Ventilator Management in the Nursing Home Setting
Are nursing homes really equipped to handle residents on ventilators? Managing ventilator care in long-term settings comes with serious risks if not done properly, including infection, injury, or even death. Families need to know what safe and effective ventilator management looks like. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Valerie Creel to talk about the standards, challenges, and responsibilities of ventilator care in nursing homes.
Creel:
O2 U saturation or oxygen saturation is the percentage of oxygen that’s present in the blood. A normal SPO two, it would be about above 90 or more. COPD patients can maintain like 88 to 96 or so. You want to keep your patient that is within a vital, fine range that compatible with life and comfort.
Schenk:
Hey, out there everybody. Welcome back to the Nursing Home Abuse podcast. My name is Rob. I’ll be your host for this episode. We’re talking today about ventilator management. In the long-term care settings, like what does it mean to receive appropriate care when your loved one has a ventilator? But we’re not doing that.
We’re certainly not doing that alone because I don’t know anything about this subject. And that definitely comes across in all the questions that I ask. So we have a professional with us today. We have Valerie Creel to talk all about ventilator management in hospitals and long-term care.
I would love to do that. Nice. Steak and potato right now would be great. Anyway, the meat and potatoes of this episode. We don’t do that alone. We have Valerie Creole this week. Valerie Creole is a registered nurse with almost 20 years of clinical experience. She’s board certified as an intensive care unit nurse and has extensive expertise in ventilator management, medication and IV management and complex cases involving a variety of medical diagnosis and trauma.
Valerie currently works as a legal nurse consultant and expert witness with attorneys nationwide and is the owner of BridgePoint Legal Nurse Consulting, and we are so happy to have her on the show. Valerie, welcome to the show.
Creel:
Thank you for having me today.
Why would a resident be placed on a ventilator?
Schenk:
Valerie, I said this before we started recording, but I honestly do not know very much about ventilators, the nursing behind, keeping people safe on ventilators, any of this stuff.
So I’m gonna really start very easy for you, and the first question I have is, I have an idea of what a ventilator is, but can you just tell us what it is from a broad perspective and what it does?
Creel:
Of course. So a ventilator, or it’s sometimes known as a mechanical ventilator. Mechanical ventilator. It’s a device that helps support a person’s respiratory system.
And that can be done with an endotracheal tube orally or in long-term care settings. It’s generally done with the tracheostomy. By an airway that’s placed in a person’s neck, which helps reduce the breakdown of skin in around the airway. There are a lot of different ventilator modes that can be managed, and it’s either to support volume or respiratory rate, and it can go anywhere from just minimal pressure support all the way up to ventilating a person’s respiratory volume and rate.
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Schenk:
So I guess in my mind, is it just, it’s a machine that is blowing air into the lungs or helping the lungs expand? What’s what’s mechanically happening inside there?
Creel:
Yes. In summarized version that is essentially what’s happening. And it can control either pressure or volume or rate or any of the different settings depending on what mode is prescribed for the person and what type of support they need.
What is ventilator management in a nursing home?
Schenk:
Why would someone in any setting, whether it’s long-term care, hospital, whatever, why would someone need a ventilator?
Creel:
So there are a lot of different reasons, but the short answer would be is that their body is not able to sufficiently do that function on its own. So whether it be in a lot, in a short term acute care setting just to support them during an acute illness, or if a person has, for example, a stroke or head injury and that portion of their brain can’t do that function for them to the effect that it can sustain life.
Schenk:
So we have the patient, or in long-term care, the resident and they have the machine. There’s tubes, there’s machines, there’s, it’s making noises. It’s this and that. Typically, who is, who are the individuals responsible for making sure that it’s doing what it’s supposed to do, that it’s clean, that it’s working properly.
Creel:
That’s a really good question. There’s a team of people that would be required to manage this. I’m so sorry that someone just ring my doorbell.
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Schenk:
That’s okay. I didn’t hear it. But look, every week there’s it’s dogs. Like people’s kids are coming in. This is a family podcast. It’s the neighbor, the bring the neighbor in.
It’s all good.
Creel:
So there’s a team of people that manages a ventilator. So the doctor would be the one that essentially prescribes the order for the ventilator mode. The respiratory therapist is the person that is the most hands-on with the ventilator, adjusting modes and taking care of the oxygenation, doing trach care, doing the respiratory care.
But the registered nurse, even in a long-term care setting, is responsible for. Continuing to assess, intervene, and communicate any changes. Additionally, someone as a registered nurse, even in a long-term care setting, will have to have specialized training for ventilator care. So they would have to be trained to identify if a person is in distress, provide suction and care because sometimes respiratory therapist is not available and the registered nurse needs to be trained to respond in an emergency.
Schenk:
When you say suction, what do you mean?
Creel:
So suction is usually, it’s attached to a wall, but there are portable suction units as well. A lot of times when a person is on a ventilator, they can’t control the respiratory secretions that take place. So especially in the setting of critical illness or even long-term illness, a person, can sometimes be able to cough, but a lot of times they may lack that reflex if they’re critically ill for an extended period of time. And a nurse or a respiratory therapist would have to insert a suction catheter into the airway or the mouth to clear out any secretions, and that’s something that should be done routinely or as needed, depending on what the patient needs.
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How do nursing homes care for ventilator patients?
Schenk:
What does routinely mean? Is that once a shift, is it once a day?
Creel:
It’s usually about once a shift, but it’s highly dependent on what the patient needs because any introducing anything into the airway is going to be irritating to the patient. And the suction catheter is no exception to that. It would be up to the respiratory therapist or nurse to assess if the person needs it and clear out their airway accordingly, because anything that is in the airway can obstruct it and can cause a medical emergency if it’s not treated.
What are the risks of ventilator use in nursing homes?
Schenk:
So this is a naturally occurring mucus or saliva or whatever that might go into the tube itself that could potentially cause a problem.
What are some of the other, what are some of the other risks? That not the underlying chronic condition that you know you need the ventilator for, but literally what are some of the other risks of having a ventilator like that?
Creel:
A ventilator acquired pneumonia is a type of pneumonia that’s unique to someone on a ventilator.
Just because it’s a foreign device and you’re introducing foreign substances and sometimes you’re inserting saline and the normal. Physiologic processes that our airways have to protect us in our nose and mouth may not be present in a tracheostomy. So it’s important to take everything into consideration, use aseptic or sterile technique to everything clean and try to prevent those infections from happening whenever possible.
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Schenk:
What would you be using saline for you? You mentioned saline being in the tube. Is that to clean it?
Creel:
Yeah, so when you are breathing through your nose and mouth, your nose and mouth already, it moistens the air that goes into your airway. So if you don’t have that, if someone’s breathing through a tracheostomy, you don’t have that moisture being introduced.
So there is humidification that is part of ventilation, but sometimes secretions that are produced by the lungs can get thick. And if they’re not lavage, if saline is not introduced whenever it’s needed, it can actually cause mucus plugging and completely obstruct the airway.
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Schenk:
And how often does that does that typically occur or not?
Not how often should you be watching for that, I guess is a better question.
Creel:
So it’s totally dependent on the patient. Some patients have just produced more secretions than others. But it should be assessed at least once a shift, once every four hours. And that can be adjusted depending on how often the patient requires it. But usually at least once a shift.
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Schenk:
Are there any ramifications for having the ventilator through a trach with respect to the wound? ‘Cause there’s a wound, right? Like there’s a, like to have a trach, that necessarily means there is a wound. So is there any effect on the, and I’m using wound and I guess in quotation marks.
Can you talk about that a little bit?
Creel:
So the wound in regards to just the opening that the trach is placed into?
Schenk:
Correct.
Creel:
So the respiratory therapist would be the person that does trach care and they would ensure that the area is clean, do a visual assessment of the area and they would change dressings that are around it because the tracheostomy itself can place pressure on the neck.
Skin around the tracheostomy and cause skin breakdown. So it’s the job of the respiratory therapist and the nurse to continuously assess and try to prevent.
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Schenk:
When the nurse or the therapist approaches for the routine okay, I’m here on this shift. What’s the checklist? What’s, what, what does that individual, what does trach care mean in that particular instance?
Creel:
So trach care. In the setting that I worked in, I actually never had to do trach care, so I would defer to a respiratory therapist to speak the details of it. But from what I’ve noticed as a as a ICU nurse is that they would remove the dressing that’s there change it, do a visual inspection report any changes in skin breakdown and replace the dressings underneath.
They would also take out the inner cannula, which is a, tube that inserts into the tracheostomy, change it if needed. Visually inspect it, make sure that it’s not obstructed by any secretions. Ensure that the ventilation is working appropriately surrounding the trache.
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Schenk:
So in your experience, what are some of the more emergent situations when a patient or a resident has a trach?
Creel:
That’s a great question. When it comes to ventilator care, the nurse is continuously assessing for safety. So when we first come on shift I always double check that the ventilator is functioning, that no ventilator alarms are going off that the patient appears calm. Their vital signs are normal.
In an ICU setting, I always double check my alarm limits. When it comes to alarm limits, those can be adjusted based on the patient’s condition. So I would check to see where my patient’s average respiratory rate is, and if they’re breathing, say 22 times a minute, instead of within the normal range of 16 to 20, then I can adjust my alarm limits to the patient’s comfort so their alarm isn’t going off all day.
So I can adjust it to say, alarm when it gets to 24 and 14 or something like that. So I would adjust all of those parameters for safety. Make sure that they’re oxygenating okay. Make sure that their oxygen saturation is normal. I would bring my stethoscope and do a, auditory inspection out auscultate or listen to their lung sounds.
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And if they have any signs of secretions, then I would suction that patient, make sure that their airway is clear. And if I can hear any audible leak with any of the functionality of the tracheostomy or the ventilator, then I would collaborate with my respiratory therapist or physician if needed just to maintain that person’s safety and ensure that everything is good to go when I leave the room.
Schenk:
It’s okay. Fir first question is, it seems to me that o obviously the patient or the resident being in distress is a good indicator that they need to have a suction done or at least look and see. Then you mentioned that if you hear sounds then they, you might need to a suction.
Yeah. Is there, are there any other kind of telltale signs that tell you, Hey, we need to suction this tray or the vent.
Creel:
Absolutely. So any abnormal changes in vital signs any alarms on the ventilators that may indicate a, an obstruction, like a high pressure alarm would indicate there is an obstruction and pressure is building up on one side of the unit or on the patient side.
So in some cases I would have to disconnect the vent ventilator and, manually ventilate the patient in an emergency or suction the patient. In some cases you would call a code, and have a team come in and help assist the patient. And in any situation you would, try to intervene yourself initially, and if the respiratory therapist is there, collaborate and just call for help early and, I guess they need it maybe cut out early and often, but just trying to identify try to identify any signs of distress early on to prevent any kind of emergency.
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Schenk:
What is the, what is an appropriate O2 said O2 saturation level? What, first of all, what is O2 saturation level, and then what’s a good level?
Creel:
So O2 saturation or oxygen saturation is the percentage of oxygen that’s present in the blood. And a normal SPO two, it would be about above 90 or more. Some patients have. Different respiratory disease processes like chronic obstructive pulmonary disease where they can maintain a lower oxygenation rate.
So in that case, usually COPD patients can maintain like 88 to 96 or so. But once you get below the 88 range, you’re going to need some kind of treatment or different intervention, different vent settings, maybe different physician. There are a lot of different interventions that you can do, but.
You want to keep your patient that’s within a vital sign range that’s compatible with life and comfort.
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Schenk:
How does the how does the nursing staff get the saturation level? Like how do you, is that is that your, are you drawing blood every shift or is it like the little thing on your, the end of your finger?
Creel:
Yeah, that’s a good question actually. You can do both. Continuously you would use a pulse oximeter, which can be placed on a finger. Sometimes people have poor circulation to their fingers, so it can be placed on the ear or a toe or anywhere where it’s a little red light that actually reads the capillary oxygenation saturation.
So you can place it wherever you can get a good reading. Additionally, when a patient is on a ventilator, whenever a ventilator change is made where you’re making significant changes to oxygen concentration or ventilator modes, then the respiratory therapist or nurse would draw an arterial blood gas or a venous blood gas to assess the details of the components of the blood that would reflect oxygenation, acidosis, and things like that.
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Schenk:
So you’ve got a family of a loved one in a nursing home that’s on a ventilator, and they ask you what are some things that we can do as family members that are gonna keep my loved one safe with respect to ventilator maintenance and care and moving forward.
Creel:
So that is, that’s a really great question because a lot of times with these types of patients that are on a ventilator long term, family is very involved and they’re usually really helpful and concerned. And we want to work with family to help everyone feel safe and comfortable. The number one thing is just to. Have a good relationship with your nurse and your respiratory therapist. Don’t ever test the ventilator or any of the components around it because it requires a lot of special training.
And we need to understand, as healthcare providers, we need to know that when we leave the room, things are going to stay the way that we lift them for safety. So just have a good communication with your healthcare providers and if they notice that their loved one is becoming restless or they have.
Skin changes that they just report that to the nurse.
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Schenk:
What would this, how, what would this skin change be an indicator of? Like why is that an important thing to report to the nursing staff?
Creel:
So if you imagine someone that’s in distress, sometimes they would have a sign of agitation, like they would have a scared look in their eyes, or they would have a skin change that would show their skin becoming more pale.
Or in late stages they may have cyanosis, but we want to intervene before, or you have any si cyanotic signs, like or blueish color around the lips.
What are the signs of poor ventilator management?
Schenk:
What would be an observable sign of poor ventilator management?
Creel:
So I think one of the main things that a lay person could look for would be just alarms going off.
If a person has trouble breathing, they’re going to present in an anxious way or as someone that’s gasping for air or restless, and that’s going to be one of the first signs of distress. So if a person appears uncomfortable that would be a sign of distress because if you think about it, anyone on a ventilator is essentially breathing through a straw.
So any change to that oxygen delivery may present with anxiety first and foremost. So if a person appears comfortable and calm, that’s very reassuring.
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Schenk:
Well, Valerie that was extremely insightful and I really appreciate you coming on the show and sharing your knowledge with us.
Creel:
Of course.
Thank you for having me.
Schenk:
Folks, I hope that you found this episode educational or perhaps entertaining. If you have any ideas for topics that you would like for me to discuss, please let me know. If you have ideas for people that you would like for me to talk to, let me know that as well.
Again, there’s also a fire cell on nursing home abuse podcast mugs. If you want one just tell me, okay. I gotta get these things outta my house. And with that folks. We’ll see you next time.
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