[IngyRN]

I am so anxious about sending this particular patient home w/trach ( I am literally losing sleep!). He is a 46 yo male w/HIV and laryngeal Ca. His caregiver is his sister in law who is a physical therapist. She is very anxious about suctioning secondary to blood tinged sputum and potentially being exposed. He has done trach care/ suctioning w/RN supervision. (He did well but only did it once). MD is pushing to get him out-tried to explain pt/family not ready ( they must be independent w/trach care/suctioning prior to d/c)-just got attitude from the MD. Pt is independent w/ambulation/ADL's would not qualify for rehab and understanably so, does not want to got to NH (as suggested by my boss who wants to get him out too)

I am the case manager- and have ordered the equipment thru a resp company w/assistance from their RT and set him up w/homecare. The RT will teach pt use of suction in hopsital and will meet pt at home on d/c to set him up with O2.

However, I keep getting mixed suggestions form other case managers re: sending him home via ambulance ( he lives 40 minutes form hospital) vs pt's family taking him home vs sending him to a nursing home. I was wondering what other facilities do since I cant seem to get a straight answer from my hospital. Do you routinely send them home via ambulance otherwise what setup w/the portable O2 are they sent with?? ( The RT suggested venti mask w/portable O2 tank as it only uses 3l but what about humidification?)


I have only sent trach pt to rehab/NH in the past. My colleagues either make me feel incompetent for asking for guidance or make it seem like Im worrying too much ( hello this is airway management!!) or suggest to send him via ambulance to cya or NH. Not very helpful I feel at a loss---Thanks for your help!!

[IngyRN]

I cant believe 20 viewed this and no one had any insight to share. Are there any hospital case managers out there? If yes, is this situation this rare or just not worth your time to give some suggestions?

[dria]

Ingy...
let me warn you that I work outpt...
i think that you have the "bare bones" of a plan in place. i would encourage you to consider what the patient wants and what is safe for him vs. what is "routine." Is it fair to send him to a SNF (even though you mention that he does not want to go) just "because we send ALL our new trachs to SNFs." Is a SNF the best environment for an immunocomprimised patient? On the other hand, if he goes home, does he really have all that he needs in place to care for himself? Are he and his caregiver competent in the necessary areas of care? Is an emergency plan in place? Will intermittent homecare visits meet his needs, or is private duty nursing an option for 24-72 hrs? Does he need the ambulance transport home or is an RN/RT "ride along" sufficient?
Some thoughts regarding humidity from an ex HHRN...why not cap the trach with a heat/moisture exchanger (thats what they are made for) then put a trach collar over the whole works...or use a trach collar with a NSS neb in line PRN (you can leave the air compressor in the hospital and just crank up the O2 to make it aersolize) or many people do tolerate short periods without humidity just fine. Definitely needs to be figured out unless you want this gentleman to wind up homebound!
Hope this helps...let me know how he turns out

[SICU Queen]

Originally Posted by IngyRN

I cant believe 20 viewed this and no one had any insight to share. Are there any hospital case managers out there? If yes, is this situation this rare or just not worth your time to give some suggestions?

Well, I didn't think *MY* insight would be helpful as I'm brand-spanking-new at Case Management and don't know beans about anything yet... and in case you didn't notice, this isn't the most happening Case Management forum. Lots of people stop in for a look see just out of curiosity... just like I've done for a few years now.

[gr8rnpjt]

Are you working with his insurance company--do they have Case management? They will tell you if it is or is not covered. By all means if covered you can feel better but I work for a Medicaid plan and we do not cover ambulance transport to home. I would look into Wheelchair van companies in the area, if they take trach/O2 needs pt's as an alternative plan. Once home, you have the DME covered, but what about home care? If you send a home care nurse or social worker in to evaluate his home situation, they can better deal with his needs that were not adressed when he was in the hospital. (you can't be aware of all the nuances of his home situation)
Hope this helps. sorry but I did not see this when you first sent it out

[kTIE]

You can also sent him to a board and care if he needs "round the clock" monitoring or just someone to be around in case something goes wrong. This is not covered by Medicaid, but it would be a better situation than home with a person who may not be comfortable with the situation. They will allow nursing into the b/c so this is still possible to have the home care nursing and r/t to provide this support. I sent a couple home when I was a case manager in an ICU of a hospital. Just one family member is a little "iffy" as what if she wants to shop for groceries or needs to leave the home. Is she 24 hour going to be at his side. Does the patient feel comfortable with a trach?
Or, if he really is not ready a subacute facility that takes Medicaid may be another option, for suctioning and trach care ( both are covered by Medicare but if no real skilled need other than this he can go custodial). I have sent people with new trach's who cannot care for them to this type of facility...only drawback is his age...they usually do not want young patients and if he is immunocompromised, he would probably get an infection, so they would not accept with a neutropenic status.

A w/c van is a good alternative for transport, you probably need to set up 24 hours in advance for transport or if you are aware of a gurney transport ambulance co, there are some still out there I think...

Anyway, good luck.

[IngyRN]

Thank you all for your replies-they were all greatly appreciated.

Just to give an update, pt ended up staying in the hospital an additional 2 weeks secondary to other complications. In that time, the nurses worked with the sister-in-law and pt on thoroughly teaching the patient. By the time of d/c the pt was independent with all trach care and suctioning as well as the S-I-L ( she realized that the pt needed 24 hr supervision and was currently unemployed).
The resp company delivered the portable suction that was going to be used in the home setting and pt/S-I-L were independent using this.
On d/c the RT went over O2/suction again and the patient went home w/family in car. (Father was driving and S-I-L available in case suctioning needed.) Fortunately the patient had not need any deep suctioning for about 3d prior to d/c.

The O2 had been delivered to pt's home prior to d/c and the family had been taught set-up so that pt would just need to be connected upon arrival to home.

The visiting nurse was scheduled to see pt that afternoon.

My follow-up call to pt revealed everything had gone well.

My biggest lesson learned is to have teaching done VERY early so that by d/c the pt/caregiver are independent or alternative plans can be made.

Again thanks for allyour input !

[dria]

what a great outcome!
and what a great illustration of why discharge planning begins on admission.