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ICU Discharge for Tracheostomy Client to INTENSIVE CARE AT HOME, What are the Quality Standards?

Hi, it’s Patrik Hutzel from intensivecareathome.com where we provide tailor-made solutions for long-term ventilated adults and children with tracheostomies at home and where we also provide tailor-made solutions for hospitals and intensive care units at home whilst providing quality care for long-term ventilated adults and children with tracheostomies at home, otherwise medically complex adults and children at home, which includes Home BIPAP (Bilevel Positive Airway Pressure), Home CPAP (Continuous Positive Airway Pressure), home tracheostomy care for adults and children that are not ventilated, Home TPN (Total Parenteral Nutrition), home IV potassium infusions, home IV magnesium infusions, and home IV antibiotics. We also provide port management, central line management, PICC (Peripherally Inserted Central Catheter) line management as well as Hickman’s line management at home, and we also provide palliative care services at home.

We have also sent, and we are sending our critical care nurses into the home for emergency department bypass services, and we have done so successfully in the past for the Western Sydney Local Area Health District, their in-touch program.

So, today I actually want to look at a hospital discharge patient or ICU discharge patient with a tracheostomy and what needs to be put in place and also what needs to be the overarching framework for this. So, what I mean by this is that for any hospital discharge, especially when it comes to Intensive Care at Home, there needs to be a framework around it. It needs to be safe, and we are providing that evidence-based framework.

Let me dive into that a little bit in more detail and it also comes down to having accredited third-party services that can provide that framework because anything less could be dangerous and could result in patients dying at home if they’re not having critical care nurses 24 hours a day at home.

Let’s talk about the framework. The framework is around the Mechanical Home Ventilation Guidelines that you can find on our website. The Mechanical Home Ventilation Guidelines are evidence-based and they say that for every patient at home with ventilation and tracheostomy, but even with tracheostomy without ventilation, there needs to be 24-hour critical care nurses and those critical care nurses all need to have a minimum of two years critical care nursing experience. So, that is actually evidence-based. Those Mechanical Ventilation Guidelines are a result of 25 years Intensive Care at Home nursing predominantly in Germany, but also a result out of 12 years Intensive Care at Home nursing in Australia with Intensive Care at Home.

Furthermore, healthcare services that provide Intensive Care at Home need to be third party accredited, which means they need to have the framework, the policies, the guidelines, the staff that enable to replicate an intensive care bed in the community. Once again, we are the only provider in 2024 that has such third-party accreditation for Intensive Care at Home, and you can look that up on our website that is in Australia where we are third-party accredited.

Now, let’s look at a case study where we are helping a client to go home from ICU to home with intensive care nurses 24 hours a day and what the medical records say about this discharge.

So, “As for the patient’s notes on the 8/28/24, vital signs are stable, continued with neuro checks.” This lady had a brain bleed and she’s not really awake at the moment, but the family obviously wants her at home, and they want her to live because that would be her wishes. “Vital signs are stable, continued with neuro checks, sleep hygiene, repositioning every two hours, monitoring her intake and output which is fluid intake and output, and promoting comfort, safety, and rest.”

Now, once again, that is what she’s currently getting in ICU so the same needs to happen at home because her care needs are not changing at home. The minute you provide this level of care with family members or with general registered nurses, it’s going to fall apart. Patients have died if you’re not providing the critical care nurse 24 hours a day when you’re discharging patients from ICU to home. Also, medication management needs to happen at home, of course. She is on medication, on anti-seizure medication such as Keppra and again, that needs to be monitored by registered nurses and not by any other personnel. Tracheostomy care obviously needs to happen.

A modified home oxygen study was done yesterday, where she has been taken off the tracheostomy collar (set at 28% oxygen) with humidified oxygen and then she was placed on an HME (Heat and Moisture Exchanger) filter. During the 5- minute study, her oxygen saturation (SpO2) remained stable. After the study, she returned to the trach collar and the ICU nurse will need to continue monitor the patient as needed.

As per her lab results, it’s good to note that her white cell count and hemoglobin levels showed improved results.

Her blood glucose levels continue to fluctuate as high as 409 more on the high side. It is important to adjust the insulin dose regimen to achieve better glucose control and repeat blood glucose checks after administering insulin to ensure the correction is effective. I have not seen that they are addressing this in the medical records. The issue must be addressed before discharge, and it must be addressed at home with having 24-hour critical care nurses. Confirm that Intensive Care at Home will assist with blood glucose monitoring and insulin administration at home. Also, consulting an endocrinologist is recommended for further treatment, more precise glucose management and to prevent further episodes of hyperglycemia.

Then it goes on with blood results here, obviously.

Glucose hemoglobin is around 10.1 which is fine, white cell count is around 14.3.

Now, white cell count should be between 4 and 11. Many patients in ICU have a high white cell count. They are prone to having an infection. A high white cell count will indicate that there’s an infection looming. The reason that many patients, if not most patients in ICU, have a high white cell count and are prone to an infection is simply that they are living in an infectious environment. They are surrounded by other infectious patients. Doctors and nurses and physiotherapists are walking around in ICU, yes they’re doing hand hygiene that might be wearing plastic aprons and all the rest of it, but there’s still a much higher risk that the infection will travel from patient to patient, quite literally killing a patient. Whereas at home, it’s a much cleaner environment, the risk for an infection is much lower.

Next is, she also has a PEG (Percutaneous Endoscopic Gastrostomy) tube, and as much as you might have heard me say in some of my videos, do not give consent to a PEG tube in ICU. Once a patient is ready for discharge and can’t eat and drink orally, they will need to have a PEG tube. I have also said that if a patient can’t have the tracheostomy and the ventilator removed beyond the shadow of a doubt and they want to go home, that’s when a PEG tube must be happening.

So obviously, dressing change needs to happen daily. The flushes need to happen after every feed or after every medication is given through the PEG. There should be a 20 to 50 mL water flushes to avoid clogging the PEG. Furthermore, dressing changes need to happen daily, sometimes twice daily. Clean it with saline, put in a split gauze and making sure it’s sitting at the right level and also check the balloon of the PEG tube.

Then this is the doctor’s letter, “I certify based on my findings, the following services are medically necessary, Intensive Care at Home services for tracheostomy care, 24 hours a day.” All critical care nurses need to have a minimum of two years ICU or critical care experience, which is synonym to what is documented in the evidence-based Mechanical Home Ventilation Guidelines. “The patient requires assistance with critical care nurses, 24 hours a day, to leave ICU safely.”

Now, the discharge summary continues with,

“The listed equipment are respiratory suction machine and supplies, manual wheelchair, oxygen, tracheostomy supplies,” which is a size 6 tracheostomy. So, it needs a size 6 tracheostomy for emergency management as well as a size smaller, which is a size 5.5 or 5. In case of an emergency, if you can’t put the size 6 back in, you then need to go on one size smaller,

“…especially mattresses, which is air mattress, Hoyer lift or ceiling hoist, hospital bed, respiratory suction machines and supplies, and enteral feeding supplies for the PEG tube. Please check all these types of equipment and supplies, making sure of their durability, good functions and well calibrations.” Again, this is what we do here at Intensive Care at Home, making sure the equipment is in working order and passes all the tests because otherwise it could be unsafe.

“Familiarization with the operations functions, alarms and indicators of the equipment. Before discharging the patient, a thorough assessment, evaluation and clearance from her attending doctors as well as doctors who were following her during her ICU confinement with health teachings, instructions, take-home medications, scheduled appointments to their respective clinics and the alarming signs and behavior when to take the patient back to hospital or to the emergency department.”

Well, I argue our clients do not have any hospital readmissions. Generally speaking, one of our KPIs (key performance indicators) is to have no non-elective hospital readmissions, and most of the time we are achieving that because it’s a win-win. It’s a win for the hospital, it’s a win for the patient, it’s a win for us. It’s all about creating win-win situations.

“Ask the doctors for all your concerns, doubts, and queries before you leave the hospital. Check breathing, vital signs, feeding, urination, bowel movement, mobility, skin color, level of consciousness, infections, sugar levels, operations, dressings, wounds, etc. are acceptable, stable, normal and no problems or issues before leaving the hospital. The patient safety must be guaranteed.”

Again, this is what we provide with Intensive Care at Home. We are guaranteeing the patient safety at home. Also, with those safety checks that the doctor highlights whether it’s breathing, vital signs, feeding, urination, bowel movement, again, this is why you need a critical care nurse, 24 hours a day, because it’s almost like doing a constant head to toe assessment, and making sure patients are getting regular suction with the tracheostomy, they’re getting regular dressing changes with the tracheostomy, regular inner cannula changes, making sure when you go from the humidifier or the trach collar to the HME, it’s safe. You monitor when a patient can no longer tolerate an HME because there’s usually a limited time when patients can tolerate the HME. Also making sure she gets two hourly pressure area care, getting turned every two hours, so that the skin isn’t breaking down, so that is really, really important. I’m glad the doctor has documented that.

Current medications are she’s on Keppra for seizures. She is on Motrin, Advil, ibuprofen, Celebrex, Vioxx, naproxen, Keppra and dexamethasone, and dexamethasone is a steroid that needs to be weaned over time. Once again, this is something that needs to be monitored by critical care nurses and can’t be monitored by lay people.

So, I hope that this snapshot will give you a really good idea. I was giving you a really good idea of what needs to happen before you can have Intensive Care at Home, and I’m glad that the doctors are spelling it out in no uncertain terms. Another thing that I forgot to mention, it’s not only when you look at the tracheostomy, in particular, you also need to look at other emergency equipment such as a resuscitation bag, and tracheostomy dilator in case the tracheostomy collapses. Once again, to know what to organize at home for tracheostomy or ventilated patients only comes with the skill of a critical care nurse.

So, I hope that helps and illustrates a really, really well-rounded view into what an ICU discharge needs to look like. On top of that, obviously, it needs to be the 24-hour intensive care nurses. On top of that needs to be the funding, but that’s already been established so it’s really important that you have a plan when it comes to those discharges.

Now, with Intensive Care at Home, currently, we are operating all around Australia and all major capital cities as well as in regional and rural areas. We are a NDIS (National Disability Insurance Scheme) approved service provider in Australia, TAC (Transport Accident Commission) and WorkSafe in Victoria, NIISQ (National Injury Insurance Scheme) in Queensland, iCare in New South Wales, and a DVA (Department of Veteran Affairs) all around the country. Our clients have also received funding through public hospitals, private health funds as well as departments of health.

We are the only service in Australia in 2024 that is third-party accredited for Intensive Care at Home and that brings us to a position where we are, that’s why we can employ hundreds of years of intensive care and critical care nursing experience combined in the community and that is unmatched of in 2024 in Australia. Nobody can bring a higher skill level into the community than Intensive Care at Home in Australia.

If you’re at home already in a similar situation where your family member or yourself is ventilated with a tracheostomy and you feel unsafe because you don’t have the level of support that I described so vividly in this video, I urge you to reach out to us because we can put the support in place and we can also get the funding for you, otherwise we wouldn’t be in business. We have shown it for the last 12 years that we can help with the advocacy and the funding for our clients. Because you don’t want to go back to hospital, you don’t want to go back to ICU, the ICUs don’t want you there. Again, it’s all about creating that win-win situation.

Now, we’re also providing Level 2 and Level 3 NDIS Support Coordination for our clients and also TAC case management.

If you’re looking for a NDIS support coordinator, I encourage you to reach out to us or if you’re looking for more funding because your current NDIS support coordinator can’t get the funding for you, I also encourage you to reach out to us. We are the experts in getting the funding and we’ll help you to get the right level of care and the right team.

Now, if you’re a NDIS support coordinator watching this, we are also providing Level 2 and Level 3 NDIS support coordination. We have our own NDIS support coordinator, so if you want to change or if you don’t have a NDIS plan and you need to get a NDIS plan, we can help you with that. We’re also providing TAC case management. I also have done an interview with our NDIS support coordinator, Amanda Riches, and I will link to that interview below.

If you are a critical care nurse looking for a career change, we’re currently offering jobs for critical care nurses in the home in Melbourne, Sydney, Brisbane, in Albury, Wodonga, in Bendigo in Victoria, as well as in Warragul in Victoria. If you have worked in critical care for a minimum of two years pediatric ICU, ED, and you have already completed a postgraduate critical care qualification, we will be delighted to hear from you.

Because we are offering a tailor-made solution for our clients, which includes regular staff, our clients want to have the same staff coming over and over again because they are very vulnerable and it’s all about building those critical relationships and having regular and stable teams. So, if you’re looking for agency work where you can come and go, this may not be the right fit for you because we’re looking to engage with you on a long-term basis and our clients want to engage with you on a long-term basis. So, it’s all about building those critical relationships long-term so that it remains a win-win situation for everyone.

If you’re an intensive care specialist, ICU consultant, or ED specialist, we also want to hear from you. We are currently expanding our medical team as well.

We can help you eliminate your bed blocks in ICU, ED for your long-term patients in particular or patients that are coming back over and over again. We are here to help you to take the pressure off your ICU and ED beds. In most cases, you won’t even pay for it.

If you’re a hospital executive watching this and you have bed blocks in your ICU, ED, or respiratory wards, please reach out to us as well. We can help you there.

Lastly, if you’re in the U.S. or in the U.K. and you’re watching this, and you need help, we want to hear from you as well. We can help you there privately.

Once again, contact us at intensivecareathome.com. Call us on one of the numbers on the top of our website or send us an email to info@intensivecareathome.com.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecareathome.com and I will talk to you in a few days.

Take care for now.