Chapter 2 Alternative Settengs for Critical Care

The user of emerging technology and the increased availability of pharmaccutical options have
provided opportunities for inscreased survival in critically ill patients over the past 15 years.
To that end, many individuals who may not have survived the early phases of illness are able
to recover to a stable level and leave the boundaries of traditional critical car units. The
emergence of progressive care has provided additional venus for care. Characteristics of
patients whose clinical stability is appropriate for these venues will be reviewed and the
challenges facing caregivers in each setting described. This chapter will focus on the
progressive care unit (PCU), the skilled nursing/ long term care facility, the ambulatory setting,
and home healthcare.

MOVING CRITICAL CARE BEYOND TRADITIONAL CRITICAL CARE

Critical care has roots dating back to early twentieth century. One of the earliest critical
care units was developed in 1923 at the johns hopkins hospital in Baltimore, Maryland. In the
1940s, there was an explosive growth in technology used for the care of the critically ill. These
early advancements included increased knowledge of anesthesia, the development of the first
successful dialysis machine, new resuscitative measures with intravenous (IV) fluids and blood
products, and the introduction of the first external defibrillator. External cardiopulmonary
resuscitation (CPR) was first introduced in the 1960s, leading to descreased mortality.
In addition, critical care was developed in response to inadequate staffing and resources
on general medical-surgical floors. Evidence demonstrated that closer nursing observation led
to better patient outcomes. As a result of the ever-growing number of critical care nursing, the
american association of Critical-Care Nurses (AACN) was established in 1971. AACN and its
members help develop guidelines and define best practice for critical care nursing.
Addiitionally, in recent years, AACN has expanded its critical care certifications program to
include progressive care, recognizing progressive care as a critical care specialty, certification
across the critical care continuum has helped to validate knowledge, establish standards, and
promote excellence among nurses within the progressive care specialty.
In the late 1980s special care units began to emerge to adress the needs of chronically
critically ill patients. In addition, a number of factors led health-care leaders and their
institutions to seek other alternatives to delivering critical care, often in environments outside
of the traditional critical care areas. While only 5% af all hospital beds are considered critical
care, these patients consume almost 25% of all hospital expenses, according to the national
center for health statistics, the average life expectancy in the United State in 2002 wa 77.3
years. Current technology has enabled tratment of diseases thet were considered futile 10 to
20 years ago. Backlogs in critical care have resulted in overcrowded emergency departments
(Eds) and the admission of inappropriate patients to general medical-surgical units. Patients
may require frequent monitoring and nursing interventions but not need the intensity of critical
care or requre the invasive monitoring more typically seen in critical care patients.
Progressive care, as defined by AACN< is the care delivered to patients whose needs fall
along the acute end of the continuum of care and is used to desribe areas that may be referred
to as intermediater care units, direct observation units, step-down units, telemetry units, or
transitional care units. Box 2-1 lists AACN’s core competencies for the progressive care unit
nurse.
Progressive care units are an option both to help alleviate the demand for the traditional
critical care beds and to transition patients between critical care beds and to transition patients
between critical care and general medical-surgical units. These units, also referred to as
intemediate care units of step-down units, provide care to the chronically critically ill patient
with varying levels of acuity, resiliency, and stability. Progressive care units may specialize in

Box 2-1

AACN’s Core Competencies for the standardized interventions to

progressive care Nurse stabilize the patient awaiting
 Dysrhythmia monitoring techniques transfer to critical care
 Basic and advances life support  Interpretation of arterial blood
 Basic dysehythmia gases (ABGs) and communication
interpretation and treatment of findings
 Drug dosage calculation,  Rocognition of indications for and
continuous medication infusiom management of patients requiring
administration, and patient noninvasive O₂ delivery systems
monitoring for medication effects including oral airways, BiPAP, and
(e.g., nontitrated vasoactive agents, nasak continous positive airway
platelet inhibitors, antiarrhythmic pressure (CPAP)
agents, and insulin)  Assessment of the ventilated patient
 Patient monitoring using to ensure delivery of the prescribed
standardized procedures for before, treatment and patient response
during, and after procedures (e.g.,  Assessment and understanding of
cardioversion, transesophageal long-term mechanical ventilation
echocardiography [TEE], cardiac and weaning
catheterization with percutanseous  Recognition of the indications for
coronary intervention [PCI], and complications of enteral and
bronchoscopy, esophagogastro- parenteral nutrition
duodenoscopy [EGD], percutaneous  Assessment, monitoring, and
endoscopic gastrostomy [PEG] tube management of patient requiring
placement, chest tube insertion). renal therapeutic interventions (e.g.,
 Hemodynamic monitoring, hemodialysis, peritoneal dialysis,
including equipment setup, stents, continuous bladder
troubleshooting, and monitoring as irrigation, and urostomies)
well as recognition of signs and  Recognition of and evaluation of the
symptoms of patient instability family’s need for enhanced
 Recognition of the signs and involvement in care to facilitate the
symptoms of cardiopulmonary transition from hospital to home
emergencies and initiation of

certain patient populations (e.g., cardiac, surgical, neurologic, or pulmonary) or may

encompass a broader continuum of general diagnoses. These units are traditionally
multidisciplinary in nature. The patien care team often includes the staff nurse, advanced
practice nurse, nurse manager, clinical educator, respiratory therapist, speech therapist,
dietitian, and chaplain or pastor. The complex nature of these patients is benefited by this
multidisciplinary approach. The case presented in box 2-2 illustrates the complexity of these
patient and the effectiveness of the multidisciplinary approach.
Macthing the skill of the caregiver with the needs of the patient, in an altenative
environment, can be variable without a model of care on which to base decisions. As outlined
in chapter 1, using the sygnergy model the proresive care patient is moderately stable with less
complexity and requires moderate resources and intermitten nursing vigilance. Characteristics
defining the differences in progressive care patients versus traditional critical care patient
include decreased risk of a life-threatening event, decreased need for invasive monitoring,
increased stability, and increased ability to participate in care. Progressive care patient venues
are not limited by geography, but by the needs and required interventions for the patient.

THE PATIENT’S JOURNEY TO PROGRESSIVE CARE

The need for progressive care may occur during a number of points on the acute care
illness continuum. One point may occur within the recovery period of critical care, when
technology and intervention have brought an individual to a plateau level. The patient is stable
with the current high level of interventions, but has failed to progress to wellness. If therapies
(e.g., ventilation, airway maintenance, enteral nutrition, and dialysis) are reduced or
withdrawn, clinical deterioration will follow. This patient has become “chronically critically
ill”.
End-of-life discussions are pivotal at this time. It is important to review the intensity of
illness and the potential for recovery. These discussions assess the elements of quality and
quantity of life with the individual and relevant family/ significant orhers. The primary care
team members are all esential contributors to this discussions. Assessing and providing for
spiritual support may be helpful.
For the individual who chooses not to continue the chronically critically i'll lifestyle, the
choices available for end of life care are many. Limiting current and future interventionis within
the scope of choice. Choices range from allowing natural to total withdrawal of care. Specific
issues relative to this can be referenced in chapter 54, end-of-life care.

Box 2-2

Case Example of a patient weight, and is completely dependent in

Appropriate for the PCU
J.W. is a 67 years-old male diagnosed
with Guillain-barre syndrome. He
experienced respiratory failure, and a
tracheostomy tube was placed because of
his inability to wean off the ventilator.
He expreriences profound weakness in
all of his extremities, is unable to bear
all areas of activities of daily living. He
receives nutrition via a small-bore
feeding tube because of his high risk for
aspiration. He has a stage II pressure
ulcer on his sacrum as a result of his
immobility and inadequate nutritional
intake. Before his hospitalization, J.W.
was a self-employed farmer and now
 risks losing his livehood. J.W.’s illness
has placed a great strain on his wife and
two adult sons.
This is a patient typical of the
progressive care population. An example
of the multidisciplinary approach
follows. The patient’s highest priority
need is his fragile respiratory status. The
nurse practitioner, respiratory, therapist,
and primary nurse collaborate to
implement an appropriate weaning plan
for the patient. The weaning process is
pronolonged, but eventually tha patient is
able to tolerate tracheostomy plugging
with supplemental oxygen and minimal
suctioning. Monitoring of the patient
during this process may include
continuous oxymetry and frequent
assessment by the primary RN and
respiratory therapist, the patient is able to
slowly regain strength and the ability to
walk using an assitive device.
Ambulantion also becomes a joint effort
of the physical therapist, primary nurse,
and respiratory therapist. The speech
therapist works with the patient to assess
the safety of oral feeding. Speech therapy
and nursing work together to create a safe
eating plan for the patient to prevent
aspiration. Occupational therapy fits the
patient with assitive devices to help him
perform his activities of daily living more
independently. The bedside nurse is
instrumental in helping the patient to use
the techniques he has learned. Social
work consults with the patient and family
to make the appropriate refeeals and
nescessary financial arrangement.
Pastoral care help the family to find
coping mechanisms to deal with this life-
changing illness. After a 6-month
hospital stay, the patient is discharged
home after being decannulated and
having a short stay in the acute
rehabilitation unit.

If patient and their support system accept the current situation and necessary support, the
team begins a plan of care that includes strategies for adaptation to a limited lifestyle with
technology for life support. The venue of care in the hospital environment at this point of the
illness has continuum is either a critical care unit or a PCU. A Second point on the acute care
illness continuum may a occur when patients are the directly admitted to a PCU from the ED
or other general medical-surgical units. These patients generally require close monitoring or a
specific therapy that the general unit is unable to provide. Table 2-1 provides examples of PCU
admission criteria. Admission criteria are set to ensure care needs are matched with the nurse
competencies and resources available in the progressive care venue.

PROGRESSIVE IN THE HOSPITAL SETTING

Assessment and triage are pivotal for appropriate patient placement in the PCU. In a
PCU, the RN-to-patient ratio varies from 1:3 to 1:4 ratios vary depending on the specific patient
population and acuity levels. Usually, different levels of licensed nurse are available to provide
care; unlicensed assistive personnel may also be part of the care team. The delivery models
selected for PCUs optimize resources and each caregivers's ability to practice with in his or her
scope. Successful model implement the team approach. The RN as charge nurse or team leader,
delegates tasks to licensed practical nurses and unlicensed caregivers as appropriate to their
ability and within their legal scope of practice. The RN collaborates which members of the
multidisiplinary team, including the physical, occupational, speech, and respiratory therapist;
dietitian; chaplain or pastor; and social worker. Optimal plans of care revoive around meeting
the holistic needs of each patient.
In addition to the multidisiplinary focus, each unit's leadership determines the tools
necessary to deliver care. Devices for oximetry, ventilation, and cardiac monitoring are option
to assess vital parameters, individualized for each patient. Equipment to assist with lifting,
moving, or transferring patient support the caregiver team and ensure optimal mobility with
savety awareness. Many device that once required a patient to be prescribed bed rest have
progressed to allow mobility for the patient, thus echancing,recovery. Fir example smaller,
more protable mechanical ventilators may enhance mobility.

Competency mechanical ventilation Name:

Savina intensive care ventilator Date :
Patient care unit: Critical Care Unit and PPCU Proceptor/ Validator

Performance Criteria Proceptor/ validator

initials
General Considerations
1. Verbalized knowledge of equipment refence
2. Inspects equipment for safety and cleanliness
 Verbalizes method of cleaning visible soil
 Verbalizes process for reporting equipment in need of repair
Volume Ventilator
1. Demonstrates ability to locate ventilator controls
 Alarm silence
 100% suction (O₂) suction
2. Demonstrates ability to locate ventilator settings (located on
front panel)
 Tidal volume
 O₂
 Set rate
 PEEP if applicable to mode
 Ventilator mode (AC/SIMV/CP AP)
 Verbalizes the function and meaning each mode
3. Identities patient data monitors on the display panel (Presses the
values key and measured value are displayed)
 Airway pressure (P aw)
 Tidal volume (Vt)
 Peak airway pressure (P peak)
 Rate patient’s inspiratory source ( assisted, spontaneous)
Alarm Considerations
4. Identifies ventilator alarm and conditions causing alarms
Identifies three levels of alarm (troubleshooting) conditions
 Warning!!! (red LED flashes and five-tone sequence
sounds)
 Caution!! (yellow LED flashes and three-tone sequence
sounds)
  Advisory! (yellow LED light and two-tone sequence
sounds)
Informational message will appear in upper-right corner of main
screen
 Airway pressure high! Patient is fighting the ventilator
or coughting.
 Check patient’s condition and ventilation pattern
 Airway pressure low! Leaking cuff of disconnection
 Cuff may need inflating. Check patient circuit for
tight connections.
 Apnea! Patient’s spontaneous breathing has stopped or
disconnection has occured
 Reconnect if necessary. Check patient’s
condition and notify respiratory therapy
 Apnea ventilation! Apnea detected-system switched to
mandatory ventilation
 Check ventilation mode and notify respiratory
therapy
 Device failure! Ventilator fault
 Disconnect ventilator and ventilate patient with
an ambu bag. Notify respiratory therapy.
 Fan Failure!
 Disconnect ventilator and ventilate patient with
ambu bag. Notify respiratory therapy.
 High Frequency! Patient is breathing at a high
spontaneous breathing frequency
 Check patient’s condition and ventilation paltem.
 Leakage! Leaking cuff
 Cuff may need inflating. Check tightness of
circuit connections
Untilize this tool in adition to mechanical ventilation (generic)
competency assessments.
FIGURE 2-1 Sample competency checklist for a pulmonary unit. Courtesy rochester general
hospital, departemen of patient care service. AC = assist control, CPAP = continuous positive
airway pressure, P aw = airway pressure, PEEP = positive end-respiratory pressure, P peak =
Peak airway pressure, SIMV = Synchronized intermittent mandatory ventilation, Vt = Tidal
volume.

TABLE 2-1 Description admission criteria of selected types of progressive care units
PULMONARY CARDIOLOGY GENERAL
PROGRESSIVE CARE STEP-DOWN INTERMEDIATE
UNIT UNIT CARE

Patient in repiratory failure, Patients after cardiac Patient with low

with failure to wean catheterization, stent probability or who
Patient actively weaning from placement, have been ruled ous
Patient ventilator and requiring angioplasty, and as having a
Population frequent monitoring and peripheral stenting myocardial
respiratory interventions by patients requiring infarction (MI)
nurses and respiratory cardioversion, Patient who are
therapists transcutaneous midly hypertensive
Patients with significant pacing without evidence of
suctioning needs and impending organ
requiring close monitoring failure
Patients requiring Patient requiring
noninvasive ventilation (e.g., noninvasive
BiPAP) ventilation with
Patients requiring dialysis, demonstrated home
telemetry, or frequent wound stability on
care appropriate device
Oxygen needs may be (e.g., BiPAP)
significant, preventing Patients with
discharge. resolving sepsis
Patients with
gastrointestinal
bleeding who are
responding to
therapy
Patients requiring
frequent nursing
interventions (e.g.,
hyperglycemia, drug
withdrawal)

Skill mix nurse precititioner Skill mix of nurse Skill mix of nurse
clinical nurse specialist, practitioner, clinical practitioner, clinical
Staffing mix clinical aducator, registered nurse specialist, nurse specialist,
nurses, licensed practical clinical educator, clinical educator,
nurses, and unit technicians. registered nurses, registered nurse, and
Nurse-to-patient ratio: 1:3 to licensed practical unit technicians.
1:4 nurses, and unit Nurse-to-patient
techniciants. Nurse- ratio may range from
to-patient ratio is 1:4 1:3 to 1:5
to 1:5
Telemetry
Ventilator Hardwire and monitoring pulse
Telemetry monitoring portable telemetry oximetry lifting
Equipment Wireless ventilator monitor arterial line devices
and pulse oxymetry
Lifting equipment

Accepted Nitroglycerin Nitroglycerin Nitroglycerin

medications; Heparin Heparin Heparin
some with Dobutamine (dobutrex) Dobutamine Dobutamine
dosage Diltiazem (Cardizem) (dobutrex) (dobutrex)
limitations Insulin Diltiazem Diltiazem
Fruosemide (lasix) (Cardizem) Insulin
 within unit Morphine Amiodarone Furosemide (Lasix)
standard Octreotide (sandostation) (cordarone) Morphine
Nesiritide (Natrecor)

Percutaneous inserted centrail PICC lines PICC lines

Intravenous Catheters (PICCs) Central lines Central lines
access Central lines Dialysis catheters Dialysis catheters
Dialysis catheters

TABEL 2-1 Description admission Criteria of Selected types of progressive Care Units-
cont’d
PULMONARY CARDIOLOGY GENERAL
PROGRESSIVE STEP_DOWN INTERMEDIATE
CARE UNITS UNITS CARE
Not Femoral lines Patient requiring Patients with acute
Acceptable must be Patients who require continuous external MI who are not
considered for higher Continuous IV pacing hemodynamically
level of care sedation aPatients stable
Patients on hemodynamically Patients with acute
vasoactive unstable after respiratory failure
Continuous IV drips angiogram Patients requiring
that require hardwire Patiens in large amounts of IV
monitoring cardiogenic shock sedation
Patients requiring Patients requiring
external pacing vasoactive drips
Patient requiring Patients requiring
vital sign taken more continuous external
than every 2 hours pacing
Data from refrences 10, 11

SELECTED MEDICATIONS USED IN THE PROGRESSIVE CARE UNIT

DRUG CLASS DRUG NAME INDICATION FOR USE IN PCU

Antiarrhythmic Amiodarone Loading and maintenance infusions for
(cordarone) treatment of supraventricular
dysrhythmias.
Maintenance infusions for treatment of
hemodynamically stable ventricular
tachycardia
Lidocaine Initial and maintenance infusions for
Vaughn william class IB treatment of hemodynamically stable
supraventricular dysrhythmias or
ventricular tachycardia
 Procainamide Loading and maintenance infusions for
Vaughn williams class treatment of hemodynamically stable
IA ventricular tachycardia
Diltiazem (Cardizem) Loading and maintenance infusions to
Vaughn williams class control rate of hemodinamically stable
IV supraventricular dysrhythmias
Esmolol (brevibloc) Loading and maintenance infusions to
Vaughn williams class control rate of hemodinamically stable
II supraventricular dysrhythmias
Vasoactive Dopamine Used in does to increase renal perfusion
Maintenance infusion of 5 mcg/kg per
minute cardiac transplant patients
Vasoavtive Nitroglycerin Hemodinamically stable patient with
anginal signs and symptoms, acute
coronary syndrome, uncomplicated non-
ST-segmen myocardial infarction, or after
percutaneous coronary interventions;
patient awaiting vardiac surgery;
postoperative patients requiring stable
dose.
Inotropic Dobutamine Maintenace infusion to improve cardiac
output in patient with chronic heart failure;
used primarily for patient awaiting cardiac
transplantation
Milrinone (primacor) Maintenace infusion to improve cardiac
output in patient with chronic heart failure;
used primarily for patient awaiting cardiac
transplantation
Natriuretic peptide Nesiritide (Natrecor) Loading and maintenance infusion to treat
decompensated congestive heart failure.

Pleural drainage, once reserved for acute care settings, can now be used with water seal
drainage systems or intermittent sampling of fluid by aspiration. Small, self-sealing chest tubes
allow egress from the acute care environment. Standardized plans of care or pathways are
useful in this population guide and then evaluate care and can offer an opportunity for the team
to measure success compared to national benchmarks.
Patients transitioning from a tradisional critical care to a PCU typically move from a less
physically demanding to a more physically demanding environment. The PCU's philosophy is
to maximize the patient's own capabilities while promoting increased physical independence.
This requires a multidiciplinary approach related to all aspects of care.
Collaboration between unit leadership within the institution can achieve adherence to
admission standards among the PCU. The critical care area, ED, and general medical-surgical
units must be familiar with admission criteria for this patient population. Adminission and
discharge should be congruent among all step-down unit for consistency. Documentation of
these standard can also improve continuity across care units. The result of the coordinated
efforts will be effective patient flow.
Nursing competency should be assessed upon here and on an annual basis for each staff
member. Skill competency assessment should be based on the needs of the specific unit and
patient population (highrisk/ low-volume). As outlined previously (see box 2-1), core
competencies for PCUs should be include, but not be limited to, the following mechanical
ventilation, and sheath removal (Figure 2-1). In addition, a variety of medications not usually
seen outside of critical care is often used in progressive care unit. An example of one unit's use
of medication is seen in the medication table on p. 27. Decisions on the level of care and
interventions provided on any given PCU will need to be made at the institutional level AACN
has a variety of resqurces available to support nurses working in progressive care unit (Box 2-
3).
Box 2-3
AACN Resources For Progressive Care
 AACN Essentials of critical care nursing (2005). New york: McGraw-Hill
 AACN Essential of progressive Care Nursing (2007). New York: McGraw-Hill
 AACN Pocket Essentials of critical care nursing (2005). New york: McGraw-Hill
 AACN Pocket Essentials of progressive Care Nursing (2007). New york: McGraw-
Hill
 AACN procedure Manual for critical care (5td ed.) (2005). Philadelphia: saunders.
 AACN Protocol for Practice: Noninvasive Monitoring (2nd ed.) (2005). Boston:
Jones and bartlett.
 AACN Protocols for Practice: Palliative Care and End-of-life Isuues in Critical Care
(2006). Boston: Jones and Bartlett.
 AACN Protocols for practice: Caring for Mechanically Ventilated Patients (2nd ed)
(2006). Boston: Jones and Bartlett

PUBLISHED BY AACN
 AACN Protocols for practice : Care of the Cardiac Oatient Series Protocol, 2002
Care of the Cardiac Patient in Rehabilitation and Recovery
Care of the Patient Undergoing Cardiovascular Surgery
Care of the Patient with an IABP
Care of the Patient with Acute Coronary Syndrome
Care of the Patient with Heart Failure
Care of the Patient with a Ventricular Assist Device
Care of the Patient with an Arrhythmia
 AACN Protocols for Practice: Symptom Management in Acute and Critical Care
Series (2003)
Management: Diarrhea Protocol
Management: Dyspnea Protocol
Management: Fever Protocol
Management: Nausea and Vomiting Protocol
 AACN Protocols for Practice: Hemodynamic Monitor- ing Series (1998)
Arterial Pressure Monitoring
Cardiac Output Monitoring
Pulmonary Artery Pressure Monitoring
SVO2 Monitoring
OUT-OF-HOSPITAL VENUES
Skilled Nursing Facilities/Long Term Care Facilities
Reimbursement available to skilled nursing facilities promotes wise resource utilization.
Given the nature of long-term, ongoing care, participation in social activ- ities and
normalization of activity patterns tant aspects of the plan of care. Registered competent in
assessment of needs and delegation of duties are best suited for this venue. Direct care roles
can be delegated to an unlicensed individual. The RN or the licensed practical nurse (LPN) is
responsible for medication administration. Other care as airway care and ventilator monitoring,
a joint responsibility with respiratory therapists. Activ- ities and rehabilitative therapies are
jointly plished with physical medicine therapists along with activity support personnel or
volunteers.
Community resources vary as to skilled nursing/ long term care facilities and healthcare
venues. When a patient has reached his or her potential of recovery and demonstrates
hemodynamic stability even with high technology (e.g., ventilator support), referrals can be
initiated to appropriate nursing facilities outside of the hospital setting. Long term care venues
that accept the ongoing ventilator-dependent patient have criteria for admission. These criteria
set by using staffing patterns that consider patient characteristics are and needs as well as When
a nursing competencies.
When a hospital initiates a patient referral, an admission team from the new venue
reviews the patient data submitted. A representative from the admission team visits the hospital
to review the record and complete an assessment of patient appropriate- ness. Careful selection
of future residents helps to assure the appropriate match of patient need with caregiver
availability and competence. If a patient is too vulnerable or requires excessive resources, the
long term care team may suggest plan of care amend- ments. They may defer acceptance at this
point, and offer to reassess the patient at a patient is accepted, visits to the facility by the
patient's family and a video or internet tour for the patient may be helpful to ease transition.
Developing a partnership between patients and families who have made the tran- sition with
prospective patients and families may help with questions and acceptance. Skilled nursing
facility admission criteria are outlined in Table 2-2.

TABLE 2-2 Skilled Nursing Facility Admission Criteria

CRITERIA APPROPRIATE FOR ACCEPTANCE

Hemodynamic Stable
Ventilator Support Stable with minimal changes
No recent airway emergencies
Adequate oxygenation with Fio₂ less then 40%
Immune system Up to date on immunizations
No active infection
Isolation needs known (drug-resistant Isuues)
If IV access, long- term IV line Present without infections (PICC)
Hematopoietic No active blood loss; hematocrit stable with minimal or no need
for transfusion
 Nutritional Adequate oral intake or stable feeding access (G-tube or
percutaneous endoscopic gastrostomy tube [PEG] placed).
Renal Adequate function
Renal failure requiring hemodialysis is challenging option for
skilled nursing facility (SNF) ventilator patient
Advance Directives Written document
Patient with need known to caregivers for future hospitalizations
Psychosocial Patient and family accepting of long term care option and financial
accountability.

BOX 2-4
Patient Transition From Hospital to Skilled Nursing Facility
IL. is a 75-year-old female with a history of lung cer and chronic obstructive pulmonary
disease (COPD). She was treated with radiation and chemo- therapy 5 years before
admission. She continued to smoke and was on home oxygen at 2 L/min. She developed
respiratory failure secondary to pneumonia and was intubated. After multiple failed attempts
at extubation, a tracheostomy tube was she slowly gained strength, she developed recurrent
nonmalignant pleural effusions and required repeated pleural drainage. Hypoxia and dyspnea
limited her ventilator weaning. She was a candidate for place- ment of a self-sealing pleural
tube, allowing intermit- tent drainage of the pleural space. After more than 3 L were removed
over the course of 3 weeks, she was weaned from the ventilator and required less oxygen;
she was also able to tolerate increased activity. She was moved to a rehabilitation unit at a
nursing home. The skill of assessment and drainage of the pleural tube was taught to the
nurses caring for her at the hospital and nursing facility. Eventually her husband assumed
the skill and she was can- placed. While discharged home.
In this example, some of the details of the patient's transition have been omitted for
simplification. Nev- ertheless, I.L.'s experience offers a broad and instruc- tive illustration
of the progressive care continuum.

On the day of discharge, the discharging team may choose to send with the individual.
This accomplishes three goals: patient safety on the journey, continuity of care, and comfort to
the patient during the trip. Patient anxiety is increased during the transfer; therefore having a
familiar practitioner is very valuable. The discharge, despite planning, may be a stressful event,
so meet- ing the breathing needs with the most comfortable approach is most helpful for the
patient. Collaboration among the respiratory therapists, providers, nurses, and accepting team
for meeting ventilation needs helps patient appropriate for transfer to a skilled nursing facility
is described in Box 2-4.

Ambulatory Setting
Ambulatory gressive illnesses, and those requiring intermittent adminis- tration, can be
delivered episodically. For example, positive inotropic drugs (e.g., nesiritide [Natrecor]) can
be delivered on an episodic basis to help manage heart failure. These types of drugs have been
limited to critical care or hospital settings in the past. With pre- scribed criteria for the levels
of resilience and stability, patients can be seen as an and treatment by a team with competence
in this skill. This affords disease management with the potential of increased quality of life and
potential decreased hospital admissions.
Home Care
The choice of home care is the desire of many (Box 2-5). However, this option creates
the most challenges for those delivering care. For example, individuals requiring mechanical
ventilation need 24-hour super- vision, 7 days a week (unless they are independent enough to
manage airway and ventilation needs). Additiona! therapies that may be managed at home
include peritoneal dialysis, TPN (total parenteral nutri- tion), and complex wound
management. Peritoneal dialysis may be initiated in the hospital, and taught to families and
caregivers by the dialysis team. Total par- enteral nutrition may also be managed at home.
Families are instructed how to access and maintain central lines. Training related to dressing
changes and site assessment may be managed with the assistance of the home care intravenous
nurse. Patients may also return home with complex surgical wounds or existing pressure ulcers.
Coordination with the outpatient wound ostomy nurse and home care agency is essen- tial to
determine appropriate supplies and insurance coverage for equipment.
Public funds and private insurance do not rou- tinely cover the cost of direct caregivers
in the home the responsibility of care falls to the family or signif- icant others. For covered
services, the availability of licensed caregivers (KNs or LPNS) is often at a premium.
An examination of personal resources is necessary to project a healthcare budget. State
rules govern Med- icaid eligibility. A social worker referral can provide support to the
individual/family as financial resources and funding applications. With approved Medicaid,
some states will allow funding of durable medical equipment and some caregiver cover- age,
based on physician appeal to the state governing office.
The hospital, skilled nursing care facility, or long term care institution team assesses the
feasibility of discharging the patient to home, using input from patients and their support
systems. When home is chosen as the appropriate venue for these complex patients, extensive
education and training must be completed with the patient and family. A teaching plan is
established and educational sessions coordinated with patients and their chosen caregivers. A
complex discharge plan follows to meet the specialized needs of the patient.

Box 2-5
Patient Transition From Hospital to Home
S.F. was a 68-year-old woman initially admitted to criti- complex medical history including
cal care. She had a amyotrophic lateral sclerosis (ALS), respiratory failure, and hypertension.
Her 73-day hospital stay included respiratory failure, pneumonia, life-threatening infec-
tions, and several returm admissions to the critical care unit. Following stabilization and
extubation failures, she received a tracheostomy tube for ongoing airway management. After
being weaned off intravenous sedation and vasoactive medications, she was transferred to
progressive pulmonary unit.
Initially her management out of critical care was complicated by agitation and
restlessness, followed by period of increased strength and poor decision making. Lorazepam
(Ativan) eventually titrated to a lower dose before discharge to help with anxiety
management. Her course was complex, but with diligent management and multidisciplin-
ary planning she was able to improve her strength and tolerate a tracheostomy collar
(spontaneous breathing) during the daytime hours with ventilator support at night. Her
airway needs (approximately every 3 hours). Oral secretions and dysphagia prevented
successful oral intake. She had a jejunostomy tube J-tube) placed within the months before
admission, based on the progressive nature of the ALS. S.F.used the oral suction indepen-
dently to manage the high volume of clear saliva she produced and could not swallow. Fall
prevention strate- gies were also implemented with supervised out of bed activity. Physical
and occupational therapists collabo- rated with the nursing team to promote independence
and strength.
S.F. had a who made the decision to care for S.F. at home. They believed they needed
to make the effort for the care at home, ity of the plan was discussed with the family, and
sev- eral difficult financial and personal decisions were made because of the 24-hour daily
coverage needed for S.F.'s care. S.F.'s daughter would resign from her job and assume the
role of her mother's primary caregiver, with her husband and children assuming backup roles.
A family meeting, including the multidisciplinary team and all potential caregivers, of care
that would meet the patient's needs.
The nurse practitioner and clinical educator devised a teaching plan individualized for
the patient's needs. Teaching included ventilator management, suctioning techniques,
nutrition via J-tube, medication manage- ment, and wound care. Advanced decision making
also discussed using a decision tree. Teaching sessions were conducted with small groups of
family members. Skills were demonstrated and family members per- formed return
demonstrations several times. Teaching initially performed by the nurse practitioner and
clinical educator, and reinforced by staff nurses and supportive daughter and grandchildren
nursing home was not an option. The feasibil- as a was held to discuss a plan was was
respiratory therapists. The respiratory therapist from the home oxygen vendor also met with
the caregivers on several occasions to teach the logistics and manage- ment of the ventilator.
S.F. was all caregivers had demonstrated competence. Follow-up visits at home by the nurse
practitioner and clinical educa- tor provided both a social connection and a continuity of care
connection. Community home care continued the plan of care. home environment with her
smaller, home ventilator.