Guidelines Patients requiring noninvasive ventilation for palliative care purposes who are also DNAR status may be managed on all nursing units. A. Respiratory Care Monitoring 1.The respiratory care department staff will be responsible for initiation of all non- invasive positive pressure ventilation. 2. Respiratory care staff will check in with nursing staff at least once per shift during duration of therapy to discuss the use of the noninvasive device and to communicate needs specific to the patient care plan. 3.Respiratory care staff will provide physical assessment and ventilator system monitoring q 4 hours and prn. The assessment and monitoring will include respiratory rate, breathing pattern, chest excursion, breath sounds, secretions, ventilator settings, alarms, ventilator assessment parameters 4.Respiratory care staff will document initiation, ongoing physical exam/ equipment assessment and monitoring, and plan of care

4. Oxymizer The Oxymizer is designed as a oxygen conserving device Higher equivalent liter flows possible from O2 concentrators Longer lasting home and portable tanks Especially at lower flows How does it work???

5. Oxymizer 20 ml reservoir is filled during exhalation

6. Oxymizer 20 ml bolus of O2 is delivered at the beginning of inspiration

7. Oxymizer This results in a 75% savings in O2 for patients on 2 lpm Patients on 6lpm only realize a 41% savings in O2 At 12 lpm (as you might guess) the advantage is minimal

8. Oxymizer Use in the Hospital –patients unable to wear a mask –meal time for some –7SE nurse frenzy O2 is purchased in bulk. It is literally cheaper than tap water. In house use should be limited to 8 lpm or greater. No humidification

9. BHP Has it decreased the number of unnecessary CPTs? Are patients who need our services being seen? Are patients who are OK on own being DC’d? Josh, John, Hal, met with Surg C and Thoracic service fellows. They were supportive.

10. BHP Something New!

11. BHP Acapella = One time instruction by RT with respiratory assessment. If continued therapy is indicated, then start BHP

12. P&P Update Current P&P on PCS Web: –outdated policies –miss-information –downright lies What we want: –useful, practical information –information pertinent for RNs and MDs –printable forms –linked pages

13. P&P Update Major Overhaul of P&P Manual –temporarily removed from PCS Web –re-organized into P&P Manual Unit Guidelines Red Book Charge Guidelines –currently updating Removing obsolete policies Standardizing common policies (Perry & Potter) Updating tired policies or linking to nursing, APOP Creating new/needed policies Link

14. P&P Update Define process –step by step for updating –and for new policies Make it ongoing –regular review by RCS Leadership –collect staff input –utilize staffing resources