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Kindred Management Conference

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Speaker Panel Stacie Kyanko-West, Supervisor of Respiratory Care Kindred Hospital, Albuquerque, NM Alan McLean, Director of Rehab, SLP Kindred Hospital, Indianapolis ... – PowerPoint PPT presentation

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Title: Kindred Management Conference


1
(No Transcript)
2
Speaker Panel
  • Stacie Kyanko-West, Supervisor of Respiratory
    Care
  • Kindred Hospital, Albuquerque, NM
  • Alan McLean, Director of Rehab, SLP
  • Kindred Hospital, Indianapolis, IN
  • Mary T. Cohen, Director of Rehab, SLP
  • Kindred Hospital, Albuquerque, NM
  • Linda Johnson, Clinical Mentor, SLP
  • Mount Carmel Medical and Rehab, Burlington, WI
  • Michelle Tristani, Clinical Specialist, SLP
  • Peoplefirst Rehab, Kindred Hospital, Boston, MA

3
Toward Best Practice PMV Management
  • Presentation Background
  • Introductory Goal Statements
  • Current Passy-Muir Literature
  • The Ongoing Best Practice Search
  • Presentation Agenda
  • Cardiopulmonary Care and the PMV
  • Communication
  • Swallowing
  • PMV Utilization Across the Continuum of Care

4
Best Practice Guidelines
  • Best practice guidelines and expectations
  • Standardization of evidence based protocols
  • The ripple in the pond
  • EBP --gt Improved outcomes --gt EBP --gt Improved
    outcomes

5
Best Practice Guidelines
  • Essential Organization Elements to Achieve Best
    Practice
  • Leadership Team
  • Culture of respect and trust in knowledge, skill
    and role
  • Consistent multidisciplinary effort education
  • Employee retention
  • Administrative support

6
Best Practice Guidelines
  • Kindred Performance Measures
  • Customer satisfaction
  • Clinical outcomes
  • Cost
  • Competency
  • Census
  • Compliance with accreditation requirements

7
The Diagnostic Relationship
  • Neurological
  • Progressive Neurologic Diseases, CVA, TBI
  • Head and Neck CA
  • Cardiopulmonary
  • COPD, ARDS, ARF, Lung CA
  • Multiple Medical Co-morbidities

8
Cardio-Pulmonary Care The PMV
9
Mechanics of Cough
  • Protective Mechanism
  • Reflex
  • Receptor Sites

10
Mechanics of Ventilation
  • Inspiration
  • Expiration
  • Mechanical Ventilation

11
Weaning from Ventilator
  • - Ventilator Weaning Protocol
  • - RT Admission Protocol
  • - Care Plans
  • - Mandated Physician Rounds
  • - Weekly Team Conference

12
TEAM Approach
PHYSICIAN
RESPIRATORY THERAPIST
CASE MANAGEMENT
WEEKLY TEAM CONFERENCE
NURSING
DIETARY
SPEECH THERAPY
PHYSICAL OCCUPATIONAL THERAPY
WOUND CARE
13
Ventilator and PMV
  • When to initiate/Settings on Vent
  • PB 760
  • Speaking Valve Mode

14
The Results
Crude Wean Rate
15
Ventilator Wean Rates
  • 124 Ventilator Discharges
  • 82 Successful Ventilator Weans
  • 2004 - 68
  • 2005 (YTD) - 66
  • Industry Gold Standard - 50

16
WEAN RATES BY DIAGNOSIS GROUP
17
Changes and Positive Impacts
  • Company Engineers
  • Re-evaluation of Policies
  • Home Care
  • Quality of Life (QOL)

18
The Passy-Muir Speaking ValveImpact on
Communication
19
Non-Verbal
  • - Writing
  • - Mouthing words (lip reading)
  • - Yes/No questions
  • - Spelling/communication board
  • - Electro larynx
  • - Talking trachs
  • - Electronic/augmentative equip

20
Verbal Communication
  • - Past Medical History
  • - Current Medical History
  • - Agitation
  • - Sedation
  • - Trach changes
  • - Vent setting changes
  • - Weaning schedule

21
Common Types of PMVs
  • Familiar types of Passy-Muir Valves

22
PMV is placed (vent support)
  • - Baseline vital signs
  • - Positioning
  • - Patient education!
  • - Secretion removal
  • - Modification of vent settings
  • - Airflow/vent alarms
  • - Hypersensitivity
  • - To voice or not to voice

23
PMV is placed (TCT)
  • - Obtain baseline data
  • - Provide education
  • - Control anxiety
  • - Secretion removal
  • - Assist with coughing
  • - Ambu bag?
  • - Are there saturation limits?
  • - Teamwork, teamwork, teamwork

24
Phonation
  • - Air movement?
  • - Is phonation present?
  • - Vocal quality?
  • - React or not react?
  • - What was previous vocal quality?
  • - Trust your training
  • - Monitor trach size
  • - Do the math
  • - Refer if necessary

25
Suggestions
  • - Get compd for suctioning
  • - Get to know your RT staff
  • - Train other caregivers
  • - PMV as a step in weaning process
  • - Be flexible
  • - Be the driving force

26
PMV And Swallowing Disorders
27
Readiness for Dysphagia Assessment and Treatment
  • Medical clearance
  • Secretion control
  • Tolerance for wearing PMV
  • Self protective skills and advocacy/support

28
PMV Benefits to Safe Swallowing
  • Reduces secretions
  • Restores cough
  • Improves sense of smell and taste
  • Improves oxygenation
  • Improves mucosal sensation restores
    sub-glottal pressure
  • Improves swallow efficacy and reduces aspiration

29
Compatibility of the PMV with Various Treatment
Modalities
  • Thermal/tactile stimulation
  • Gustatory stimulation
  • Electrical stimulation

30
Progressing Through Trial Consistencies
  • Selecting stimuli by
  • Temperature
  • Texture
  • Taste
  • Safety
  • Bolus size, bolus control

31
Bedside Safety Assessment Options
  • Signs and symptoms of aspiration
  • Blue Dye Testing
  • Chem Strip Testing

32
Instrumentation
  • Instrumental assessment with and without the PMV
  • What does the research tell us?
  • Data from MBSS/VFSS, FEES

33
Eating on the Ventilator
  • Making the decision
  • The Team Approach
  • Patient, Physician, SLP, RT, and S.O.s

34
Restoring PO Intake
  • Special considerations across the continuum of
    care
  • Resources and the clinical decision process
  • Who to train, when and how?
  • Team approach
  • Assuring consistent use of safe swallow
    precautions
  • Thorough training and retraining

35
Passy-Muir Valve Across The Continuum of Care
HIGH
INTENSIY OF PATIENT SERVICE
LOW
SEVERITY OF PATIENT ILLNESS
LOW
HIGH
36
What do Policy Makers say about thePost-Acute
Space?
Spending is Increasing
Billions of dollars
37
ICU
38
PMV Utilization - ICU Acute Care
  • Initiation of PMV Trials and Treatments
  • How soon is too soon?
  • Medical Team SLP Collaboration and Consultation
  • Prerequisites for PMV Success
  • Medical History and Status
  • Hemodynamically stable
  • Baseline Vital Signs and Measures SpO2, HR, RR
  • Can we rely on the numbers?
  • Respiratory Considerations
  • Communication Barriers and Facilitators
  • Medications
  • Anxiety

39
Acute Care
40
PMV Utilization - ICU Acute Care
  • Communication Prognosis
  • Nutrition and Hydration
  • Determining Safe PO Candidacy
  • SLP Competency
  • Patient / Family / Staff Education
  • Pre and Post Tracheotomy
  • JCAHO Standards
  • Communication and Referral to Next Setting

41
Short Term Rehab LTAC Setting
42
SHORT TERM REHAB / LTAC the PASSY-MUIR VALVE
  • Initiation of PMV Trials and Treatments
  • Prerequisites for PMV Success
  • Medical History and Status
  • Recommendation and results of recent ENT consult
  • Respiratory Considerations
  • Granulation tissue, fistula, tracheal malasia
  • Type and size of trach tube
  • Cuff deflation
  • O2 requirements with PMV in place
  • Communication With Acute Care SLP
  • Communication Barriers and Facilitators
  • Long-term PMV Use Cuffless Trach Tube

43
SHORT TERM REHAB / LTAC the PASSY-MUIR VALVE
  • Communication Prognosis
  • PMV Tolerance as a Prerequisite for Capping
  • Nutrition and Hydration
  • Timing of the Swallowing Assessment
  • Consider interventions that minimize negative
    effects of trach / vent dependence
  • Tolerating PMV for at minimum - periods of PO
    intake
  • SLP Competency
  • Patient / Family / Staff Education
  • Team Interdisciplinary Communication Systems
  • JCAHO Standards
  • Communication and Referral to Next Setting

44
Kindred Best Practice Study
  • LTAC Setting
  • Vent Management Weaning Guidelines
  • Standing / automatic pulmonary and rehab
    consultation at admission
  • Establish goal-driven weaning process
  • Rehab initiation within 48 hours of admission,
    unless contraindicated
  • Aggressive anxiety management
  • Positive impact on patient outcomes
  • Raises the bar on quality care

45
Best Practice Guidelines
  • Kindred Performance Measures
  • Customer satisfaction
  • Clinical outcomes
  • Cost
  • Competency
  • Census
  • Compliance with accreditation requirements

46
Long Term Care
47
PMV Key Points LONG TERM CARE
  • PMV Physician orders
  • Medical History and Status
  • Respiratory Considerations
  • Nutrition / Hydration
  • PO intake with PMV
  • SLP Competency and Involvement
  • Patient / Family / Staff Education
  • Awareness
  • Specific PMV Plan of Care
  • Team Interdisciplinary Communication System
  • Team Roles
  • Safety Considerations

48
Home Care
49
PMV Considerations HOME CARE
  • PMV Physician orders
  • Medical History and Status
  • Neuro Status
  • Prior Therapy History
  • Respiratory Status
  • Nutrition / Hydration
  • SLP Competency and Involvement
  • Need for Caregiver Assist
  • Intensity of PMV treatment
  • SLP Flexibility with Settings

50
PMV Considerations HOME CARE
  • Patient / Family / Staff Education
  • Interdisciplinary team involvement interaction
  • Communication Methods
  • Considerations for Success
  • Specific Routine
  • Infection Control
  • Patient Goals
  • Caregiver Consistency
  • Quality of Life
  • Community Access
  • Public Awareness and Acceptance

51
Browns End-of-Life Decision ToolReference
www.asha.org
52
PMV Considerations End of Life
  • Identifying End of Life
  • Browns End of Life Tool
  • Implication of facility location
  • Physician orders
  • PMV trials
  • Medical and respiratory status
  • Nutrition / Hydration
  • SLP Competency and Involvement
  • Palliative care role

53
PMV Considerations End of Life
  • Awareness of PMV
  • Patient communication needs and opportunities
  • Decision making
  • Expressions to others
  • Spiritual
  • Respiratory and Airway Management
  • State Regulations
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