Equipment Used in Home Health Setting

1. Equipment Used in Home Health Setting October 2013 CE Condell Medical Center EMS System Site Code: 107200E-1213 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the EMS provider will be able to: • Discuss population served by Home Health Care or in need of specialized equipment. • Discuss the psychosocial concerns patients experience when receiving home health care. • Describe various pieces of equipment used in the home care population • Describe EMS care related to the piece of equipment while transporting the patient

3. Objectives • Actively participate in case scenario discussion. • Actively participate in review of equipment typically present in the home setting of chronically ill patients. • Successfully complete the post quiz with a score of 80% or better.

4. Population Served by Home Health Care • A patient being discharged from an acute care setting • To home • To skilled nursing facility • Nursing home • Assisted living • Rehabilitative services • Patient care continuing with some type of device or specialized care required that promotes health and well-being

5. Psychosocial Aspects of Home Health Care Patients • Patient and caregiver(s) have received education on the medical condition and equipment • Use them as a resource – they may know better • Some patients are sick and tired of being sick and tired • Patient and caregiver may not be at their best and can be frustrated, angry, short tempered • We are caring for people who are at their lowest • Treat the patient and caregiver as you would want your family member treated

6. EMS Interaction with Patients Receiving Home Health Care • You may know more about medicine in general but the patient and family/care giver know more about the patient’s medical condition and equipment than you do (usually) • Use the resources at hand when dealing with additional equipment that is foreign to you

7. Oxygen Trach tubes Ventilators Central lines PICC lines NG tubes PEG tubes Dialysis Foley catheters Suprapubic tubes Nephrostomy tubes Ostomies Colostomy Ileostomy Wound vacs Typical Equipment in the Home Health Environment

8. Home Oxygen • Patient on home oxygen would be transferred to EMS O2 source • When turning off any O2 tank, bleed down the valve • Prevents inadvertent leakage of oxygen through an open system • Turn valve off (counter clockwise) • Turn up flow rate • When needle bleeds down to “0”, turn flow rate to “0” • Prevents damage to O ring

9. Oxygen Concentrator • Device resembles a dehumidifier and concentrates oxygen from ambient gas removing Nitrogen to deliver an oxygen rich supply (approx 97-98%) • Typically can deliver 1 – 5 lpm of O2 • This device allows the patient unrestricted mobility – can run on batteries • Would be useful in a power outage

10. Tracheostomy • Surgical opening in the anterior wall of the trachea to facilitate breathing • Air bypasses the pharynx and larynx • Generally, patients are unable to speak • May be taught/trained depending on trach tube size, design, and condition of larynx • Can be placed when there is obstruction present • Used to obtain an airway due to injuries or surgery to the head and neck area • Used to prevent the risk of aspiration in patient with poor cough/gag reflex

11. Tracheostomy • Introduction of obturator • Similar to placing a QuickTrach • Tube being placed into position in trachea • Trach tube in place • Inner cannula separated from outer cannula

12. Tracheostomy • Potential complications • Loss of tube patency (i.e.: secretions, mucous plugs) • Displacement of tube • Assessment • Signs / symptoms respiratory distress? • Decreasing oxygen saturation? • Tachycardia/bradycardia? • Hypotension? • Decreasing level of consciousness?

13. Tracheostomy • Typical equipment • Outer cannula inserted into trachea • Cuff at distal tip protects airway against aspiration • Cuff allows positive pressure ventilation • Some tubes are uncuffed for some populations • Inner cannula inserted through the outer cannula • Device secured in place with trach ties around the neck

14. Tracheostomy - Trach Tubes • Equipment may consist of a fenestrated (hole(s) in tube) or non-fenestrated tube • Fenestrated tube facilitates ease of producing a voice; used during the weaning process • Trach can also be “plugged” during weaning • Trach tubes have an inner cannula in place • Inner cannula removed every day for cleaning • Spares are generally kept with the patient

15. Tracheostomy • EMS care • Assess the patient’s airway status • Be prepared to assist with ventilations • BVM connects to universal 15mm proximal end of trach tube • Some long term trachs have shorter profiles that don’t connect to BVM’s • Be prepared to suction patient • Limit time to 10 seconds per attempt • If possible, allow patient to reoxygenate between suctioning attempts • Enrich environment with blow-by O2 • Hold O2 tubing next to trach opening

16. Ventilators • Used for patients unable to ventilate / breath on their own • Patient would have a tracheostomy (“trach”) tube if home on a vent • Ventilators can be set to assist with the patient's own breaths or totally control the patient’s breathing

17. Ventilators • If patient must be transported, continue to keep patient ventilated • If ventilator is small enough and can be transported with patient, do so • If patient cannot be transported with ventilator, would need to ventilate patient via BVM • Pay particular attention to maintain the patient ventilation rate as set by ventilator • In absence of knowledge of pre-set rate, follow AHA ventilation guidelines for advanced airway device • Neonate – 1 breath every second • Infant and child – 1 breath every 6 seconds • Adult – 1 breath every 6 seconds

18. Central Lines • These lines are placed in a large vein • Intended for long term use (i.e.: months or years) • Generally placed under general anesthesia by a surgeon • Prevents repeated needle sticks through the skin into a vein • Used to administer medication and fluids directly into the bloodstream • Blood products can be administered • Blood for lab work can be withdrawn

19. Central Lines • Hickman or Broviac PICC line Port-a cath

20. Central Lines – Hickman or Broviac • Long silicone catheter inserted into a large vein (i.e.: superior vena cava) directly into the heart • May be one or two separate lumen catheters • Cuff just under skin helps to anchor catheter in place • Cuff also blocks bacteria from migrating into bloodstream • Initially, visible sutures secure catheter in place until cuff is adhered to tissue • Meticulous care necessary at exit site

21. Central Lines – Port-a cath • Port totally implanted under the skin providing access to central venous circulation • Port has a reservoir with injectable septum • Catheter attached to reservoir is threaded into large vein leading to heart • Port placed under general anesthesia by surgeon • Most placed under collarbone • May be placed under arm on chest wall or in abdominal area • Port requires no special care for skin care Device implanted below the skin surface

22. Central Lines - PICC • Peripherally inserted central line • May have single or multiple lumens • Inserted into a peripheral vein, generally in the upper arm • Catheter advanced until tip terminates in a large vein in the chest near the heart • Point of entry is from the periphery • Inserted under the benefit of ultrasound by specially trained staff • Can remain in place for a longer duration than other central or peripheral access devices

23. Central Lines – PICC cont’d • Used for • Prolonged antibiotic therapy • Medication administration • Prolonged nutrition • Chemotherapy • Blood draws for lab work • Home or sub-acute treatment at home for long periods • Lower complication rates over alternative central lines

24. PICC Lines

25. Central Lines and EMS Care • EMS must protect site from potential infection • Dressings should remain in place • Wet or loose dressings increase risk for infection • Avoid pulling/tugging on lines • NEVER access site • This is a central line • Some sites need specialized equipment • A meticulous protocol is followed to access site • Appropriate PPE equipment is worn when dressing changes are performed

26. Central Lines and EMS Care • Avoid obtaining B/P in arm cannulated with PICC • Do not use scissors around the catheter site to avoid inadvertently cutting the catheter • Avoid getting the dressing wet • Never flush the catheter for the patient • Catheters are flushed daily and must follow a set protocol • Solutions may include saline and/or heparin

27. Nasogastric Tubes • This is a tube inserted though the nose or mouth and into the stomach • Used to allow drainage of the stomach or to provide nutrition when the patient is unable to take oral food and liquids themselves • J-tube (Dobhoff tube) is a weighted tube that passes through the stomach, past the pyloric sphincter, and ends in the jejunum

28. Nasogastric (NG) Tubes • Typical patient • Any patient unable to swallow due to change in anatomical structures or for disease • EMS care • If tube is clamped off, leave it as is • If tube feeding in process and cannot be disconnected, transport with patient in same position (usually upright) and tube feeding bag at same height

29. Nasogastric (NG) Tubes – EMS Care • Do not put anything into tube • Tube placement must ALWAYS be confirmed prior to administering anything into it • Tube may have slipped from esophagus into the trachea • All medications must be well dissolved and in liquid form • If tubing is misclamped, may start leaking from ports • Cover end of tubing with gauze • Inform nurse upon arrival at hospital • If tube is not properly flushed when disconnected, may become plugged • Inform ED staff if NG tube not flushed when disconnected

30. PEG Tube • Percutaneous endoscopic gastrostomy • A soft, plastic tube inserted into stomach through the abdominal wall • May be permanent or temporary • Typical patient • Patient unable to eat or drink and this allows for feedings • May be fed via a syringe, gravity drip bag or feeding pump

31. PEG Tube cont’d • Precautions • Skin care is required daily around insertion site • Hub of tube (tube opening) needs to be cleaned daily • Tube must be flushed before and after each use

32. PEG Tube cont’d • EMS care • If PEG tube is clamped, leave clamp in place • Do not pull on tube • Bumper around end of tube should be flush and snug to the skin • If tube feeding is in process, can maintain equipment at same height and transport patient • If tube comes out, patient needs to have tube replaced at hospital right away • Stoma can start to close within 2 hours

33. Dialysis • A life saving procedure to substitute for normal duties of the kidneys • Filtering of waste products from blood • Regulation of the body’s fluid balance • 2 types used • Hemodialysis • Mature, healthy fistula site can be used for many years • Peritoneal dialysis

34. Dialysis • Peritoneal • Hemodialysis

35. Dialysis cont’d • Typical patient • Patient in kidney failure • Can be an acute event or a chronic condition • Condition often monitored by measuring the blood levels of creatinine and blood urea nitrogen (BUN) • Increasing levels indicate the decreasing ability of kidneys to cleanse the body of waste products

36. Hemodialysis • Hemodialysis • Use of a special filter to remove excess waste products and water from the body • Blood passes from the patient's body through a filter in the dialysis machine • A needle is placed into the graft or fistula • Blood is delivered to the dialysis machine • Blood is filtered • Blood is returned to the patient

37. Hemodialysis Try to • AV Fistula • Connection of a vein and an artery in your arm • Allows blood from body to be pulled out into dialysis machine and then put back into the body • The physician assesses for the best site (i.e.: a strong vein and artery) • The fistula will most likely be needed for a long time • Graft • A plastic tube placed between an artery and a vein in the arm or leg

38. Hemodialysis cont’d • Patients generally in treatment 3 times per week on alternating days • Treatment lasts from 2½ to 41/2 hours • A working fistula is a life insurance policy

39. Peritoneal Dialysis • Patient’s own body tissues inside abdominal cavity act as the filter • Plastic tube placed though abdominal wall into abdominal cavity • Special fluid flushed into abdominal cavity and washes around the intestines • Intestinal wall acts as filter between fluid and blood stream • Fluid drained out back into a collection bag

40. Peritoneal Dialysis cont’d • Patient has a major role in maintaining a clean surface on the abdominal wall to prevent infection • Each procedure takes 30 minutes to accomplish • Procedure repeated 4 – 5 times a day 7 days a week • As an alternative, patient may use a special machine every night • 5 – 6 bags of dialysis fluid used in the exchange while the patient sleeps

41. Dialysis • Care by EMS • NEVER place tourniquets or B/P cuffs on extremity with graft or fistula • NEVER start an IV in the extremity with a graft or fistula • If peritoneal dialysis is in process, maintain bag at same height • If draining into patient, will be elevated like an IV bag • If draining from patient, will be lower than the patient's waist

42. Foley Catheter • Closed drainage system device to drain the urinary bladder • Catheter is placed through the urethra into the bladder • A water filled balloon holds the catheter in place • External tubing then secured to the patient • Typical patient • Debilitated patient • Comfort to keep patient clean and dry and free from skin breakdown due to exposure to urine • Non-functioning urinary system

43. Foley Catheters cont’d • Indications • Need to drain the bladder of urine • Catheter allows for continuous drainage of urine • Catheter held in place by water filled balloon at end of tube inserted into bladder via the urethra • Usually 10 ml of saline/water in balloon

44. Urine Drainage Bags • Bedside drainage bag • Usually worn when at home Typically worn at night • Caution with length of tubing that it does not get “caught” on anything • Leg bag • Typically worn when out of the house • Usually secured with straps to the leg

45. Foley Catheter cont’d • Care by EMS • NEVER pull on foley catheter • ALWAYS keep drainage bag below the level of the patient’s waist • Prevents back flow of urine into bladder to reduce the risk of infection • Do NOT lay drainage bag on floor • Catheter often secured to the patient’s thigh or abdomen without tension on the tubing

46. Suprapubic Catheters • Surgically implanted catheter through the abdominal wall and into the urinary bladder • Held in place with water filled balloon

47. Suprapubic Catheters • Typical patient • Alternative route used when a catheter cannot be passed through the urethra due to obstruction • Can be used for patients with a neurogenic bladder • Bladder does not contract to empty urine • Often found in patients with spinal cord injury • Indications • Used for long term use to drain the urinary bladder

48. Suprapubic Tubes cont’d • EMS care • NEVER pull on foley catheter • ALWAYS keep drainage bag below the level of the patient’s waist • Prevents back flow of urine into bladder to reduce the risk of infection • Do NOT lay drainage bag on floor

49. Nephrostomy Tubes • Urinary drainage device surgically implanted into the renal pelvis of the kidney • Consists of a nephrostomy tube and a collection bag • Typical patient • Used in patients with some form of kidney disease • Allows for drainage of urine from the kidney when normal urinary flow is impeded or obstructed • Often used for urinary obstruction such as a renal stone

50. Nephrostomy Tubes • Indications • Permits drainage of urine from the kidneys • Catheter tube may be sutured in place or secured with velcro-like device to a wafer dressing similar to ostomies • Precaution • Increased risk of infection due to direct pathway to the kidney