CPAP on the unit

[canoehead]

I recently had a man with broken ribs as a patient, he told us he usually has CPAP overnight, and brought his machine and mask in. I was on night shift, and when I assisted him with the setup it was clear that the mask and harness had about four flaws that destroyed the seal. I'd McGyver the thing with tape and something else would give. It was unusable.

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 RT says that each machine must be paired with a mask specifically designed for a particular machine. He said by using one of the hospital masks with an outpatient machine, the air flow wouldn't be correct, and we would risk patients dying of co2 toxicity. I've thought about this since....I think the CO2 toxicity issue is bogus. Those masks must hold less than 50ml of air, and it's air that's constantly flowing with the pressure. Even without the machine turned on, tidal volume is what, 500ml? It just doesn't jive for me.

Second, the issue of needing a specific mask with each make of CPAP machine. Also doesn't ring true. The machine and the mask don't communicate with each other. Every machine will generate the required air pressure, and if a mask has more or less ventilation the pressure will be maintained. If a mask has safe airflow with one machine, what changes to make it unsafe with another machine?

If anyone has information that supports or negates what I've said, could you let me know?

i'm thinking that this is all about which department has to pay for the equipment.

[icuRNmaggie, BSN, RN]

to GrannyRRT,

I had a patient die from complications of Legionella pneumonia. The Health Department identified the source of the infection was his home CPAP machine.

It sounds like if the pt is sick enough to be admitted for a cardiac or pulmonary diagnosis, we need to use the hospital BiPap/CPAP and obtain a physicians order for the pressures and to titrate the Fi02. I would prefer to see the waveforms, resp rate and pressures anyway.

[GrannyRRT]

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?

I posted the major differences between the hospital machines normally used for CHF and sleep machines.

You didn't mention any specific names for either masks or machines in your original post. Sleep medicine is now a huge field with lots of new technology. It has expanded so much that it is now a specialty with its own credentials and licensure by the states.

The NBRC (like NCLEX for RTs) has a credentialing exam now for RTs. There is a free practice exam online you can take if you want to challenge yourself later.

https://www.nbrc.org/sds/pages/default.aspx

Sleep Board for credentialing.

http://www.brpt.org/

http://www.absm.org/credentials.aspx

This is a great magazine for the latest trends and products.

http://www.sleepreviewmag.com/

The Buyer's Guide section will show you have many products there are for CPAP therapy.

http://www.sleepreviewmag.com/buyers-guide/

http://www.sleepreviewmag.com/buyers-guide/cpap-therapy/

This site has some of the major journals for the specialty where you can get abstracts and sometimes full access.

http://www.aasmnet.org/library/default.aspx

To learn about hospital NIV, Respironics has a great site. RNs get CEUs also.

http://www.usa.philips.com/healthcare-medical-specialty/sleep-apnea-care.html

http://www.learningconnection.philips.com/en/catalog/product-group/respiratory-care

Yes, Sleep Medicine is recognized as a business and a growing health care need. Just the cost of the training materials and exams are a good indication of that.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208833/

http://www.aasmnet.org/learningcenter/home.aspx

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/PAP_DocCvg_Factsheet_ICN905064.pdf

This Apria website gives some good examples of just a few of the many different machines, masks and all the new modes available in the field of sleep medicine. This site is mostly just ResMed/Respironics. RTs are good but it is almost impossible to keep up with all the changes in this field unless they specialize and if they still must keep up with ICU ventilation. It is no different than all the various med pumps you could use and some do require proprietary tubing.

http://www.apria.com/wps/portal/apria/home/therapies/healthcare-professionals/sleep-apnea/sleep-apnea-devices

Manuals

http://www.apria.com/wps/portal/apria/home/education-and-manuals/product-manuals/01-respiratory/!ut/p/b1/rZNbb6MwEIV_UeIxvhA_uuYSAhiCgQZeKrZ7EZA03SraJPz6kt2sVm215KW2ZGmkb-acOZJRjaoZJ5xisIVAG1Q_Nb_aH82h3T8120td8wfpUn-19AkkIDwI3DgClnJMgaF7VLkjVY0U_OdImByC-bV_LSwdhj6GJDdqBBZJaZQA3-a3TPzpnxC4uUT9G1G-XFI7AlhEPoNALotMrAmBNb0CUytOihh2BWhy5_hMY-7l0oGgkInHXAVK8ukJicQ3gOCvxFSOkxO4haoRsP-ZLJVHRwBs1xIrokKKcrQB-mC683Mw9EPWwXHI-22ki-cId2Vi8k2hi21y0AbHjjzioYy084j1S3HUxd4yhzz9WmbFnXRstk3a94LaCyUEOHJWKRMAlH-64ArV7Zfd_Pi4m8OcCSGwIMQSbHwFQfcK6eV-9206iJDgD76G9WA69xQPCoNThqbbGJ2754NWo6_wiKPRj1Od8nGzuP8JsU6vvtQp6x3zQTB1rTGIjPhRzjAs-KcLvgmCcIEpZSAo4TZhlz_hoV39cm7bWZ-5mftdXy5tZs2segVW4ZYw/#2

Devibiss

http://www.devilbisshealthcare.com/products/sleep-therapy

CEUs

http://www.brpt.org/default.asp?contentID=54

http://ce.effectivehealthcare.ahrq.gov/continuing-education/CER16/Guidance-for-Informed-and-Shared-Decision-Making-about-Diagnostic-Tools-and-Treatments-for-Obstructive-Sleep-Apnea

Good site for CE learning about CPAP and sleep medicine

http://learning.aarc.org/store/provider/provider09.php

[GrannyRRT]

to GrannyRRT,

I had a patient die from complications of Legionella pneumonia. The Health Department identified the source of the infection was his home CPAP machine.

It sounds like if the pt is sick enough to be admitted for a cardiac or pulmonary diagnosis, we need to use the hospital BiPap/CPAP and obtain a physicians order for the pressures and to titrate the Fi02. I would prefer to see the waveforms, resp rate and pressures anyway.

Yes, the use of respiratory equipment including CPAP and nebs are now on the CDC questionnaire for required reporting. We also have changed our policies on routine nebulizers and their care in the hospital setting. We are also very, very reluctant to allow our disposable nebs go home with a patient because they are not meant to be cleaned for long term use. We use sterile water to rinse and air dry but also dispose of every other day. If placed in plastic bags they should be the open mesh type. Hospital acquired infections are serious stuff.

[icuRNmaggie, BSN, RN]

to GrannyRRT,

Thank you for listing all of those references.

Just to be clear, if we have an order for CPAP, and we use the hospital equipment instead of the patient's home CPAP machine, and the patient is charged, is there any way that someone could make a case for Medicare fraud?

thanks,

Maggie

[MunoRN, RN]

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.

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.

Again, the OP was quite clearly referring to use of their home CPAP machine, we're not talking about using a home CPAP machine for patients who actually require more than their home CPAP machine or using a Vision circuit with home CPAP machine.

We're also not talking about supplying the patient with a new permanent mask, we're talking about making sure he has a mask that can get him through the night instead of knowingly have him use a mask that is not effective, because that is the biggest concern for liability in this situation.

[MunoRN, RN]

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.

I have seen many patient home CPAP machines because we highly encourage patients to bring in their own CPAP machines, even in the ICU.

Again, we're talking about using Vision Bipap circuits on CPAP machines, we're talking about using a standard CPAP mask on a standard CPAP machine.

You seem to be ignoring the fact that the patient is going to use this machine once they go home, and it is possible the machine could contribute to an acute problem which is one of the main reasons we encourage patients to use their home machine as soon as the therapy it provides is adequate.

What you seem to be arguing is that the patient's home machine could cause an acute problem, and the hospital is no place for acute health problems. Our belief is that a hospital is clearly the preferable place to require medical attention and since the patient is still going to end up using that home machine whether you let them use it in the hospital or not, all you're potentially doing is creating a more dangerous situation for the patient, for the purpose of taking some of the responsibility off of you.

[GrannyRRT]

Again, the OP was quite clearly referring to use of their home CPAP machine, we're not talking about using a home CPAP machine for patients who actually require more than their home CPAP machine or using a Vision circuit with home CPAP machine.

We're also not talking about supplying the patient with a new permanent mask, we're talking about making sure he has a mask that can get him through the night instead of knowingly have him use a mask that is not effective, because that is the biggest concern for liability in this situation.

You clearly do not understand what is meant by not having the equipment available in the hospital to git home CPAP machines.

If the hospital only uses Visions and V60s, those masks are clearly not meant to be used on home CPAP machines.

If the hospital allows home CPAP machines, the patient will need to be responsible enough to see it meets hospital standards by having it properly maintained through the DME or other vendor.

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.

Sometimes CM can fill out the voucher to have the correct mask delivered that same day or a family member can use the voucher to pick it up at a DME store.

Help fix the problem instead of adding to it.

[VANurse2010]

I have seen many patient home CPAP machines because we highly encourage patients to bring in their own CPAP machines, even in the ICU.

Again, we're talking about using Vision Bipap circuits on CPAP machines, we're talking about using a standard CPAP mask on a standard CPAP machine.

You seem to be ignoring the fact that the patient is going to use this machine once they go home, and it is possible the machine could contribute to an acute problem which is one of the main reasons we encourage patients to use their home machine as soon as the therapy it provides is adequate.

What you seem to be arguing is that the patient's home machine could cause an acute problem, and the hospital is no place for acute health problems. Our belief is that a hospital is clearly the preferable place to require medical attention and since the patient is still going to end up using that home machine whether you let them use it in the hospital or not, all you're potentially doing is creating a more dangerous situation for the patient, for the purpose of taking some of the responsibility off of you.

I never get excited about home equipment in the hospital - because honestly it is a huge pain in the ass compared to just using hospital equipment. However, you bring up an important point about the need to assess home function for possible problems post-discharge.

[GrannyRRT]

to GrannyRRT,

Thank you for listing all of those references.

Just to be clear, if we have an order for CPAP, and we use the hospital equipment instead of the patient's home CPAP machine, and the patient is charged, is there any way that someone could make a case for Medicare fraud?

thanks,

Maggie

What's the one question CMS or their representative agency ask for anything?

Where's your policy?

No department can bill for anything unless it is approved at multiple levels and a policy is in place.

First RT will check out what CMS will allow.

They will consult with their Medical Director and finance coding people.

"A policy will be written."

The Medical Director will present it to the hospital Medical Review panel.

If approved, the MD of RT will sign it.

The approved billing code will be made available to RT if all the conditions in the policy have been met.

If the policy is to use only hospital equipment, the RT will do so by ensuring they have purchased enough units or have a good rental contract.

If the hospital allows patients to have their own machines then there must be a policy to inspect and inform patients, in writing, of the policy which will consist of no changes to their equipment and the option to use hospital equipment if unsafe. CMS has no problem with this.

If you do not have a policy and are not inspecting with thorough documentation or are doing the McGyver thing or piece milling or ignoring home machines, CMS will be all over your hospital and whoever cared for that patient in an adverse event or just during a routine trace on that chart.

[GrannyRRT]

I never get excited about home equipment in the hospital - because honestly it is a huge pain in the ass compared to just using hospital equipment. However, you bring up an important point about the need to assess home function for possible problems post-discharge.

Big issue now and some DME and sleep centers do not take the time to explain the patient's insurance and warranty benefits (or patient did not understand). Many will provide for filters and at least one, sometimes two, hose and masks per year. If the patient has COPD, Pneumonia or CHF in their admission dx, expect a trace on that chart especially if readmission within 30 days.

[Been there,done that, ASN, RN]

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?

We are talking AIRWAY here.

You are spot on to consult RT as to how to maintain the patients home CPAP therapy.

RT needs to be written up. They did not follow your direction and put the patient at risk.

In this case... a call to the physician to obtain a physician's order could have solved the immediate problem.

Either use the home equipment or provide the hospital equipment.. whatever gets you ( and the patient) through the night.

[GrannyRRT]

We are talking AIRWAY here.

You are spot on to consult RT as to how to maintain the patients home CPAP therapy.

RT needs to be written up. They did not follow your direction and put the patient at risk.

What exactly is that going to do? If the hospital managers (nursing, RTs and medical directors) have not had the foresight to establish a policy and allow funding for the little sleep machine, there is nothing much a Respiratory Therapist can do. The masks used for the ICU machines are not for use on the home machines.

"Your direction" could also mean they know their policy better than you. Look up your policy. Instead of trying to get into a ******* contest by trying to order the RT around, try asking them if they have encountered this before and see what has been done in the past. Read the waiver you got the patient to sign. Some health care professionals get patients to sign things they themselves have not read.

Chances are the patient's mask did not get into that shape over the past couple of hours and may even have been used in the hospital in that shape prior to the OP finding it. Yes, there should be an option but if the hospital does not have the equipment for this machine or their own CPAP machines, weigh the options of safety as it is vs calling the physician for an ICU transfer.

In this case... a call to the physician to obtain a physician's order could have solved the immediate problem.

Let's use a nursing example. If your managers did not order chairs or lifts to get more patients out of bed, it does not matter how many orders the doctors write, there are just so many chairs and lifts. I have seen this over and over in hospitals. Nurses are yelled at by doctors and families and "written up" by each other for not getting a patient out of bed as ordered on the other shift. It sucks to be at the low end of the pile.

Either use the home equipment or provide the hospital equipment.. whatever gets you ( and the patient) through the night.

You can not make something materialize if the hospital does not have it. The OP provided enough information to tell us that this hospital does not supply the home type CPAP machines or their supplies. The statement about putting the patient in ICU indicates they have only the big BIPAP/CPAP machines. Chances are it is nursing which also has a policy about putting these machines on a med surg floor. Some are even opposed to them on tele unless their staff has been trained on them.

So there is a lot of blame to share in this problem since Sleep Medicine has been around for over 30 years.

Call the Case Manager and see how fast the voucher can be typed up and sent to the DME. The mask can arrive in a couple of hours. You can also put the patient on a tele monitor with a pulse oximeter.

Instead of trying to get the RT who had the misfortune of being on shift that night fired, try to find a solution with the managers. If RT is operating on a shoe string due to dwindling reimbursement, the nursing unit may have to purchase the CPAP machines. That is what some floors have done just like the ICUs and EDs have purchased high tech ventilators out of their budget when RT couldn't.

I am a huge advocate for Sleep Apnea screening and providing the autotitration CPAP devices. But, that has also been met by a big resistance from nursing since it involved an extra check box for screening. It also meant a tele pulse ox monitor. So, we could got at it from that point of view also since some nurses feel this is just more bs charting and work for them.