When admitting a patient to a skilled nursing facility, it's crucial to assess their medical history, current condition, and any special needs, including respiratory support. NJRA's guide provides helpful factors to consider for respiratory admissions, but ultimately, the two most critical considerations are the patient's stability and the interdisciplinary team's comfort with providing the required care.

Oxygen Therapy via Nasal Cannula or Oxygen Mask

Skilled nursing facilities can use oxygen concentrators to deliver up to 10LPM, providing around 60% FiO2. For SNFs with an oxygen pipeline, higher flow rates are possible but patient stability should be closely monitored. Patients requiring more then 8LPM or 50%-60% FiO2 are generally not suitable candidates for SNFs because they are considered higher risk.

BiPAP/CPAP/AVAPS

Skilled nursing facilities can manage pressure and volume support devices to assist with obstructive sleep apnea and non-invasive ventilation needs. However, SNFs should not admit patients who require continuous use of these devices as this typically indicates the need for 24/7 ventilation, which exceeds the monitoring capabilities of most facilities. CPAP (Continuous Positive Airway Pressure) delivers a single, constant pressure to keep the airways open. BiPAP (Bilevel Positive Airway Pressure) provides two levels of pressure—higher during inhalation and lower during exhalation. AVAPS (Average Volume Assured Pressure Support) adjusts the pressure automatically to maintain a consistent tidal volume, offering more precise ventilation for patients with changing needs, though all three devices use similar masks and interfaces for delivery.

High Flow Oxygen Therapy (HFOT)

High flow oxygen therapy is a non-invasive form of respiratory support that delivers a high flow of humidified air mixed with oxygen to help increase oxygenation and reduce work of breathing. This is typically done through a specialized device, such as an Airvo commonly used in SNFs, which can control the flow rate and oxygen concentration. HFOT can be effective in treating respiratory conditions like acute respiratory failure, COPD, and other debilitating pulmonary conditions.

When evaluating a potential HFOT admission, there are two important settings to consider: flow rate and FiO2. These settings can affect each other, so each referral must be assessed on a case-by-case basis. However, patients requiring over 35% FiO2 and 40LPM of flow are generally not suitable candidates for SNFs. Visit our Airvo page for more information by clicking here.

Tracheostomy

In the SNF setting, managing tracheostomy cases can be highly fulfilling. To do so effectively, it's important to keep your nursing competencies up to date and have all necessary equipment on hand, including oxygen, humidity (via 50PSI or Airvo), and a suction machine, as well as necessary supplies including a backup tracheostomy tube and ambubag bedside. Here are a few additional considerations:

(1) Status post (S/P) tracheostomy should be > 7-days

(2) Plan for physician to complete first tracheostomy change if still pending or sutured in.

(3) Ensure suctioning frequency is manageable for your nursing team given the patient's current secretions levels. Patients requiring suctioning more frequently than every 2 hours may not be suitable for SNFs.

(4) FiO2 requirements < 55%.

Ventilator

If the SNF has a licensed ventilator unit (requirements may vary by state), several factors should be considered for admissions:

(1) Available Ventilator Modes: A/C, Spontaneous, SIMV and Pressure Support

(2) Available Breath Types: PC, VC, SIMV-PS (Patients requiring modes and breath types other than those listed above, such as PRVC, should be transitioned to suitable modes and breath types at least 24 hours before admission.)

(3) FiO2 settings should not exceed 60%.

(4) PEEP settings should be less than 10 cmH2O.

(5) Patient must have a tracheostomy for ventilator support, as intubated patients are not suitable for admission. Status post (S/P) tracheostomy should be > 2-days

(6) Patients cannot be sedated or on required restraints.

It's important to note that this list may not cover all possible considerations, and additional factors may need to be reviewed on a case-by-case basis. Before admitting a patient, it's crucial to obtain approval from the respiratory director.

Readmissions

It's important to note that just because a patient was previously in your SNF and the hospital would like to send them back, it doesn't necessarily mean that they are clinically ready. Be sure to review their current status before accepting them back.

** This resource is constantly evolving, so please check back frequently for updates.