By David Newcomer, MHSA, RRT
Vapotherm Area Clinical Manager
Vapotherm Area Clinical Manager
Vapotherm’s Hi-VNI® Technology can be used to treat respiratory distress in hospital settings. The views and ideas presented in this video are solely those of the speaker, and individual results may vary. Vapotherm does not practice medicine or provide medical services. Practitioners should refer to the full indications for use and operating instructions of any products referenced herein before prescribing them.
Before starting to work for Vapotherm, I was the Respiratory Director at a 450 bed hospital in Virginia. Now that I work with other Respiratory Directors as a Vapotherm Area Clinical Manager, I encounter many clients who appreciate the value of the technology as a viable alternative to noninvasive positive pressure therapy (NIPPV).11. Doshi P, Whittle JS, Bublewicz M, et al. “High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial.” Ann Emerg Med 2018;72:73-83 e5.Read Full Text They are very much like I was when I realized that Vapotherm was a mask-free tool to treat undifferentiated respiratory distress, including hypercapnia—they want to get more units into their hospital. As we all know, that’s not an easy feat, but when I was a Respiratory Director, I had acquired 28 Vapotherm Precision Flow® Plus units in just one year. I think the story of how I did it would serve as a model to those wondering how they too could get more units.
Step One: Identify Where You Can Reduce NIPPV (e.g. BiPAP®) Usage
In my specific case, I started to get several emails and phone calls from the ICU Nursing Director asking me why so many patients were getting there on BiPAP. They clogged up the ICU so that it was always at 90-95% capacity. The lack of ICU beds caused a delay in the Emergency Department (ED) throughput here. And as many of us know, there are few things worse than holding patients in the ED, especially since the ED performance is measured on how quickly they can get patients out of the ED.
While brainstorming how we could reduce the ICU clog up, we briefly thought of changing our protocol that dictated that patients on BiPAP had to be put into the ICU, just by virtue of using that modality. However, we decided against changing that protocol because we knew that only the ICU provided the level of monitoring that a patient wearing a mask needed.
Every hospital might have a slightly different story, but in my experience, NIPPV modalities require more time from the nurses and respiratory therapists and are uncomfortable for the patients. Reducing the usage of pressure-bases mask therapies benefits not only the clinicians, but also our patients.
Step Two: Get Buy In and Staff Education, Starting in the ED
For respiratory treatment to be consistent, a hospital must have buy-in across all the departments where a patient might get moved to. In my case, if I wanted to reduce patients from the ED going into the ICU on BiPAP, I needed to get the ED respiratory therapists educated on the fact that Vapotherm is a viable alternative to NIPPV and has been clinically shown to be equivalent to NIPPV in spontaneously breathing adult all-comers in the ED with respiratory distress who require non-invasive ventilatory support.
That’s exactly what I did. I made sure that when I was first implementing Vapotherm use in the ED, I brought in clinical managers from Vapotherm to educate and train my ED respiratory therapists. They were ultimately the ones who had a close relationship with ED physicians and could advise the physician on a new modality.
Of course, it’s not like I presented this new clinical practice and everything was immediately peachy. In fact the ED Medical Director was initially skeptical about the technology. But ultimately the physicians could decide how to practice and thanks to the education the respiratory therapists had received, they were able to convince the rest of our team to give Vapotherm a try. Once the physicians realized that the technology worked on hypercapnic patients and was able to stabilize work of breathing, the going became easier.
As a matter of fact, three months after implementing Vapotherm in the ED, I received an angry call from a physician telling me that all five Precision Flow Plus units were taken up and we needed more units.
Step Three: Allocating Rental Budget and Pitching a Cost Savings
I could have listed this step three as step two, but I firmly believe that a hospital should only acquire technology if they know they will use it. If I didn’t have a need for a bigger Vapotherm fleet, I never would have gotten creative trying to acquire one. That’s why education is so important.
The first five units in the ED, I’d acquired through capital budgeting. But three months after the initial purchase, my capital budget was tied up and all I had available was rental budget.
At this time, I was renting 5-10 BiPAPs at about $1000 each a month. Given that Vapotherm was reducing my hospital’s NIPPV usage, I rented fewer BiPAPs, and assigned that budget to a 12-month Vapotherm rent-to-own program that the company offered. Renting two Vapotherm units a month was still cheaper than renting a BiPAP. On top of that, my hospital would own the units at the end of a year. When I explained this to the Purchasing Department, they ended up promoting the deal as a hospital cost savings—which is exactly what it was.
And so, almost overnight, I had acquired another 5 Vapotherm Precision Flow Plus units.
Step Four: Expanding to the Floor and Getting Nurse Buy In
Now that the ED had adopted Vapotherm as a first line of defense for patients coming in with undifferentiated respiratory distress, patients on Vapotherm started streaming onto the general care floor. I needed to make sure the nurses understood the usefulness of the technology and how it worked.
I repeated the same strategy I’d used just a couple months earlier with the respiratory therapists in the ED. I asked a Vapotherm Clinical Manager to come by and do education and answer questions.
Step Five: Assess Effect of Trach Patient Management on ICU
At my hospital, we had ten trach patients a day, particularly from the surgical ICU. They would be downgraded to the floor, but then after a little while would have to go to the ICU because of secretion issues. We were using aerosol and had some trouble weaning the patients successfully and in a timely manner.
As mentioned at the beginning, our concern was that our ICU was being clogged. That of course had significantly improved as we reduced our NIPPV usage, but the trach patients became an additional opportunity for streamlining a process both for the patient’s and the hospital’s good.
At the monthly critical care meeting, I put on our agenda “trach weaning via Vapotherm.” I had to get approval from the hospital pulmonologists to use try this, but by giving the patients heated humidification through Vapotherm via a trach mask interface, we were able to maintain good secretion management on floor and largely avoid mucus plugs. This is yet another example of incremental buy-in that improved our clinical practice.
Step Six: Vapotherm in the NICU
We had a level 3 NICU and three main neonatologists at the hospital. At this point so much of the hospital was aware of how to best use Vapotherm that the neonatologist ultimately approached me and asked to have units dedicated to the NICU as an additional tool available to them.
I still made sure to educate neonatologists and the NICU respiratory therapist who was close to them. They understood that Vapotherm was a viable alternative to CPAP for post-extubation support of premature infants22. Collins C, Holberton J, Barfield C, Davis P. “A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants.” J Pediatrics. 2013 May; 162: 949-54.Read Full Text as well as for primary management33. Lavizarri A, Colnaghi M, Ciuffini F, Veneroni C, Musumeci S, Cortinovis I, Mosca F. “Heated, humidified high-flow nasal cannula vs nasal continuous positive airway pressure for respiratory distress syndrome of prematurity – a randomized clinical noninferiority trial.” JAMA Pediatr. 2016 Aug 8.Read Full Text among other appropriate uses.
Your Needs May Vary
All in all, by the time a year was up, I’d acquired 20 Vapotherm Precision Flow® Plus units through the rent-to-own program, using my rental budget, and another 8 through capital reallocation. I of course could not have done any of this without the buy in and education of all my relevant colleagues across the hospital.
Not every hospital may have a need for 28 units, and some may need more, but I am confident that every hospital could save money and increase patient comfort through reduced NIPPV usage. You can use this Cost Calculator to find out how reducing BiPAP usage with Vapotherm could impact your budget.
1. Doshi P, Whittle JS, Bublewicz M, et al. “High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial.” Ann Emerg Med 2018;72:73-83 e5.