Our very own Curt Merriman was asked to prepare a 4-part article for HME News “Smart Talk” column. We happily are reprinting it here.

Curt Merriman

Updated 11:47 AM CDT, Tue June 8, 2021

Q. How can I grow my home ventilation program? 

A. In part 1 of this series, I talked about “raising some eyebrows in a good way.” The topic was remote PAP setups. Let’s continue with remote ventilator follow-ups. The RT labor shortage has hit HME companies particularly hard, so looking “outside the box” for solutions is certainly a good idea. 

Removing barriers to success is essential for providing telehealth in the home setting. This is important whether you are using your RT staff to perform the remote visits or seeking outside assistance. Telehealth can provide the HME company with the tools necessary to remotely provide ongoing follow-ups with non-invasive and invasive ventilator care. I suggest using a simple video chat solution that is HIPAA-compliant without having to download an app or having patient usernames, passwords etc.  

Speaking of video-chat, the ability to visualize the customer’s equipment and environment is beneficial when performing routine follow-up on the ventilation services you are providing. The adage “a picture is worth a thousand words” comes to mind. Assessing and troubleshooting is much easier when you don’t have to rely on verbal descriptions.  

Outsourcing a ventilation follow-up process allows for your protocols to be followed without having to worry about finding and hiring RTs. Let your staff take care of other business and allow for convenient virtual visits for routing follow-ups. Your customers and caregivers may find the remote visits less intrusive, simpler and easier to schedule. 

While the pandemic has given us a lot of problems, it has also provided opportunities. Growing your ventilation program fearlessly is now possible with tele-respiratory therapists and technology. 

Curt Merriman is Chief Sales Officer for rtNOW. Reach him at curt@rtNOW.net.

Our very own Curt Merriman was asked to prepare a 4-part article for HME News “Smart Talk” column. We happily are reprinting it here.

TELEHEALTH: BREAK HME PARADIGMS 

Smart Talk

Curt Merriman

Updated 10:27 AM CDT, Wed May 12, 2021

Q. What is driving the telehealth landscape? 

A. The next four articles are going to raise some eyebrows – in a good way! For the last six years, I have been involved in empowering respiratory care in new and exciting ways, and I will paint a picture of the emerging HME/telerespiratory landscape. 

Let’s start with remote PAP set ups.   

Along came a public health emergency: COVID-19. This took the HME industry into the uncharted territory of providing remote services to customers/patients in the home. Customers didn’t want anyone entering their homes; clinicians were not excited to enter homes.  

The federal government:

• Lifted HIPAA rules to allow for any video chat platform to be used;  

• Expanded telehealth to include a telephonic connection; 

• Included the customer’s home as a telehealth place of origin; and 

• Expanded telehealth provider definitions. 

HME providers scrambled to insert themselves into telehealth and struggled with technology for their customers and their staff learned on the fly, as well.  

Other challenges occurred for the HME provider. There was already an RT shortage, and HME RTs transitioning to acute care only exacerbated the short supply. 

The HME industry and its RTs are used to change and challenges in health care. The industry is rising to the challenge with more and more tele-respiratory remote PAP set ups being performed each and every day. The RT shortage did not go away but being able to fearlessly scale your businesses is now possible. Outsourcing remote PAP set ups is a growing reality.  

Outsourcing services can play an essential role in an organization. Inserting outsourced resources when and where needed without having to recruit staff and worry about business volume changes can be a “pressure relief valve” for any business. 

Curt Merriman is Chief Sales Officer for rtNOW. Reach him at curt@rtNOW.net. 

FOR IMMEDIATE RELEASE

Contact: Chuck Stadler Jr. – rtNOW Phone: (989) 284-0198 Email: chuck@rtnow.net

rtNOW Announces New “HME Services” Line

Telerespiratory Line includes Remote PAP Setup, Remote PAP Adherence, and Remote Vent Follow-Up

FRANKENMUTH, MI, April 1, 2021 – Telerespiratory company rtNOW announced today a new line of services aimed at the HME market, collectively known as “rtNOW HME Services”.  These services include Remote PAP Setup, Remote PAP Adherence, Remote Vent Follow-Up, and their previous HME On-Call service.  

“We are excited to empower HME companies with these new service lines.  They will provide a pressure-relief valve for HME companies and their respiratory therapists during the current and growing RT shortage.  Our HME Services line will allow companies to scale fearlessly, taking care of a costly bottleneck that would otherwise be an obstacle,” said Chuck Stadler, Jr., President and CEO of rtNOW.

The service line includes flexible price-per-visit options, and includes rtNOW staff using their proprietary telehealth software, CoreLink, to establish a secure HIPPA compliant video connection.  

“Our executive leadership includes a respiratory therapist with HME experience.  Our eyes have been on the HME space for years, and we are now able to bring a cost-effective, per-visit model to HME companies that want to be a hero to their staff respiratory therapists while preventing ‘RT Burnout’.  Our company’s purpose is to empower respiratory care, and we are excited to drive healthcare forward with innovative services for HME providers.”  

rtNOW is a telerespiratory staffing company based in Frankenmuth, Michigan that services clients nationwide.  It has unique access to experienced, licensed, respiratory therapists, and is known as a pioneer in telerespiratory care.  

###
For additional information about rtNOW please visit www.rtnow.net or contact Chuck Stadler at chuck@rtnow.net

When we introduced rtNOW to the world in 2016, the concept of telehealth (let alone telerespiratory care) was foreign to many clinicians.  It goes without saying that Covid-19 has accelerated telehealth adoption dramatically. As the first RT-owned telerespiratory solution in the world, we were positioned during the pandemic to capture first-hand accounts of what respiratory care looks like to our rtNOW agents during the public health crisis.  It is with great joy that we present to you three testimonials from our telerespiratory therapists on how they positively affected the healthcare outcomes of their patients.  These are taken, with only minor edits, directly from our rtNOW agents.

Ann

I just very recently had an encounter with a patient who had come in through one of our facilities emergency rooms and he was in a great deal of distress and putting the nurses into a great deal of distress as well.  It gave me an opportunity to connect with the doctor on the case, and it was enough to interact with them and for me to see very quickly that this gentleman was going to deteriorate faster than they were going to be able to provide him non-invasive ventilation (which was what they were hoping for).  They forgot about me for a second but I piped back up and came back in as they were struggling to get this gentleman situated. I was able to connect with the doctor at that point and expressed that I felt the patient was in too much distress and he really required immediate intubation.   That was the choice that they made.  It just so happened I had to reconnect with them… and it turns out that was the way to go.  That gentleman was stable enough that they were then able to ship him to a larger care facility that was able to take care of him.   

Chris

The other day I helped ween a Covid patient back down to room air, and they were on their way out the door home.  Just a week or week and a half earlier I had to help the same patient with life-saving ventilator ventilation support. 

Angela

This morning I received a call from (hospital name redacted) from a frantic MD and RN with a patient SOB and a CO2 greater than 100 on abg. Pt was also COVID positive. Patient Came in after satting in the 70s all night according to patient. We intubated, x-rayed, mechanically vented, and sedated until air flight arrived 18 minutes later to transfer to (city name redacted).  Was a great 40 minute call.

A video in a series introducing rtNOW telerespiratory therapists.

Top 5 Reasons HME Companies Need Telehealth

Being a HME company in America isn’t easy.  You want to provide quality care for patients, but every year it seems to get harder.  There are respiratory therapist shortages, dwindling dollars, mountains of regulations, and billing rates that are simply not adequate?  

The good news is that there is a pressure-release valve, and it’s name is “HME On-Call”.  If these problems sound familiar, read on for 5 reasons you should consider a telehealth solution. 

Patient Safety

Prior to the coronavirus pandemic, attitudes toward telehealth were mixed at best.  The prevailing attitude (among the elderly in particular) was that visiting a hospital or having a provider visit the home were the “safest” options, and many people simply didn’t question whether or not this was accurate for their particular circumstances.  The reasons for this range from personal habit to lack of physician adoption, but one thing that can be said for certain is that coronavirus has dramatically shifted public opinion – especially in elderly populations.  

Hospitals and providers that used to be considered safe are now viewed as potential dangers – and for good reason.  It makes little sense to get in-person training or troubleshooting on a piece of equipment while being potentially exposed to coronavirus.

Enter telehealth.  

Telehealth can mitigate unnecessary trips to patient homes, reduce hospital readmissions, and provide patient confidence that they are getting the safest form of care possible in a pandemic and post-pandemic world.  This can reduce stress and at times provide working equipment faster than dispatching a technician, further contributing to the overall health of the patient. 

Provider Safety

The same reasons for mitigating exposure to patients can also apply to providers.  Coronavirus has shown that danger exists not only to patients, but to clinicians and technicians entering the home environment.  With the delay in onset of symptoms, challenging access to testing, and an ongoing growth of knowledge of the virus, the best answer to protect providers (and the companies that employ them) is to limit contact with patients.  As such, telehealth has emerged as a powerful and necessary resource to handle all but the most essential home visits.  It protects providers, preserves essential supplies, limits liability, and fosters a confidence with employees that their lives are protected and valued, resulting in both tangible and intangible benefits.

Telehealth Reduces Expenses

Is there any HME cost more unnecessary than dispatching an RT or technician to plug in a machine?  The great news is that there are numerous ways that telehealth can be utilized to reduce these trips.  From tracking a line problem to confirming that a GFCI outlet has been reset, telehealth can be utilized as a first line of defense before sending someone to a patient’s home.  

A potentially greater, although harder to define, reduction of expenses can be found in reducing “RT Burnout”.  With the current shortage in respiratory therapists, it is more important than ever to keep RTs satisfied in their job.  As such, removing on-call demands – especially the unnecessary ones – goes a long way to showing respiratory therapists they are valued.  This boosts morale and reduces attrition, reducing the HR burden associated with replacing an RT, as well as the costs associated with downtime.

The Competitive Edge

Telehealth is still in its infancy – especially in the HME/DME space.  As with most new technological solutions, those who reap the greatest benefits are those who adopt the changes early enough to maintain a competitive edge.  The use of telehealth can be communicated to your clients – providing another value-add that shows you are on top of industry changes.  The associated benefits to patient and provider health are selling points that can position your company as the vendor of choice.  Speaking of positioning, it also allows the ability to scale your business in ways previously unattainable as some of the limits of time and space are removed from everyday tasks.  

Patient Satisfaction

Moving a step beyond patient safety, we can begin to focus on areas of customer service.  Telehealth technology and workflow can provide a level of patient feedback that is consistent and reportable.  Is the technician or provider representing your company well? What areas of improvement or innovation can be found?  Giving the patient a voice while taking care of their problems remotely can be a powerful way to create lasting relationships with your company without sacrificing time or money.

Making the Move to a HME Telehealth Solution

rtNOW pioneered a HME telehealth solution called “HME On-Call” – a service that provides telerespiratory therapists to HME patients up to 24/7/365.  HIPAA-compliant telehealth software is utilized, and the therapists are trained to troubleshoot HME equipment in any state.  If your HME company has trouble with “RT Burnout”, unnecessary dispatches, and patient/provider safety, then visit rtnow.net/HME, call (833) 786- 6948, or email Curt Merriman at curt@rtnow.net. 

FOR IMMEDIATE RELEASE
Contact: Curt Merriman – rtNOW C.S.O.
Phone:(833) 786-6948
Email: curt@rtnow.net

“HME On-Call” Provides HME/DME Telehealth Resources

Initiative aims to reduce “RT Burnout” while improving patient care.

FRANKENMUTH, MI, October 13, 2020 – Telerespiratory pioneer rtNOW announced a new service aimed at solving respiratory therapy problems in the HME/DME healthcare industry.  Named “HME On-Call”, the service provides 24/7/365 access to a respiratory therapist who is trained to troubleshoot HME calls using proprietary telehealth software.

“HME Companies have had a rough time keeping respiratory therapists – especially during the current RT (respiratory therapist) shortage,” said Chuck Stadler, Jr., President and CEO of rtNOW.  “A large part of the reason is that too much is required of them.  Our telerespiratory therapists have been trained to navigate the complexities of HME equipment, patient interactions via telehealth, and how to dispatch a client’s RT only when necessary.  As a result, patients and providers are safer, disease exposure is mitigated, and respiratory therapists are able to have the work-life balance necessary for a long-term position.  This also reduces costs associated with RT turnover, downtime, and continuity of care.”

The concept of telerespiratory care has been rapidly gaining momentum in recent years.  rtNOW has had success as the first respiratory-care specific telehealth company in the nation. 

“We have been fortunate to maintain a culture of innovation, and our services have been well received.  HME On-Call utilizes our CoreLink software solution, making HIPAA-compliant telehealth easily accessible to most patients.  We know the industry well, we want to connect patients and providers, and we have a passion for empowering respiratory care,” Mr. Stadler said. 

rtNOW is a respiratory care telehealth solution that provides up to 24/7/365 access to an experienced, licensed respiratory therapist.  It provides inpatient and outpatient respiratory care solutions, as well as solutions for higher education and HME/DME companies.

###

For additional information about rtNOW please visit www.rtnow.net/HME or contact Curt Merriman at curt@rtnow.net.

 

Please note, with the unprecedented demands COVID-19 has placed on our profession, the distribution of certificates for the CEU will be slightly delayed.  We apologize for this.  As you can imagine, we are doing our best to be responsive to the needs of the participants, but our first priority has to be responding to the immediate needs of this pandemic.  

We have done our best to post and answer all of the questions posted in the webinar below.  Please note that there are a few questions to Shawna and Sarah that do not have an answer.  We will post the answers as we get them.

Clinical Practice Questions

Q: what are we doing about performing PFT s :Comments below are taken from the Diagnostic section of AARConnect:

A: Infection Prevention Team, we have been (obviously) extra conscientious about hand hygiene and monitoring for staff and patient symptoms. We have also been instructed to wear masks, eye shield and gloves when performing PFTs, given that PFTs can be cough-inducing, i.e. being at higher risk of exposure.

We have also instructed our team to wear masks, eye shields and gloves when performing PFTs. Additional screening has been put into place prior to testing. We are postponing all testing in patients who have been symptomatic (flu-like symptoms) within 21 day prior to the appointment. If a patient comes in symptomatic, we are obtaining a temperature and following our emergency room protocol.

Calling patients prior to testing and asking health screening questions to help determine if they should come in for testing or not.

I have also been hearing many health organizations are looking to halt OP testing of any sort if it is routine or does not have an impact on other treatment or surgical interventions.

Q: For patients who are having a hard time oxygenating, is proning appropriate?

A: There are good article references in the AARConnect “Resources for COVID-19” community if you are an AARC member. Also from what I have been reading using ventilation/oxygenation techniques as you would for any patient would be appropriate.

Q: RT can perform PCR NASOPHRAYNGEAL swap?

A: This would be up to your facility & lab policy.

Q: How many days Do patients is expected to remain intubated?

A:  This will vary from patient to patient due to all the individual variables factoring into the specific case.

Q: Any idea what percentage of infected patients are experiencing respiratory symptoms? 

A: I refer you to the CDC.gov  web page for the most up to date information. I have not seen the statistics presented exactly as you have asked in your question.

Q: should outpatient, routine PFTs be postponed until further notice? 

A: This is unfolding in realtime and would look to your internal organizations plans and following the CDC.gov web site. I have heard of some OP diagnostic centers considering postponing testing unless essential for treatment determination.

Q: Is there a special protocol for COVID-19 patients?

A: The CDC.gov has great information and suggested guidelines. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Q: What is the course of treatment?!? My hospital does not see using NIV or HFNC has producing droplets (which I’ve always disagreed with) and are not following the proper precautions?!? How do we treat these patients when everyone says something different?!?

A: One of our speakers referenced an article from China indicating that NIV was not very effective in treating some of the patients and they also discussed using a “helmet” patient interface with NIV. 

Q: Do these patients need to be in a negative flow environment?

A: CDC says to use airborne infection isolation rooms only when a known COVID-19 infection + aerosol generating procedures 

Q: Still use multi canister mdi’s?

A: What I have seen is that protocols for use of multi-canister mdi are not applicable for patients in isolation.

Q: Still use multi canister inhalers?

A: What I have seen is that protocols for use of multi-canister mdi are not applicable for patients in isolation.

Q: Hand held nebulizer or MDI??? Which is best practice for covid19?

A: Because of the droplet transmission, it is recommended to minimize aerosols that may carry and disperse aerosols. It would be reasonable to consider non-aerosol generating therapeutic inter-change.

Q: What do we know about children and COVID?

A: Refer to CDC.gov, however children have not been affected as much compared  with influenza viruses 

Q: What is the clinical recommendations for treating COVID 19? Are they saying not to use HFNC and NIV?

A: Due to the potential aerosol/droplet dispersion of these modalities, some references discourage their use.

Q: So is the recommendation to not use nebulizers and just use MDI and DPI on these patients?

A: Because of the droplet transmission, it is recommended to minimize aerosols that may carry and disperse aerosols. It would be reasonable to consider non-aerosol generating therapeutic inter-change.

Q: Is it worth using NIV, HFNC, aerosols? Or just going straight to intubation? 

A: Each patient presents a unique situation, the decision to intubate, or not, will depend on a number of factors specific to each patient.  Using evidence based criteria in determining the appropriateness of intubation in any specific situation is recommended. 

Q: How do you stop physicians from ordering unneeded treatments to this population. Bronchodilators does not fix hypoxia.

A: This is certainly a challenge…even when protocols are utilized! If your ordering physician is receptive to seeing information present the treatment guidelines from the CDC.

Q: What is the CXR pattern for viral PNA?

A: The following may be a good resource: https://www.itnonline.com/content/how-does-covid-19-appear-lungs

Q: How to handle the ventilator?

A: Like disinfection the surface & equipment etc.. Look to CDC.gov for guidance and your standard procedures

Q: After intubation how could disinfect the scope, blade,other misc equipment.?

A: Look to CDC.gov for guidance and your standard procedures

Q: Shawna, I know you recommended MDIs and DPIs in place of SVNs. For those that can’t do those and need a SVN would putting an HME (viral/ antibacterial filter on the end of the SVN a good idea to eliminate droplets in the air?

A: Shawna Strickland@Victoria Hodges – I believe the advice is to put the patient in a negative pressure (airborne infection isolation room) during that procedure if possible.

Q: How do we confirmed in the lab test if it is ncov? What kind of point of care testing ? Thank you & please take care.

A: I refer you to CDC.gov the CDC and private labs are ramping up production of testing kits with daily updates. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: Alos niños los está afectando y si esos ninos tenían todas sus vacunas (Translation: Children are affecting them and if those children had all their vaccines)

A: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics 

Q: Los pacientes adultos que fueron afectados tenían sus vacunas completas y los que fallecieron las tenían también ,se que no hay vacuna para covide 19pero existe relación en la Morbi mortalidad de esto. (Translation: The adult patients who were affected had their vaccines complete and those who died had them too, I know there is no vaccine for covide 19 but there is a relationship in the Morbi mortality of this)

A: I don’t know that there has been enough evidence reported to date regarding other vaccinations. Underlying chronic conditions has a significant factor affecting the mortality rate in conjunction with the age of the patient. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: Is there a recommendation for facilities whose therapist who care for NICU/pediatric and adult populations? Should therapists be dedicated to one age population?

A: Facility internal resources will likely be the determining factor. 

Q: As i said before I work as home care rt, do you think we can spread it if go from one home to another?

A: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html

Q:  How about using nebulization anti viral – specific for RNA viruses ? What’s your opinion using in-line nebulization of antiviral – RNA like Ribavirin and Zanamivir ? or other Anti-viral – RNA virus

A: I personally have not seen data to support this and refer you to CDC.gov guidelines https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: Is there a need to put a patient into a negative pressure room?

A: CDC recommends this when possible https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: Covid19 recovery patient do they have recurrent ?

A: I believe I saw a repeat case in China from one of the published studies on CDC.gov.

Q: How about checking IgM and IgG covid 19 ?

A: I believe this testing is pending FDA approval at this time 

 

CDC Questions:

Q: Is there any idea about how widespread this could become in coming weeks/months?

A: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: I heard mix things coming from different source are we verified that if it is airborne and contact ? Or is it strictly airborne?

A: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#investigational-therapeutics

Q: How should pregnant RRTs protect themselves while taking care of pt in hospital?

A: CDC is saying we don’t know if pregnant women are more susceptible to the coronovirus

https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fspecific-groups%2Fpregnancy-faq.html 

Q: Is it known how many days post symptom presentation the inflammatory response peaks?

A: Information is more specific to symptom changes, the CDC has some more information on this here; https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html

Q: How long do these droplet particles last on solid surfaces?

A: CDC indicates the virus may live for hours to possibly days depending on the surface. https://www.cdc.gov/coronavirus/2019-ncov/prepare/cleaning-disinfection.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcommunity%2Fhome%2Fcleaning-disinfection.html

Q: Is there a time line for how long the virus lasts or at what day it would peak?

A: Repeat, https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Q: I might have missed this slide but, the virus supposedly has an incubation period 5-10 days or so, what of the chances of contracting the virus of an asymptomatic host if you don’t wear a mask if you’re not sick?

A: I don’t know if this is known however here is a good link you may find useful; Healthcare FAQ’s: https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html

Q: Of the patients that have confirmed with COVID-19, What is the instance of patients needing respiratory support (ie invasive ventilation)?

A: Approximately 20-30% of hospitalized patients with COVID-19 and pneumonia have required intensive care for respiratory support.[2–3] Compared to patients not admitted to an intensive care unit, critically ill patients were older (median age 66 years versus 51 years), and were more likely to have underlying co-morbid conditions (72% versus 37%). [3] Among critically ill patients admitted to an intensive care unit, 11–64% received high-flow oxygen therapy and 47-71% received mechanical ventilation; some hospitalized patients have required advanced organ support with endotracheal intubation and mechanical ventilation (4–42%).[3–4,9] A small proportion have also been supported with extracorporeal membrane oxygenation (ECMO, 3–12%).[3–4,9] Other reported complications include cardiac injury, arrhythmia, septic shock, liver dysfunction, acute kidney injury, and multi-organ failure. Post-mortem biopsies in one patient who died of ARDS reported pulmonary findings of diffuse alveolar damage. [14]; 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Q: How long are you contagious? How long should we self-quarantine?

A: Resolution of fever, without use of antipyretic medication

Improvement in illness signs and symptoms

Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive sets of paired nasopharyngeal and throat swabs specimens collected ≥24 hours apart* (total of four negative specimens—two nasopharyngeal and two throat). See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for 2019 Novel Coronavirus (2019-nCoV) for specimen collection guidance.

Q: Once a person has it, and gets over it, is there a chance for re-exposure?

A: The immune response to COVID-19 is not yet understood. Patients with MERS-CoV infection are unlikely to be re-infected shortly after they recover, but it is not yet known whether similar immune protection will be observed for patients with COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html

Q: I see on tv other countries are using head to toe ppe. Are we safe just using goggles, Updated PPE recommendations for the care of patients with known or suspected COVID-19:

A: Based on local and regional situational analysis of PPE supplies, facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand.  During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to HCP.

• • Facemasks protect the wearer from splashes and sprays.
  • Respirators, which filter inspired air, offer respiratory protection. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html

Q: Mask, and gown only? What if droplets from treating a COVID-19 patient get on our hair, skin, shoes. Wouldn’t that travel with us to other non-infected patient rooms?

A: We are unsure at this time.  Please continue to visit the CDC. 

Q: Doesn’t humidity diminish the virus?

A: We are unsure at this time.  Please continue to visit the CDC. 

Q: Is there evidence on how the virus will respond as our season temps warm up?

A: Not fully understood at this time continue to follow the CDC.gov page

Q: Is there a way for anyone to learn of having the virus before being diagnosed or having any symptoms?

A: There is testing in development that can be quick test self nasal swab testing. 

Q: My job insists that NIV & HFNC are not droplet 🤔 Because both of these modalities involve very high flows and/or pressures, any potential moisture collected in the circuit or interface can easily be dispersed into the air and onto surfaces. 

A: Perhaps a demonstration would provide better understanding.

Q: I work in long-term care facilities that currently do not have a respiratory protection program and N95 fit testing protocols in place. In the event that we have a resident test positive for COVID-19 how would we be protected if we were unable to transfer the patient out?

A: This is from the CDC.gov

Capacity across the healthcare continuum: Use of N95 or higher-level respirators are recommended for HCP who have been medically cleared, trained, and fit-tested, in the context of a facility’s respiratory protection program

The majority of nursing homes and outpatient clinics, including hemodialysis facilities, do not have respiratory protection programs nor have they fit-tested HCP, hampering implementation of recommendations in the previous version of this guidance. This can lead to unnecessary transfer of patients with known or suspected COVID-19 to another facility (e.g., acute care hospital) for evaluation and care. In areas with community transmission, acute care facilities will be quickly overwhelmed by transfers of patients who have only mild illness and do not require hospitalization.

Many of the recommendations described in this guidance (e.g., triage procedures, source control) should already be part of an infection control program designed to prevent transmission of seasonal respiratory infections. As it will be challenging to distinguish COVID-19 from other respiratory infections, interventions will need to be applied broadly and not limited to patients with confirmed COVID-19.

This guidance is applicable to all U.S. healthcare settings. This guidance is not intended for non-healthcare settings (e.g., schools) OR for persons outside of healthcare settings. For recommendations regarding clinical management, air or ground medical transport, or laboratory settings, refer to the main CDC COVID-19 website.

Q: If your family member gets sick, can you come to work?

A: There is not a simple answer to your question here is a link that can provide you more information. One of the recommendations is to speak with your organizations Occupational Health group for further guidance. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

Q: Is the current recommendation is to wear the N95 mask for all confirmed COVID-19 patients?

A: This is from the CDC.gov – 

Capacity across the healthcare continuum: Use of N95 or higher-level respirators are recommended for HCP who have been medically cleared, trained, and fit-tested, in the context of a facility’s respiratory protection program

The majority of nursing homes and outpatient clinics, including hemodialysis facilities, do not have respiratory protection programs nor have they fit-tested HCP, hampering implementation of recommendations in the previous version of this guidance. This can lead to unnecessary transfer of patients with known or suspected COVID-19 to another facility (e.g., acute care hospital) for evaluation and care. In areas with community transmission, acute care facilities will be quickly overwhelmed by transfers of patients who have only mild illness and do not require hospitalization.

Many of the recommendations described in this guidance (e.g., triage procedures, source control) should already be part of an infection control program designed to prevent transmission of seasonal respiratory infections. As it will be challenging to distinguish COVID-19 from other respiratory infections, interventions will need to be applied broadly and not limited to patients with confirmed COVID-19.

This guidance is applicable to all U.S. healthcare settings. This guidance is not intended for non-healthcare settings (e.g., schools) OR for persons outside of healthcare settings. For recommendations regarding clinical management, air or ground medical transport, or laboratory settings, refer to the main CDC COVID-19 website.

Q: As a home care provider our employees come into contact with people in their homes and in our offices. We have no idea their exposure risks. what precautions should our staff be taking?

A: Not a simple answer however the CDC has home care guidelines you can access. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html

Q: I’m over the age of 60 and being told I shouldn’t even leave my house. Thoughts on working in a hospital where it may happen that I’m giving to undiagnosed covid 19 patients.

A: Not a simple answer suggest speaking with your hospital’s Occupational Health group for further guidance. 

Q: Do you recommend we stay in surgical masks while in the hospital, and then step up to N95s when caring for patients in strict isolation?

A: I don’t believe the CDC is suggesting that we wear surgical masks while in the hospital as a precautionary measure. They do have clinical guidelines for PPE that you can find at: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html

Q: In addition to COPD, are our patients with pectus excavatum also considered high risk? Also, there is an abundance of information out saying that it is droplet and an equal amount stating airborn. What is the official transmission/isolation for this virus? I have also seen a couple articles recommending intubate patients be placed prone, is this being considered best practice?

A: Droplet is the accepted transmission occurrence. https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-patients.html

Proning may be required if clinically indicated however I don’t know that this has been established as best practice.

Q: In CF clinic they didn’t do PFT for my daughter due to her being positive for flu so I don’t think they would for COVID no reason its diagnostic from what we were told.? Her respiratory illness we were told to take extra precautions in crowds stay home as much as possible, so anyone with pulmonary issues I would think that would be the same?

A: As currently recommended,  anyone with compromise is advised to self-isolate to avoid potential infection.

Q: What is the actual treatment for this?

A: Not a simple answer, I will defer to the CDC guidelines for mgt. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Q: Should therapist that work full-time in the hospital setting stay away from contingent jobs in the LTAC setting?

A: Might be best answered by the Occupational Health at your LTAC.

Q: I work as a RRT in LTC with most patients being in the range of 60 plus. We are allowing no visitors unless its terminal illness. Anything you think we could do or look for to help out?

A: This is a common mitigation protocol used across the nation. Stay in the know with CDC 

Q: Based off of the incubation period for the virus, can you please clarify again why those who are not infected have no need to wear masks unless you’re caring for a pt with covid-19? What if the host is asymptomatic?

A: I defer to CDC however it is likely most of us will be exposed to this virus as we are to influenza etc. Most people will have non to mild symptoms unless you are in the high risk groups.

Conference/CRCE Questions

Q: Does one need to be a member to access these AARC resources? Free to Non-members?

A: There is some information on the AARC web site that does not require membership however you would be best served by becoming one to access all the resources available from the AARC, CRCE’s, access to the AARConnect communities and much much more. (not a paid endorsement for the AARC just an RT that believes in what they offer).  

Q: Will this be archived, and if so, when and how to access?

A: We have recorded the webinar event for you available here: https://event.webinarjam.com/go/replay/1/oyl7rawtntqt0

Q: Dr Shawna, Will we have the chance to listen the full Webinar again or you planned to publish it via AARC websites ?

A: We have recorded the webinar event for you!  Replay video: https://event.webinarjam.com/go/replay/1/oyl7rawtntqt0

 

Emergency Changes Make Me Uncertain How to Best do My Job Safely

Q: How are pulmonary rehab facilities functioning? We have closed, are you calling the patients at home to screen? Screen on arrival to PR?

A: Suggest checking with AACVPR for recommendations. 

Q: I work as home care rt what is the other extra precaution i need to tak?

A: Here is the CDC link for home care providers: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html

Q: How can we use telemed in the home care world right now?

A: rtNOW has software available now that can be utilized by home care companies that can send a link via text or email to a patient in the home if they have a smart device or computer with camera. If you want more info email: connect@rtnow.net

Q: Anyone in the cardiac/pulmonary rehab world cancelling rehab? Our patients are the most high risk.

A: Yes seeing this in many OP settings not just PR programs

Q: What about programs such as pulmonary rehab?

A: Starting to see OP programs being postponed, telerespiratory follow in the home is a potential to stay in touch and help support them in their home environment. Not reimbursable (as of 2020-03-16) however clinically beneficial.

Q: We can’t use telehealth because we actually have to deliver equipment to the patients and set up equipment in our office. We want to protect ourselves and our workers.

A: Can be useful for follow up especially for high tech respiratory equipment being able to visualize the equipment for troubleshooting is a plus.

Q: What things have you done to use telerespiratory service scenarios?

A: rtNOW has used telerespiratory to assess patients RCAT’s, set up NIV, follow up on NIV adjustments to therapy, troubleshoot equipment alarms, just-in-time education for staff and patients as well as remote patient monitoring (RPM)

Q: It seems clear that telerespiratory is a great option. But how can RT programs be covered if they’re not approved already? how can a telerespiratory program provide without RT component?

A: rtNOW’s experience has been that organizations see the benefits of not having to transfer patients out, decreasing re-admissions from SNF’s, maximizing resources and in case of COVID-19 putting the RT remotely where the pt is: home/isolation etc. It also can be used to support our argument for reimbursement with CMS. (CONNECT ACT)

Q: No one is talking about protecting ourselves from the asymptomatic. Don’t you think telerespiratory would be a great way to teach the public how to safely wear masks?

A: Yes, it could!  It could also be used for screening pt’s helping to identify the need for seeking testing or medical treatment in a facility.

AARC questions

Q: How to raise the quality of service for COVID-19: patients ??

A: Continue to follow real time updates from reliable sources, CDC, NIH 

Q: What about incorporating more student RT workers?

A: I am sure this will be addressed at the local level. My comment is that because an RT student can’t work independently it increased the PPE supplies being used when they are already in short supply 

Q: Do you think the AARC will post clinical practice guidelines ?

A: Shawna Strickland @Robyn Mustachccio – CPGs take an awful lot of time to develop. Right now, we’re focused on making sure all literature is getting to members as quickly as possible. There will likely be CPGs at some point, probably a joint effort from multiple organizations.

 

COVID-19 Clinical Presentation and Treatment

Q: Does bronchospasm present in the symptoms of Covid 19 pneumonia?

A: Likely not different that any other viral infection that can cause bronchial irritability/spasm.

Q: Does Covid19 really produce fibrosis in the lungs which is not reversible?

A: Not seeing this in the literature.  

Q: How’s everyone treating these patients????? What’s happening first?!! Hypoxia? Hypercarbia?

A: Appears hypoxia respiratory failure and these patients are requiring high FiO2’s and PEEP.

Too great not to share.  We recently did a webinar for a closed group of potential telerespiratory therapists.  Check out this case study involving a newborn, bubble CPAP, some great nurses, and a lot of critical thinking!  This is how it’s done!

By Chuck Stadler, Jr – President and CEO of rtNOW.

One of my nursing instructors/mentors (Mona White) told me years ago, “The gauge of a great nurse is not to know everything, rather to know what questions to ask and where to find the answer”.   Nobody can be comfortable and knowledgeable with every aspect of nursing, and anyone who claims to be is crazy. Nurses have all been taught to lean on their clinical peers for guidance. A respiratory therapist has always been a pivotal member of the clinical team, offering specialized respiratory expertise.

Using Minnesota as an example state¹, in urban areas 1 respiratory therapist has the potential to serve 2,647 patients. In small rural towns, the ratio is 1 respiratory therapist to 5,746 patients.  On the far end of the spectrum, in isolated rural areas the gap widens to an enormous 1 therapist to 29,143 patients. During the 2018 – 2019 data collection period a projected 104 openings across the state with a supply of 81 graduates to fill these openings².

This is one example of respiratory therapist shortages that continue nationwide.  They are a problematic reality in today’s healthcare landscape, but current technology can also provide an answer.

PDPM provides a unique opportunity for skilled nursing facilities to grow their respiratory resources through telerespiratory care while capturing PDPM dollars.

Whether you have partial respiratory coverage or no coverage at all, telerespiratory care is emerging as a viable way to increase the number of medically complex patients your staff can successfully handle, while capturing PDPM dollars.  Nurses can quickly connect with a respiratory therapist via phone and video chat, who can then consult on equipment, perform respiratory assessments, make recommendations for treatment plans (i.e. NIV, CPAP, trach care), and serve as a supportive bedside resource to nurses, providers, and patients/residents. Once telerespiratory is integrated into a culture, experience has shown that it can be key to avoiding transfers.  For examples of this, look at these case studies from rtNOW.

And the good news is that it makes financial sense.  For all the change that is happening there are 9 stackable NTA codes³ specific for patients with respiratory comorbidities (Chart 1). As you know, there are many other codes that would be also associated with some of these patients with multiple comorbidities.  PDPM provides a unique opportunity for skilled nursing facilities to grow their respiratory resources via telerespiratory care while capturing PDPM dollars.

 

If your organization is planning to take on the medically complex population, you will start to get pressure from all sides on how to care for them properly.  It may be that your organization has been fortunate in finding and maintaining a respiratory therapist on day shifts, but what about the nights? Your evening/night shift clinical team probably has less experience and different staffing ratios than the day shift.  Who are evening/night shift team supposed to use for guidance through the night? The administrator? DON, ADON? Will they wake up one of your day shift RT’s? Or will they continue to transfer the patient to the hospital? These are important questions, and thankfully we now have an answer.

I would like to propose that an easy solution is to give them a team of licensed RRT’s available with the touch of a button via telerespiratory.  Pricing packages range between $4-5/hr depending on the amount of coverage desired. A small price to pay to add a knowledgeable team member at the immediate time and place your staff has a need.

References: 

1. Minnesota Department of Health: Office of Rural Health and Primary Care report on Minnesota’s Respiratory Therapist Workforce, 2016: https://www.health.state.mn.us/data/workforce/rt/docs/2016rtb.pdf 
2. Minnesota State Careerwise: https://careerwise.minnstate.edu/lmiwise/demand?id=OPS025&area=000000&ord=1
3. CMS Website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Fact_Sheet_NTAComorbidityScoring_v2_508.pdf