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.

[PMFB-RN, RN]

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.

Wow! That RT has no idea what he is talking about. You are exactly right and he is wrong.

[GrannyRRT]

Wow! That RT has no idea what he is talking about. You are exactly right and he is wrong.

Explain yourself.

Have you seen the circuits and masks of ICU machines vs those of home CPAP?

Let me see if I can go more into detail about this so it will be clearer.

The ICU BIPAP machines usually use nonvented masks. The same are used for transport ventilators when doing NIV. The exhalation port is on the circuit.

Home CPAP machines use vented face masks with the exhalation valve built into it. Older masks required a whisper valve.

Deadspace is a selling feature of masks to reduce CO2 buildup.

Example of a nonvented mask which is used in the ICU or ED.

http://www.fphcare.com/products/freemotion-rt043-non-vented-full-face-mask/

Under chin seal provides for a more comfortable and stable fit FreeMotion Glider™ with quick release clip enables freedom of movement with single motion refit

Low deadspace design for improved CO₂ washout

Unique headgear system designed for patient comfort and security

Dual swivel elbow aids patient movement

Built in ports allow supplementary oxygen and pressure monitoring

Glider coloured blue to indicate the mask is non-vented

Anti-asphyxiation / non-rebreather valve included for safety in the event of flow source failure

For use with single limb systems where venting is in the circuit through the exhalation port

Also for use with flow driver CPAP systems with PEEP valve

Available in three sizes; Small, Medium and Large

Example of a Vented Mask:

http://www.fphcare.com/products/freemotion-vented-full-face-mask/

Under chin seal provides for a more comfortable and stable fit 15 small vented holes at the bridge of the nose for quieter operation while minimizing dead space

Dual swivel elbow aids patient movement

Built in ports allow supplementary oxygen and pressure monitoring

Free Motion Glider™ with quick release clip enables freedom of movement with single motion refit

Anti-asphyxiation / non-rebreather valve included for safety in the event of flow source failure

For use with single limb systems

Available in three sizes; small; medium and large

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.

[icuRNmaggie, BSN, RN]

to GrannyRRT,

This has been a very informative discussion and I will be looking for those policies.

Excellent point about how if you do a procedure without a policy in place and bill Medicare or Medicaid, that constitutes fraud.

It is a source of frustration when I call the RT for help with a problem such as the original poster had and the RT responds with "well I don't know what to tell you."

It as if they don't want to take responsibility or get involved with or come to the unit and assess the pt.

With a couple of exceptions, who are very experienced RRTs, it seems like we have to do all of their thinking for them.

I guessing you feel the same way about nurses.

Thank you for sharing the links to the different types of masks and for sharing your expertise.

[GrannyRRT]

It is frustrating but when a hospital decides to allow home equipment to come in without providing alternatives or resources you have tied the hands of the caregivers.

For what it's worth RTs sometimes have the same opinion of nurses. Examples are being paged to check an SpO2 on a patient because you are to busy to see if the patient is hypoxic or finding the nasal cannula attached to the air flow meter again.

[amoLucia]

To GrannyyRRT - I agree with icuRNmagie that this has been a very informative and thought provoking discussion.

In my LTC experiences, I've often thought about some of the issues you bring up re cleanliness, maintenance/safety, equip integrity, etc. Nobody else has seemed to question the use of machines from home. NOBODY questions the equip reliability and efficacy. At least in the acute setting, you have a Respiratory Dept. We struggle in LTC.Icouldn't even begin to fathom how to address our circumstances.

But you have brought up some thoughtful issues.

[icuRNmaggie, BSN, RN]

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.

to GrannyRRT,

Why should the nurse be responsible for obtaining parts for respiratory equipment such as ordering a new home CPAP mask?

Shouldn't the RT be the one to troubleshoot the problem?

When the RT says "I don't know what to tell ya" in these home CPAP situations, they really do, they just don't want to be bothered?

If they know the policy doesn't exist why dump it in the nurses lap? What's that about?

Sorry for being snarky but it is very very frustrating.

[GrannyRRT]

to GrannyRRT,

Why should the nurse be responsible for obtaining parts for respiratory equipment such as ordering a new home CPAP mask?

Shouldn't the RT be the one to troubleshoot the problem?

When the RT says "I don't know responsibilityto tell ya" in these home CPAP situations, they really do, they just don't want to be bothered?

If they know the policy doesn't exist why dump it in the nurses lap? What's that about?

Sorry for being snarky but it is very very frustrating.

The OP asked for a face mask and assumed that since patients with CHF got CPAP, all maks were tne same. The RT said the masks would not work. It should be clear that you don't rig up homecare equipment. In hospitals which allow patients to bring in their machine and don't have alternative change out policies should have the wavier saying RTs nor RNs will not touch their equipment . Period. We touch and patient can say we broke it or made the situation worse. You are also asking someone to troubleshoot equipment they are not familar with. I don't know how to make that any clearer to you. It is not the RTs responsibility to fix home equipment. The machines the RTs use are for the ICU so the patient would need to be transferred. The RT essentially gave the OP the policy. The patient has a responsibility for his equipment and it may cost him an ICU charge.

Telling the RT to do something against policy like setting up equipment he knows not to be appropriate or safe is much more snarky and disrespectful.

Having you call the CM is also not dumping and really shouldn't burden you that much.

No fraud would be committed since the policy is to place patients requiring the use of their big ICU CPAPs in the ICU. To go against a policy and put that machine on a med surg floor would be a very serious offense for the RT and for the nurse to assume responsibility for it which she is not trained for.

You should not force an RT to do something against policy or try to make something fit knowing it is not the appropriate mask or alter a home machine which is a given for any home DME equipment.

If a doctor tells you to push a cardiac med without a monitor on your floor against policy do you consider yourself snarky to say no?

Respect the policies in place and don't expect someone to violate it. The hospital should have other options but this one apparently doesn't. If it did the RT would probably just bring up his machine, provided the patient has a sleep test result on file along with a doctor's order.

Of course the one other option is to call the doctor and have him call the Medical Director (usually the CC Director) who wrote the policy and argue. But, in the meantime CALL THE CASE MANAGER for a definitive solution. DMEs will expedite a hospital order. Fix the problem for the patient who did not take the initiative to maintain his equipment thus violating his patient responsibiliy agreement.

I think it is ridiculous for hospitals to ignor sleep medicine but many do not see it as an issue. Many doctors will say just pt the patient on a couple liters of oxygen for the night if there is no other alternative available. That is what we did before they allowed any CPAP machines on the floor. Not the best answer but then I am not at your hospital to advocate for a policy change.

A nurse also bears some responsibility to know the policy concerning home equipment accepted on their floor.

[GrannyRRT]

To GrannyyRRT - I agree with icuRNmagie that this has been a very informative and thought provoking discussion.

In my LTC experiences, I've often thought about some of the issues you bring up re cleanliness, maintenance/safety, equip integrity, etc. Nobody else has seemed to question the use of machines from home. NOBODY questions the equip reliability and efficacy. At least in the acute setting, you have a Respiratory Dept. We struggle in LTC.Icouldn't even begin to fathom how to address our circumstances.

But you have brought up some thoughtful issues.

I hear you. LTC is on a very tight budget with limited resources and poor reimbursement. CMS will not reimburse for the services of an RT.

But, if the RT department in the hospital wants to change the patient over to their own equipment, some nurses want to accuse them of fraud or doing it just to bill.

You can't win.

[wooh, BSN, RN]

to GrannyRRT,

Why should the nurse be responsible for obtaining parts for respiratory equipment such as ordering a new home CPAP mask?

Shouldn't the RT be the one to troubleshoot the problem?

Because as a billing department, they don't have to do anything without orders (and thus reimbursement). It's like, "Why does nursing have to troubleshoot instead of PT coming to do it?" Because without an order for something they can get reimbursed on, PT doesn't get involved. We're part of the room charge so it falls on us unless we can get an order to dump it on a department that will get paid to deal with it.

[GrannyRRT]

True but still if the policy is not to touch the home care equipment, it is not about reimbursement. You can get a doctor to order me to touch the home care equipment and I will be calling my Medical Director and Risk management who should know what the policy is just as the nurse should. If the policy says put the patient on CPAP in the ICU because that is the only place that machine can be, so be it. The home care machine does NOT belong to RT. A doctor can order whatever he or she wants but if it goes agajnst policy there will be resistance. Just because a doctor orders something does not mean it is appropriate or that the department will be reimbursed. Reimbursement comes only if in compliance with the billing codes per policy and the many steps have been taken to get it on that department's list of charges. It is a lengthy process but necessary to keep in compliance. Troubleshooting a homecare machine is not billable and altering it is against most all hospital policies.

Instead of fighting, bullying and writing people up or making accusations of fraud (very serious accusation) as some have in this dicussion, consult someone who can help which would be the CM. If the patient has to spend the night in ICU or tele on a Vision or V60 per the policy, that is what will need to be until the DME or family brings in the mask. The RTs hands are tied due to a lack of home style machines and the policy to go with them. They can not fix the patient's homecare machine even if a doctor orders them to. It is not their machine. Complain to the managers who believe the existing policy is adequate but in tbe meantime you may need to follow it and have a responsibility to inform the physician of that policy. Reimbursement is not the problem. The policy to allow the homecare machines in the hospital with a better plan B is.

[JustBeachyNurse, LPN]

Why can the RT recommend an in hospital solution or come up and advise the nurse as to what is needed? Such as we could switch to our machines with an order or have CM call DME to send out their RRT/biomed to troubleshoot the machine (or send the new mask if that's all that's broken). We all know patients are great at doing PM checks on equipment at home (lol). Some RTs say nope not my problem others say "policy states we can't work with home equipment we need to either get an order to switch to our equipment or have CM call DME vendor"

[GrannyRRT]

Why can the RT recommend an in hospital solution or come up and advise the nurse as to what is needed? Such as we could switch to our machines with an order or have CM call DME to send out their RRT/biomed to troubleshoot the machine (or send the new mask if that's all that's broken). We all know patients are great at doing PM checks on equipment at home (lol). Some RTs say nope not my problem others say "policy states we can't work with home equipment we need to either get an order to switch to our equipment or have CM call DME vendor"

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.