Title: Kindred Management Conference
1(No Transcript)
2Speaker 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
3Toward 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
4Best 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
5Best 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
6Best Practice Guidelines
- Kindred Performance Measures
- Customer satisfaction
- Clinical outcomes
- Cost
- Competency
- Census
- Compliance with accreditation requirements
7The Diagnostic Relationship
- Neurological
- Progressive Neurologic Diseases, CVA, TBI
- Head and Neck CA
- Cardiopulmonary
- COPD, ARDS, ARF, Lung CA
- Multiple Medical Co-morbidities
8Cardio-Pulmonary Care The PMV
9Mechanics of Cough
- Protective Mechanism
- Reflex
- Receptor Sites
10Mechanics of Ventilation
- Inspiration
- Expiration
- Mechanical Ventilation
11Weaning from Ventilator
- - Ventilator Weaning Protocol
- - RT Admission Protocol
- - Care Plans
- - Mandated Physician Rounds
- - Weekly Team Conference
12TEAM Approach
PHYSICIAN
RESPIRATORY THERAPIST
CASE MANAGEMENT
WEEKLY TEAM CONFERENCE
NURSING
DIETARY
SPEECH THERAPY
PHYSICAL OCCUPATIONAL THERAPY
WOUND CARE
13Ventilator and PMV
- When to initiate/Settings on Vent
- PB 760
- Speaking Valve Mode
14The Results
Crude Wean Rate
15Ventilator Wean Rates
- 124 Ventilator Discharges
- 82 Successful Ventilator Weans
- 2004 - 68
- 2005 (YTD) - 66
- Industry Gold Standard - 50
16WEAN RATES BY DIAGNOSIS GROUP
17Changes and Positive Impacts
- Company Engineers
- Re-evaluation of Policies
- Home Care
- Quality of Life (QOL)
18The Passy-Muir Speaking ValveImpact on
Communication
19Non-Verbal
- - Writing
- - Mouthing words (lip reading)
- - Yes/No questions
- - Spelling/communication board
- - Electro larynx
- - Talking trachs
- - Electronic/augmentative equip
20Verbal Communication
- - Past Medical History
- - Current Medical History
- - Agitation
- - Sedation
- - Trach changes
- - Vent setting changes
- - Weaning schedule
-
21Common Types of PMVs
- Familiar types of Passy-Muir Valves
22PMV 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
23PMV is placed (TCT)
- - Obtain baseline data
- - Provide education
- - Control anxiety
- - Secretion removal
- - Assist with coughing
- - Ambu bag?
- - Are there saturation limits?
- - Teamwork, teamwork, teamwork
24Phonation
- - 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
25Suggestions
- - 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
26PMV And Swallowing Disorders
27Readiness for Dysphagia Assessment and Treatment
- Medical clearance
- Secretion control
- Tolerance for wearing PMV
- Self protective skills and advocacy/support
28PMV 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
29Compatibility of the PMV with Various Treatment
Modalities
- Thermal/tactile stimulation
- Gustatory stimulation
- Electrical stimulation
30Progressing Through Trial Consistencies
- Selecting stimuli by
- Temperature
- Texture
- Taste
- Safety
- Bolus size, bolus control
31Bedside Safety Assessment Options
- Signs and symptoms of aspiration
- Blue Dye Testing
- Chem Strip Testing
32Instrumentation
- Instrumental assessment with and without the PMV
- What does the research tell us?
- Data from MBSS/VFSS, FEES
33Eating on the Ventilator
- Making the decision
- The Team Approach
- Patient, Physician, SLP, RT, and S.O.s
34Restoring 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
35Passy-Muir Valve Across The Continuum of Care
HIGH
INTENSIY OF PATIENT SERVICE
LOW
SEVERITY OF PATIENT ILLNESS
LOW
HIGH
36What do Policy Makers say about thePost-Acute
Space?
Spending is Increasing
Billions of dollars
37ICU
38PMV 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
39Acute Care
40PMV 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
41Short Term Rehab LTAC Setting
42SHORT 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
43SHORT 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
44Kindred 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
45Best Practice Guidelines
- Kindred Performance Measures
- Customer satisfaction
- Clinical outcomes
- Cost
- Competency
- Census
- Compliance with accreditation requirements
46Long Term Care
47PMV 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
48Home Care
49PMV 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
50PMV 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
51Browns End-of-Life Decision ToolReference
www.asha.org
52PMV 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
53PMV Considerations End of Life
- Awareness of PMV
- Patient communication needs and opportunities
- Decision making
- Expressions to others
- Spiritual
- Respiratory and Airway Management
- State Regulations