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alternative care settings

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-Home Care (most common) -Subacute facilities -Rehabilitation facilities -Skilled nursing facilities

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The most common respiratory care services provided in postacute care facilities are?

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-Continuous O2 therapy -Long-term mechanical ventilation -Aerosol drug therapy -Airway care -Sleep apnea treatment and monitoring -Pulmonary rehabilitation

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most post-acute respiratory care is provided in the home: What are those common clinical conditions treated at home?

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-COPD -Cystic fibrosis -Chronic neuromuscular diseases -Chronic restrictive disease -Carcinoma of the lung

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____________ plays a major role in setting the standards for care outside the hospital

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Medicare

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standards for providing respiratory care in subacute & home settings derived from?

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1. AARC clinical practice guidelines 2. Federal and state laws 3. Private-sector accreditation standards

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The primary organization responsible for setting patient care standards in the subacute care setting is ?

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The Joint Commission -approximately 90-95% of health care organizations voluntarily subscribe to JC accreditation

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traditional acute care vs post-acute care : RTs working in alternate care settings?

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1. Have less equipment and resources 2. Work more independently 3. Complete more paperwork 4. Are often on-call 5. Are part of a team approach

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Discharge planning: multidisciplinary team

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1. All team members must be a part of the discharge 2. A team approach produces the best patient results

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Discharge planning: site & support service evaluation

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1. The appropriate site for discharge is determined by the needs of the patient 2. For discharge to home, caregivers must be trained and prepared 3. A reliable durable medical equipment supplier may need to be involved

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Oxygen Therapy in Alternative Settings: The O2 therapy prescription must include?

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1. Flow rate in liters/minute and/or concentration 2. Frequency of use 3. Duration of need 4. Diagnosis 5. Laboratory evidence (ABGs)

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Oxygen Therapy in Alternative Settings: O2 supply methods?

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1. Compressed oxygen cylinders a. Primarily used for ambulation (small (E/D) cylinders) or as a backup to liquid or concentrator systems (H/K tanks 2. Liquid oxygen systems a. Large quantity in small space b. Liquid O2 at approx. -300 degrees F. 3. Oxygen concentrators a. Separates O2 from room air (Most common concentrators use a molecular sieve)

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Oxygen Therapy in Alternative Settings: Delivery methods

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1. The most common O2 delivery system for long-term care is the nasal cannula 2. Transtracheal O2 therapy is used in selected patients: it conserves the use of O2 and has cosmetic advantages 3. Demand-flow O2 systems

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Demand-flow O2 systems also known as

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pulsed dose (O2 conserving device)

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The most common O2 delivery system for long-term care is?

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the nasal cannula

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Patient selection for Vent support in alt setting

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-Tolerate mechanical ventilation -Acceptable ABG and other labs -Lower FiO2 -Mental stability -Absence of life-limiting disorders and diseases, including cardiac dysfunction and arrhythmias -PEEP should not exceed 10 cm H2O -Able to clear secretions by cough, suction or cough-assist device -Tracheostomy tube, as opposed to ET tube -No expected readmissions for > than 1 month

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most often used Noninvasive ventilatory support

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Noninvasive positive-pressure ventilation (NPPV)

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Patients receiving NPPV must meet what certain criteria ?

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patient must be cooperative and not need high FIO2

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A backup ventilator should be provided for patients who cannot maintain what?

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spontaneous ventilation for more than 4 hours

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Selecting the appropriate ventilator

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The choice of a ventilator depends on the needs of the patient A backup ventilator should be provided for patients who cannot maintain spontaneous ventilation for more than 4 hours Ventilators used in alternative sites must be dependable and easy for caregivers to operate The ventilator must be portable for patients who are mobile Electrically powered ventilators are often the best choice in alternative health care sites

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Positive-pressure ventilators

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Most patients, especially those with COPD, prefer pressure-limited over volume-cycled ventilation The biggest challenge with NPPV is getting a good, comfortable, leak-free interface

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Negative-pressure ventilators

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Iron lung has been replaced with the chest cuirass and wrap or "pneumosuit" Rarely used for ventilatory support in postacute care settings

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Ventilator Support in Alternative Settings: Evaluation and follow-up

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Vital signs, lung sounds, and sputum production should be monitored on a daily basis ABGs and lung compliance only on an as-needed basis Routine follow-up visits by a respiratory therapist help ensure the success of patient management in the home

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Other Modes of Respiratory Care in Alternative Settings

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Bland aerosol therapy Aerosol drug administration Airway care and clearance methods Nasal continuous positive airway pressure (CPAP) therapy Apnea monitoring

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Bland aerosol therapy

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1. Delivered by jet or ultrasonic nebulizers 2. May be intermittent or continuous 3. May be useful in patients with thick secretions as an adjunct to airway clearance procedures 4. Infection is the primary risk

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Aerosol drug administration

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1. Bronchodilators and anti-inflammatory agents are given via metered-dose inhalers, dry powder inhalers, or small volume nebulizers 2. Reimbursable expenses related to aerosol drug therapy in the home are limited

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Airway care and clearance methods

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1. Patients with tracheostomies require daily care 2. Tube changes should be done only by a nurse, respiratory therapist or physician 3. Suctioning is provided using a portable electrically powered suction pump 4. Patients can be taught to independently apply coughing, forced exhalation, active cycle of breathing and autogenic drainage methods 5. Caregivers can be trained to apply chest physical therapy and mechanical devices when retained secretions are a problem

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An accepted form of therapy to treat sleep apnea

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Nasal CPAP

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Nasal CPAP for Medicare reimbursement, the diagnosis must be confirmed by a

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polysomnogram or sleep study

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

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Screening Treatment planning Ongoing assessment Discharge

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Home care: Factors to consider when determining the frequency of home visits include:

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-Patient's condition and therapeutic needs -Level of family or caregiver support -Complexity of home care equipment -Overall home environment -Ability of patient to provide self-care

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Home care: Functions of the respiratory therapist during a home visit

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-Patient assessment -Patient compliance with treatment plan -Equipment assessment -Identification of any patient problems -Statement related to patient goals and treatment plan

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Palliative Care

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Maximizing comfort of the patient who is terminally ill is a goal of home care Palliative care involves control of symptoms such as pain and dyspnea in the terminally ill patient while maximizing the psychological and spiritual well-being of the patient Respiratory therapists may play a key role when lung disease is present in the terminally ill patient

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