chapter 51 respiratory care in alternative settings

Chapter 51 Chapter 51

Respiratory Care in Alternative Respiratory Care in Alternative SettingsSettings

Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 2

ObjectivesObjectives

Describe alternative care settings in which respiratory care is Describe alternative care settings in which respiratory care is often performed.often performed.

Describe the recent developments and trends in alternative site Describe the recent developments and trends in alternative site respiratory care.respiratory care.

Describe who regulates postacute care.Describe who regulates postacute care.

List the standards that apply to the delivery of postacute List the standards that apply to the delivery of postacute respiratory care.respiratory care.


Objectives (cont.)Objectives (cont.)

Describe how to help formulate an effective discharge plan.Describe how to help formulate an effective discharge plan.

List factors to evaluate when assessing alternative care sites List factors to evaluate when assessing alternative care sites and support services.and support services.

Describe how to justify, provide, evaluate, and modify oxygen Describe how to justify, provide, evaluate, and modify oxygen (O(O22) therapy in postacute care settings.) therapy in postacute care settings.

Describe how to select, assemble, monitor, and maintain ODescribe how to select, assemble, monitor, and maintain O22 therapy equipment in alternative settings.therapy equipment in alternative settings.



State the special challenges that exist in providing ventilatory State the special challenges that exist in providing ventilatory support outside the acute care hospital.support outside the acute care hospital.

Describe how to instruct patients or caregivers and confirm their Describe how to instruct patients or caregivers and confirm their ability to provide postacute care.ability to provide postacute care.

Identify which patients benefit the most from ventilatory support Identify which patients benefit the most from ventilatory support outside acute care hospitals.outside acute care hospitals.

Describe how to select, assemble, monitor, and maintain Describe how to select, assemble, monitor, and maintain portable ventilatory support and continuous positive airway portable ventilatory support and continuous positive airway pressure (CPAP) equipment, including applicable interfaces or pressure (CPAP) equipment, including applicable interfaces or appliances.appliances.



Describe proper documentation regarding patient evaluation Describe proper documentation regarding patient evaluation and progress in postacute care. and progress in postacute care.

State how to ensure safety and infection control in alternative State how to ensure safety and infection control in alternative patient care settings.patient care settings.


Recent Developments and TrendsRecent Developments and Trends

IntroductionIntroduction Medicare introduced the prospective payment system (PPS) in Medicare introduced the prospective payment system (PPS) in

the 1990s.the 1990s.

This system limits the reimbursement for respiratory care This system limits the reimbursement for respiratory care equipment to a predetermined monthly payment.equipment to a predetermined monthly payment.

Other legislation has limited payment for home OOther legislation has limited payment for home O22 therapy. therapy.


Recent Developments and Trends Recent Developments and Trends (cont.)(cont.)

Introduction (cont.)Introduction (cont.) Reimbursement for the care provided by respiratory therapists Reimbursement for the care provided by respiratory therapists

in the homecare setting is not provided by Medicare.in the homecare setting is not provided by Medicare.

Recent research is showing that respiratory therapists can Recent research is showing that respiratory therapists can reduce the cost of care and achieve better outcomes for reduce the cost of care and achieve better outcomes for patients in skilled nursing facilities.patients in skilled nursing facilities.


Definitions and GoalsDefinitions and Goals

The most common respiratory care services provided in The most common respiratory care services provided in postacute care facilities are:postacute care facilities are: Continuous OContinuous O22 therapy therapy Long-term mechanical ventilationLong-term mechanical ventilation Aerosol drug therapyAerosol drug therapy Airway careAirway care Sleep apnea treatment and monitoringSleep apnea treatment and monitoring Pulmonary rehabilitationPulmonary rehabilitation


Definitions and Goals (cont.)Definitions and Goals (cont.)

Subacute careSubacute care A comprehensive level of inpatient care for stable patients who:A comprehensive level of inpatient care for stable patients who:

Have experienced an acute event from injury or illnessHave experienced an acute event from injury or illness Have a determined course of treatmentHave a determined course of treatment Require diagnostics or invasive proceduresRequire diagnostics or invasive procedures

All age groups can be found at these sites.All age groups can be found at these sites.


Definitions and Goals (cont.)Definitions and Goals (cont.)

Home careHome care Most postacute respiratory care is provided in the homeMost postacute respiratory care is provided in the home Common clinical conditions treated at home:Common clinical conditions treated at home:

COPDCOPD Cystic fibrosisCystic fibrosis Chronic neuromuscular diseasesChronic neuromuscular diseases Chronic restrictive diseaseChronic restrictive disease Carcinoma of the lungCarcinoma of the lung


StandardsStandards

Standards for providing respiratory care in subacute and home Standards for providing respiratory care in subacute and home settings are derived from:settings are derived from: AARC clinical practice guidelinesAARC clinical practice guidelines Federal and state lawsFederal and state laws Private-sector accreditation standardsPrivate-sector accreditation standards


Standards (cont.)Standards (cont.)

RegulationsRegulations Medicare plays a major role in setting the standards for care Medicare plays a major role in setting the standards for care

outside the hospital.outside the hospital.

Institutions undergo certification surveys to determine their Institutions undergo certification surveys to determine their compliance with the standards.compliance with the standards.

Each state also has regulations in place for quality assurance.Each state also has regulations in place for quality assurance.


Standards (cont.)Standards (cont.)

Private sector accreditationPrivate sector accreditation The primary organization responsible for setting patient care The primary organization responsible for setting patient care

standards in the subacute care setting is The Joint Commission. standards in the subacute care setting is The Joint Commission.

Approximately 95% of health care organizations voluntarily Approximately 95% of health care organizations voluntarily subscribe to The Joint Commission accreditation.subscribe to The Joint Commission accreditation.


Traditional Acute Care Versus Traditional Acute Care Versus Postacute CarePostacute Care

Respiratory therapists working in alternative care settingsRespiratory therapists working in alternative care settings Have less equipment and resourcesHave less equipment and resources Work more independentlyWork more independently Complete more paperworkComplete more paperwork Are often on-callAre often on-call Are part of a team approach Are part of a team approach


Discharge PlanningDischarge Planning

Multidisciplinary teamMultidisciplinary team All team members must be a part of the discharge.All team members must be a part of the discharge.

Site and support service evaluationSite and support service evaluation The appropriate site for discharge is determined by the The appropriate site for discharge is determined by the

needs of the patient.needs of the patient. For discharge to home, caregivers must be trained and For discharge to home, caregivers must be trained and

prepared.prepared. A reliable durable medical equipment supplier may need to A reliable durable medical equipment supplier may need to

be involved.be involved.


Oxygen Therapy in Alternative Oxygen Therapy in Alternative SettingsSettings

The OThe O22 therapy prescription therapy prescription Must include:Must include:

Flow rate in liters/minute and/or concentrationFlow rate in liters/minute and/or concentration Frequency of useFrequency of use Duration of need Duration of need DiagnosisDiagnosis Laboratory evidence (ABGs)Laboratory evidence (ABGs)


Oxygen Therapy in Alternative Oxygen Therapy in Alternative Settings (cont.)Settings (cont.)

Supply methodsSupply methods Compressed OCompressed O22 cylinders cylinders

Primarily used for ambulation (small cylinders) or as a Primarily used for ambulation (small cylinders) or as a backup to liquid or concentrator systemsbackup to liquid or concentrator systems

Liquid OLiquid O22 systems systems

Oxygen concentratorsOxygen concentrators



Delivery methodsDelivery methods The most common OThe most common O22 delivery system for long-term care is the delivery system for long-term care is the

nasal cannula.nasal cannula.

Transtracheal OTranstracheal O22 therapy is used in selected patients; it therapy is used in selected patients; it

conserves the use of Oconserves the use of O22 and has cosmetic advantages. and has cosmetic advantages.

Demand-flow ODemand-flow O22 systems systems


Ventilator Support in Alternative Ventilator Support in Alternative SettingsSettings

Patient selectionPatient selection


Ventilator Support in Alternative Ventilator Support in Alternative Settings (cont.)Settings (cont.)

Invasive vs. noninvasive ventilatory supportInvasive vs. noninvasive ventilatory support Noninvasive ventilatory support is becoming increasingly Noninvasive ventilatory support is becoming increasingly

popular.popular.

Noninvasive positive-pressure ventilation (NPPV) is most often Noninvasive positive-pressure ventilation (NPPV) is most often used.used.

Patients receiving NPPV must meet certain criteria (e.g., patient Patients receiving NPPV must meet certain criteria (e.g., patient must be cooperative and not need high Fmust be cooperative and not need high FIOIO22).).



Selecting the appropriate ventilatorSelecting the appropriate ventilator The choice of a ventilator depends on the needs of the patient.The choice of a ventilator depends on the needs of the patient.

A backup ventilator should be provided for patients who cannot A backup ventilator should be provided for patients who cannot maintain spontaneous ventilation for more than 4 hours.maintain spontaneous ventilation for more than 4 hours.



Selecting the appropriate ventilator (cont.)Selecting the appropriate ventilator (cont.) Ventilators used in alternative sites must be dependable and Ventilators used in alternative sites must be dependable and

easy for caregivers to operate.easy for caregivers to operate.

The ventilator must be portable for patients who are mobile. The ventilator must be portable for patients who are mobile.

Electrically powered ventilators are often the best choice in Electrically powered ventilators are often the best choice in alternative health care sites.alternative health care sites.


Ventilator Support in Alternative Ventilator Support in Alternative SettingsSettings (cont.)(cont.)

Positive-pressure ventilatorsPositive-pressure ventilators



Positive-pressure ventilators (cont.)Positive-pressure ventilators (cont.) Most patients, especially those with COPD, prefer pressure-Most patients, especially those with COPD, prefer pressure-

limited over volume-cycled ventilation.limited over volume-cycled ventilation.

Those with neuromuscular disorders may prefer volume Those with neuromuscular disorders may prefer volume ventilation.ventilation.

The biggest challenge with NPPV is getting a good, The biggest challenge with NPPV is getting a good, comfortable, leak-free interface.comfortable, leak-free interface.



Negative-pressure ventilatorsNegative-pressure ventilators Iron lung has been replaced with the chest cuirass and wrap or Iron lung has been replaced with the chest cuirass and wrap or

“pneumosuit.”“pneumosuit.”

Rarely used for ventilatory support in postacute care settingsRarely used for ventilatory support in postacute care settings



Evaluation and follow-upEvaluation and follow-up Vital signs, lung sounds, and sputum production should be Vital signs, lung sounds, and sputum production should be

monitored on a daily basis.monitored on a daily basis.

ABGs and lung compliance only on an as-needed basis.ABGs and lung compliance only on an as-needed basis.

Routine follow-up visits by a respiratory therapist help ensure Routine follow-up visits by a respiratory therapist help ensure the success of patient management in the home.the success of patient management in the home.


Other Modes of Postacute Other Modes of Postacute Respiratory CareRespiratory Care

Bland aerosol therapyBland aerosol therapy Delivered by jet or ultrasonic nebulizersDelivered by jet or ultrasonic nebulizers

May be intermittent or continuousMay be intermittent or continuous

May be useful in patient with thick secretions as an adjunct to May be useful in patient with thick secretions as an adjunct to airway clearance proceduresairway clearance procedures

Infection is the primary risk.Infection is the primary risk.


Other Modes of Postacute Other Modes of Postacute Respiratory Care (cont.)Respiratory Care (cont.)

Aerosol drug administrationAerosol drug administration Bronchodilators and antiinflammatory agents are given via Bronchodilators and antiinflammatory agents are given via

metered-dose inhalers, dry powder inhalers, or small volume metered-dose inhalers, dry powder inhalers, or small volume nebulizers.nebulizers.

Reimbursable expenses related to aerosol drug therapy in the Reimbursable expenses related to aerosol drug therapy in the home are limited.home are limited.



Airway care and clearance methodsAirway care and clearance methods Patients with tracheostomies require daily care.Patients with tracheostomies require daily care.

Tube changes should be done only by a nurse, respiratory Tube changes should be done only by a nurse, respiratory therapist, or physician.therapist, or physician.

Suctioning is provided using a portable electrically powered Suctioning is provided using a portable electrically powered suction pump.suction pump.



Airway care and clearance methods (cont.)Airway care and clearance methods (cont.) Patients can be taught to independently apply coughing, forced Patients can be taught to independently apply coughing, forced

exhalation, active cycle of breathing, and autogenic drainage exhalation, active cycle of breathing, and autogenic drainage methods.methods.

Caregivers can be trained to apply chest physical therapy and Caregivers can be trained to apply chest physical therapy and mechanical devices when retained secretions are a problem.mechanical devices when retained secretions are a problem.



Nasal CPAPNasal CPAP An accepted form of therapy to treat sleep apneaAn accepted form of therapy to treat sleep apnea

For Medicare reimbursement, the diagnosis must be confirmed For Medicare reimbursement, the diagnosis must be confirmed by a polysomnogram.by a polysomnogram.



Nasal CPAP (cont.)Nasal CPAP (cont.)


Patient Assessment and Patient Assessment and DocumentationDocumentation

In the institution providing subacute or long-term care, the In the institution providing subacute or long-term care, the assessment and documentation process involves:assessment and documentation process involves:

1.1. ScreeningScreening

2.2. Treatment planningTreatment planning

3.3. Ongoing assessmentOngoing assessment

4.4. Discharge Discharge


Patient Assessment and Patient Assessment and Documentation (cont.)Documentation (cont.)

Home careHome careFactors to consider when determining the frequency of home visits Factors to consider when determining the frequency of home visits

include:include: Patient’s condition and therapeutic needsPatient’s condition and therapeutic needs Level of family or caregiver supportLevel of family or caregiver support Complexity of home care equipmentComplexity of home care equipment Overall home environmentOverall home environment Ability of patient to provide self-careAbility of patient to provide self-care


Patient Assessment and Patient Assessment and Documentation (cont.)Documentation (cont.)

Home care (cont.)Home care (cont.)Functions of the respiratory therapist during a home visit:Functions of the respiratory therapist during a home visit: Patient assessmentPatient assessment

Patient compliance with treatment planPatient compliance with treatment plan

Equipment assessmentEquipment assessment

Identification of any patient problemsIdentification of any patient problems

Statement related to patient goals and treatment plan Statement related to patient goals and treatment plan


Equipment Disinfection and Equipment Disinfection and MaintenanceMaintenance

The American Respiratory Care Foundation has developed The American Respiratory Care Foundation has developed guidelines for disinfecting home respiratory care equipment.guidelines for disinfecting home respiratory care equipment.

AARC has produced clinical practice guidelines that outline AARC has produced clinical practice guidelines that outline accepted infection control techniques.accepted infection control techniques.


Equipment Disinfection and Equipment Disinfection and Maintenance (cont.)Maintenance (cont.)

Proper hand washing by all caregivers in the home is important.Proper hand washing by all caregivers in the home is important.

Visits by friends with respiratory infections are discouraged.Visits by friends with respiratory infections are discouraged.

Distilled water is the first choice for humidifiers used in the Distilled water is the first choice for humidifiers used in the home.home.


Palliative CarePalliative Care

Maximizing comfort of the patient who is terminally ill is a goal of Maximizing comfort of the patient who is terminally ill is a goal of home care.home care.

Palliative care involves control of symptoms such as pain and Palliative care involves control of symptoms such as pain and dyspnea in the terminally ill patient while maximizing the dyspnea in the terminally ill patient while maximizing the psychological and spiritual well-being of the patient.psychological and spiritual well-being of the patient.

Respiratory therapists may play a key role when lung disease is Respiratory therapists may play a key role when lung disease is present in the terminally ill patient.present in the terminally ill patient.

chapter 51 respiratory care in alternative settings

Documents

mosby items

derived items

subacute care

cost of care

alternative care settings

respiratory care equipment

postacute care settings

postacute care facilities