Thoughtful Planning Eases Homecomings for Patients on Mechanical Ventilation

Vol. 11 •Issue 2 • Page 16
Thoughtful Planning Eases Homecomings for Patients on Mechanical Ventilation

By James Stegmaier, RRT, RPFT, CCM

Discharging a patient on a mechanical ventilator to the home environment can seem intimidating and complex, not only to patients, families and caregivers, but to respiratory therapists as well. With appropriate planning and training, however, the passage can be a seamless process.

When a potential candidate is identified for discharge, a care conference should be initiated to determine if a safe transition is feasible. The conference should be attended by all of the patient’s health care providers at the facility and those professionals who will provide services in the home. It’s best that patients and their families not be present so that an open and honest discussion can occur regarding the appropriateness of the discharge.

Factors to consider will include the number of caregivers available to care for the patient at home, the stability of the patient’s medical condition and the financial resources available to meet the patient’s needs. Those attending the care conference must not be afraid to decline a discharge if the safety of the patient may be compromised.

You may find as many as 40 percent to 50 percent of referrals for home mechanical ventilation are declined. The lack of an adequate number of home caregivers often is the main disqualifier. Remember: The patient must be taken care of 24 hours per day, seven days per week without interruption. Two caregivers aren’t adequate, and the process can still be a challenge with three.

Contracting with private duty nursing is an option if the resources are available. Unfortunately, Medicare won’t pay for home nursing, though some private insurance carriers and Medicaid will. Even if the funds are available, however, the current nursing shortage makes it a challenge to find an agency that can provide the coverage for the number of hours approved by the insurance carrier.

If the conference attendees determine that the patient can be discharged safely, another meeting needs to be arranged, this time with the home caregivers. They need to be provided with a realistic view of what to expect in the home, emphasizing procedures and the tremendous responsibility being placed upon them. Even if home nursing is an option, caregivers must be reminded that they’ll need to step in at a moment’s notice if a nurse fails to show up at the home, an occurrence that can and will happen.

In addition, the meeting should set up a training program timetable. Ideally, the program should be held over a two- or three-week period with no more than three training sessions per week. Rushing through a program in only a few days to a week won’t give the caregiver enough time to practice the skills taught in previous sessions. In addition, sessions lasting longer than two hours can cause the caregiver to have difficulty retaining information.

The caregivers should be given all supplemental reading materials beforehand so that they can prepare for each session. Include clear objectives and skills checklists to document the caregivers’ competency and to ensure all essential training aspects are covered. (See Table 1.) Minimum training requirements should include:

Sample Home Mechanical Ventilation Skills Checklist
Mechanical Ventilator and Circuit Training Session
The family/caregiver is able to:
  • Identify function and setting of each control
  • Identify all filters and frequency for cleaning/replacement
  • Describe the concept of peak airway pressure and indicate high/low pressures
  • Describe the purpose of high and low pressure alarms
  • Describe causes of high and low pressure alarms
  • • mechanical ventilator: basic function of each control or parameter

    • mechanical ventilator circuit and humidification system

    • suctioning and airway maintenance

    • tracheostomy tube and stoma site care

    • ancillary equipment specific to each individual discharge.

    During the first week of the training sessions, a home evaluation should be performed. (See Table 2.) Its purpose is to assess the home environment’s suitability for the patient. To help with the evaluation, the assistance of an occupational or physical therapist is beneficial in determining what, changes, if any, are required based on the patient’s activities.

    Geographic Location

    Sample Home Mechanical Ventilation Environmental Checklist
    Physical Environment
  • General Condition
  • Number of grounded outlets
  • Required number of grounded
  • outlets
  • Amperage available
  • Minimum amperage required
  • Room size
  • Doorway size
  • Bathroom location and size
  • Patient call system
  • Telephone location
  • Heating/Cooling systems
  • Area for supply storage
  • Is the home well marked for EMS
  • personnel?
  • Proximity to EMS
  • ________ miles _______ minutes
  • Proximity to hospital
  • ________ miles _______ minutes
  • Proximity to DME
  • ________ miles _______ minutes
  • Does this geographic location require additional backup equipment?
  • The evaluator needs to make sure the patient can be removed safely from the home in case of a fire, medical emergency or for routine trips into the community. Doorways must be wide enough for the patient to use the bathroom or a bedside commode, and an alternative type of bathing will be necessary. There also must be adequate electrical outlets and power. If possible, the patient’s room should have its own dedicated power through separate circuit breakers from the rest of the residence. Preparations must be made quickly. All necessary corrections regarding wheelchair ramps and widening of doorways, for example, should be completed prior to discharge.

    The necessary supplies and equipment also should be delivered to the home one to two days prior to discharge. To make sure nothing is forgotten or misplaced, use a checklist system. (See Table 3.)

    Sample Home Mechanical Ventilation Equipment Checklist
    Patient Name: _____________________
    Equipment Delivery Date:____________
    Discharge Date: ____________
    Mechanical Ventilator
    Manufacturer and model:____________
  • Backup battery
  • Battery cable
  • Bacteria filters
  • Ventilator circuits
  • Adaptors
  • Humidification System
    Manufacturer and model:____________
  • Mounting system for humidifier
  • Humidifier chambers
  • Heat/Moisture exchangers
  • Oxygen Therapy
  • Oxygen concentrator
  • Liquid oxygen stationary system
  • Portable oxygen system
  • Bleed in adaptors
  • Oxygen tubing 7′, 25′ and 50′
  • Nipple adaptors
  • Peep valve
  • Tracheostomy Supplies
  • Suction machine
  • Suction canisters
  • Suction tubing
  • Suction catheters
  • Size: __________
  • Trach care kits
  • Swivel adaptors
  • Specimen trap
  • Normal saline
  • Trachestomy tube
  • Manufacturer:__________
  • Size:________
  • Cuffed
  • Uncuffed
  • Aerosol Therapy
  • Nebulizer
  • Aerosol generator
  • The insurance carrier generally governs the amount of supplies provided. Many times, it establishes allowable levels that are the maximum amount of a supply it will reimburse in a given 30-day period. Other supplies aren’t reimbursable at all because the insurance carrier has determined that the particular item is included in the rental of a certain piece of equipment. Examples of nonreimbursable supplies would be the ventilator circuit, back battery and humidification stem.

    When a patient is finally discharged, the RT can plan on spending much of the first day at the patient’s home, and a fairly intensive visitation schedule will continue throughout the first week. Regardless of how well the training has gone, caregiver anxiety will be at its highest point, and many procedures will need to be reviewed.

    The home visits should consist of the following action items:

    • functional check of all equipment

    • education/review of procedures as needed

    • monitoring of supply levels

    • patient assessment. (Most accrediting organizations require a physician’s order to perform the patient assessment, and the order itself should state what specifically is to be assessed.)

    Over time, home visits will gradually become less frequent until the RT will only need to see the patient once per month. By that point, mechanical ventilation in the home will have become part of the patient’s daily routine.

    Stegmaier is the vice president of clinical services for Hytech Homecare, an Omnicare Company in Mentor, Ohio.