Homeward Bound
Page 22
ventilation today
Homeward Bound
Successful Home Mechanical Ventilation Begins with Patient Instruction
By Susan L. McInturff, RCP, RRT
Patients have been using invasive and noninvasive mechanical ventilators in the home for decades, from iron lungs and chest shells to the relatively sophisticated ventilators of today. It’s estimated that more than 11,000 patients nationwide are currently on long-term ventilator support.1
These patients have diagnoses ranging from central nervous disorders, such as spinal cord injuries; neuromuscular disorders, such as muscular dystrophy and postpolio syndrome; skeletal disorders, such as kyphoscoliosis; and respiratory disorders, such as bronchopulmonary dysplasia and chronic obstructive pulmonary disease. They range in age from infant to elderly. Most are cared for by family members and other lay caregivers, yet some home ventilator patients receive care from nurses and other paid health care professionals.
HOME ADVANTAGE
The home is the preferred site for patients requiring long-term ventilatory assistance.1 The most obvious advantage is that it’s far less costly to maintain the ventilated patient at home than it is to keep them in an acute care facility. Improved quality of life is another benefit for patients who can be cared for at home as opposed to being institutionalized. As well, home ventilator patients are encouraged to maximize their independence, which they may lose when residing in a care facility.
Sending a patient home on mechanical ventilation is quite complex but can be done successfully. Patient selection is critical to ensure a safe transition from hospital to home. The patient should have medical stability, an acceptable home environment and an adequate number of family members or friends who can be trained to provide the necessary care.1
The patient’s safety is the primary concern when considering home mechanical ventilation; some feel the potential for ventilator malfunctions or failure is too great. However, in a Children’s Hospital (Los Angeles) study of 150 patients on home mechanical ventilation, they had one home ventilator failure for every 1.25 years of continuous use.2 They also found that functional equipment was being used improperly in 30 percent of the reported “failures.” As such, improved caregiver education and support could reduce these reported failures.2
RT EDUCATION
Patient and caregiver training begins in the hospital, well before the projected discharge date. It can begin only after it has been determined that the patient, family and other caregivers are willing to provide care and undergo training. The home medical equipment (HME) provider brings the specific ventilator and related equipment to the hospital for the patient and family to become familiar with and learn how to use.
The RT employed by the HME provider is uniquely qualified to train patients and caregivers on the ventilator’s use and in performing the necessary respiratory care procedures. Home care RTs understand the functions of the home care ventilator and related equipment, which are, in fact, quite different from hospital ventilators.
They also know how respiratory care procedures like endotracheal suctioning and tracheostomy care are performed in the home care setting. These procedures, as performed at home, again differ from how they are done in the hospital. These distinctions are important because it is confusing to the patient and family if they’re taught more than one way to perform a task like suctioning or responding to a ventilator alarm.
TEACHING TIPS
Once training begins, there are several things RTs must keep in mind. It’s a challenge to teach a layperson to use high-tech equipment and perform procedures usually done by credentialed health care professionals in intensive care units. We expect them to learn these procedures in a short amount of time and to perform them flawlessly, without being squeamish.
RTs must also remember that caregivers are being trained to perform a litany of nursing care procedures like bowel and bladder care, enteral feeding, range of motion exercises and IV care. And all the health care professionals are competing for time with the patient.
Thorough, comprehensive training before the patient is discharged will reduce the likelihood of reported ventilator failures. There are several teaching tips RTs can use to make their training more effective:
* Always teach the patient how to care for the equipment and perform the procedures themselves when possible. If patients have physical limitations, they should at least be included in the training. This way, they can learn how the equipment works and also see that the other caregivers are learning.
* Limit the training sessions to 30 minutes if possible, to avoid taxing or tiring learners. RTs should present only the absolutely necessary information. Going into ventilator theory or college-level anatomy and physiology is unnecessary; caregivers want to know how to make it run and what to do in an emergency.
* Minimize interruptions and outside stimuli during the training sessions. Turn off the television, limit the number of people in attendance and make sure the patient doesn’t need to leave for a chest X-ray, CT scan or other activity.
* Present the information in the simplest terms possible and avoid medical jargon. Providing equipment demonstration is useful and leaving the equipment and related written instructions for them to review at another time is important. RTs should demonstrate the skill exactly as they want others to perform it to avoid confusing the learners. When ready, the patient and caregivers should give return demonstrations of each skill, repeating as necessary until they are confident they can perform them safely. Document details of all training sessions and skills mastered.
Just prior to discharge, it’s helpful to give the patient and family a “trial run.” The patient, family, caregiver and sometimes a home health nurse are responsible for providing total patient care, as well as responding to and troubleshooting any alarms or other problems. Each caregiver takes an eight-hour shift, and the hospital staff serves as a backup for them. This trial run helps the staff identify any weak areas that need additional training, and gives the caregivers a better sense of what it will be like when the patient goes home.
HOME EVALUATION
Education and training do not stop once the patient is discharged. Rather, the RT must evaluate the care the patient receives on an ongoing basis, during each and every home visit.
Once the patient is settled at home and caregivers become confident and comfortable, they often “relax” their skills. RTs might find ventilator circuits and tubings that aren’t being cleaned or changed as often as instructed. There could be frequent low pressure alarms due to water trapped in the pressure line of the ventilator circuit, caused by not draining condensation in the tubing as often as necessary. The ventilator’s back-up battery may not be recharged properly and ventilator settings may have been changed inadvertently or on purpose.
The RT will also find that caregivers change with some frequency, and the nurse providing the primary care is no longer working with the patient. Staff changes often require more training by RTs, and many nursing agencies bring in home care RTs for staff inservices on a routine basis to ensure that all new staff are trained properly in ventilator care. There could be frequent changes in family members or other lay personnel recruited to provide care. The RT should always offer to provide training to anyone who will be brought in to work with the patient. Sometimes this means training someone who will work the night shift, or training on a weekend if that’s the only time the caregiver is available.
RTs should use the same teaching guidelines as they do when patients are in the hospital. Turning off the television, sending the grandchildren out to play, putting the dog in the garage and limiting input from visitors can increase the training session’s effectiveness.3
The detective work is never done. Careful monitoring and support are the keys to success in home mechanical ventilation. Every time the RT gets called to respond to a reported ventilator failure should be used as another opportunity to review and refresh the caregivers’ skills.
REFERENCES
1. Make BJ, Hill NS, Goldberg AI, et al. Mechanical ventilation beyond the Intensive Care Unit: Report of a consensus conference of the American College of Chest Physicians. Chest 1998;113(3):289s-344s.
2. Srinivasan S, Doty SM, White TB, et al. Frequency, causes, and outcome of home ventilator failure. Chest 1998;114(5):1363-7.
3. Dunne PJ, McInturff SL. The Home Visit. In: Respiratory Home Care: The Essentials. FA Davis Company: Philadelphia; 1998.
McInturff is a staff therapist at Farrell’s Home Health in Bremerton, Wash.
