home respiratory care
Home environment must be evaluated for the specific medical equipment being provided.
(i.e) home O2: no open flames and a working smoke detector.
If the patient has not already completed an advanced directive, they should be given one to complete
(so the RT knows how to respond to an emergency in the home).
local ems and firefighter
Not all patients can communicate the same way; some are verbal, some are not. Must have a means for the patient to contact 911 on their own.
daily routine of a home care RT is much different from that of a hospital-based therapist.
Often on call 24-7 Make own schedule A home care therapist often develops long-term relationships with patients and their families.
Clinical Respiratory Services:
Performing clinical assessments and diagnostic procedures, administering treatments or medications, providing patient education, and monitoring the patient's respiratory status.
flows up to
15 lpm
Accreditation usually repeated every
3 years, but varied depending upon the agency.
___ on non-invasive ventilation with a back-up rate.
7600
accreditation agencies
Joint Commission, Community Health Accreditation Program (CHAP) and Accreditation Commission for Health Care (ACHC).
Electrical safety/Backup electrical/ battery power
Electrical outlets for equipment are properly grounded No overloading of any one outlet Priority restoration list (those on vents)
Four types of Home Care Services:
Home Medical Equipment Services Episodic Home Health Care Hospice Home Health Care Chronic Home Care Services
The patient should receive the HME company's policy for HIPAA compliance.
How their information will be stored and who will have access to it.
Goals of Home Respiratory Care
To achieve the optimum level of patient function through goal setting Educate patients and their care givers Administer diagnostic and therapeutic modalities and services Conduct disease management Promote health
Home care RT should work with hospital staff to complete an instructional check list to make sure
all family and caregivers are properly trained.
Compressed Gas Systems:
Small cylinders are still used with stationary oxygen, in conjunction with a concentrator transfilling system.
safe storage of oxygen
Smoking or open flames Functioning smoke detectors Securing oxygen cylinders when driving
Oximeters are used to assess a patient's
SpO2.
Continuous Flow:
Standard for oxygen delivery in the hospital setting with unlimited oxygen supply. Increased activity; increase the flow
part b
Supplementary medical insurance. Most people have to pay a premium for Part B coverage. Covers outpatient services, tests, lab services. Also covers home health services including nursing care,
Portable Oxygen Concentrators:
They manufacture oxygen, they don't store oxygen.
Chronic home care services (private duty)
are provided on an hourly basis and involve nurses, health aides, chore providers, and companions.
putting bag down on a clean surface like
blue chux
environmental issues
safe storage of oxygen, electrical safety or back up electrical or battery power, emergency plan/ alarms communication
Increased respiratory rate will
shorten inspiratory time and may reduce the amount of oxygen a patient receives.
Good for the EMS to visit the patient at home,
so they know the set-up, etc. If patient is a DNR, this is important, and the documentation should be kept visible somewhere in case they are called to the house.
Liter meters are devices that are used to
spot-check the continuous flow from a low-flow oxygen device.
Patients on home oxygen therapy need to
stay active to prevent complications associated with a sedentary lifestyle.
washing hands before
taking anything out of the bag
On inhalation, the patient receives
that stored oxygen, essentially adding a bolus volume to the ongoing continuous flow delivery.
The RT may give the patient a list of community resources, such as
the American Lung Assoc. (ALA), Better Breathers Clubs, Meals on Wheels, etc.
wiping everything down after use before going back into
the bag
Small cylinders come in a variety of sizes and shapes designed to provide
the lightest system for the patient, along with the greatest operating range.
Oxygen conservation is achieved because
the patient is usually able to be given the equivalent of CFO therapy with nasal breathing at a lower continuous-flow setting.
Another factor driving the increase in home care is
the proportion of the population older than 65 years, which is projected to increase to 19.6% of the total population in 2030.
Home respiratory care, particularly for ventilator-assisted individuals can be highly complex; therefore
the risk of negative outcome is great if the services are not performed by a highly skilled professional.
Home care RTs carry a bag containing
their hand wash, stethoscope, blood pressure cuff, pulse oximeter, CO2 monitor, peak flow meter, and other necessary implements.
Patient needs vary as much as the POCs, so
there is no right POC for all patients
Overnight oximetry is strongly recommended for intermittent-flow oxygen delivery devices,
to see whether or not the device is triggering with each breath and maintaining the patient's SpO2.
Intermittent-flow devices operate by
turning oxygen delivery on during some portion of inhalation and off for the balance of the breathing cycle.
demand delivery devices
turns on during inhalation and off during exhalation. They use a dual lumen cannula.
Oxygen is conserved
two to four times longer than it would be if it were continuous.
Must be able to asses patient and care giver's ability to
understand information that is taught and ability to maintain prescribed medical equipment.
Transtracheal oxygen
uses a catheter that is placed during a surgical procedure to bypass the upper airway.
the respiratory therapist is the most competent healthcare professional to provide home respiratory care through
virtue of education, training, and competency testing,
Guided Self-Management:
when patients/ caregivers have appropriate knowledge/ are adequately trained when they can make adjustments to the treatment plan, what adjustments they can make, and when they need to seek medical attention.
The patient should receive a copy of the company's complaint form;
which allows the patient to file a complaint.
landline is helpful for EMS to pinpoint location of
call and quickly find address
Patients will need to be provided with an oxygen system that is light enough to transport and
capable of providing the required O2 to meet their needs with activity.
Since the early 1990's, increased data support the
cost-effectiveness of home care for respiratory patients.
Must be well-organized and must be aware of
current insurance coverage for commonly prescribed home medical equipment.
The Nocturnal Oxygen Therapy Trial (NOTT) and Medical Research Council (MRC) both
demonstrated that continuous use of oxygen improves survival.
medicare encourages
early hospital discharge
In a report of 621 ventilator users with neuromuscular conditions; one-third were
employed, and a few others were active on a daily basis as volunteers or students. They can lead meaningful lives!!
A 6-minute walk is recommended for
exercise
The patient should receive a rights and responsibility document;
explaining their right to refuse services.
There is a high incidence of depression among
family caregivers
A liter meter can verify
flow in the home, or determine if extra tubing has caused a drop in flow.
Based on 2005 numbers, there are approx. 10,000 patients on
home ventilators receiving invasive ventilation
part a medicare benefits
hospital insurance: covers inpatient care, skilled nursing facility care, and hospice care.
Medicare will rent a ventilator for a qualified patient as long as medical necessity exits
however, Medicare places ventilators in the capped rental category.
Oxygen in the home or alternate-site healthcare facility is indicated for the treatment of
hypoxia and has been proven to significantly improve survival in hypoxic patients with COPD.
Improved medical equipment has resulted in an increase
in home health care
A benefit of TTO therapy is an
increase in patient compliance with therapy because it is hidden from others to see the catheter.
Episodic home health care
is ordered for the time period immediately following the patient's hospital stay and is for a finite period of time.
Hospice care
is provided for the terminally ill and provides palliative end-of-life care. Usually for up to the last 6 months of the patient's life.
What happens on the initial home visit varies depending upon whether
it is a equipment management services visit or a clinical respiratory services visit.
Bag technique means
keeping the bag and its contents as clean as possible.
Because the RT will be traveling from home to home, it is prudent that the therapist minimize the
likelihood of disease transmission.
part c
low cost alternative to medicare
If the patient is going home on a ventilator, the respiratory therapist must
make a visit to the patient's home prior to the patient's discharge to check for any safety issues or inadequacies so that they can be identified and corrected prior to the patient being discharged.
Carts have helped patients be more
mobile with their oxygen systems
Home care providers check continuous flow units with devices that
monitor oxygen concentration and flow.
Modern therapies for the treatment of newborns have resulted in
more infants and pediatric patients requiring home O2 and home mechanical ventilation.
Reservoir cannulas
mustache or pendant cannulas) have approx. 20 ml. of reservoir space that stores oxygen during exhalation.
The RT may want to ask the family member about his/her quality and amount of sleep to determine whether there are
nuisance ventilator alarms interrupting their sleep (or is the patient having nocturnal issues).
The RT should also be knowledgeable about
ocal respite programs, daycare facilities that accept ventilator patients; camps for ventilator dependent kids, or other agencies that may provide some respite for the family caregiver.
Oxygen dependent patients should be tested
on their O2 system at different activity levels reflecting real-life conditions- sleep, rest, and exercise, as well as at altitude.
Caregiver must know how and when to
order supplies, maintain good infection control processes, verbalize and demonstrate proper response to emergencies such as power outages, equipment failure or accidental patient decannulation.
Either double the dose oxygen flow for altitude or
perform a high altitude simulation study.
part d
prescription drug coverage
The goal for efficient oxygen delivery is
proper arterial oxygen saturation at all activity levels.
the care givers Must be able to explain and demonstrate
proper use, troubleshooting, and routine maintenance of the ventilator and all related equipment (bag and mask, suctioning, etc.)
Home medical equipment (HME) companies (durable medical equipment (DME) companies)
provide services by a technician, respiratory therapist, or a qualified nurse
oxygen conserving devices are divided into
pulse flow and demand delivery devices
home long-term oxygen therapy reduced healthcare costs by
reducing hospitalizations!
pulse flow
responds to the pt.'s inspiratory effort and terminates flow at a predetermined time as it is controlled electronically.
Home oxygen therapy is provided in the range of
1-6 lpm
Most home care companies require that a minimum of
2 family or lay caregivers be identified and trained prior to the patient's discharge.
final indication that the patient and family are ready for discharge is
A 24 hr. live-in demonstration, where family and caregivers perform all patient's care without any help from RT or hospital staff
for HMEs you need two types of accreditation
Equipment Management Services and Clinical Respiratory Services (required if company provides hands on patient assessment, treatment, education, etc)
During the initial visit, the RT should:
Establish a rapport with the patient and family. Evaluate the home environment. Complete the equipment setup and instruction. Perform any ordered patient assessments and diagnostic or therapeutic procedures. Determine if there are unmet needs and make a plan for addressing those needs. Communicate with other professional caregivers. Complete the required admission paperwork.
Oxygen Concentrator:
Have been the standard for stationary oxygen delivery in the home for decades. Uses Pressure Swing Absorption (PSA) methodology to separate oxygen from nitrogen, with an FiO2 of 0.93 + 0.03. Have become more reliable, smaller, and use less energy over the years. Today's models can produce up to 5 Lpm and produce less noise and heat (which had been an issue in previous years). Good for home use, but ambulatory patients require portable oxygen for when they leave the home.
important points of information for the clinician to consider when working with the patient to determine therapy options.
Knowing the capabilities of the POC, the needs of the patient, and the activities the patient will be doing while using the POC
Patients requiring higher flows use a
LOX system for efficient operation.
Equipment Management Services
NOT hands-on patient care services The RT checks the home medical equipment (i.e. the percent oxygen from the concentrator or the ventilator settings and alarms)
Emergency plan/ Alarms and communication
Power outage; backup generator? Battery/ DC battery for car use Alarms must be loud enough to be heard t/o the house Baby alarms and remote alarms
HME company requirements:
Retail license/ HME license A bedding supplier license An O2 manufacturer/distributor license Other licenses/permits as required by the state Liability insurance A surety bond of at least $50,000 (to be able to fulfill an obligation to a third party)
Intermittent-Flow:
Senses the patient's inspiratory effort and triggers a dose of O2 at the beginning of the patient's inspiratory cycle. All sensing is done through a nasal cannula.
the most important skill for home respiratory therapists
The ability to assess many different aspects of the patient
Liquid Oxygen Storage Systems:
The greatest storage capacity for oxygen. The concentrator generates oxygen for the portable, but rather than pressurizing the gas, it is liquefied and transfills to the portable. Used for patients that require higher flow oxygen with ambulation.
If a hospitalized patient is prescribed home mechanical ventilation
a comprehensive team approach to discharge planning is required. min 2 weeks prior to discharge
Medicare was established to provide
a health insurance program for aged persons to compliment the retirement, survivors, and disability insurance benefits.
Equipment management services require
a physician's order for the home medical equipment and settings.
The RT must wear their company photo ID
at all times, and it must be visible to allay any security concerns.
In the United States, approximately 80% of all persons over the age of 65 have
at least one chronic condition and 50% have at least two
The clinician needs to know the capabilities of a POC to
determine the appropriate device to use for the patient.
The DME provider receives a fee for the first 13 months, after that,
ownership of the equipment is transferred to the Medicare beneficiary.