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.
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.
At my hospital, the biomed department has to inspect the home machine before it can be used. There's a brightly colored sticker they put on it. The problem is that biomed is not there 24/7 and I work overnights. The patient being admitted overnight doesn't want to use the hospital unit(which is why they brought their own), so they will either use their home unit before it's inspected or not use one at all. Far from a perfect system.
I have had pts bring in their own CPAP machines in sub-acute, usually there was some problem with the mask. We would call our DME supplier and they would bring out a mask/nasal pillow set up and fit the patient. There was never an issue with the mask not fitting the machine and the DME supplier never really asked about the manufacturer of the CPAP. There is liability when the home equipment is not addressed in your policy and procedure manual and if there is no policy to allow for home equipment then that needs to be clear by case management, nursing staff and somehow made known to the public. Why should they pay for something they already own?? It is usually about revenue, most likely the RT could not charge for the time he was going to spend fitting a mask when there was not a machine provided by the same department. It does set both of you up for liability. Bring it up to the next QA meeting!!
I have had pts bring in their own CPAP machines in sub-acute, usually there was some problem with the mask. We would call our DME supplier and they would bring out a mask/nasal pillow set up and fit the patient. There was never an issue with the mask not fitting the machine and the DME supplier never really asked about the manufacturer of the CPAP. There is liability when the home equipment is not addressed in your policy and procedure manual and if there is no policy to allow for home equipment then that needs to be clear by case management, nursing staff and somehow made known to the public. Why should they pay for something they already own?? It is usually about revenue, most likely the RT could not charge for the time he was going to spend fitting a mask when there was not a machine provided by the same department. It does set both of you up for liability. Bring it up to the next QA meeting!!
Hypoxia, CO2 narcosis and cardiac strain from doing nothing are an even greater liability.
The issue of the mask has been covered ad nauseum.
Are you suggesting that respiratory care should assess and intervene only if they can bill for it?
Specializes in critical care, ER,ICU, CVSURG, CCU.
i am a RRT & RN!
the mask are inter change able!
revenue, issues
yes ther is the unknown of the home unit maintance, but a respiratory therapist should be able to evaluate the support and physiologic response of any delivery system.
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.
" allow funding for the little sleep machine?"
How can you refer to CPAP as a little sleep machine?
What does funding have to do with providing airway support to a hospitalized person?
Let's get up close and personal here. I require CPAP. I use it RELIGIOUSLY. OSA finally diagnosed when I was hospitalized for the atrial fibrillation caused by the OSA.
If I required a hospital stay, the hospital better let me use my equipment or provide me with theirs.
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.
I'm not sure why hospital CPAP can't be used on a med/surg unit. It really doesn't require more monitoring than I'd be doing anyway except for responding to the occasional alarm.
yes ther is the unknown of the home unit maintance, but a respiratory therapist should be able to evaluate the support and physiologic response of any delivery system.
i am going to try and "bite my tongue now "
I think I have shown enough resources to support the differences between a hospital machine used for rescue using a NON VENTED Mask and a home machine using a VENTED mask.
The RT does not bill for time. It not charged to the patient. It can be counted toward accountability for their time.
The Respiratory therapist does not get any of the money they "bill" for.
The nurse already identified the problem and the RT told her the options. What more do you want? A nurse should be able to determine if a patient can get by with their mask until a new one arrives or if the patient should be moved to another unit so the big BIPAP machine can be used. This hospital seems to have limited options. But, this is still not that uncommon.
No, the RT should not be responsible for fixing "any" machine especially if it is not theirs or one they have never seen before. Many of these home machines have a preprogrammed card and nothing to even tell you the settings or what is being delivered.
Specializes in critical care, ER,ICU, CVSURG, CCU.
unless i read incorrect, the OP said, the Resp. therapist, just took a look and said our mask will not work with the machine, and I grant if all the hosp had was a nonvented mask that would be true, and almost exclussive, as GrannyRRT said the "rescue units mask" are non vented, as circuit and hosp. units are non vented at the mask...... at that time effort should have been made to contact physician provider, and obtain order for application of the hoso. cpap......most all DME companies home mask, etc are vented, & inter change able, most hosp. mask are non vented.......of course nasal pillow would negate the venting non venting issues......but nasal pillow may not be the best choice in all patients
Being a former RRT I would agree with the therapist. There are too many liabilities when using a hospital equipment on a patients home unit-airway. The OP should've contacted the physician to obtain A cpap order, so the patient could use a hospital cpap
I'm not sure why hospital CPAP can't be used on a med/surg unit. It really doesn't require more monitoring than I'd be doing anyway except for responding to the occasional alarm.
It will depend on the policy.
If the alarms are set tight as they are in ICU, no one gets any rest. If the RT loosens the alarms out of the policy parameters, big, big problems if something happens or even if a QA is done and the data is downloaded from that machine to ensure compliance with JCAHO or whatever agency you use for accreditation.
If the nurses have not been inserviced on the machine, not many nurse managers will allow it on their unit. Even in the ICUs we can not bring in any piece of equipment without some introduction to it. It might just be a quickie at bedside RT-RN with the RT signing the sheet the RN is now aware of this machine.
This machine takes up alot of space. It must be plugged into a 50 psi O2 source. Some medsurg units have secured their flowmeters to the wall and it takes an engineering work order to unfasten them to put a different one in with the appropriate connections. You must still maintain enough O2 sources for the other patient an also for this patient when they are off BIPAP or in the event of an emergeny.
The patient should be on a tele oximetry monitor especially if there is no record of their setting. The mask is nonvented which may mean it does not have all the safety features like the nonrebreathing valve or addition venting ports of a home mask. These machines are intended for a high acuity setting with a nurse and RT close by.
Also, if the person was not sure about liking CPAP for sleep, they may learn to hate it after one night on the Vision. The alarms are sensitive. May or may not have humidity. The exhalation port is drafty. The flow rate can go up to 240 l/m. It is really noticed when compensating for a leak. There is no "ramp" to ease the patient into it. We sometimes try to make a joke like "hang on, strong winds predicted" or "pretend you're a puppy hanging out the window (@ 60 mph)".
sistrmoon, BSN, RN
842 Posts
At my hospital, the biomed department has to inspect the home machine before it can be used. There's a brightly colored sticker they put on it. The problem is that biomed is not there 24/7 and I work overnights. The patient being admitted overnight doesn't want to use the hospital unit(which is why they brought their own), so they will either use their home unit before it's inspected or not use one at all. Far from a perfect system.