Reprinted from the December 1995 issue of RESPIRATORY CARE [Respir Care 1995;40(12):1308–1312]
AARC Clinical Practice Guideline
Discharge Planning for the Respiratory Care Patient
DPRP 1.0 PROCEDURE:
Development and implementation of a comprehensive plan for the safe discharge of the respiratory care patient from a health care facility and for continuing safe and effective care at an alternate site.
DPRP 2.0 DESCRIPTION:
The discharge plan is the mechanism that guides a multidisciplinary effort to achieve the successful transfer of the respiratory care patient from the health care facility to an alternate site of care. Implementation of the discharge plan is used to assure the safety and efficacy of the continuing care of the respiratory care patient.(1-10)
The discharge plan includes: 1) evaluation of the patient for the appropriateness of the discharge; 2) determination of the optimal site of care and of patient-care resources; and 3) determination that financial resources are adequate.
DPRP 3.0 SETTING:
The discharge plan can be developed at any site at which the respiratory care patient resides.
DPRP 4.0 INDICATIONS:
Discharge planning is indicated for all respiratory care patients who are being considered for discharge or transfer to alternate sites including the home. The alternate site may provide a higher or lesser level of care (depending on the patient's condition). The discharge plan should always be developed and implemented as early as possible prior to transfer.(11-13)
DPRP 5.0 CONTRAINDICATIONS:
There are no contraindications to the development of a discharge plan.
DPRP 6.0 HAZARDS/COMPLICATIONS:
Undesirable and/or unexpected outcomes may occur if the patient is discharged prior to the full implementation of the discharge plan. An undesirable and unexpected patient outcome may be a hazard or complication of the discharge plan; however, not all undesirable outcomes can be attributed to the discharge planning process but may be a result of the natural course of the disease or other factors beyond the control of the discharge planning process.
DPRP 7.0 METHOD:
Discharge planning and implementation should begin as early as possible. The complexity of the plan is determined by the patient's medical condition, needs, and goals. Members of the discharge planning team and their responsibilities should be identified and a coordinator specified. The steps in the planning process are:
- 7.1 Patient evaluation:(2,8,11,14-16)
- 7.1.1 The patient's medical condition
- 7.1.2 The respiratory and ventilatory support required.(1,11,17)
- 126.96.36.199 Mechanical ventilation
- 188.8.131.52.1 Type, method of application, and duration
- 184.108.40.206.1.1 Positive-pressure, negative-pressure, or other (eg, pneumatic belt, rocking bed, diaphragm pacer)
- 220.127.116.11.1.2 Invasive (via tracheostomy) or noninvasive (all methods that do not include tracheostomy)
- 18.104.22.168.1.3 Continuous--requiring > or = 20 hours of ventilator assistance per day(18) or noncontinuous, which may be nocturnal only (requiring assistance only during hours of sleep) or other--requiring > 8 but < 20 hours of ventilator assistance per day.
- 22.214.171.124 Other respiratory care and equipment:
- 126.96.36.199.1 Oxygen therapy
- 188.8.131.52.2 Aerosol therapy
- 184.108.40.206.3 Airway clearance therapy
- 220.127.116.11.4 Monitoring and diagnostic procedures
- 18.104.22.168.5 Treatment for sleep-disordered breathing
- 7.1.3 The patient's physical and functional ability, including acute and chronic neuromuscular conditions, other conditions, and activities of daily living.(1,12,14)
- 7.1.4 The patient and family's psychosocial condition
- 7.1.5 The patient and family's desires for medical and ventilator care.(1,12,19-22)
- 7.1.6 The goals of care(1,5,11,14,23) from the perspective of the patient and family, the patient's physician, the health-care professionals who have and will be involved in the patient's care, and the bedside caregivers.
- These may include:
- 22.214.171.124 treatment of acute medical conditions;
- 126.96.36.199 weaning;
- 188.8.131.52 rehabilitation;
- 184.108.40.206 assurance of optimal quality of life.
- 7.2 Site evaluation for continuing care
- The primary factors to be considered in site determination are the goals and needs of the respiratory care patient. These goals and needs should be met in an optimal and cost-effective manner using the resources available at the alternate site.(1,3,5,8,11,22,24-30)
Possible sites for the respiratory care patient include acute, intermediate, and long-term care facilities, such as long-term acute, subacute, rehabilitation, skilled nursing facilities, and home. The respiratory care patient may transition among the sites according to changing medical condition.
- The site must be evaluated for available resources:
- 7.2.1 Personnel
- 220.127.116.11 The staff of the selected health-care facility
- 18.104.22.168.1 must clearly demonstrate and have documented (by the time of discharge) the competencies required for the patient's ventilatory and respiratory needs;
- 22.214.171.124.2 must be able to provide other health-care services as may be indicated (eg, occupational and physical therapy).
- 126.96.36.199.3 must be adequate for 24-hour coverage;
- 188.8.131.52 For discharge to the home:
- 184.108.40.206.1 The ability of the caregivers to learn and perform the required care must be evaluated.
- 220.127.116.11.2 The caregivers must clearly demonstrate and have documented (by the time of discharge) the competencies required for caring for the specific patient.
- 18.104.22.168.3 Availability of caregivers (lay and professional) for each 24-hour period must be assured.
- 7.2.2 The chosen site must be capable of operating, maintaining, and supporting the equipment required by the patient's medical condition. This should include both respiratory and ancillary equipment and supplies as needed, such as the ventilator, suction, oxygen, intravenous therapy, nutritional therapy, and adaptive equipment.(1,14)
- 7.2.3 Physical environment--The physical environment must be evaluated for safety and suitability. It should be(1,2,8,14, 20,31,32) free of fire, health, and safety hazards; provide adequate heating, cooling, and ventilation; provide adequate electrical service; provide for patient access and mobility with adequate patient space (room to house medical and adaptive equipment) and storage facilities.
- 7.3 Financial resources--Financial resources must be identified at the beginning of the discharge process. Lack of funding or inadequate funding impacts the entire discharge plan and can determine the care site.(1,2,5,6,8,11,16,19,20-22,25,27,28,33) It is essential to determine sources and adequacy of funds for alternate-site care, medical equipment and supplies, the required medical personnel, any modifications necessary to environment, and ongoing medical care.
- 7.4 Development of the plan of care--A multidisciplinary plan of care is developed based upon the evaluation of the patient's needs and goals. The plan should be consistent with recommended practices and guidelines for the patient's condition.(1,6,8,10,11,14,19,20,34,35) Key elements should include delineation of
- 7.4.1 plan for integration into the community;
- 7.4.2 plan for patient self-care as appropriate;
- 7.4.3 roles and responsibilities of team members for daily care management;
- 7.4.4 documented mechanism for securing and training additional caregivers;
- 7.4.5 alternative emergency and contingency plans;
- 7.4.6 plan for use, maintenance, and troubleshooting of equipment;
- 7.4.7 plan for monitoring and appropriately responding to changes in the patient's medical condition;
- 7.4.8 medication administration;
- 7.4.9 method for ongoing assessment of outcomes;
- 7.4.10 time frame for implementation;
- 7.4.11 method to assess growth and development of pediatric patients;
- 7.4.12 follow-up (eg, medical, respiratory care);
- 7.4.13 mechanism for communication among all members of healthcare team.
- 7.5 Education and training with clear demonstration and documentation of competencies must occur prior to discharge. Education and training must address key elements of the plan of care.(1,2,6-9,17,22,27,28,30,33,36-38)
- 7.6 Limitations of method:
- Barriers to full implementation and discharge may occur due to(1,25,30,34,39)
- 7.6.1 patient's medical condition;
- 7.6.2 lack of availability of appropriate site;
- 7.6.3 lack of financial and patient care resources;
- 7.6.4 patient/family desires and cooperation;
- 7.6.5 failure to identify all pertinent problems or needs (including problems stemming from language or other barriers to communication).
DPRP 8.0 ASSESSMENT OF NEED:
All patients with a primary respiratory diagnosis should be assessed for the need for a discharge plan.
DPRP 9.0 ASSESSMENT OF OUTCOME:
The desired outcome of the discharge plan is determined by(19,40)
- 9.1 no re-admission to an alternate care site due to discharge plan failure;
- 9.2 satisfactory performance of all treatments and modalities by caregivers as instructed;
- 9.3 caregivers' ability to assess the patient, troubleshoot, and solve problems as they arise;
- 9.4 the treatment's meeting the patient's needs and goals;
- 9.5 the equipment's meeting the patient's needs;
- 9.6 the site's providing the necessary services;
- 9.7 the patient and family's satisfaction.
DPRP 10.0 RESOURCES:
The discharge planning process requires(1,3,5-8,16,22,31)
- 10.1 a written discharge plan that clearly delineates
- 10.1.1 the educational materials, training aids and assessment tools;
- 10.1.2 the amount of time anticipated to complete the process and discharge the patient;
- 10.1.3 team member access to patient and family for information gathering and training;
- 10.1.4 the source and limits of funds to implement the plan.
- 10.2 physical and financial support adequate to implement the discharge plan.
- 10.3 personnel.(1,3,5-8,16,22,31) One member of the team with particular expertise in respiratory care(1,5,16,22) should be designated to coordinate the efforts of all team members.
- 10.3.1 patient;
- 10.3.2 family and/or caregiver (lay or professional);
- 10.3.3 physician;
- 10.3.4 nurse;
- 10.3.5 respiratory care practitioner;
- 10.3.6 medical equipment provider;
- 10.3.7 social worker;
- 10.3.8 physical, occupational, and speech therapist, as indicated by patient condition;
- 10.3.9 case manager;
- 10.3.10 nutritionist;
- 10.3.11 representative of the alternate site.
DPRP 11.0 MONITORING:
The discharge plan coordinator and the physician should monitor the progress of the discharge plan.(22) Each team member should participate in regularly scheduled team conferences to assess the progress of the discharge plan. Modifications may be made according to the individual patient's goals and needs.
DPRP 12.0 FREQUENCY:
The discharge planning process should be developed, reviewed, modified, and implemented whenever the patient is considered for transfer to an alternate site.
DPRP 13.0 INFECTION CONTROL:
The presence of transmissible infection and the presence of compromised immunity in the patient should be taken into consideration when discharge planning is undertaken. Appropriate steps to protect patient, caregiver, and family should be incorporated into the plan of care,(41,42) including provision for age-and condition-specific immunizations.(43)
Respiratory Home Care Focus Group:
Peggi Robart RRT RCP, Chairman, Boston MA
Barry J Make MD, Denver CO
Susan L McInturff RRT RCP, Bremerton WA
Dennis W Tureson Sr RRT CRTT, Minneapolis MN
Melissa P Weimer RRT, McKeesport PA
- O'Donohue Jr WJ, Giovannoni RM, Goldberg AI, Keens TG, Make BJ, Plummer AL, Prentice WS. Long-term mechanical ventilation: guidelines for management in the home and at alternate community sites. Chest 1986;90(1, suppl):1-37.
- Gilmartin ME. Transition from the intensive care unit to home: patient selection and discharge planning. Respir Care 1994;39(5):456-480.
- Baldwin-Myers A, Geiger-Bronsky M, Chacona A, Ewing L, Huiskes B, Shiroma J, Gold P. Standards of care for the ventilator-assisted individual: a comprehensive management plan from hospital to home. Loma Linda University Medical Center, 1995.
- Feldman J, Tuteur PG. Mechanical ventilation: from hospital intensive care to home. Heart Lung 1982;11 (2):162-165.
- Donar ME. Community care: pediatric home mechanical ventilation. Holistic Nurs Pract 1988;2(2):68-80.
- Gilmartin ME. Long-term mechanical ventilation: patient selection and discharge planning. Respir Care 1991;36(3):205-216.
- Kopacz MA, Moriarty-Wright R. Multidisciplinary approach for the patient on a home ventilator. Heart Lung 1984;13(3):255-262.
- Gilmartin ME. Long-term mechanical ventilation outside the hospital. In: Pierson DJ, Kacmarek RM, editors. Foundations of respiratory care. New York: Churchill Livingsone, 1992:1185-1204.
- Make BJ. Long-term management of ventilator-assisted individuals: the Boston University experience. Respir Care 1986;31(4):303-310.
- Naylor M, Brooten D, Jones R, Lavizzo -Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med 1994;120(12):999-1006.
- Department of Geriatric Health, Home Care Advisory Panel. Guidelines for the medical management of the home care patient. American Medical Association, Chicago, 1992.
- King C, Macmillan M. Documentation and discharge planning for elderly patients. Nurs Times 1994;90 (20):31-33.
- Parfrey PS, Gardner E, Vavasour H, Harnett JD, McManamon C, McDonald J, Dawe J. The feasibility and efficacy of early discharge planning initiated by the admitting department in two acute care hospitals. Clin Invest Med 1994;17(2):88-96.
- McInturff SL, Dunne PJ. Assessment of the home care patient. In: Wilkins RL, Krider SJ, Sheldon RL, editors. Clinical assessment in respiratory care, 3rd ed. St. Louis: Mosby-Year Book, 1995:367-374.
- American Thoracic Society. Standards of nursing care for adult patients with pulmonary dysfunction. Am Rev Respir Dis 1991;144(1):231-236.
- Make BJ, Gilmartin ME. Care of ventilator-assisted individuals in the home and in alternative community sites. In: Hodgkin JE, Connors GL, Bell CW, editors. Pulmonary rehabilitation: guidelines to success, 2nd ed. Philadelphia: JB Lippincott, 1993:359-391.
- Peters SG, Viggiano RW. Home mechanical ventilation. Mayo Clin Proc 1988;63:1208-1213.
- American College of Chest Physicians. ACCP consensus statement on mechanical ventilation outside the critical care unit. Chest 1995;108 (in press).
- Thomas VM, Ellison K, Howell EV, Winters K. Caring for the person receiving ventilatory support at home: care givers' needs and involvement. Heart Lung 1992; 21(2):180-186.
- Smith CE, Mayer LS, Parkhurst C, Perkins SB, Pingleton SK. Adaptation in families with a member requiring mechanical ventilation at home. Heart Lung 1991;20(4):349-356.
- Moss AH, Casey P, Stocking CB, Roos RP, Brooks BR, Siegler M. Home ventilation for amyotrophic lateral sclerosis patients: outcomes, costs, and patient, family, and physician attitudes. Neurology 1993;43:438-443.
- Prentice WS. Transition from hospital to home. In: Gilmartin ME, Make BJ, editors. Mechanical ventilation in the home: issues for health care providers. Probl Respir Care 1988;1(2):175-191.
- McBride RC. An audit of current discharge planning arrangements and their effectiveness on elderly care wards and community nursing services together with aspects of client satisfaction. J Nurs Manag 1995;3(1):19-24.
- Clark, K. Psychosocial aspects of prolonged ventilator dependency. Respir Care 1986;31(4):329-333.
- DeWitt PK, Jansen MT, Davidson Ward SL, Keens TG. Obstacles to discharge of ventilator-assisted children from the hospital to home. Chest 1993;103(5): 1560-1565.
- Nochomovitz ML, Montenegro HD, Parran S, Daly B. Placement alternative for ventilator-dependent patients outside the intensive care unit. Respir Care 1991; 36(3)199-204.
- Gilmartin ME, Make BJ. Home care of the ventilator-dependent person. Respir Care 1983;28(11):1490-1497.
- Prentice WS. Placement alternatives for long-term ventilator care. Respir Care 1986;31(4):288-293.
- Popovich Jr J. Intermediate care units: graded care options (editorial). Chest 1991;99(1):4-5.
- N Morrow-Howell, Proctor E. Discharge destinations of Medicare patients receiving discharge planning: who goes where? Med Care 1994;32(5):488-497.
- American Thoracic Society. Home mechanical ventilation of pediatric patients (statement). Am Rev Respir Dis 1990;142:258-259.
- US Consumer Product Safety Commission. Safety for Older Consumers: home safety checklist. Washington DC: US Consumer Product Safety Commission, 1986.
- Goldberg AI, Frownfelter D. The ventilator-assisted individuals study. Chest 1990;98(2):428-433.
- Findeis A, Larson JL, Gallo A, Shekleton M. Caring for individuals using home ventilators: an appraisal of family caregivers. Rehabil Nurs 1994;19(1):6-11.
- Jackson NC. Pulmonary rehabilitation for mechanically ventilated patients. Crit Care Nurs Clin North Am 1991; 3(4):591-600.
- Glenn KA, Make BJ. Learning objective for positive pressure ventilation in the home. Denver: National Center for Home Mechanical Ventilation and National Jewish Center for Immunology and Respiratory Medicine, 1993.
- Daley White K, Walsh Perez P. Your ventilator patient can go home again. Nursing 1986;12:54-56.
- Thompson CL, Richmond M. Teaching home care for ventilator-dependent patients: the patients' perception. Heart Lung 1990;19(1):79-83.
- Murtaugh CM. Discharge planning in nursing homes. Health Serv Res 1994;28(6):751-769.
- Haddock KS. Collaborative discharge planning: nursing and social services. Clin Nurse Spec 1994;8(5)248-252,288.
- Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-382,387-388.
- Centers for Disease Control. Guidelines for preventing the transmission of tuberculosis in health-care settings, with special focus on HIV-related tissues. MMWR 1990;39(RR-17):1-29.
- Mostow SR, Cate TR, Ruben FL. Prevention of influenza and pneumonia: official statement of the American Thoracic Society. Am Rev Respir Dis 1990;142(2): 487-488.
Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit AARC and Respiratory
Reprinted from the December 1995 issue of RESPIRATORY CARE [Respir Care 1995;40(12):1308–1312]