1. Trends in Alternate Site
LINDE RSS
Respiratory Care Delivery
5/10/2012 1
Trends in equipment
LINDE RSS
More technology
More modalities
Portability
Cost vs reimbursment
5/10/2012 2
1

2. 1940s – 50s
LINDE RSS
5/10/2012 3
LINDE RSS
5/10/2012 4
2

3. Puritan Bennett- LP10
LINDE RSS
Weight 35 Lbs (16 kg)
Patient Size >22 LBS
Internal battery life 1 hours
Hot Swap Battery None
PM Schedule 6k or 1 yrs
Touch Screen No
Proprietary Circuits No
Circuit Type Single limb
Flow Capabilities 20-100 LPM
Oxygen Connection Low flow
Ongoing Cost Low
5/10/2012 5
New Technology
LINDE RSS
Less than 13 lbs
Long battery life
Multiple Modes
5/10/2012 6
3

4. Now a 1 pound device
LINDE RSS
5/10/2012 7
Types of Interfaces
LINDE RSS
5/10/2012 8
4

5. Other Equipment Needs
LINDE RSS
Cough Assist devices (MAC)
— A REQUIREMENT for NIV in PMV patients
Suction Equipment
High Frequency Percussive Ventilation
Airway clearance devices
High flow humidified gases Airvo
5/10/2012 9
Telemedicine
LINDE RSS
5/10/2012 10
5

6. Patient expectations
LINDE RSS
Quality of life
Mobility
Prompt service
5/10/2012 11
LINDE RSS
Meet Matt Johnston.
Matt is a 35 year old ventilator
user who's lifelong
dream was to go scuba diving.
He asked us 2 questions, 1) Is it
possible and 2) will you help me.
We of course said yes to both!
5/10/2012 12
6

7. LINDE RSS
My brother Scott is a diver so he took
the role of Matt and we began the
process of experimenting with
different vents and settings for a
shallow dive.
The results were somewhat out of the
box but doable. We fed the
information to Matt via internet and
cross checked it with clinicians from
across the country.
Although ventilated from the surface
Matt could still get below and
experience the underwater world.
5/10/2012 13
LINDE RSS
He had goals set to extend his time under water
5/10/2012 14
7

8. LINDE RSS
His final goal was to be able to spend an hour
under water. Once he achieved this it was time
for the next step.
Arrangements were made for a dive boat and
team to go along.
Flights were paid for by the vent
manufacturer.
And finally, the Today show was contacted
5/10/2012 15
LINDE RSS
November 14, 2006
Matt made diving history!
He became the first in his
condition to complete two
open water dives in the warm waters
off the Florida Keys!
Cumulative dive time for the day was
25 minutes at a depth of 5 feet.
The Today Show went along……..
5/10/2012 16
8

9. Provider expectations
LINDE RSS
No readmissions..
Training…
Responsibility of partners…
5/10/2012 17
LINDE RSS
TRAINING, TRAINING, TRAINING
Training is key to success in Home ventilation, there are 2 important aspects of training
Internal staff training
— Policies & Procedures
— Equipment
— Clinical training
— On call services – Heavy time commitment on front end
— Laws and regulations
Patient/Family training
— Must be comprehensive
— Must include your staff and hospital staff
— Must be check off and hands on
— Caregivers must be trained to the worst case scenario
— Repetition, Repetition, Repetition
— Don’t be afraid to say NO!
5/10/2012 18
9

10. New care sites & models
LINDE RSS
Green house skilled nursing facilities
Group homes – cross between institution and home
Independent living – younger patients &
older parents
Self directed care
5/10/2012 19
The number one challenge
LINDE RSS
Staying on the edge
&
Keeping up with change
5/10/2012 20
10

11. Less invasive less cost
LINDE RSS
Arterial Blood Gases etCO2 and Pulse Oximetry
Invasive, risk of injury, requires special handling, time Noninvasive, no risk, no special handling, less costly
consuming, costly over time
Aerosalized Meds MDI
Time consuming, requires disposables etc.., of Less time, effective if properly administered, Less
infection, great for acute exacerbations and patients cost, good for long term maintenance,
unable to cooperate
Suction Cough Assist
Invasive, great for rt main stem clearance, Noninvasive, total lung clearance, more comfortable,
uncomfotable, traumatic, risk of infection, requires no trauma, no infection risk, less costly over time, can
equipment and ongoing supplies be self administered
Compressors Airvo
Loud, space consuming, cool particulate matter, risk Quiet, high flow, vapor, less infection risk
of infection,
5/10/2012 21
Practice Standards
AARC CPGs LINDE RSS
http://www.rcjournal.com/cpgs/index.cfm
•Application of Continuous Positive Airway Pressure to Neonates Via Nasal Prongs, or
Nasopharyngeal Tube, or Nasal Mask 2004 Revision & UpdateHTMLPDF
•Assessing Response to Bronchodilator Therapy at Point of CareHTML
•Bland Aerosol Administration 2003 Revision & UpdateHTMLPDF
•Blood Gas Analysis and Hemoximetry 2001 Revision & UpdateHTML
•Body Plethysmography 2001 Revision & UpdateHTMLPDF
•Bronchoscopy Assisting PDF
5/10/2012 22
11

12. AARC QRCR Standards
LINDE RSS
AARC - LTC QUALITY RESPIRATORY CARE RECOGNITION
I attest that this organization adheres to the following respiratory care standards:
• All respiratory therapists who are employed or contracted by the long term care facility to deliver
bedside respiratory
care services are either legally recognized by the state as competent to provide respiratory care
services or hold the CRT
or RRT credential in non-licensed states.
• All respiratory therapy employees must have completed background checks.
• For routine care and patient assessment, respiratory therapists are available 24 hours a day.
• Respiratory therapists provide patient assessments and make clinical recommendations
regarding the service needs and
plan of care for the respiratory-impaired residents to respective physicians.
• A policy and procedure manual that is reviewed annually and addresses the provision of
respiratory care and services is
available at the facility.
•
5/10/2012 23
LINDE RSS
•A competency-based training program shall be in place for personnel administering respiratory
related care.
• A doctor of medicine (preferably a pulmonologist) or osteopathy is designated as a medical
director of respiratory care services.
• A preventive maintenance program must be in place for all RT equipment.
• An established respiratory QA/PI program must be in place.
• The medical director reviews plan of care at least weekly in facilities providing ventilator care and
at least monthly in
facilities providing only routine respiratory care.
• In facilities that provide ventilator management, respiratory therapists are available 24 hours per
day within the facility.
• All ventilator systems shall have a remote external alarm system and an emergency back-up
power source.
I will notify the AARC in writing when any of these standards cannot be upheld.
5/10/2012 24
12

13. Ventilator and High Acuity
RC Standards LINDE RSS
American Association for Respiratory Care
Position Statement
Delivery of Respiratory Therapy Services in Skilled Nursing Facilities
Providing Ventilator and/or High Acuity Respiratory Care
Skilled nursing facilities are increasingly becoming the venue for the management of patients
who require the full array of respiratory therapy services, from oxygen therapy and inhalation
medication management to pulmonary rehabilitation and ventilator management. Skilled
nursing facilities should recognize the clinical value to the patient of utilizing a respiratory
therapist to provide the complete spectrum of services that respiratory therapists are both
educated and competency tested to provide.
The American Association for Respiratory Care recommends that the basic standard of care for
skilled nursing facilities be to employ Respiratory Therapists to render care to patients.
Additionally, the following basic standards are recommended to ensure the safe and efficient
delivery of respiratory therapy services in skilled nursing facilities delivering ventilator and/or
high acuity respiratory care:
5/10/2012 25
LINDE RSS
• A Certified, or Registered, Respiratory Therapist—licensed by the state in which he/she is practicing if
applicable—will be on site at all times to provide ventilator care, monitor life support systems, administer
medical gases and aerosol medications, and perform diagnostic testing.
• A Pulmonologist, or licensed physician experienced in the management of patients requiring respiratory
care services (specifically ventilator care), will direct the plan of care for patients requiring respiratory
therapy services.
• The facility will establish admission criteria to ensure the medical stability of patients prior to transfer
from an acute care setting.
• Facilities will be equipped with technology that enables it to meet the respiratory therapy, mobility and
comfort needs of its patients.
• Clinical assessment of oxygenation and ventilation—arterial blood gases or other methods of monitoring
carbon dioxide and oxygenation—will be available on site for the management of patients receiving
respiratory therapy services at the facility.
• Emergency and life support equipment, including mechanical ventilators, will be connected to electrical
outlets with backup generator power in the event of power failure.
• Ventilators will be equipped with internal batteries to provide a short term back-up system in case of a
total loss of power.
• An audible, redundant ventilator alarm system will be located outside the room of a patient requiring
mechanical ventilation to alert caregivers of a ventilator malfunction/failure or a patient disconnect.
• A backup ventilator will be available at all times that mechanical ventilation is being provided to a
patient.
5/10/2012 26
13

14. LINDE RSS
Iron lung rides
$5 to enter $500 to get back out
Iron
lu ng ri
des
$500 !! $5
5/10/2012 27
LINDE RSS
gene.gantt@linde.com
931-239-0123
5/10/2012 28
14