Kindred Management Conference

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(No Transcript)
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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, 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

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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

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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

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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

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Best Practice Guidelines

• Kindred Performance Measures
• Customer satisfaction
• Clinical outcomes
• Cost
• Competency
• Census
• Compliance with accreditation requirements

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The Diagnostic Relationship

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

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Cardio-Pulmonary Care The PMV
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Mechanics of Cough

• Protective Mechanism
• Reflex
• Receptor Sites

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Mechanics of Ventilation

• Inspiration
• Expiration
• Mechanical Ventilation

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Weaning from Ventilator

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

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TEAM Approach
PHYSICIAN
RESPIRATORY THERAPIST
CASE MANAGEMENT
WEEKLY TEAM CONFERENCE
NURSING
DIETARY
SPEECH THERAPY
PHYSICAL OCCUPATIONAL THERAPY
WOUND CARE
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Ventilator and PMV

• When to initiate/Settings on Vent
• PB 760
• Speaking Valve Mode

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The Results
Crude Wean Rate
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Ventilator Wean Rates

• 124 Ventilator Discharges
• 82 Successful Ventilator Weans
• 2004 - 68
• 2005 (YTD) - 66
• Industry Gold Standard - 50

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WEAN RATES BY DIAGNOSIS GROUP
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Changes and Positive Impacts

• Company Engineers
• Re-evaluation of Policies
• Home Care
• Quality of Life (QOL)

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The Passy-Muir Speaking ValveImpact on
Communication
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Non-Verbal

• - Writing
• - Mouthing words (lip reading)
• - Yes/No questions
• - Spelling/communication board
• - Electro larynx
• - Talking trachs
• - Electronic/augmentative equip

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Verbal Communication

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

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Common Types of PMVs

• Familiar types of Passy-Muir Valves

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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

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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

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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

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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

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PMV And Swallowing Disorders
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Readiness for Dysphagia Assessment and Treatment

• Medical clearance
• Secretion control
• Tolerance for wearing PMV
• Self protective skills and advocacy/support

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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

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Compatibility of the PMV with Various Treatment
Modalities

• Thermal/tactile stimulation
• Gustatory stimulation
• Electrical stimulation

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Progressing Through Trial Consistencies

• Selecting stimuli by
• Temperature
• Texture
• Taste
• Safety
• Bolus size, bolus control

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Bedside Safety Assessment Options

• Signs and symptoms of aspiration
• Blue Dye Testing
• Chem Strip Testing

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Instrumentation

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

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Eating on the Ventilator

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

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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

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Passy-Muir Valve Across The Continuum of Care
HIGH
INTENSIY OF PATIENT SERVICE
LOW
SEVERITY OF PATIENT ILLNESS
LOW
HIGH
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What do Policy Makers say about thePost-Acute
Space?
Spending is Increasing
Billions of dollars
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ICU
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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

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Acute Care
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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

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Short Term Rehab LTAC Setting
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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

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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

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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

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Best Practice Guidelines

• Kindred Performance Measures
• Customer satisfaction
• Clinical outcomes
• Cost
• Competency
• Census
• Compliance with accreditation requirements

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Long Term Care
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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

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Home Care
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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

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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

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Browns End-of-Life Decision ToolReference
www.asha.org
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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

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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