CPAP on the unit

MunoRN, RN · Sep 10, 2014

The masks are interchangeable aren't specific to a particular machine. Hospitals can bill when using hospital provided CPAP, they can't bill for equipment the patient owns. A patient using their own machine but a hospital provided mask would be tricky to bill for which was probably the real reason why the RT didn't want to give you a mask since you are correct, the RT's reasoning was bogus.

GrannyRRT · Sep 10, 2014

We no longer allow home CPAP/BIPAP machines in our hospital due to the many safety concerns. This is also the trend in other hospitals.

Increased levels of CO2 is just one concern. It is a very real factor. It is being preached enough in patient home education so that it is routinely a discussion on patient forums. Patients are told to notify their sleep physician immediately if experiencing headaches or more drowsiness.

You do not know how well that home machine is functioning or the last time it was serviced. What type of mask interface and exhalation system is being used? What are the actual settings? Many patients now are on some hybrid setting. When was the last time the machine, humidifier, filter and circuit was cleaned or changed? Infection leading to death is one sentinel mentioned in ECRI reports. The RT would have to chart to justify just a mask charge on a home CPAP machine which opens up the issues about maintenance.

When the RTs set up BiPAP or CPAP machines on CHF patients, especially in acute situations, I would hope they are not using the little CPAP macines which have few to no alarms and no ventilating monitoring capabilities. There is also the issue of oxygen titration. Bleed in O2 is not the best for emergent situations and may be resticted to 4 liters or less.

The bigger machines (V60, Vision) more commonly used in acute situations are capable of blending air and oxygen as well as achieving flows of 240 lpm. These machines also require a pre test to monitor exhalation port flow or the masks have an identifying number to be set in the machine identifying its characteristics.

There are also several brands and styles of mask with variations in exhalation ports to fit certain machines. Some are very brand specific which means a company wants you to buy their masks.

If you alter a home CPAP machine in any way, you are setting yourself up for huge liability. This includes McGyver stuff involving tape. Review your hospitals policy. Obtain a copy of the patient's script from the DME. Yes, they will fax it if you submit the request properly. Ask the RT staff to set up their own equipment per an order AND a policy. Contact Case Manager to assist patient with getting a new mask. Most insurances will pay for 2 sets of gear per year. But, if your patient cannot provide proof of a script or admits to getting his stuff from ebay or a friend because he thought he has OSA, be careful. This is now more common than you think. This might be the first time a doctor is admitting a patient and might chart what the patient states as fact before getting other records.

Many of the home style CPAP/BiLEVEL machines used in the hospital are auto titrating which make it nice for OSA screening but all equipment is machine or brand specific.

suanna · Sep 10, 2014

We no longer allow home CPAP/BIPAP machines in our hospital due to the many safety concerns. This is also the trend in other hospitals.
Increased levels of CO2 is just one concern. It is a very real factor. It is being preached enough in patient home education so that it is routinely a discussion on patient forums. Patients are told to notify their sleep physician immediately if experiencing headaches or more drowsiness.
You do not know how well that home machine is functioning or the last time it was serviced. What type of mask interface and exhalation system is being used? What are the actual settings? Many patients now are on some hybrid setting. When was the last time the machine, humidifier, filter and circuit was cleaned or changed? Infection leading to death is one sentinel mentioned in ERCI reports. The RT would have to chart to justify just a mask charge on a home CPAP machine which opens up the issues about maintenance.
When the RTs set up BiPAP or CPAP machines on CHF patients, especially in acute situations, I would hope they are not using the little CPAP macines which have few to no alarms and no ventilating monitoring capabilities. There is also the issue of oxygen titration. Bleed in O2 is not the best for emergent situations and may be resticted to 4 liters or less.
The bigger machines more commonly used in acute situations are capable of blending air and oxygen as well as achieving flows of 240 lpm. These machines also require a pre test to monitor exhalation port flow or the masks have an identifying number to be set in the machine identifying its characteristics.
There are also several brands and styles of mask with variations in exhalation ports to fit certain machines. Some are very brand specific which means a company wants you to buy their masks.
If you alter a home CPAP machine in any way, you are setting yourself up for huge liability. This includes McGyver stuff involving tape. Review your hospitals policy. Obtain a copy of the patient's script from the DME. Yes, they will fax it if you submit the request properly. Ask the RT staff to set up their own equipment per an order AND a policy. Contact Case Manager to assist patient with getting a new mask. Most insurances will pay for 2 sets of gear per year. But, if your patient cannot provide proof of a script or admits to getting his stuff from ebay or a friend because he thought he has OSA, be careful. This is now more common than you think. This might be the first time a doctor is admitting a patient and might chart what the patient states as fact before getting other records.
Many of the home style CPAP/BiLEVEL machines used in the hospital are auto titrating which make it nice for OSA screening but all equipment is machine or brand specific.

Although I appreciate to info, I still cannot figure out the physics of why a hospital mask would be in any way a risk factor for OSA CPAP. The air flow increases to a certain pressure- all the sensing is in the machine. Why would a different mask make any difference? The best mask, for the best seal, that the patient will wear is what we have always used. There may be a difference with "full face mask"vs the nasal CPAP/BiPAP we commonly see for OSA, but even then, I cannot figure why the mask would make any difference. Sounds like a marketing scare tactic to me.

GrannyRRT · Sep 10, 2014

What type of whisper valve or exhalation port is on the mask or hose? How much deadspace does that machine model compensate for? Different mask brand can vary in deadspace. Does the machine have external pressue lines? Is the machine set up for adaptive flow with varible pressures? How do you know what pressure the machine is achieving and when the last time it had a tuneup for accuracy?

The machines uses in the hospital for acute situations will usually have a very different tubing with separate pressure lines for feedback to the machine. The exhalation port will be diiferent to accomondate the high flows. Home machines may have only a solid hose and have and exhalation port built in to the face mask. An additional safety valve may also be present on full face masks in case of power failure or disconnect.

The home CPAP machines today are sophisticated with complex sensors for optimum performance. Hopefully the brown ST boxes with a couple of spin knobs have all gone to a museum.

A few hospitals learned the hard way when they used extra 22 or 15 mm adapters to attach the masks to their equipment and ended up doing Rapid Responses later and some hefty paperwork to the state. The point, don't make it fit and use the style recommended with the correct exhalation assembly.

Face masks designed for homecare are more easily adaptable but not the short term disposable ones designed for the hospital CPAP/BiPAP machines. If you want to get your Respiratory Therapist in deep trouble, send the mask from the ICU machine home with the patient to use on their home unit.

MunoRN, RN · Sep 10, 2014

We no longer allow home CPAP/BIPAP machines in our hospital due to the many safety concerns. This is also the trend in other hospitals.

I can't find anything that says this is a "trend", maybe you could direct me to a source?

There are certainly compelling reasons not to allow home CPAP, but it's based on billing, not safety.

The only current information on the use of home CPAPs in hospitals makes no reference to safety concerns, but does point out that requiring patients to use hospital provided CPAP costs the patient an additional $416 per day.

Financial incentive of home continuous positive... [Laryngoscope. 2014] - PubMed - NCBI

Increased levels of CO2 is just one concern. It is a very real factor. It is being preached enough in patient home education so that it is routinely a discussion on patient forums. Patients are told to notify their sleep physician immediately if experiencing headaches or more drowsiness.
You do not know how well that home machine is functioning or the last time it was serviced. What type of mask interface and exhalation system is being used? What are the actual settings? Many patients now are on some hybrid setting. When was the last time the machine, humidifier, filter and circuit was cleaned or changed? Infection leading to death is one sentinel mentioned in ECRI reports. The RT would have to chart to justify just a mask charge on a home CPAP machine which opens up the issues about maintenance.
When the RTs set up BiPAP or CPAP machines on CHF patients, especially in acute situations, I would hope they are not using the little CPAP macines which have few to no alarms and no ventilating monitoring capabilities. There is also the issue of oxygen titration. Bleed in O2 is not the best for emergent situations and may be resticted to 4 liters or less.
The bigger machines (V60, Vision) more commonly used in acute situations are capable of blending air and oxygen as well as achieving flows of 240 lpm. These machines also require a pre test to monitor exhalation port flow or the masks have an identifying number to be set in the machine identifying its characteristics.
There are also several brands and styles of mask with variations in exhalation ports to fit certain machines. Some are very brand specific which means a company wants you to buy their masks.
If you alter a home CPAP machine in any way, you are setting yourself up for huge liability. This includes McGyver stuff involving tape. Review your hospitals policy. Obtain a copy of the patient's script from the DME. Yes, they will fax it if you submit the request properly. Ask the RT staff to set up their own equipment per an order AND a policy. Contact Case Manager to assist patient with getting a new mask. Most insurances will pay for 2 sets of gear per year. But, if your patient cannot provide proof of a script or admits to getting his stuff from ebay or a friend because he thought he has OSA, be careful. This is now more common than you think. This might be the first time a doctor is admitting a patient and might chart what the patient states as fact before getting other records.
Many of the home style CPAP/BiLEVEL machines used in the hospital are auto titrating which make it nice for OSA screening but all equipment is machine or brand specific.

I think your confusing the machine and mask. If the patient requires PPV functionality or monitoring capability that exceeds what a home machine can provide then absolutely they need to be on hospital equipment. We're talking about someone who just needs their baseline PPV and needs a functional mask. Masks are not specific to machines and are intentionally interchangeable which is why the major manufacturers use a single standard fitting size for home equipment.

**NICU Guy, BSN, RN** · Sep 10, 2014

I have been a registered sleep technologist for 14 years and I have seen CPAP being used in the hospital during nursing clinicals. The disposable masks used in the hospitals are cheap versions of the home masks. I agree that the use of their home machine opens up to all the above concerns (maintenance, mold, accurate pressure (which can be easily verified with a CPAP meter). Although some home machines have a setting for certain masks, the problem is the home machine lasts 5-7 years and new mask models come out every 6 months. It would be way too cost prohibitive for the patient to replace their machine each time they got a newer model of mask not available on their machine. Patients bring in their own masks and hoses for their overnight CPAP titration study in my sleep lab. They bring in one of a dozen different masks from 3-4 different manufacturers. So for the RT to say that their mask is incompatible to the patient's machine is BS. Every mask and hose is interchangeable regardless of the manufacturer.

**canoehead, BSN, RN** · Sep 10, 2014

Our hospital allows use of the home CPAP machine and mask without any restrictions. I've asked for a replacement mask before when the patient's equipment was just repulsive, and possibly why they ended up with an infection in the first place. Never been able to get any assistance from the RT department, they don't even want to come look at the situation. What gives? Even to the point of not replacing the straps of the patient's setup.I'd be totally happy if they just allowed an in hospital mask and machine during the admission, but they say it would require an ICU admit order. It sounds like hospital politics are interfering with patient care to me.

I came on duty at 7:30pm, to a patient that needs respiratory support, and his equipment is nonfunctional. The patient is admitted with a respiratory concern, we need to provide the support he needs. What the hell?

granny RRT it sounds like you are imagining a more complex system than we encounter for home based care. There's no feedback from the mask. I would like to educate myself though...do you have any links, or reliable sites I could look at to learn about CPAP use and standards of care?

wooh, BSN, RN · Sep 10, 2014

I had a family member with a home bipap machine. Was told something about a valve was different and thus why the hospital mask we brought home wouldn't work. I don't think every machine requires its own mask, but could see there being a few different kinds. I don't know, will defer to the RTs in this thread on that one.

As for policies and liability:

RTs don't mess with home bipap because RTs get to bill for their services unlike nurses. So while we're tucked into the room charge, everything the RTs do can be reimbursed. But if they're just helping with home stuff, they're opening themselves (and the hospital) up to liability for things they aren't being reimbursed on. What hospital is going to allow that?

When nurses help with non-hospital approved/biomed checked equipment, we're also opening ourselves up to liability. Do you know if the machine has been maintained? (Especially if you can immediately see problems with the mask/equipment, what else is going on with it that you can't see?)

Anytime we have patients/families that want to use home equipment they bring in, it has to be checked by our biomed team first (which can at times be ridiculous, things like a feeding pump are pretty obvious when they aren't working right, but with breathing equipment, not so obvious so I'd agree a good thing to check) and generally we can't touch them, patient/family has to do all the adjustments. Unless there is a really good reason the home equipment is superior, using hospital equipment is just easier and avoids all sorts of liability issues.

The bigger question is why on earth does CPAP require transfer to ICU? It makes sense if a patient out of nowhere is requiring it (because why they suddenly need it likely requires close monitoring), but on a patient that regularly uses it at home?

GrannyRRT · Sep 10, 2014

i called RT to obtain a mask for him to use temporarily, and the tech said they don't have any. Well, yeah they do...we use hospital CPAP on CHF patients routinely. Then he said the hospital mask is not compatible with the patient's machine. I didn't think anyone could say that without actually looking at the patient's machine, so I asked the RT to come to the unit, with the mask, please. He refused to bring a mask, but he came, took one look, and said the hospital mask couldn't be used.

The machines used for rescue CPAP are usually the Vision and the V60. I will again say I hope the RTs are not running to ER or ICU with a little home style machine to rescue a patient in CHF. That would be embarrassing.

Look closely at these machines. You will see the circuit and masks are different from those used in the home.

These big hospital machines will have extra tubings which give feed back to the machine to the machine for pressure. There is also a very obvious open "hole" plus an addition port never the end by the mask. I'm sure some of you may have gotten sprayed from that with air or water if using a heat wire circuit. The end of the tubing is "male" to fit into a mask "female". There should be no additional attachments to make it fit. (Adapters for nebulizers are made to fit but not the circuit to mask assembly.)

Now look at a home CPAP unit. The hose is usually one solid piece and the mask is "make" fitting INTO the hose. Long ago we had to make sure whisper valves were also included but it still fit inside the hose before the mask. These differences ensure the wrong mask which is used for hospital rescue machines do not end up on a home machine.

Our hospital allows use of the home CPAP machine and mask without any restrictions.

Then your hospital probably has a waiver which states the patient is TOTALLY responsible for the functioning of their machine. This means the patient should not expect a fix-it shop believing they will get whatever they have failed to address with the home machine. It also means the hospital does not stock any supplies for home CPAP machines and the responsibility is on the patient. You give a patient a disposable part like a hospital mask and it falls apart in 2 days once home, you have not fixed the probably but rather have created more and set yourself and the hospital up for a bad situation. DMEs and Sleep Centers look for this if the patient does decide to call them for assistance. If the patient suffered harm even as much as a pressure sore from the hospital's mask you gave them, your hospital will not be happy with you and especially not the RT who was so stupid to violate policy.

For a reference I did cite ECRI earlier but I will post more.

This is from AARC TIMES March 2012

Hospital policies on use of home medical equipment

According to the ECRI Institute (a nonprofit organization that is a

designated federal patient safety organization by the HHS): “Healthcare

organizations have a duty to ensure the safety of equipment and devices

used in their institutions. When they allow the use of patient supplied

equipment, they may also assume the responsibility for the equipment’s

performance and safety.”10 Generally speaking, ECRI recommends that

hospitals prohibit the use of patient-owned medical equipment except in

well-defined circumstances as outlined in a hospital policy. In a Health

Device Alert released December 2009, ECRI made reference to two patient

deaths involving the use of patient-owned CPAP units while admitted to

the hospital.11 One of the patients died after the CPAP machine was seen

to be misting or smoking. The second patient was unable to maintain the

equipment, and cultures of the humidifier revealed the same infectious

agent as was determined to be responsible for his postoperative

infection. Hospitals must ensure that all medical equipment (including

CPAP devices) are appropriately used and safe for the patient. Bedside

caregivers and RTs need to be provided with education and informational

resources about the safe and effective use of the equipment they are

responsible for. A physician’s order for use of the home equipment along

with a prescription for machine settings is essential, as is an

inspection of the equipment by biomedical staff before use. In most

instances, legal council or risk management will develop a liability

waiver for the patient to sign. Finally, ensure that the hospital has a

policy in place that defines under what circumstances patient-owned

medical equipment can or cannot be brought into the facility and

outlines the steps the facility will take to ensure the appropriate

education is provided to staff and that infection control, maintenance.

and electrical patient safety issues are addressed, as shown in Table 2.

ECRI Institute website. Healthcare risk control: patient supplied

equipment. Available at: https://www.ecri.org/Documents/RM/

HRC_TOC/MedTech8ES.pdf Accessed Nov. 23, 2011

The legal eagles will side with the patient in saying if the hospital allowed the machine to be brought into the hospital, the hospital may be at fault regardless of how many waivers you get the patient to sign.

GrannyRRT · Sep 10, 2014

I can't find anything that says this is a "trend", maybe you could direct me to a source?
There are certainly compelling reasons not to allow home CPAP, but it's based on billing, not safety.
The only current information on the use of home CPAPs in hospitals makes no reference to safety concerns, but does point out that requiring patients to use hospital provided CPAP costs the patient an additional $416 per day.
Financial incentive of home continuous positive... [Laryngoscope. 2014] - PubMed - NCBI
I think your confusing the machine and mask. If the patient requires PPV functionality or monitoring capability that exceeds what a home machine can provide then absolutely they need to be on hospital equipment. We're talking about someone who just needs their baseline PPV and needs a functional mask. Masks are not specific to machines and are intentionally interchangeable which is why the major manufacturers use a single standard fitting size for home equipment.

The risk and cost of an infection definitely will exceed that amount. As cited by ECRI, an infection resulted in death.

I guess you haven't seen many of the home machines brought into the hospital or to surgery for an OP procedure. We have a fleet of machines we will use. But, these are home machines maintained by hospital and contractors to ensure safety with filters changed after every use. Sometimes the head gear and mask can be used but if there is ANY doubt, we provide them with one. The patients are informed of this during their pre op so it is not like we are blindly screwing them over. This is all part of the responsibilities of being a caregiver in some situations and educating the patient on the responsibilities of their part which might include financial. It is a safety issue and not intended to penalize the patient. During the procedure, some changes might be needed on the settings. This is not always possible nor should it be allowed on a home CPAP machine. This is why the hospital's machine is used and one which the Anesthesia department is familiar with. The charge does not always have to go to RT. PACU also has CPAP machines just for recovery but they are usually disposable gas driven similar to the ones EMS uses. It is also a single charge similar to one from any supply system.

I described the differences between the BIPAP/CPAP machine hoses and masks used in ICU/ER vs home. As the ICU or ED RTs to show you the circuit on the machine they use in these areas. You will notice the different connections (male/female), the placement of the exhalation ports and the extra tubings on the hose itself.

GrannyRRT · Sep 10, 2014

So for the RT to say that their mask is incompatible to the patient's machine is BS. Every mask and hose is interchangeable regardless of the manufacturer.

Have you worked with hospital machines used for CHF? Their circuits and masks are not compatible.

Do you do any patient education in your sleep center about hospital admissions? I hope this "bs" that all are interchangeable. You are not educating the patient appropriately to hospital policies. The patient needs to be educated about their own responsibilities of see their machine is properly maintained. They also should ask questions about their hospital stay and their equipment. They should be aware the policies will vary. Hospitals are not the fix it centers for personally owned equipment.

You should be aware of the procedure to get CMS or whatever insurance to provide for another mask if you work in a sleep center. Hospitals must also go through the same procedure which may mean Case Management/SW involvement to file out the forms. Do not expect a disposable mask with the life expectancy of 2 - 3 days to replace on used in the home.

If the hospital does not have the home style sleep machines, do not expect them to have the supplies. If you are not familiar with the machines used for CHF and other rescue measures in the hospital, get familiar before calling them bs.