The Role of Long-Term Ventilator Hospitals

2014 ◽  
Author(s):  
Jeremy M Kahn
Keyword(s):  
Mechanical Ventilation ◽  
Critically Ill ◽  
Acute Care ◽  
Critically Ill Patients ◽  
Prolonged Mechanical Ventilation ◽  
Acute Care Hospitals ◽  
Cost Of Care ◽  
Current Evidence ◽  
Chronically Critically Ill

Long-term ventilator facilities play an increasingly important role in the care of chronically critically ill patients in the recovery phase of their acute illness. These hospitals can take several forms, depending on the country and health system, including �step-down� units within acute care hospitals and dedicated centres that specialize in weaning patients from prolonged mechanical ventilation. These hospitals may improve outcomes through increased clinical experience at applying protocolized weaning approaches and specialized, multidisciplinary, rehabilitation-focused care; they may also worsen outcomes by fragmenting the episode of acute care across multiple hospitals, leading to communication delays and hardship for families. Long-term ventilator facilities may also have important �spillover effects�, in that they free ICU beds in acute care hospitals to be filled with greater numbers of acute critically ill patients. Current evidence suggests that mortality of chronically critically ill patients is equivalent between acute care hospitals and specialized weaning centres; however, mechanical ventilation may be longer and cost of care higher in patients who remain in acute care hospitals. Given the rising incidence of prolonged mechanical ventilation and capacity constraints on acute care ICUs, long-term ventilator hospitals are likely to serve a key function in critical illness recovery.

Chronic Comorbid Illnesses Predict the Clinical Course of 866 Patients Requiring Prolonged Mechanical Ventilation in a Long-Term, Acute-Care Hospital

2018 ◽  
Vol 35 (8) ◽  
pp. 745-754 ◽  
Author(s):  
J. Dermot Frengley ◽  
Giorgio R. Sansone ◽  
Robert J. Kaner
Keyword(s):  
Mechanical Ventilation ◽  
Acute Care ◽  
Clinical Course ◽  
Prolonged Mechanical Ventilation ◽  
Acute Care Hospital ◽  
Care Hospital ◽  
Term Survival ◽  
Group A ◽  
Chronically Critically Ill

Objective: To determine whether burdens of chronic comorbid illnesses can predict the clinical course of prolonged mechanical ventilation (PMV)patients in a long-term, acute-care hospital (LTACH). Methods: Retrospective study of 866 consecutive PMV patients whose burdens of chronic comorbid illnesses were quantified using the Cumulative Illness Rating Scale (CIRS). Based on increasing CIRS scores, 6 groups were formed and compared: group A (≤25; n = 97), group B (26-28; n = 105), group C (29-31; n = 181), group D (32-34; n = 208), group E (35-37; n = 173), and group F (>37; n = 102). Results: As CIRS scores increased from group A to group F, rates of weaning success, home discharges, and LTACH survival declined progressively from 74% to 17%, 48% to 0%, and 79% to 21%, respectively (all P < .001). Negative correlations between the mean score of each CIRS group and correspondent outcomes also supported patients’ group allocation and an accurate prediction of their clinical course (all P < .01). Long-term survival progressively declined from a median survival time of 38.9 months in group A to 3.2 months in group F ( P < .001). Compared to group A, risk of death was 75% greater in group F ( P = .03). Noteworthy, PMV patients with CIRS score <25 showed greater ability to recover and a low likelihood of becoming chronically critically ill. Diagnostic accuracy of CIRS to predict likelihood of weaning success, home discharges, both LTACH and long-term survival was good (area under the curves ≥0.71; all P <.001). Conclusions: The burden of chronic comorbid illnesses was a strong prognostic indicator of the clinical course of PMV patients. Patients with lower CIRS values showed greater ability to recover and were less likely to become chronically critically ill. Thus, CIRS can be used to help guide clinicians caring for PMV patients in transfer decisions to and from postacute care setting.

Cytokines in Chronically Critically Ill Patients After Activity and Rest

2007 ◽  
Vol 8 (4) ◽  
pp. 261-271 ◽  
Author(s):  
Chris Winkelman ◽  
Patricia A. Higgins ◽  
Yea Jyh Kathy Chen ◽  
Alan D. Levine
Keyword(s):  
Physical Activity ◽  
Mechanical Ventilation ◽  
Critical Illness ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Prolonged Mechanical Ventilation ◽  
Serum Levels ◽  
Inflammatory Factors ◽  
Chronically Critically Ill ◽  
Critically Ill Adults

Inflammation, a common problem for patients in the intensive care unit (ICU), frequently is associated with serious and prolonged critical illnesses. To date, no study has examined whether physical activity influences inflammatory factors in critically ill adults. The objectives of this study were to (a) examine the relationships between type and duration of physical activity and serum levels of interleukin 6 (IL-6), a proinflammatory cytokine; IL-10, an anti-inflammatory cytokine; and their ratio and (b) determine if there are associations between cytokines or their ratio and activity or outcomes. This descriptive feasibility study investigated the approaches to measuring levels of physical activity and its relationship to serum levels of IL-6 and IL-10 and the ratio between them in patients with prolonged mechanical ventilation during periods of activity and rest. Measurements included serum IL-6 and IL-10 levels, direct observation and actigraphy, and prospective chart review. Ten critically ill patients who were mechanically ventilated for an average of 10 days in a large, urban, teaching hospital were enrolled. The average ratio of IL-6 to IL-10 improved after an average of 14.7 min of passive physical activity, typically multiple in-bed turns associated with hygiene. IL-6, IL-10, and their ratio were not associated with patient outcomes of weaning success or length of stay. High levels of IL-6 were associated with mortality. Cytokine balance may be improved by low levels of activity among patients with prolonged critical illness. The pattern of cytokines produced after activity may improve patients' recovery from prolonged critical illness and mechanical ventilation.

scholarly journals Time spent in prior hospital stay and outcomes for ventilator patients in long-term acute care hospitals

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Berna Demiralp ◽  
Lane Koenig ◽  
Jing Xu ◽  
Samuel Soltoff ◽  
John Votto
Keyword(s):  
Mechanical Ventilation ◽  
Endotracheal Intubation ◽  
Acute Care ◽  
Prolonged Mechanical Ventilation ◽  
Acute Care Hospitals ◽  
Care Hospital ◽  
Mechanical Ventilator ◽  
Ventilated Patients ◽  
Ventilator Patients

Abstract Background Long-term acute care hospitals (LTACHs) treat mechanical ventilator patients who are difficult to wean and expected to be on mechanical ventilator for a prolonged period. However, there are varying views on who should be transferred to LTACHs and when they should be transferred. The purpose of this study is to assess the relationship between length of stay in a short-term acute care hospital (STACH) after endotracheal intubation (time to LTACH) and weaning success and mortality for ventilated patients discharged to an LTACH. Methods Using 2014–2015 Medicare claims and assessment data, we identified patients who had an endotracheal intubation in STACH and transferred to an LTACH with prolonged mechanical ventilation (defined as 96 or more consecutive hours on a ventilator). We controlled for age, gender, STACH stay procedures and diagnoses, Elixhauser comorbid conditions, and LTACH quality characteristics. We used instrumental variable estimation to account for unobserved patient and provider characteristics. Results The study cohort included 13,622 LTACH cases with median time to LTACH of 18 days. The unadjusted ventilator weaning rate at LTACH was 51.7%, and unadjusted 90-day mortality rate was 43.7%. An additional day spent in STACH after intubation is associated with 11.6% reduction in the odds of weaning, representing a 2.5 percentage point reduction in weaning rate at 18 days post endotracheal intubation. We found no statistically significant relationship between time to LTACH and the odds of 90-day mortality. Conclusions Discharging ventilated patients earlier from STACH to LTACH is associated with higher weaning probability for LTACH patients on prolonged mechanical ventilation. Our findings suggest that delaying ventilated patients’ discharge to LTACH may negatively influence the patients’ chances of being weaned from the ventilator.

scholarly journals Noninvasive ventilation during the weaning process in chronically critically ill patients

2016 ◽  
Vol 2 (4) ◽  
pp. 00061-2016 ◽  
Author(s):  
Jesus Sancho ◽  
Emilio Servera ◽  
Luis Jara-Palomares ◽  
Emilia Barrot ◽  
Raquel Sanchez-Oro-Gómez ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Critically Ill ◽  
Noninvasive Ventilation ◽  
Critically Ill Patients ◽  
Predictive Value ◽  
Spontaneous Breathing ◽  
Prolonged Mechanical Ventilation ◽  
Respiratory Care ◽  
Spontaneous Breathing Trials ◽  
Chronically Critically Ill

Chronically critically ill patients often undergo prolonged mechanical ventilation. The role of noninvasive ventilation (NIV) during weaning of these patients remains unclear. The aim of this study was to determine the value of NIV and whether a parameter can predict the need for NIV in chronically critically ill patients during the weaning process.We conducted a prospective study that included chronically critically ill patients admitted to Spanish respiratory care units. The weaning method used consisted of progressive periods of spontaneous breathing trials. Patients were transferred to NIV when it proved impossible to increase the duration of spontaneous breathing trials beyond 18 h.231 chronically critically ill patients were included in the study. 198 (85.71%) patients achieved weaning success (mean weaning time 25.45±16.71 days), of whom 40 (21.4%) needed NIV during the weaning process. The variable which predicted the need for NIV was arterial carbon dioxide tension at respiratory care unit admission (OR 1.08 (95% CI 1.01–1.15), p=0.013), with a cut-off point of 45.5 mmHg (sensitivity 0.76, specificity 0.67, positive predictive value 0.76, negative predictive value 0.97).NIV is a useful tool during weaning in chronically critically ill patients. Hypercapnia despite mechanical ventilation at respiratory care unit admission is the main predictor of the need for NIV during weaning.

Critically Ill Patients and Long-term Acute Care Hospitals—Reply

JAMA ◽  
2010 ◽  
Vol 304 (13) ◽  
pp. 1441
Author(s):  
Jeremy M. Kahn ◽  
Theodore J. Iwashyna
Keyword(s):  
Critically Ill ◽  
Acute Care ◽  
Critically Ill Patients ◽  
Acute Care Hospitals
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