SIMULATION. SKILL FOCUS: BiPAP Initiation, ABG s & Intubation Assist DISCIPLINE: Respiratory Therapy LEVEL: 3B HEART FAILURE

Transcription

1 SKILL FOCUS: BiPAP Initiatin, ABG s & Intubatin Assist DISCIPLINE: Respiratry Therapy LEVEL: 3B HEART FAILURE Estimated Time: 45 minutes Debriefing Time: 40 minutes Scan t Begin SCENARIO OVERVIEW Patient Name: Hectr Fernandez Students are called t the Emergency Department t prepare fr the arrival f a patient frm a lcal nursing hme wh is in acute respiratry distress/failure. They receive reprt frm EMT/Paramedics at the beginning f the scenari. He needs t be placed n the BIPAP immediately and ABG s need t be drawn. After ABG s have resulted, a decisin is made t intubate the patient. Students will assist with the intubatin. This scenari includes vides f bth right and left Mdified Allen s test fr students t assess prir t ABG puncture. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

2 LEARNING OBJECTIVES 1. Perfrm a fcused respiratry assessment 2. Recgnize and respnd t abnrmal findings 3. Evaluate bjective and subjective data 4. Implement and fllw evidence-based standards and prtcls 5. Safely manage nn-invasive mechanical ventilatin 6. Assist prvider in medical prcedures 7. Demnstrate apprpriate cmmunicatin 8. Dcument accurately CURRICULUM MAPPING WTCS RESPIRATORY THERAPY PROGRAM OUTCOMES Apply respiratry therapy cncepts t patient care situatins Demnstrate technical prficiency required t fulfill the rle f a respiratry therapist Practice respiratry therapy accrding t established prfessinal and ethical standards RESPIRATORY DISEASE Analyze signs, symptms, etilgy, pathgenesis and treatment fr cardivascular diseases/disrders RESPIRATORY AND CARDIAC PHYSIOLOGY Interpret bld gas data Evaluate fluid and electrlyte balance RESPIRATORY THERAPEUTICS II Perfrm arterial puncture HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

3 RESPIRATORY PHARMACOLOGY Examine the pharmacdynamics f anesthetics, muscle blckers, analgesics, sedatives, hypntics, and tranquilizers RESPIRATORY AIRWAY MANAGEMENT Demnstrate the use f manual resuscitatrs Assess the need fr artificial airways Apply basic artificial airways Apply advanced artificial airways Demnstrate skill f secretin remval RESPIRATORY LIFE SUPPORT Apply nn-invasive mechanical ventilatin Evaluate patient respnse t mechanical ventilatin RESPIRATORY CLINICAL PRACTICE Apply standard precautins Asses vital signs Perfrm pulse ximetry Apply nn-invasive psitive pressure ventilatin Perfrm arterial puncture Assist with intubatin HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

4 SIMULATION LEARNING ENVIRONMENT & SET-UP PATIENT PROFILE Name: Hectr Fernandez DOB: 09/06/19XX Age: 62 MR#: Gender: Male Height: 175 cm (5 10 ) Weight: 86.4 kg (195#) Allergies: penicillin (hives) Admitting Diagnsis: Right lwer extremity cellulitis and CHF Medical Histry: cngestive heart failure, crnary artery disease, anterir MI with stenting 4 years ag, chrnic atrial fibrillatin, hypertensin, chrnic renal insufficiency, COPD, OSA, restless leg syndrme, hypthyridism, diabetes mellitus 2, chrnic cnstipatin Surgical Histry: R TKR 15 years ag Cde Status: Full Ethnicity: Hispanic Spiritual Practice: Cathlic Primary Language: Spanish Secndary Language: English EQUIPMENT/SUPPLIES/SETTINGS Envirnment Inside rm: Patient in bed, as clse t fwlers psitin as pssible Inside r utside rm: Hand sanitizer and/r sink Outside rm: Cmputer r frm(s) fr dcumentatin Patient Hspital gwn N mulage ID band present with QR cde Mnitr Settings Simulatr vitals: HR 108, RR 32, BP 138/92, Temp 37.1, Sat = 93 % n 15 lpm nnrebreather mask HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

5 Supplies General Respiratry Equipment BiPAP machine and supplies Equipment t btain an ABG Intubatin equipment Orpharyngeal airways Resuscitatin Bag and Mask Oral and endtracheal suctin supplies Medicatins (realistic labels are available by scanning QR Cdes) Succinylchline (200 mg/10 ml) 10 ml injectin slutin Etmidate (20 mg/10 ml) 10 ml single-dse vial Prpfl (1% - 10 mg/ml) 100 ml single-patient infusin vial HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

6 QR CODES START PATIENT REPORT PATIENT ID PATIENT IV RIGHT LEG LEFT LEG BIPAP LEFT ALLEN S RIGHT ALLEN S FACILITATOR HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

7 CHEST QR CODES Cut alng the dtted lines. Fld alng the slid line t create a bi-fld f the diagram and QR cde. ANTERIOR 2 ANTERIOR 3 ANTERIOR 6 ANTERIOR 7 POSTERIOR 0 POSTERIOR 1 POSTERIOR 4 POSTERIOR 5 HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

8 RIGHT AXILLARY 1 LEFT AXILLARY 1 HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

9 TEACHING PLAN PREBRIEF The facilitatr shuld lead this prtin f the simulatin. The fllwing steps will guide yu thrugh Prebrief. Scan the QR Cde: Scan t Begin while students are in Prebrief. Meet Yur Patient (n ipad) and explain hw the ipad wrks in the simulated learning envirnment including: Explain hw t use the ipad scanner and QR cdes. Remind students that there are multiple QR cdes in the simulatin, but they shuld nly scan them if they think it will prvide data necessary fr their assessment and evaluatin f the patient. Fr sme scenaris, it may be helpful t tell students where the QR cde are lcated. Fr thers, yu may want students t find the QR cdes during their assessments. This is yur chice. Describe hw a QR cde sund will wrk in the scenari. Fr the mst authentic sund experience, student shuld use ear buds r the ARISE stethscpe fr all QR cdes with the fllwing symbl:. Example: QR Cde: Chest Anterir 1 As the facilitatr, yu shuld be aware that thrughut the simulatin sme QR cdes are necessary t the prgramming f the ipad cntent. Directins fr which QR cdes are required (t be scanned) in each state are listed under each state f the dcumentatin belw. The QR cdes are als in BOLD type. Level tab This tab tells the cntent in the ipad t change t what is needed fr the next state f a simulatin. It is used a few times in this scenari after the prvider is ntified t display new rders (thse just given ver the phne) and lab results, etc Medicatin QR Cdes The student(s) must scan QR Cde: Patient ID prir t scanning any medicatin. That scan is valid fr 2 minutes and then it times ut. The student(s) will need t scan QR Cde: Patient ID again t give mre medicatins. MAR Hyperlinks On the MAR all medicatins are underlined and hyperlinked t DailyMed, which is a medicatin reference hused by the HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

10 Natinal Library f Medicine. Students can click n these links during the simulatin fr up-t-date medicatin cntent, labels, and package insert infrmatin. Discuss the simulatin Learning Objective(s) (n ipad) as well as any ther Prebrief materials Get Reprt n ipad Pssible Facilitatr Questins What are yur pririties fr this patient? View Patient picture n ipad Pssible Facilitatr Questins Given this image, can yu make any cnclusin abut Hectrs cnditin? Advance t the Patient Prfile screen (n ipad). This will act as a simulated patient chart. Students can view the tabbed cntent n the ipad (see belw) prir t entering the patient s rm and thrughut the simulatin as needed. H&P N reprts available. Facilitatr Nte: As the patient is arriving directly t the ER, the students culd start in the patient s rm with reprt. In additin, the ipad des nt have any data with the exceptin f a BiPAP Prtcl which culd be reviewed with students at this time. ORDERS N reprts available. MAR N reprts available. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

11 DAILY RECORD N reprts available. VITALS The ipad shws the enterable vitals screen. VENTILATOR FLOWSHEET The ipad shws the enterable ventilatr flwsheet. PROGRESS NOTES N reprts available. LABS-DIAGNOSTICS N reprts available. IMAGING N reprts available. PROTOCOLS The ipad displays the Adult BiPAP Prtcl Acute. See Appendix A fr a printable versin. LEVEL 1 The ipad reads, The ipad is at Level 1. SCANNER Use this t scan available QR Cdes. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

12 EXIT The ipad reads, Are yu sure yu want t exit? All data will be lst. If N is selected, the ipad will return t the tabbed cntent. If Yes is selected, the ipad will let the student(s) exit and prmpt them t cmplete an embedded 3-5 minute survey. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

13 STATE 1 PATIENT ASSESSMENT, BIPAP INITIATION & ABG S Patient Overview The patient is n a NRB when he arrives in the ED. He needs t be placed n BiPAP immediately and ABG s need t be drawn. Students shuld als perfrm a patient assessment. The patient is nt able t talk much since he is exhausted and/r n the BiPAP. Expected Student Behavirs Perfrm apprpriate hand hygiene and infectin cntrl Intrduce themselves and verify the patient (can scan QR Cde: Patient ID) Accurately btain vital signs and interpret fr an adult patient Students can enter vitals n the ipad, but they are nt tied t any ipad prgramming. Perfrm a fcused respiratry assessment Inspectin Students will nt find any abnrmalities in the chest exam. When the extremities are evaluated, bilateral pitting edema and Right-lwer extremity cellulitis is fund. (Scan QR Cde: Right Leg & QR Cde: Left Leg) Palpatin Students will nt find any abnrmalities in the chest exam. Percussin Students will nt find any abnrmalities in the chest exam. Auscultatin Scan QR Cde: Chest There are ten QR cdes t apply t the chest see abve Chest QR Cde chart fr lcatins Students will hear the fllwing breath sunds: Crackles are nted in all lung lcatins. Patient Histry HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

14 If students ask questins abut the patient histry, Hectr is t tired t answer much. Can maybe answer a few Yes r N questins. Respnses d nt matter as the students shuld recgnize that the patient s answers may nt be accurate secndary t his cnditin. Safely perfrm a radial ABG Facilitatr Nte: This shuld be dne as part f the included BiPAP prtcl, but yu can have smene call r state that an ABG is needed per MD rder. An actual ABG rder is written n the Prvider Orders that becme available in State 2. Facilitatr Nte: There is a vide f a right Mdified Allen s test (QR Cde: Right Allen s) and a left Mdified Allen s test (QR Cde: Left Allen s). Students can scan either r bth QR Cdes t evaluate fr cllateral circulatin prir t the ABG puncture. Safely apply nn-invasive ventilatin There is an Adult BiPAP Prtcl Acute lcated in the Prtcl tab n the ipad. If needed, an image f a BiPAP is available by scanning QR Cde: BiPAP Recgnize and respnd t abnrmal findings Dcument accurately Technician Prmpts This can be dcumented n the prvided enterable ventilatr flwsheet lcated n the ipad in the Ventilatr Flwsheet tab. Patient is exhausted and nly able t answer sme Yes r N questins. Respnses d nt matter as the students shuld recgnize that the patient s answers may nt be accurate secndary t his cnditin. Patient respnse can include: Facilitatr Questins If he is n the BiPAP, yur vice shuld be very muffled t add realism t the scenari. Analyze the vital signs: are they within nrmal limits? HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

15 Analyze the findings frm the pulmnary exam: d yu have any cncerns? Hw shuld yu respnd t Hectr s LOC? Why is it necessary t perfrm a Mdified Allen s test? Hw d yu knw that BiPAP is effective fr this patient? What side effects can yu expect fr the BiPAP? Tabbed ipad Prmpts and Cntent LEVEL 1/2 When the Level 1 tab is tapped, the ipad reads, The ipad is at Level 1. The Level 1 tab will autmatically change t a Level 2 tab after QR Cde: Facilitatr is scanned. When the Level 2 tab is tapped, the ipad reads, The ipad is at Level 2. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

16 STATE 2 ABG RESULTS & PROVIDER NOTIFICATION Patient Overview State 2 begins with the ipad making a dinging sund and a plaque that reads Labs have resulted. ABG results (as well as ther labs) are nw available fr review by tapping n the Labs tab. In additin, Prvider Orders and the MAR are available (see belw). Students shuld interpret the ABG s and make adjustments t the BiPAP settings per the prvided prtcl. Once adjustments are made, students shuld update the prvider. Students shuld interpret the ABG s and call the prvider as they are indicating intubatin may be necessary. Students shuld als titrate the BiPAP per prtcl until the decisin t intubate is made. Expected Student Behavirs Interpret ABG results Titrate BiPAP settings per prtcl Demnstrate apprpriate cmmunicatin with the prvider Students shuld suggest intubatin. Dcument accurately Technician Prmpts Ensure students dcument changes n the ventilatin flwsheet. The patient is asleep n BiPAP. The technician can play the rle f the prvider in persn r via telephne. Ensure students give an accurate update in SBAR frmat. Prvide the fllwing rders: Prepare the patient fr intubatin. I am entering the needed rders in the cmputer nw. Facilitatr Questins Interpret the lab results: What is f primary cncern fr this patient and why? HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

17 D the lab results lead yu twards a certain diagnsis? If s, what wuld that be and why? Hw des the given medicatin (fursemide) crrelate t the lab results and the patient cnditin? Hw des a prtcl aid yur treatment f the patient? Tabbed ipad Prmpts & Cntent The scenari advances t Level 3 after students tap n the Level 2 tab and answer Yes t the questin, Have yu ntified the prvider? ORDERS Prvider Orders Date Time Order Tday nw Emergency Department Orders Cntinuus telemetry and SpO2 mnitring Obtain current weight Insert Fley catheter fr strict I &O Obtain accurate hme medicatin histry STAT Labs: CBC with differential, Chem 7, Magnesium, BNP, Liver Enzymes, CK & Trpnin, INR STAT prtable chest x-ray: respiratry failure STAT ECG STAT bedside echcardigram STAT Respiratry Therapy Cnsult STAT BiPAP per prtcl, O2 t keep SaO2 > 90% STAT ABG 80 mg fursemide IV, STAT K+ replacement prtcl dr. Hspita, MD HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

18 MAR Medicatin Administratin Recrd Scheduled Cntinuus Infusin PRN Discntinued Fursemide 80 mg IV, STAT Discntinued Last Given 10 minutes ag 10 minutes ag LABS-DIAGNOSTICS Labratry Results CBC with Differential Tday 10 minutes ag Units Reference Range WBC 11.8 x10 3 ul F: /M: RBC 3.6 x10 6 ul F: /M: Hgb 9.9 g/dl F: /M: HCT 30.2 % F: /M: MCV 76.7 fl F: /M: MCH 25 pg MCHC 30 g/dl RDW 12.3 % F: /M: Platelet 182 x10 9 ul F: /M: MPV Neutr Lymph Mn Es HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

19 Bas Chem 7 with Magnesium Tday 10 minutes ag Units Reference Range Glucse 162 mg/dl Fasting BUN 32 mg/dl Creatinine 3.2 mg/dl F: /M: Sdium 134 meq/l Ptassium 3.8 meq/l Chlride 108 meq/l Carbn Dixide 28 meq/l Magnesium 1.7 meq/l Liver Enzymes Tday 10 minutes ag Units Reference Range ALT 53 U/L 7-55 AST 36 U/L 8-48 ALP 102 U/L Albumin 4.8 g/dl Ttal Prtein 6.9 g/dl Bilirubin 0.9 mg/dl BNP Tday 10 minutes ag Units Reference Range BNP 2450 pg/ml < 75 years ld = <125 HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

20 > 75 years ld = <450 CK & Trpnin Tday 10 minutes ag Units Reference Range CK 330 U/L M: /F: Trpnin 0 ng/ml <0.1 INR Tday 10 minutes ag Units Reference Range INR 2.4 secnds < 1.1 Arterial Bld Gas (ABG) Tday 10 minutes ag Units Reference Range ph PaCO 2 82 mmhg PaO 2 68 mmhg HCO 3 28 mml/l Base Excess -2 mml/l 0+/-3 SaO 2 94 % Site = Radial Mdified Allen s test = % O2 = 100 LEVEL 2/3 When the Level 2 tab is tapped, the ipad displays a plaque the reads, Have yu ntified the prvider? If N, the ipad returns t the ipad tab menu. If Yes, the ipad reads, The ipad is at Level: 3. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

21 STATE 3 INTUBATION ASSIST Patient Overview Student must prepare t assist the Prvider with intubatin. If nt already dne, students shuld titrate the BiPAP per prtcl t achieve maximum results until the patient is intubated. New Prvider Orders and MAR (see belw) reflect the needed rders fr the prcedure. Expected Student Behavirs Perfrm an Intubatin Assist prcedure Student shuld gather and assemble all supplies needed fr the intubatin and ensure an RN is present with the rdered medicatins. Demnstrate apprpriate cmmunicatin with the prvider during the prcedure. Dcument accurately Technician Prmpts The patient is asleep n BiPAP and then sedated/paralyzed fr the prcedure. The technician r facilitatr can play the rle f the prvider wh actually perfrms the intubatin. Optinal: a student culd play the rle f the prvider and actually intubate t practice thse skills. This wuld prvide an pprtunity t evaluate the skills f bth students and prvide feedback. The technician r facilitatr shuld play the rle f the RN in rder t give meds and help mnitr the patient during the prcedure. Facilitatr Questins Explain the medicatins used fr inductin. What initial mechanical ventilatr settings are apprpriate fr this patient and why? Hw will yu mnitr the patient during this prcedure? HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

22 Differentiate hypxemic and hypercapneic respiratry failure. Tabbed ipad Prmpts & Cntent The ipad advance t Exit after QR Cde: Facilitatr is canned. ORDERS Prvider Orders Date Time Order Tday 15 minutes Emergency Department Orders ag Cntinuus telemetry and SpO2 mnitring Obtain current weight Insert Fley catheter fr strict I &O Obtain accurate hme medicatin histry STAT Labs: CBC with differential, Chem 7, Magnesium, BNP, Liver Enzymes, CK & Trpnin, INR STAT prtable chest x-ray: respiratry failure STAT ECG STAT bedside echcardigram STAT Respiratry Therapy Cnsult STAT BiPAP per prtcl, O2 t keep SaO2 > 90% STAT ABG 80 mg fursemide IV, STAT K+ replacement prtcl dr. Hspita, MD Tday nw STAT intubatin fr hypercapneic respiratry failure STAT Succinylchline IV Push 1.5 mg/kg nce fr intubatin STAT Etmidate IV Push 0.3 mg/kg nce fr intubatin Pst intubatin: Prpfl IV mcg/kg/minute titrate t achieve apprpriate level f sedatin (see adult ICU sedatin prtcl) STAT prtable chest x-ray pst intubatin fr tube placement Mechanical Ventilatin per RT ABG s 30 minutes pst placement n ventilatr HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

23 Place OG tube Cnsult Pulmnlgy Dr. Hspita, MD MAR Medicatin Administratin Recrd Scheduled STAT Succinylchline IV Push 1.5 mg/kg nce fr intubatin STAT Etmidate IV Push 0.3 mg/kg nce fr intubatin Due Tday Due Tday Last Given Last Given Cntinuus Infusin Prpfl IV mcg/kg/minute titrate t achieve apprpriate level f sedatin (see adult ICU sedatin prtcl) Started PRN Discntinued Fursemide 80 mg IV, STAT Discntinued Last Given 10 minutes ag 10 minutes ag LEVEL 3/EXIT When the Level 3 tab is tapped, the ipad reads, The ipad is at Level 3. The Level 3 tab will autmatically disappear when QR Cde: Facilitatr is scanned. When the Exit tab is tapped, the ipad reads, Scenari bjectives have been met. Are yu sure yu want t exit the game? If N is selected, the ipad will return t the tabbed cntent. If Yes is selected, the ipad will let the student(s) exit and prmpt them t cmplete an embedded 3-5 minute survey. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

24 DEBRIEF Nthing needed frm the ipad. QUESTIONS 1. Hw did yu feel this scenari went? 2. What were the main issues yu had t deal with when caring fr Hectr? 3. Review understanding f learning bjective: Perfrm a fcused respiratry assessment. a. What cncerns did yu find during yur physical assessment and evaluatin? b. Is this what yu wuld expect in a patient with cngestive heart failure? Why r why nt? c. If yu culd d ver any part f Hectr s assessment, what wuld it be and why? 4. Review understanding f learning bjective: Recgnize and respnd t abnrmal findings. a. What abnrmal findings did yu encunter in this scenari? b. Hw did yu respnd t thse abnrmal findings? c. Were the findings what yu expected? Why r why nt? 5. Review understanding f learning bjective: Evaluate bjective and subjective data. a. What abnrmal findings did yu find in the vital signs and/r physical assessment? Hw did yu respnd t these findings? b. Explain hw an ABG is affected by different therapeutics including xygen, nebulizer administratin, certain hyperinflatin techniques, CPAP/BiPAP, etc 6. Review understanding f learning bjective: Implement and fllw evidence-based standards and prtcls a. Hw did the prtcl in tday s scenari help yu in caring fr Hectr? b. Hw are evidence-based standards develped and why are they imprtant? 7. Review understanding f learning bjective: Safely manage nn-invasive mechanical ventilatin a. Describe hw nn-invasive mechanical ventilatin wrks in CHF. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

25 b. When is the decisin made t switch frm nn-invasive t invasive mechanical ventilatin? c. If yu culd d ver any part f the BiPAP initiatin and management, what wuld it be and why? 8. Review understanding f learning bjective: Assist prvider in medical prcedures. a. What can g wrng when intubating a patient and hw d we prepare fr thse circumstances prir t the prcedure and/r remedy them if they ccur? b. If yu culd d ver any part f the intubatin assist, what wuld it be and why? 9. Review understanding f learning bjective: Demnstrate apprpriate cmmunicatin. a. Were the cmmunicatin techniques yu used with Hectr effective? Why r Why nt? b. If Hectr was unable t speak English, hw wuld yu have adapted yu cmmunicatin techniques? c. If yu culd d ver, hw wuld yu change yur cmmunicatin with Hectr? d. Hw did yu update the prvider after yu interpreted the ABG s and titrated the BiPAP? 10. Review understanding f learning bjective: Dcument accurately. a. What is imprtant t dcument in yur assessments and interventins? b. If smething is dne in errr, hw is this dcumented? (Relate this back t the ABG and hw if it was drawn n a nebulizer at 7 lpm O2 and nt the 4 lpm O2 that is dcumented n the lab results, that is inaccurate and an errr.) c. Hw can yu crrect errrs in the chart? 11. Summary/Take Away Pints a. Tday yu cared fr a Hispanic patient wh was experiencing an exacerbatin f his knwn cngestive heart failure. What is ne thing yu learned frm participating in this scenari that yu will take with yu int yur respiratry therapy practice? (Each student must share smething different frm what the thers share.) Nte: Debriefing technique is based n INASCL Standard fr Debriefing and NLN Thery Based Debriefing by Dreifuerst. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

26 SURVEY Print this page and prvide t students. Students, please cmplete a brief (2-3 minute) survey regarding yur experience with this ARISE simulatin. There are tw ptins: 1. Use QR Cde: Survey Nte: Yu will need t dwnlad a QR Cde reader/scanner nt yur wn device (smartphne r tablet). There are multiple free scanner apps available fr bth Andrid and Apple devices frm the app stre. This QR Cde will nt wrk in the ARIS app. SURVEY 2. Cpy and paste the fllwing survey link int yur brwser. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

27 APPENDIX A ADULT BIPAP PROTOCOL - ACUTE 1. POLICY 2. PURPOSE 3. SCOPE a. The Respiratry Therapist (and Prvider) will determine BiPAP settings based n each patient s ideal bdy weight, diagnsis, and clinical cnditin. Clinical data will be used t determine apprpriate changes t these settings. a. The purpse f this plicy is t facilitate the emergent applicatin, management, and weaning/discntinuatin f BiPAP therapy. a. These BiPAP guidelines supprt an interprfessinal apprach t patient care allwing the Respiratry Therapist t make timely adjustments t the BiPAP and better manage the patient s immediate clinical demand as his/her cnditin changes. b. This prtcl applies t patients wh are 16 years ld r greater. 4. INCLUSION CRITERIA a. Candidates fr BiPAP can include COPD exacerbatin, acute pulmnary edema, cngestive heart failure, immunsuppressed patients, and weaning failure (COPD). Other cnsideratins include hypercapneic respiratry failure in neurmuscular disease r chest wall defrmity, asthma exacerbatin, pstextubatin failure, bstructive sleep apnea, and pstperative respiratry failure. i. Mderate t severe dyspnea, accessry muscle use, paradxical breathing, respiratry rate >25/min ii. Mderate t severe acidsis and hypercapnia (ph <7.35, PaCO2 >50 mmhg) iii. Mderate t severe hypxemia (PaO2 <60mmHg, PaO2/FiO2<200) 5. CONTRAINDICATIONS (Exclusin Criteria) a. The fllwing cnditins are cntraindicatins fr BiPAP therapy: i. Apnea ii. Untreated pneumthrax r pneummediastinum HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

28 iii. Decreased LOC that prevents the patient s ability t prtect his/her wn airway iv. Inability t maintain a patent airway r adequately clear secretins v. Nn-cmpliant patient. 6. PRECAUTIONS (Pssible Exclusin Criteria) a. The fllwing cnditins are f cncern and a risk versus benefit analysis must be perfrmed prir t the initiatin f BiPAP and during the management f the therapy: i. Hemdynamic instability ii. Risk fr aspiratin f gastric cntent iii. Bullus lung disease iv. Pre-existing pneumthrax r pneummediastinum v. Acute sinusitis, titis media, r epistaxis vi. Recent facial, ral r skull surgery, esphageal surgery, r trauma t thse areas. vii. Acute upper GI bleed 7. GENERAL GUIDELINES a. Ordering Adult BiPAP Prtcl i. The prtcls will be initiated by Prvider rder. ii. Any rder nt cvered by the prtcl shuld be written n the rder sheet. iii. The attending Prvider may discntinue the prtcl at any time. b. Arterial Bld Gases i. An ABG shuld be btained prir t initiatin, if pssible, and 30 minutes pst initiatin. ii. An ABG can be btained during BiPAP management if there is a change in the patient s respiratry cnditin r LOC. iii. The Prvider must be ntified with all ABG results. 8. INITIATION & MANAGEMENT HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

29 a. Determine the apprpriate patient interface. Generally, a full face mask is the interface f chice. b. Select patient settings. The fllwing guidelines are fr initiatin nly and adjustments will need t be made based n patient respnse and/r cnditin. i. Mde: Spntaneus-timed, if alternate mde needed, cnsult with Prvider. ii. IPAP: (max 25) cmh2o iii. EPAP: 4-6 (max 10) cmh20 iv. FiO2 titrated t keep SpO2 > r = t 90% v. Initially start with lwer settings and titrate t levels that reduce wrk f breathing and allw a reductin in FiO2. This will imprve patient tlerance and cperatin. c. Titrate initial settings as fllws: i. Initially start with lwer settings and titrate t levels that reduce wrk f breathing and allw fr a reductin in FiO2. This will imprve patient tlerance and cperatin. ii. Titratin is based n patient assessment including: general appearance, bld pressure, heart rate, breath sunds, SpO2, ventilating pressures/vlumes, and ABG results iii. T imprve ventilatin, increase IPAP in increments f 2-3 cmh2o every 5 minutes until a max f 25 cmh2o is reached. iv. T imprve xygenatin: 1) Increase EPAP in increments f 2 cmh2o until a max f 10 is reached keeping pressure supprt ventilatin > 5 cmh2o. 2) Increase FiO2 3) When increasing EPAP, increase IPAP by same amunt f pressure t maintain the same level f pressure supprt. v. Ensure the patient is cmfrtable with minimal WOB and/r acceptable leak. vi. If the patient is nt cmfrtable, assess fr the fllwing: 1) Wrk f breathing: titrate settings t imprve distress 2) Optimize tidal vlume >6-7mL/kg HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

30 3) Adjust rise time and inspiratry time 4) Leak: re-adjust mask r change mask size 5) Cnsider lwer pressures d. Evaluate ABG results lking fr imprvement. i. If nt within nrmal limits r shws n imprvement ver pre-bipap ABG s and/r patients clinical cnditin has nt imprved, titrate settings until maximum settings are reached. ii. If max settings are reached with n imprvement, the Prvider must be cntacted fr further rders (i.e. intubatin). e. Skin Integrity i. Patients n cntinuus nn-invasive ventilatin must have the mask remved fr 5-10 minutes every fur hurs arund the clck at which time the skin is inspected fr redness r irritatin. ii. Any patient anticipated t be n cntinuus NIV fr greater than 10hrs, must have silicne dressing applied. iii. If pressure redness r irritatin develps, apply silicne dressing t the bridge f the nse. iv. If pressure necrsis appears t be develping, the nurse and Prvider must be ntified. f. The Prvider must be cntacted at any time if the patient assessment reveals wrsening patient cnditin. Clinical cnditins requiring ntificatin include: i. IPAP > 25 cmh2o ii. EPAP > 10 cmh2o iii. RR > 30 bpm iv. SpO2 < 92% v. Wrsening ABG vi. Hemdynamic instability vii. Change in LOC g. If there is n physilgic imprvement within 2 hurs f initiatin, intubatin and mechanical ventilatin shuld be cnsidered. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

31 h. Dcument within 15 minutes f initial applicatin and perfrm a cmplete assessment every 30 minutes x 2 then every 4 hurs and as needed. 9. WEANING a. Reversal r sufficient reslutin f underlying cause f respiratry failure is the mst imprtant factr in cmplete liberatin frm BiPAP. b. With a rapidly reversible prblem (i.e. cardigenic pulmnary edema), simple discntinuatin f NPPV is generally all that is required. c. Fr ther causes f respiratry insufficiency/failure, peridic breaks frm BiPAP shuld begin when: i. FiO2 has been decreased t 35-40% ii. IPAP <18 cmh2o iii. EPAP <12 cmh2o iv. Patient is able t sustain effective spntaneus ventilatin d. Break perids allw fr expectratin, ral intake, imprved humidificatin, and/r time fr reperfusin f skin pressure pints. The number and duratin f breaks shuld gradually increase until the patient is able t maintain adequate xygenatin and ventilatin with their nrmal wrk f breathing. e. Break perids cntinue as lng as the patient is clinically stable and maintaining adequate xygenatin n <60% O DISCONTINUANCE a. Place patient n xygen therapy b. Mnitr SpO2 and wrk f breathing c. BiPAP can be remved frm the patient s rm 24 hurs after the last use r sner if the patient s cnditin has imprved significantly. BiPAP can be reinstituted withut an additinal Prvider rder within 24 hurs f being remved frm a patient s rm, unless therwise rdered. HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

32 CREDITS BiPAP Prtc0l adapted frm RES Nn-Invasive Psitive Pressure Ventilatin Guideline frm and BiPAP/CPAP Prtcl frm tcls.htm CXR image frm: Lung sunds used with permissin frm Thinklabs Medical, LLC, Centennial, CO at Medicatin infrmatin frm Natinal Library f Medicine: Daily Med at Pitting Edema picture frm Pitting Edema picture with cellulitis frm HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

33 REFERENCES American Heart Assciatin (2016). Get with the Guidelines: Heart Failure. Retrieved frm With-The-Guidelines---HFStrke_UCM_001099_SubHmePage.jsp Cleveland Clinic. (2017). B-type Natriuretic Peptide (BNP) Bld Test. Retrieved frm Clucci, MD, W. (April 2017). Treatment f Acute Decmpensated Heart Failure: Cmpnents f Therapy. Retrieved frm Fnarw, MD, G. C. & Weber, DO, J.E. (2004). Rapid Clinical Assessment f Hemdynamic Prfiles and Targeted Treatment f Patients with Acutely Decmpensated Heart Failure. Clinical Cardilgy, 27 (Supplement V). Retrieved frm f?sequence=1 Hyzy, MD, R. (April 2017). Nninvasive Ventilatin in Acute Respiratry Failure in Adults. Retrieved frm n&selectedtitle=1~150 Jint Cmmissin (2016). Specificatins Manual fr Jint Cmmissin Natinal Quality Measures. Dwnladed frm: ailure.html HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,

34 May Fundatin fr Medical Educatin and Research. ( ). Test ID: CK. Retrieved frm Nhria, A., Lewis, E., & Stevensn, L. (2002). Medical Management f Advanced Heart Failure. Jurnal f the American Medical Assciatin, 287 (5), Retrieved frm Stella, L. (2013). Understanding Measures fr Heart Failure Treatment, American Nurse Tday, 8(2). Retrieved frm Tleyjeh, MD, I., Burdetter, MD, S., & Baddur, MD, L. Cellulitis. Anitmicrbe. Retrieved frm WebMD, Inc. (2017). Hemglbin A1c (HbA1c). Retrieved frm rmal_levels_f_hba1c_hemglbin_a1c_chart Yancy CW, Jessup M, Bzkurt B, Butler J, Casey DE Jr, Drazner MH, Fnarw GC, Geraci SA, Hrwich T, Januzzi JL, Jhnsn MR, Kasper EK, Levy WC, Masudi FA, McBride PE, McMurray JJV, Mitchell JE, PetersnPN, Riegel B, Sam F, Stevensn LW, Tang WHW, Tsai EJ, Wilkff BL. (2013) ACCF/AHA guideline fr the management f heart failure: a reprt f the American Cllege f Cardilgy Fundatin/American Heart Assciatin Task Frce n Practice Guidelines. Circulatin. 2013;128:e240 e327. DOI: /CIR.0b013e31829e8776 This wrk by the Wiscnsin Technical Cllege System TAACCCT IV Cnsrtium is licensed under a Creative Cmmns Attributin 4.0 Internatinal license. Third party marks and brands are the prperty f their respective hlders. Please respect the cpyright and terms f use n any webpage links that may be included in this dcument. This wrkfrce prduct was funded by a grant awarded by the U.S. Department f Labr s Emplyment and Training Administratin. The prduct was created by the grantee and des nt necessarily reflect the fficial psitin f the U.S. Department f Labr. The U.S. Department f Labr makes n guarantees, warranties, r assurances f any kind, express r implied, with respect t such infrmatin, including any infrmatin n linked sites and including, but nt limited t, accuracy f the infrmatin r its cmpleteness, timeliness, usefulness, adequacy, cntinued availability, r wnership. This is an equal pprtunity prgram. Assistive technlgies are available upn request and include Vice/TTY (771 r ). HEART FAILURE SIMULATION UPDATED: SEPTEMBER 27,