Next up on the CMSCG Blog “Ftag of the Week” series, we will be reviewing F695 Respiratory/ Tracheostomy Care and Suctioning, which is part of the Quality of Care regulatory group. This regulation requires that a resident who needs respiratory care is provided with appropriate care that is consistent with the resident’s comprehensive care plan, goals and preferences and professional standards of practice. This includes tracheostomy care and tracheal suctioning as well.
Per Appendix PP of the State Operations Manual, a review of MDS data shows that the most frequent respiratory diseases/ syndromes for nursing home residents are:
- Pneumonia
- Asthma
- COPD
- Chronic lung disease
- Respiratory failure
- Shortness of breath (with exertion, during illness or when sitting at rest or lying flat)
- Acute respiratory distress syndrome
- Lung cancer
- Obstructive sleep apnea
- History of TB
As with any specialized service, a facility is expected, as part of its Facility Assessment, to determine whether it has the capability and capacity to provide needed respiratory care and services for a resident with a diagnosis or syndrome that requires specialized respiratory care/services. This includes ensuring that there is sufficient and competent, qualified staff to care for a resident who is determined to have these needs on admission. Treatment/modalities can include respiratory treatment/therapy, oxygen therapy, use of BiPAP or CPAP, trach and/or suctioning, and mechanical ventilation.
Definitions
Let’s review some definitions – there’s plenty in this regulation to review, but here are some of the key terms for reference.
“Respiratory Therapy Service” – Services provided by a qualified professional (i.e., respiratory therapist or respiratory nurse) for the assessment, treatment, and monitoring of residents with deficiencies or abnormalities of pulmonary function.
“Oxygen therapy” – Administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia.
“Hypoxia” – Decreased perfusion of oxygen to the tissues.
“Tracheotomy or Tracheostomy” – Opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube. This procedure is commonly done in an operating room under general anesthesia. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is then accomplished via the tracheostomy tube rather than through the nose and mouth. “Tracheotomy” refers to the incision into the trachea that forms a temporary or permanent opening, which is called a “tracheostomy,” however the terms are sometimes used interchangeably.
“Obstructive Sleep Apnea (OSA)” – Apnea syndromes due primarily to collapse of the upper airway during sleep.
“Mechanical Ventilation” – A life support system designed to replace or support normal ventilatory lung function.
“Noninvasive ventilation (NIV)” – Administration of ventilatory support, including BIPAP/CPAP without using an invasive artificial airway (endotracheal tube or tracheostomy tube).
“Bi-level positive airway pressure (BiPAP)” – Non-invasive ventilation machine that is capable of generating two adjustable pressure levels – IPAP (high amount of pressure, applied when the patient inhales) and a low Expiratory Positive Airway Pressure (EPAP) during exhalation.
“Continuous positive airway pressure (CPAP)” – Non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure.
Policies, Practices and Staffing
Prior to admitting a resident who requires specific types of respiratory care/services, the facility, including the Medical Director, Director of Nursing and Respiratory Therapist, as indicated, must develop the necessary policies and procedures related to these services. It’s important that there are policies and procedures for every type of respiratory care and service provided in the facility, whether it is oxygen use, aerosol drugs used for respiratory treatments, infection control considerations and emergency care. Let’s not forget, if your facility uses liquid oxygen and staff are responsible for the refills, you need to have a policy and procedure in place as well as ensuring that the storage of the liquid oxygen is maintained as per code and trained staff complete the refilling.
It’s important that there are policies and procedures for every type of respiratory care and service provided in the facility.
Once the facility has determined the services it will offer, it must ensure that sufficient numbers of qualified, competent staff are available to provide care and services and that they have been thoroughly trained on the facility’s protocols. The facility is also expected to identify which staff have the authority to perform each type of respiratory care provided, including trach care, suctioning and responding to alarms for mechanical vents. There have been many unfortunate negative outcomes over the years related to staff failure to provide these services in a timely and competent manner. Remember that you also need to have a system in place for maintenance of ventilators, if in use by your facility, and the associated back-up battery. Who in your facility is trained and competent in this area?
In Part 2 of our CMSCG Blog series for F695, we will look at staff competencies and some different types of respiratory care and services outlined in this regulation.
