Consensus Statements

Mechanical Ventilation: Beyond the ICU
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Planning for Discharge to a Non-ICU Site, Care,
and Rehabilitation

A Discharge Planning Team identifies all patient-care issues to be resolved prior to discharge and develops a discharge plan to facilitate transfer. Members of the Discharge Planning Team include:

• patient and family members;
• physician (with overall responsibility for prescriptions and for team function);
• social service/hospital discharge planner;
• staff nurse or pulmonary nurse specialist;
• respiratory care practitioner (RCP);
• durable medical equipment (DME) provider;
• home health agency or alternate site representative;
• occupational therapist (as needed);
• physical therapist (as needed); and
• case manager.

The Discharge Plan, customized to meet the needs of the patient as identified by the Discharge Planning Team, provides:

• Assessment of the long-term facility environment—geographic location, available space, accessibility.
• Assessment of long-term facility resources—professional services, support systems, patient's financial resources.
• Assessment of caregivers—skill, education, psychological characteristics.
• Education and training—of patient, family, local emergency services such as fire and police regarding care of the patient and equipment and emergency measures; a comprehensive education plan should have defined learning objectives and a method of evaluation.
• Plan of care—a written, comprehensive management plan for both respiratory and medical care.

Table 5 is a checklist of equipment and supplies for the VAI beyond the ICU.

Table 5—Checklist of Equipment and Supplies That Should Be Considered for Ventilator-Assisted Patients Beyond the ICU*

Mechanical ventilator† Primary Secondary or backup system (portability†) 12-V battery and connecting cable for emergency (power source†) Ventilator circuit† Exhalation valve Tracheostomy tube adapter/connector Humidifier† Humidifier and heater Humidifier bracket Heat and moisture exchanger Manual resuscitator Oxygen† Oxygen supply system (stationary and portable) Oxygen bleed-in adapter to ventilator Oxygen tubing Tracheostomy collar or t-tube adapter Nasal cannulae Noninvasive patient interfaces Face mask Nasal mask or nasal pillows Mouthpiece: customized, standard, lipseal Head gear, chin straps Suction machine (stationary and portable)á Suction catheters Connecting tubing Suction collection container Gloves Other secretion clearance aids such as cough inex-sufflator† Disinfectant solution Vinegar/water 1:3 Quaternary ammonium compound Tracheostomy supplies Spare tracheostomy tube (including next smaller size) 10-mL syringe used only to inflate or deflate cuff Hydrogen peroxide Tracheostomy dressings or Velcro trach tube strap Tracheostomy tape Sterile saline solution Antibiotic ointment Cotton-tipped applicators Monitors and alarms for ventilator and patient† Patient communication system† Compressor for aerosolized medications Wheelchair Hospital bed and mattress Commode, bedpan, urinal, or elevated toilet seat Patient lifter Safety bars in bathroom Hand-held shower Shower chair

*Modified from O'Donohue et al. CHEST 1986; 90(suppl):1S-375

†See text for special considerations concerning these items.

Table 6 is a respiratory care plan checklist.

Table 6—Respiratory Care Plan Checklist*†

Mechanical ventilator Type and characteristics (including backup when indicated) Manual resuscitator Ventilator power source Electrical requirements Battery/generator powered Ventilator circuit Detailed description of circuits Description of alarms Instructions for cleaning, assembly, and use; documentation of the education of caregivers Use of ventilators Specific times on and off the ventilator FIO2 and range of oxygen Mode of ventilation Desired change with exercise or sleep Acceptable limits of dialed/measured exhaled volume Desired pressure ranges Appropriate alarms and monitors For ventilator dysfunction, power failure For high and low pressure, exhaled volume Others as needed Notification of local emergency care facilities Name and type of artificial airway* Size and type Cuffed or uncuffed, fenestrated Double or single cannula Instructions for care of artificial airway* Cuff inflation (conditions for inflation/deflation) Airway care plan (tube changes, cleaning, problem solving) Airway suctioning Speaking tube operation, if appropriate Adjunctive techniques Medications Aerosol (bronchodilator) Chest physiotherapy Oxygen therapy Secretion clearance devices Communication systems Intercom Physical sound (bell/siren) Telephone/beeper system

*For invasive ventilatory support only. List should be tailored to needs of individual patient.

†Modified from O'Donohue et al. CHEST 1986; 90(suppl):1S-375

Follow-up care includes periodic visits by a member of the home care team to assess the patient, caregivers, and the environment. The team members who visit most regularly may be the representative of the DME supplier or the representative of the home health agency; their findings and relevant observations should be communicated to all members of the team.

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