Using the Vivo 50: Reducing Hospital Readmissions with NIV and End Tidal CO2 in COPD patients at home: a case series.

Introduction

Hospitals are being penalized by Medicare for COPD readmission occurring within 30 days of discharge. These penalties are part of the Readmissions Reduction Program, which is part of the Affordable Care Act (Centers for Medicare & Medicaid Services). These penalties have resulted in an increased demand for DME providers to become more involved and concerned with therapies directed at meeting the clinical needs of the patient in the home to prevent hospital readmissions. EtCO2 is fairly new to the durable medical equipment industry and has been received with some scepticism as there are no billable codes for this modality. However, the potential benefits for EtCO2 include a clinical perspective into the patient’s condition which was not possible prior to the development and integration of EtCO2 modalities. With EtCO2 monitoring, home care clinicians have a chance to intervene in the patient’s care prior to exacerbations occurring.

Non-invasive Mechanical Ventilation (NIMV) has been shown to decrease readmission rates in COPD patients (Murphy, PhD, et al., 2017). EtCO2 monitoring of ventilator patients has been proven to be an effective tool in monitoring hemodynamic changes in patients in acute-care settings. This paper aims to study how EtCO2 monitoring, specifically with the Breas Vivo 50 ventilator, affects hospital readmission and clinical outcomes for patients in the home-setting. When clinicians utilize EtCO2 in the home setting, less hospital re-admissions occur. We believe causality to most likely be interventions brought about by EtCO2 readings.

Case presentation

Our test group was comprised of fifteen patients who were placed on Breas Vivo 50 ventilators with integrated monitoring continuously for 30 days. Each of the Fifteen patients have the diagnosis’ of acute on chronic hypercapnic respiratory failure secondary to COPD. Each patient had more than two hospital admissions in the last 6 months. All were setup upon discharge from a hospital readmission. Each patient was setup in PSV(TgV) mode (pressure support ventilation with target volume). Each patient was instructed to use the Vivo ventilator for greater than 8 hours a day and document the EtCO2 daily approx. the same time each day. Each patient was provided education regarding the EtCO2 monitoring. Patients were instructed to call in if their EtCO2 went 10 mmHg above their initial baseline reading. Alarms were set so the ventilator would alarm if the EtCO2 went 10 mmHg above the initial baseline EtCO2 For our control / comparison group, we studied 25 patients with COPD and Chronic Hypercapnic Respiratory Failure discharged from hospital admissions that were setup on Vivo 50 Ventilator mode PSV(TgV) but without EtCO2 monitoring for 30 days. All education and equipment provided was along identical guidelines from the test group except for EtCO2 monitoring. We were given support via Dr. Rami Arfoosh who was available for consult before and during the process of our data collection.

Conclusion

There were no patients from our test group admitted to the hospital for exacerbation of chronic respiratory failure consequent to COPD, or for any other issue. However, during those 30 days, 12 patients from our control group (no EtCO2 monitoring) were readmitted with hypercapnic respiratory failure consequent to COPD exacerbation. We found that patients with EtCO2 monitoring were more engaged with their own care due to the diagnostic data they were able to utilize in their own care management. Patients from the test group were more compliant, had higher daily usage, and demonstrated a more comprehensive understanding of the ventilator role in their care. Their caregivers (family, friends, and others involved in the patient’s care) were more supportive of the use of the device due to the EtCO2 giving them visual representation of the effectiveness of the ventilator. Our clinicians were given the opportunity to intervene in several instances which may or may not have contributed to the lack of readmissions. There were two instances where the EtCO2 alarm signalled, the patient called into our local branch, and via troubleshooting via phone our clinicians discovered the patient had been omitting their nebulizer medication therapies. We were able to re-educate those two patients on the importance of nebulized medication and likely prevent further harm. Each patient was contacted again after 48-hours and the hypercapnia was resolved back to normal level

		TgV	RR	EPAP	Pmin	Pmax	pH	CO2	O2	HCO3	BE
1	F	500	12	5	7	25	7,31	54	237	25	0,1
2	F	450	10	5	7	25	7,16	72	91	25,7	-4,5
3	F	450	12	8	12	25	7,43	51,9	55	27,9	4
4	F	450	10	8	10	25	7,19	66	49	21,1	-4,4
5	F	450	12	5	7	25	7,2	85	32	22,7	1,2
6	F	450	12	5	7	25	7,25	94	62	41,2	10
7	F	450	12	5	7	25	7,4	57	104	35,3	8,5
8	F	450	10	5	7	25	7,27	87	76	32,8	10,2
9	M	500	14	8	12	25	7,34	64,5	59,8	35,4	9,8
10	F	450	10	5	7	25	7,34	60	62	28,5	4,9
11	M	500	12	8	12	30	7,37	53	130	28,2	4,2
12	M	500	12	8	12	25	7,12	129	118	29,6	6,4
13	M	500	12	5	7	20	7,32	52	48	29,2	5,8
14	F	450	12	6	8	25	7,47	67	62	41,3	21,2
16	F	450	12	8	10	30	7,36	71	85	39	10,3

EtCO2 readings for 30 days in mmHg: Initial refers to the EtCO2 reading at initial setup

EtCO	Initial	Lowest	Highest
1	45	40	47
2	44	36	50
3	53	44	52
4	42	31	44
5	34	33	40
6	42	33	44
7	47	45	47
8	55	47	54
9	51	47	51
10	54	46	52
11	54	52	55
12	40	35	48
13	30	30	36
14	61	48	61
15	53	45	53