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.
My family member has used a CPAP for many years, from an older model to a current model, with at various times, nasal pillows, small face mask, and full face mask with exhalation port. All of these masks work with the home CPAP machine.
A separate issue is that on several occasions my family member has used their home CPAP and mask in the hospital. From our experience, I believe that further oversight and monitoring by the physician/RT of hospitalized patients who are using home CPAP's would be valuable for the patient. On the first occasion, my family member underwent a lengthy surgery that made it intolerable for them to use their perfectly functional home CPAP/mask on a med-surg unit, although they were told to do this by the surgeon. They endured six days post-op on a med-surg unit without using their CPAP before they were discharged. On another occasion my acutely ill family member on a med-surg unit was feeling too ill to tolerate using their home CPAP/mask. I would like to see these kinds of situations addressed when patients are hospitalized, and prepared for ahead of time when possible.
At first glance at the hospital and on the Respironics website, the masks look identical to the home CPAP masks. Respironics evidently use the same masks in the hospital and for home use. The difference is they replace the vented elbow with the non-vented elbow. So, I apologize for the previous comment, they are not interchangeable unless the RT department has a whisper valve (I haven't used one of those in 12 yrs) to allow venting.
We use ResMed/Respironics products for Sleep machines and mostly FP_ if we use heated wire for ICU.
The home masks also have those little holes peppered on the bridge for additional venting of CO2. This does create problems for NIV with the LTV transport ventilator even if we drop the whisper elbow.
I apologize to Maggie and Wooh for be rather rude in my last few posts.
I wish all hospitals had great managers and progressive Medical Directors. I wish CMS had the funds to reimburse everything. Some hospitals put all their funds into what they consider to be a superstar which could be anything from a cath lab to landscaping. Surgeons won't notice something until a patient suffers a bad outcome and then the patient might be in the next unit which can take the blame.
Ideally RT should inspect all home CPAP machines. But, in some hospitals the nurses don't bother telling them or anyone because "it's just a home machine". When RT hears about it, the time is late and on nightshift. This is frustrating since the patient and machine might have been there since 0800.
Respiratory Therapy is not being reimbursed as they have in the past. This is why nurses are getting more RT duties such as nebs, CPT, MDIs, ABGs and ventilator management such as in LTC. RT departments have been cut by as much as 50% in some hospitals. OSA screening would help but too much resistance. We have to be money makers for the hospital to exist but we don't work on commission. At the current reimbursement status, commission would probably be less than minimum wage. PT is still the envy of the allied healthcare professionals in that area. Their DPT degree has put them in great standing with CMS. So yes, we have to understand both the business as well as the health care issues.
How does one know whether or not the patient's CPAP machine even works properly? In our hospital, if a patient brings in their home CPAP machine, we will provide use of ours for the patient. The Intensivist (Pulmonologist) will let RT know what parameter they want the hospital CPAP machine to be set at. If the patient knows his own parameters, then we'll start out with those if they sound reasonable, however, we will watch the patient very closely for the first few hours or so of use.
This is viewed no differently than if a patient brought in his/her own glucometer and instructed the nursing staff to use it instead of the hospital glucometer. Just imagine how THAT would go down if a nurse covered a blood sugar that was 300 when it was really 30!! How do we know if the glucometer is calibrated correctly? It is the same with the CPAP machine. How do we know if the CPAP has been tested for safe functioning?
How about if a patient brought in a stack of pills and said "here, give me these at dinner time."?
The philosophy at my hospital is that pretty much anything that requires active interventions from the hospital staff should be with hospital property that is maintained and tested for proper function.
The basic problem I see is that when notified of an issue or problem, there are those who try and figure out how they can help, and there are those who try and figure out how they can avoid being involved in any way.
You've jumped to various conclusions about what the policies are in this situation that we don't know are the case and actually seem pretty unlikely. Requiring basic CPAP is not an indication for ICU admission. If the problem is that the only NIPPV devices are Visions, and those can only be used in the ICU, then the nurse would need to know this. Saying they need to go to ICU isn't going to be helpful because it's not going to make any sense to the Doc if they get a call saying the patient needs to be admitted to the unit with a reason that clearly isn't legit (they need basic CPAP therapy). What they would actually need is to remain admitted to their currently level of care, but to be moved to an ICU room to receive CPAP therapy.
If the problem is that the hospital doesn't carry any standard CPAP machines or supplies (which I've never seen in 5 different hospitals), then this also needs to be communicated in order for the problem to be addressed.
There's no reason why an RT can't inspect a patient's home equipment on request. Sure, the patient can later claim that something you did only made them (or their property) worse, but then again they can claim that about every single thing we do to them in the hospital, so that's hardly a reason to not do something since then we'd never do anything at all if that was a valid reason. The flip-side to that is that is the patient has an adverse outcome/event and you do actually end up in court. How would an RT explain that they were told specifically that a patient's needed therapy was not working properly, even if maintaining the equipment itself is not the hospital's responsibility, and the RT chose to ignore it?
While a policy can help expedite a situation such as this it is not required to deal with the situation and find an alternative. If what they need is to be put on hospital equipment, you don't need a policy to initiate that process.
How does one know whether or not the patient's CPAP machine even works properly? In our hospital, if a patient brings in their home CPAP machine, we will provide use of ours for the patient. The Intensivist (Pulmonologist) will let RT know what parameter they want the hospital CPAP machine to be set at. If the patient knows his own parameters, then we'll start out with those if they sound reasonable, however, we will watch the patient very closely for the first few hours or so of use.
This is viewed no differently than if a patient brought in his/her own glucometer and instructed the nursing staff to use it instead of the hospital glucometer. Just imagine how THAT would go down if a nurse covered a blood sugar that was 300 when it was really 30!! How do we know if the glucometer is calibrated correctly? It is the same with the CPAP machine. How do we know if the CPAP has been tested for safe functioning?
How about if a patient brought in a stack of pills and said "here, give me these at dinner time."?
The philosophy at my hospital is that pretty much anything that requires active interventions from the hospital staff should be with hospital property that is maintained and tested for proper function.
I'm not sure how prohibiting a patient from using their home CPAP prevents the patient from using a dysfunctional home CPAP machine. You realize they are going to use that machine when they go home, right?
I'm not sure how prohibiting a patient from using their home CPAP prevents the patient from using a dysfunctional home CPAP machine. You realize they are going to use that machine when they go home, right?
What do they do at your hospital to require that all DME from home is working properly upon discharge?
What do they do at your hospital to require that all DME from home is working properly upon discharge?
We encourage patients to bring in and use their own equipment. A problem with their equipment or their therapy parameters is far more likely to be noted when the patient is receiving the level of monitoring and assessment they receive in the hospital compared to at home.
We encourage patients to bring in and use their own equipment. A problem with their equipment or their therapy parameters is far more likely to be noted when the patient is receiving the level of monitoring and assessment they receive in the hospital compared to at home.
I think my hospital got their britches burned following this practice. They’re a little gun-shy now. I applaud the practice, unfortunately, I cannot follow suit due to policies.
I think my hospital got their britches burned following this practice. They’re a little gun-shy now. I applaud the practice, unfortunately, I cannot follow suit due to policies.
There's always a tug of war between risk managers/other management and patient advocates such as nursing. If risk management had it's way no patient would get any sort of intervention, medication, etc and patients would waive any liability for providing no care at all. In other words, their purpose is to lookout for themselves and the hospital regardless of harm to the patient so long as they aren't liable. Those who advocate for the patients take a different view and what policies prevail usually depends on which priority is able to prevail.
I get the argument that there is a concern with a patient using equipment where there could be a problem with it that causes the patient harm, which then results in a short-sighted policy that patients shouldn't use their home equipment. The problem with that is that it basically says the patient is better off using equipment that might cause them harm at home, even though they are clearly better off having a problem while in the hospital rather than home. So rather then being a policy that protects the patient, it's a policy that protects the hospital at the potential expense of harm to the patient, which should be a sign that their priorities and values need to be reevaluated, hopefully at the urging of patient advocates such as nurses and RT's.
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.
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.
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.
I would never "try to get a respiratory therapist fired". My thought on writing the RT up , in this case was.. I identified a patient need. RT did not work towards that goal. If the issue is lack of equipment the write up will identify that.As MUNO stated, I have never worked at a facility that could not provide the equipment. THAT would be the problem... that the write up would explore.
CPAP in this case is not an acute need, rather a chronic condition that the patient presents with.
Nursing, RT, and administration must work together to continue the patient's therapy.
There's always a tug of war between risk managers/other management and patient advocates such as nursing. If risk management had it's way no patient would get any sort of intervention, medication, etc and patients would waive any liability for providing no care at all. In other words, their purpose is to lookout for themselves and the hospital regardless of harm to the patient so long as they aren't liable. Those who advocate for the patients take a different view and what policies prevail usually depends on which priority is able to prevail.
I get the argument that there is a concern with a patient using equipment where there could be a problem with it that causes the patient harm, which then results in a short-sighted policy that patients shouldn't use their home equipment. The problem with that is that it basically says the patient is better off using equipment that might cause them harm at home, even though they are clearly better off having a problem while in the hospital rather than home. So rather then being a policy that protects the patient, it's a policy that protects the hospital at the potential expense of harm to the patient, which should be a sign that their priorities and values need to be reevaluated, hopefully at the urging of patient advocates such as nurses and RT's.
Lets say that the patient uses the CPAP in the hospital and something is found to be wrong with it. Does it hold up discharge because the patient cannot go home with a nonfunctioning CPAP machine? Perhaps a Loaner unit can be used? I don’t think CPAP’s are the kind of equipment that fall under ‘loaner’ territory.
That’s a pretty slippery slope to get on when the hospital starts qualifying equipment for home use. There’s a little thing called a “warranty” that prevents people from trying to “fix” equipment for patients while in the hospital.
A referral to a DME company should be done to repair or replace the patient’s home CPAP unit.
Susie2310
2,121 Posts
My family member has used a CPAP for many years, from an older model to a current model, with at various times, nasal pillows, small face mask, and full face mask with exhalation port. All of these masks work with the home CPAP machine.
A separate issue is that on several occasions my family member has used their home CPAP and mask in the hospital. From our experience, I believe that further oversight and monitoring by the physician/RT of hospitalized patients who are using home CPAP's would be valuable for the patient. On the first occasion, my family member underwent a lengthy surgery that made it intolerable for them to use their perfectly functional home CPAP/mask on a med-surg unit, although they were told to do this by the surgeon. They endured six days post-op on a med-surg unit without using their CPAP before they were discharged. On another occasion my acutely ill family member on a med-surg unit was feeling too ill to tolerate using their home CPAP/mask. I would like to see these kinds of situations addressed when patients are hospitalized, and prepared for ahead of time when possible.