CPAP on the unit

GrannyRRT · Sep 12, 2014

to GrannyRRT
iratory care services "own that machine" but Nursing services does.
If someone in respiratory care told me to:
1) contact the DME provider for a copy of the original prescription,
2) get a copy of the sleep study
3) call the case manager to expedite ordering a new mask " because that shouldn't overburden you"
4) call the MD for orders for use of the hospital CPAP because you don't want any involvement or liability
I would obtain physician's orders for a Respiratory Consult to have you do all of the above.
What you choose to do about it is up to you.
edited to add: I am not at the low end of the pile. I am the nurse in charge of the patient and I am not afraid to assume that responsibility.

All medical equipment requires proof of the original order. If you are in charge of a patient you should know this. Do you allow patients to bring in their own meds to take without confirming they are actually prescibed? Never assume anything.

I did not say a copy of the sleep study.

If the patient is non compliant with the maintenance of one thing like his sleep machine he probably has other issues which CM needs to address. You need to be proactive because discharge planning is a big deal now.

I also don't know how your hospital or the one in the OP works specifically. Nursing may have tied the RTs hands by establishing their own policies. There are places where RTs do not go to any floors even in an emergency unless called for later. This means the nurses take care of ALL oxygen equipment and even do the trach changes.

Yes nursing units can purchase the respiratory equipment. Who is responsible for it is per policy. It is not uncommon for an ICU to purchase the HFOV or ECMO machine but then have RT or a shared responsibilty.

LTC nurses set up and maintain their own equipment including CPAP and ventilators.

If you call the doctor for orders to place the patient on an ICU machine in the ICU, there is a really high probability the RT will be involved and will need to do all the same things required of an ICU patient which includes the monitors and maybe q2 complete assessments. I have no idea where you think this releases them of any responsibility. It would be in their best interest to keep this patient on the floor.

GrannyRRT · Sep 12, 2014

I am now going to give you my opinion of the situation. In my other posts I was trying to not offend and to explain how policies vary, equipment differs and expected safety issues.

Some here just want to focus on RT "billing". Again, the individual RT does not get a commission in their paycheck for setting up a ventilator. But, allied health departments are reimbursement based. This is why you have seen some departments disappear or go with other departments over the past few years. RT in some places have taken in cardiology and EEG. In some hospitals EEG is responsible for sleep medicine and all CPAP machines.

For the OP, I think this hospital sucks. It lacks the foresight to see sleep medicine as an issue. It lacks the appropriate policies. It lacks the equipment. And it lacks education for nursing about CPAP which means there is a huge safety issues involved when staff does not have the appropriate training. I was trying to be nice to the OP but the comments about CO2, assuming all masks the same and the thing about 500 ml for a tidal volume on CPAP showed some major areas where education is lacking. But, then the RT department should have taken more control of sleep machines. They may have tried but met resistance from the nursing departments and some physicians. It could have been decided that educating the staff was a lost cause and the only safe thing was to get a patient with any home CPAP issues off that floor even if it means ICU. The nurse managers probably agreed to that policy as well. Overall, I thinkit is really crappy to take up an ICU bed for this. But if the managers and doctors don't want to play together for the appropriate policies, training and macines, to the ICU it will be. If you are not on the low end of this pile, then you really don't get the hierarchy of hospitals when it comes to policy making and changes. For some, change takes a long time. For others, it may never come and some want to do things as they did in 1980.

If you have no verification of what the patient is on at home, just having a doctor write for CPAP of 5 is stupid and dangerous. The patient might need BIPAP or a CPAP of 18. Unknowns in my hospital get tele ox and an auto titrating machine. Just because some doctor writes some order does not mean it is the appropriate one. The "I have an order" and that makes it all better is crap in some situations. But, some go along blindly not questioning anything or thinking about potential consequences or lacking some common sense about some situations. They may just lack the proper training and education to deviate or get on a power trip of trying to order people to do inappropriate things by getting inappropriate orders they know very little about. The OP would be a good example who probably could have gotten an order to make the RT put the wrong mask on that machine. Luckily that RT department keeps the masks out of the nurse's reach on that floor.

We have a very proactive sleep medicine part of our department. Nurses, some very reluctantly, will check the risk factors such as obesity, snoring and HTN which triggers the RT department. Someone will assess the patient and can per protocol set up and auto titrating machine with a built in recorder. Tele pulse ox is also set up which most of our floors are capable of. The data from the machine and tele pulse ox are downloaded and read. If the events are significant the next step is taken to prescribe home CPAP is made. Some patients are not interested or will "get back to you".

Surgical services have embraced the sleep medicine issues. Before getting us involved they used a combination of disposable devices post op similar to what EMS use in the field. Primitive and limited devices especially if the patient needed more support or for identifying problems.

As I said before, we don't allow the patient's machine in the hospital. If the patient can direct us to their provider we will verify their settings. If older than 5 years or a change in the patient's health or weight, we will protocol to the auto titrate mode and tele monitor. The results will be read and recommendations made. Our department deals with the insurance and DME setup but also keeps CM in the loop. They can also follow the progress on the computer. If the patient already has home O2, the CPAP machine should be arranged through the same company.

The computer systems some hospitals are using makes sleep study and prescription very easy. If I get verification from outside of our system, I just get it scanned into the record. Kaiser with their EPIC medical record system is great. The latest version of CERNER is good also.

I know that some will continue to ***** about the "billing" and that RTs are greedy or the extra check box on the admission assessment is way to much work for nurses. But, our patients do appreciate having their medical issues addressed and a steamlined process for them to be qualified. Our night shifts nurses and RTs don't have the hassles of trying to set stuff up on the fly. Having the proper policies in place takes the guess work out of this part of patient care and reduces anxiety. Our policies are easily found on the computer so any staff can review them. We also email them to uninformed doctor.

Being proactive is better than reactive.

I now feel really blessed to not work in a hospital like the OP'S or to work with nursing staff who think RTs' only motivation is greed. We have a strong multidisciplinary team which eliminates most of this stupid time wasting bickering and "I'm writing you up because I can" bs.

.

JustBeachyNurse, LPN · Sep 12, 2014

The OP (nurse) knew what was needed which was the mask. The hospital masks will not work. The OP also stated if the hospital machine is used the patient must be in the ICU. That means the hospital has only the big rescue CPAP machines.
Why do you keep harping like the RT is the enemy here? The nurse obviously is not stupid and saw the mask is the problem. Does she really need an RT to also say the mask is broken? Does that change what can and can not be done? I have explained over and over and included links with pictures to show the mask differences. The OP just wanted someone to side with her when the RT tried to explain why the masks are different. The OP didn't understand vented vs nonvented masks, exhalation ports, circuit differences and CO2 in the mask if no vents or exhalation port. Hopefully she does now and will move on to either transferring the patient to ICU and calling the CM for an ETA on a new mask.
Essentally the wavier you get the patient to sign says "not the hospital's problem". Those are not words the RT made up nor did that RT write the protocol. What else do you think they can do especially if you act as if you don't know the policy and just want to argue about all masks being the same. Instead of listening to the RTs explaination about why the nurse just wanted to disagree essentially to get on a forum to start trash talk about the RT. I can now easily see how frustrated the RT was when he did try to explain it and came up against someone who wouldn't listen to the whys or the alternative which could be provided by the policy. Work to change things later but for now start the ball rolling according to what your hospital's policy dictates. I'm sure there are policies in nursing you don't like also but must abide by them. This policy of moving the patient to ICU is not the RT's fault. And don't make the RT out to be a villian because he refuses to put the incorrect mask on a home CPAP unit which will cause harm to the patient.

I'm sorry for the misunderstanding. I was not referring to the OP's situation where the respiratory therapist already offered their professional advice/ information. I'm referring to more in general as per situations I've witnessed before in hospitals. Surgeon and his office staff instruct patients to bring their CPAP unit, mask & tubing to the hospital upon admission with the intent on writing a post OP order for patient to use home CPAP unit as night as directed by pulmonologist/DME/ whomever. Only secured medical clearance from pulmonologist as to medical suitability for surgery and possible risks for general anesthesia. Patient gets to hospital for pre-op admission. Nurse notices machine is MacGuyvered Calls RT for advice. Respiratory (without coming down or reviewing preadmission records (per RRT statement) and RT has orders for consult/treat/teach for pre/post op spirometer, etc.) says not my machine not my problem. In this case the nurse wasn't familiar with the unit or the paper with the CPAP orders from pulmonary (not on staff at this facility). The nurse in this case wasn't demanding RT fix the machine but help the nurse understand what was needed to ensure continuity of care. Maybe RT had equipment on site that could meet the patient needs, maybe CM (not always involved for a 2-3 night stay for a semi-elective surgical procedure) or DME consult was needed or more.

In this case couldn't the RT at least look at the patient chart and say "ok I think you need to do XXX" or "I can get the surgeon to order a hospitalist or staff pulmonary consult" or "these records are clear. We can get an order to use our equipment but we need CM and DME coordinated to fix the home equipment before discharge." or "call DME for troubleshooting" rather than not my problem. An extreme scenario but one I witnessed ( not a nurse at the time)

Should hospital staff attempt to "fix" home equipment? No. Should respiratory therapist be valued for their expertise and knowledge of their often highly technical knowledge? Absolutely. Should nursing and respiratory try and work as a team? In the best circumstances, yes and it should not be us vs. them. Using home equipment in a facility is a practice that carries liability and risk. Not all home equipment is adaptable to a hospital environment.

There are awesome members of RT & nursing. Just like there are mediocre and crapoy professionals in every profession. Just like the RRT who decided to cut down my fathers trach tube inner cannula for a stubborn mucus plug rather than suction or replace. Still don't understand why this person thought it was a good idea. But that's a separate issue.

If you look at photos of CPAP mask, you have to admit they certainly look interchangeable but as explained in the educational posts above clearly they are not and looks can be deceiving.

GrannyRRT I am sorry again that my post was misinterpreted at trying to pass the buck or "blame" to RT. I've read your responses before and you offer a lot of excellent educational insight to respiratory care. Your input is greatly appreciated

GrannyRRT · Sep 12, 2014

Thank you for that post.

Every department has its problems.

Our problem, which nurses have told us, with be very proactive and trying to be the leader for progressive therapy would be education time is too limited to do all the teaching we would like to. As you can see by my posts, I can turn just about any RT topic into a week long seminar. In addition, nurses have their own new equipment and policies to keep up with. There are also nursing topics which RT must stay informed about.

**canoehead, BSN, RN** · Sep 15, 2014

If you only "give" a disposable mask to the patient without consulting case management for a new one, you have done nothing for the patient. Giving the patient a poor fitting mask meant to be disposed of in a couple days is irresponsible. You have now created the dangerous situation. If you have "given" them an inappropriate mask, you have created the potential for a very bad event including death. If the patient is on a med surg unit, no monitors are being used.
t.

We could have gotten a home mask from the patient's vender the next working day. I came on shift at 7p, and a mask that would have lasted one night would have been perfect. The RT on duty stated he couldn't give us one of their disposable masks because that would be "modifying the equipment" and he couldn't provide hospital equipment because policy said anyone on CPAP must go to the ICU. If the patient has a health issue, especially one involving their airway, I think we are duty bound to provide the prescribed interventions. I don't understand why the RT department can wash their hands of the whole issue and walk away.

**canoehead, BSN, RN** · Sep 15, 2014

So it is about where the exhalation port is and for safety a nonrebreather valve should be included on a home mask. Reduces deadspace is also a plus. So yes, even the manufacturers mention CO2 clearance.

Why, in the name of Pete, didn't the RT say that the circuit has the exhalation port? After all this discussion and stress, NOW I understand why the hospital type mask can't be used.

I don't mean this as an RT bashing thread. I wanted to know why he said the things he did, and I wasn't getting the information I needed by asking him. It sounds now like he was right. BUT the initial response was only by phone, and just that his equipment isn't compatible, and they don't deal with the home CPAP. So, now I have to take this to my manager, we need to get the equipment. I still think the RT dept should have seen and dealt with this issue long ago....but we can make a list of the faults in EVERY department, including nursing, on a future thread.

GrannyRRT · Sep 15, 2014

Why, in the name of Pete, didn't the RT say that the circuit has the exhalation port? After all this discussion and stress, NOW I understand why the hospital type mask can't be used.
I don't mean this as an RT bashing thread. I wanted to know why he said the things he did, and I wasn't getting the information I needed by asking him. It sounds now like he was right. BUT the initial response was only by phone, and just that his equipment isn't compatible, and they don't deal with the home CPAP. So, now I have to take this to my manager, we need to get the equipment. I still think the RT dept should have seen and dealt with this issue long ago....but we can make a list of the faults in EVERY department, including nursing, on a future thread.

.Some hospitals just suck when it comes to policies and equipment. As I stated before, the nursing management may have played a role in neglecting this issue. I stated some of the issues we went up against with nursing when we initiated our plans for using only our machines and also screening for OSA. Not everyone likes change and home equipment has been easy to ignore. ...until there is a problem.

Do you call RT to check on all home CPAP equipment?

If so then they may have or should have a primary role in problem solving.

If not, then nursing has assumed the primary responsibility.

Read the policy and see which department is primary. There are some hospitals where RT never goes to the floors or ER.

nrfitchett4 · Feb 27, 2016

Wow, opinions are like buttholes, everyone has one. Nurse asks RT to provide PT with hospital mask for home machine. RT states he can't so that, RN gets mad because PT shouldn't have to go to unit for something they do at home and then comes on here to complain by RTs. That's about the gist of it, right? First, we don't have enough information on here to really know the whole story. Yes, there are new home machines that are very picky about what you use with them. Yes hospital masks are not supposed to be used on home equipment because they are different and if we do that, we have to add an exhalation port of some type. I have seen patients (or nurses) take those out or tape over the hole. That presents the risk of death from hypercapnia because the patient will rebreathe their exhaled breath first because it has nowhere else to go. It's not safe to the patient. Some of the new machines are auto adjusting. Try bleeding in oxygen by adding a port to the circuit. Confuses the hell out of the machine. There are more brands of these things coming out all the time and I've never worked home health so I know little about them. I will help set them up, add sterile water and that is about it. If they cannot manage their home equipment, I recommend the nurse bring it up to the doctor. My guess is the RT is either a PIA or was really busy and gave the short but correct answer. I worked at a hospital that had a sentinel event from a vision bipap PT on a surgical floor (non-monitored). PT was transferred out of ICU despite being extubated that day and within hours was on continuous bipap. That ICU nurse definitely was not a patient advocate that day because she should have went up the chain to block the transfer. Hell, I've gone to the house officer myself in the past. This guy was moved, put back on the bipap, RT saw him around 8 on the Bipap. He came and saw the patient again around 1130 and the patient was off the bipap, agonal breathing, had to be coded. The floor nurse had removed the bipap without notifying RT so the distressed patient could eat, and no one ever checked on him until the RT walked in before midnight. Many people failed the patient that say, but RT wasn't one of them. But they still tried to throw RT under the bus. After that, any patient on hospital bipap had to be on a monitored floor. NO EXCEPTIONS. If that means transferring that rehab patient to tele, that is what happens.

In the OP situation, the RN should have called the doctor, explained that patient's home equipment was not functional and asked for orders. Maybe the doctor is OK with oxygen for one night, maybe he wants the patient moved. If doctor tries to violate policy, you call the house officer at night. Trying to get an order for RT to do all those things is assinine. I know an RT who has been trying for years to get into case management. No one will hire her without experience, she can't get CM certification without experience. We do not intera t with CM at my hospital except during rounding in the units or special cases like transitioning to home ventilator.

Some nurses get frustrated when you tell them no, but I've never been written up for following policy. I have a state and national license just like you do. Complaining about policies at the bedside is not the place for it. Writing up the RT is not going to fix the policy, it's just going to get you more attitude from RT's. Some hospitals have policies that nurses call the doctors. Nothing pisses a doctor off more than calling them and they try to give orders I can't take, so then they have to wait for the nurse. Nothing frustrates nurses more than taking orders they don't understand. Nothing frustrates RTs more than having to get stupid RT orders clarified because neither the nurse or the doctor know what they are talking about. We all have our frustrations with the processes.

To the RT talking about prescriptions and sleep study results, I wish. I get orders all the time for CPAP per RT. I laugh, call the doctor and tell them that I can't guess the patient's home settings so they have to. I am also uncomfortable with how the patients just use their home equipment. We are supposed to check the cord for frays after hours but that is the extent of our inspection. But hey, biomes is too expensive to call in after hours, because you know what? They charge the hospital extra for coming after hours! We all have to justify our existence in this new version of health care.

To the OP, you seem pretty ignorant about noninvasive ventilation though you seem passionate about caring for your patient. Maybe you should ask your director for the policies regarding it in your hospital and maybe have an experienced RT give an in-service on it.

**canoehead, BSN, RN** · Mar 19, 2016

In the last couple of years I've brought up this issue to RT, and the ER nursing and medical departments. Nothing has changed. I even outlined a way we could obtain home CPAP masks for free and found a group willing to provide them. Even brought in two shopping bags worth of free masks! I tentatively outlined a way to get a couple machines for hospital use, but TPTB nixed going forward on that. Everyone agrees this is an issue, no one is willing to push through to a solution.

The sticking point right now is that we have a contract for resp equipment that doesn't include the masks. So we can't get the masks, and we also can't use masks from another vendor. It's been two years though...renegotiate. If we bit the bullet and bought all the equipment outright, we'd probably still win financially with decreased LOS and complications. I don't understand why it isn't a priority, but I am not privileged to breathe the upper air layers that administration does.

We still use the patient's home equipment, even if it's encrusted and leaky.

dishes, BSN, RN · Mar 19, 2016

If a patient is admitted to hospital with their CPAP from home and the equiment is defective or the mask needs to be replaced. Why can't the respiratory services company that provided the patient with the equipment be contacted by the patient, to repair their equipment or replace the mask? The patient has a contract with the respiratory equipment company and it is the company's responsibility to maintain it, not the hospital's.