As health care reform becomes a reality, extended care facilities will continue to expand the scope of the care provided for individuals. Traditional acute care technology is no longer limited to that setting. In fact, rising acuity is a long-term care dilemma. This article describes the educational program given to staff to prepare them for caring for residents requiring mechanical ventilation.
Mechanical ventilation is fairly commonplace in the acute care setting with the outcome expected to be extubation via a process of weaning or gradual removal from mechanical ventilatory support. The elderly patient whose hospital course of stay is complicated with many comorbidities and other sequelae associated with aging may end up a weaning failure and remain on the ventilator for an extended period of time. It is estimated that between 6,000 and 10,000 persons are on ventilators in the United States, most of whom cannot be weaned (Stoller, 1991). The cost of keeping these patients in the typical critical care unit is excessive. Patients in the acute care setting often have an extended length of stay because the hospital is unable to place the patient on a mechanical ventilator in a long-term care facility. In an attempt to keep health care costs at a minimum, the New York State Department of Health approved the opening of a new extended care facility in 1990 in the metropolitan New York area. The facility was designed to accommodate one unit of "residents" who would live in the facility on mechanical ventilators. This article describes the preparation of nursing staff for the opening of this unit at the facility.
Silvercrest is a 320-bed extended care facility located in Queens, New York. The facility accepted its first resident on a mechanical ventilator in May 1992. Since that time, over 30 patients from area hospitals have been transferred out of the acute care setting and successfully made the transition to extended care. Currently, residents, families and the interdisciplinary health care team have learned to adjust to life in the extended care facility with ventilators. As the staff's confidence and experience grew, expanded programs have enhanced the quality of life for these ventilator-dependent residents.
To obtain New York state approval, an educational program was submitted that included the broad categories needed to insure staff competency. An outside consultant, who was an expert in the management of patients requiring mechanical ventilation, was hired to teach the staff, because the in-house instructor had limited experience in this area.
The educational program included a two-day didactic session for all RNs and LPNs followed by a return visit to test competency, one-on-one, through use of a mannequin with a tracheostomy tube and "balloon lungs" on a mechanical ventilator. The staffing was divided on the ventilator unit - with RNs and certified nursing assistants (CNAs) assigned to the ventilator residents and licensed practical nurses (LPNs) and CNAs assigned the care of nonventilator dependent respiratory residents. Although the staffing was divided, the nursing administration recognized the likelihood that LPNs on this joined unit might respond to a ventilator alarm and might be needed in an emergency to assist the RN, thus education was planned jointly. Both RNs and LPNs attended the same educational sessions and were required to pass the same written and skills competency exam for these reasons. The program also included a half-day session for the CNAs, which was comprised of two hours of didactic lecture, a post-test and a return demonstration of competency on the mannequin.
CONTENT OF THE EDUCATIONAL PROGRAM
The educational program was developed with safety as the focus. The topics covered in the staff development program included disease states leading to ventilatory failure, physiology of the respiratory center and gas exchange, pathophysiological changes in the elderly, advanced assessment techniques, management of a tracheostomy tube, concepts of mechanical ventilation and complications encountered when managing residents on a ventilator.
Because new vocabulary was being introduced to the staff, a list of words and phrases specific to the class content was developed and given to each staff member to use as a reference during the lechare. This facilitated a grasp of the material. The terms that were defined included:
* phrases used in arterial blood gas analysis and/or pulmonary diagnosis and management;
* modes and settings for mechanical ventilators; and
* iatrogenic complications associated with mechanical ventilation.
Although staff were familiar with the use of tracheostomy tubes, many had limited or no experience with a cuffed tracheostomy tube and why it is necessary to maintain the integrity of the airway seal. Thus, explanations and demonstrations were needed. Didactic information about the balloon and tube was given. The balloon on a tracheostomy tube was inflated and then passed around so all program participants could inflate it while gently exerting pressure with their non-dominant hand to mimic pressure against the tracheal wall. In this way, each staff member understood the need for inflating the balloon to the appropriate volume to achieve seal. They also learned why cuff pressure recordings were necessary. This was demonstrated on the mannequin by removing the chest plate, lifting the "lung balloons" up in the air, deflating the tracheostomy balloon and showing the difference in volume delivered. Tube management included the basics of changing tracheostomy ties; suctioning, changing and cleaning the inner cannula; and providing tracheostomy care while the resident is on the ventilator. All of these skills were taught and demonstrated. For the RNs and LPNs this included practice inserting a tracheostomy tube after accidental decannulation.
From an educational point of view, material being taught must be congruent with the policy and procedures of the organization. When matching the content to existing policy it became evident that waiting for a response after placing a call to 911, if a tube could not be inserted, was not acceptable. The staff were made aware that if the tube could not be inserted, adequate ventilation could be achieved through use of a face mask and manual breathing bag until emergency 911 personnel arrived. Thus, this dilemma required adding a policy that ensured that all staff were taught how to use a face mask with a manual breathing bag. The procedure was identical to that taught in Advanced Cardiac Life Support programs and was evaluated via a competency test.
For the CNAs, the didactic lecture included an overview of the respiratory system and an approach on strategies needed to bathe, turn, position, transfer and ambulate a resident on a mechanical ventilator. This segment also included the role of the CNA when responding to ventilator alarms. All were taught how to use a manual breathing bag and oxygenate the resident by bag breathing. This was evaluated during the competency portion of the instruction.
In addition, CNAs were taught how to respond to emergencies. CNAs were taught that responding to an alarm was crucial and that they were expected to assess the resident each time they entered the room. Assessment was accomplished by looking and making sure that the patient's chest was rising with each ventilator breath. If the resident was found not responsive, off the ventilator or gasping for breath, all CNAs were instructed to turn on the oxygen to the manual breathing bag, yell out loudly for help and bag breathe the resident until a nurse arrived. In this way, maximum safety would result.
The use of the manual breathing bag was new to many of the staff. Although several had used them in the past, not all staff could do so comfortably. During the didactic period of the class, a manual breathing bag was attached to a tracheostomy tube and passed around so all participants could squeeze the bag, feel the air delivered to the tube and understand the content of the lecture. Use of the bag connected to oxygen was demonstrated with the mannequin and skill acquisition of bag breathing was practiced and then tested during the competency exam.
Content addressing the mechanical ventilators included the vocabulary, settings on the ventilator, and phrases, such as positive end expiratory pressure (PEEP), pressure support ventilation (PSV), and intermittent mandatory ventilation (IMV). Ventilator alarms and how to provide care to a resident on a ventilator were important topics. During the class, an alarm was described and through the use of "balloon lungs" on the mannequin, was replicated so staff became familiar with the sounds, causes and approaches to dealing with the ventilator alarms.
Although sophisticated knowledge and expertise is desirable, safety was the foremost priority of the program. Assessment and maintenance of a patient's airway was considered critical to safe outcomes. For example, in all types of facilities the fear of inadvertent decannulation is real. In a hospital, a physician, a respiratory therapist, or an experienced nurse anesthetist usually is available to reintubate the patient. In an extended care facility, the nursing and respiratory therapy staff would have to be able to deal with the emergency until 911 responded. To reflect these scenarios, a careful list of emergency situations and strategies to deal with each was developed. The emergency situations included infection/pneumonia, inner cannula decannulation, pneumothorax, tracheostomy balloon rupture or decannulation and ventilator disconnect or failure. During the lecture and at the one-on-one hands-on competency session, all staff were asked to demonstrate how they would respond to one or more emergency situations chosen by the instructor without prior knowledge of the learner.
PROCESS FOR STAFF COMPETENCY
One educational priority was to teach the staff in a setting in which skills could be demonstrated as information was provided. Without a frame of reference about ventilators it would be extremely difficult for staff to relate to what was being taught. Actually seeing the mannequin on the ventilator, hearing the ventilator cycle and seeing the balloon lungs inflate, made learning more concrete and thus easier. In addition, the mannequin had a removable chest plate and the balloon lungs were made visible to the learner, as problems were described. When the ventilator or the manual breathing bag was used, visual confirmation of the impact on the balloon lungs added to overall comprehension of the material. This classroom became the skills lab that was used to assess competency.
All RNs and LPNs had to pass a final written exam of ten questions with a passing grade of 70% or more. When a staff member passed the written exam, all incorrect questions were verbally reviewed until the instructor was confident that the material was learned. When a staff member failed, the questions with explanations for the correct answer were carehilly reviewed with each individual. A repeat exam of the same material then followed, usually within an hour. No one required a third exam but had a failure occurred, the repeat exam was planned for another day. This approach was used to insure that minimal competency would be met regarding emergency actions expected when caring for residents on ventilators.
All RNs and LPNs were scheduled with the instructor for a one-onone demonstration of skill competency. This took place in a classroom setting with a mannequin on a mechanical ventilator. Each staff member had a 1/2-hour performance checkout appointment and each had to successfully complete the written exam before starting the performance checkout. At the performance checkout the instructor asked the learner to demonstrate desired skills including bag breathing with oxygen, suctioning, inflating the tracheostomy balloon, measuring cuff pressure, adjusting the ventilator settings, and responding to alarms. In addition, the instructor chose one emergency scenario and had the staff member demonstrate appropriate management.
A learner was considered competent when the score on the written exam, demonstration of skill competency and individual response to an emergency scenario was considered acceptable. If the staff member scored less than 90% on the written exam or seemed insecure with the equipment or skills, two scenarios were acted out. When the staff member did not do well, all scenarios were acted out and several were repeated until the instructor was satisfied with the level of competency. With the group who did not do well, skill competencies also were repeated. All staff eventually completed competency tests successfully, although some required repeated experiences. All CNAs were asked to give a return demonstration of those skills needed for their level of responsibility, as well.
The participants evaluated the educational program and believed that it was a positive experience. New learning was evidenced by the overall performance of the professional and paraprofessional staff on the post test and skills competency examination. However, several unanticipated problems occurred. Because most RNs who have chosen a career path in geriatric nursing do not have extensive ventilator experience, the facility hired RNs with a critical care background.
Despite extensive lecture during orientation addressing the unique aspects of the resident in an extended care facility, management identified that these RNs were having difficulty making the philosophical transition to extended care. These RNs addressed the immediate needs of the resident as they would have in acute care, but failed to incorporate the quality of life issues, such as the need for socialization, family involvement, participation in the plan of care, and enhanced communication, into their care of the resident. Additional group and individual learning opportunities were provided to help these RNs modify and adjust their approach to resident care. This same problem did not occur with the LPNs and CNAs who had long-term care experience.
Ideally, classroom learning should immediately be reinforced by clinical experience. An unanticipated delay in opening the unit occurred and prevented this from happening. The RNs remained comfortable with ventilator management because of their critical care experience and because many continued to work parttime in acute care with mechanical ventilators. The delay created more of a problem for the LPNs and CNAs. The LPNs needed hands on experience with a resident on a ventilator in a controlled environment. The LPNs also needed reinforcement of the concepts of how a ventilator worked and how to trouble shoot an alarm. This reinforcement was achieved by providing clinical follow up with the respiratory therapist assigned to the unit. However, the clinical instructor did note that the LPNs who had attended the course had an improved understanding of respiratory disease and improved skill with tracheostomy care and suctioning, which is utilized in caring for non-ventilator residents.
When the unit opened, the CNAs were assigned to work with the clinical care coordinator or a staff RN to provide care for the ventilator dependent resident. Because of the admission trends of the ventilator unit, this approach worked initially. Now each new CNA is precepted by another experienced CNA. One of the most difficult aspects for the CNA was developing the skill of actually turning, positioning and moving the resident with all of the additional equipment. Although the CNAs knew how to position the equipment, each had to learn how to be comfortable with it. Working alongside an experienced RN helped them to achieve the necessary confidence and expertise without jeopardizing resident safety or care. The level of competency for this CNA group is seen in their ability to respond appropriately to emergency situations with this resident population.
The nursing implications of the successful opening of this new ventilator unit are far reaching. The success of the educational program is evidenced by resident and family satisfaction and positive resident outcomes. Since opening, five residents who were deemed "unweanable" have been weaned off the ventilator. Utilizing portable ventilators, selected residents participate in group activities, go to rehabilitation therapy and on occasion go out onto the patio to enjoy the fresh air. Improved resident communication has been achieved through the active involvement and commitment of Speech Therapy in team planning of care. Communication aides such as the Passe Muir ® Valve and picture/ letter boards always are in use. Staff at all levels have incorporated resident advocacy and family support in practice. When new challenges are identified, the staff respond appropriately meeting physiologic, psychologic, social and spiritual needs of the ventilator residents who choose to come and live at the unit. Finally, consumers and health care advocates can look to extended care facilities as a potential site for reducing skyrocketing health care costs.
- Stoller, J.K. (1991). Establishing clinical unweanability. Respiratory Care, 36, 186-198.