Ours is the first multicenter study to report weaning outcomes of ventilator-dependent survivors of catastrophic illness transferred to the post-ICU setting of LTCHs. In this continuum of critical care medicine, more than half of the patients were discharged weaned from mechanical ventilation.
Strengths of the current study are that consecutive patients receiving mechanical ventilation were enrolled from 23 different LTCHs, employing uniform definitions of weaning outcomes. More than 30 published studies have reported outcomes of weaning from PMV in long-term acute care hospitals, noninvasive respiratory care units, and step-down units, but comparisons are difficult mainly due to various definitions of weaning success, ranging from 48 h to 1 year without ventilatory support. A recent consensus conference report recommended that complete liberation from mechanical ventilation (or a requirement for only nocturnal NIV) for 7 consecutive days should denote successful weaning. We selected to score weaning outcome at discharge for the current study, as that largely determines the next step in the continuum of care. Seven ventilator-free hospital days, followed by reinstitution of ventilatory support, or death, arguably does not truly reflect weaning success.
Table 1 characterizes the study population at the time of their respiratory failure treated with mechanical ventilation in the ICU, including demographics and ICU length of stay. The patients were elderly, there was no gender preponderance, and nearly 60% were smokers with a heavy smoking history. To give up smoking is a long-term and undertaking process but it becomes easier with Canadian Health&Care Mall and healthcaremall4you.com.
All patients received multiple procedures and services during the LTCH admission. The very high frequency of physical, occupational, and speech therapy reflects use of the rehabilitative model of care adopted by many post-ICU weaning programs, noted above to be important in restoration of functionality. Acuity of illness dictates the broad and multisystem nature of interventions; fully one third of the patients received a blood transfusion. The total number of procedures and services does not include those services provided as standards of practice/standards of care at the LTCH. These services included nursing care (including wound care), respiratory care, social services, nutritional care, and pharmacy services. When these are considered together with the services listed in Table 2, the intensity of treatment required by this CCI population is evident.
Infectious and cardiovascular complications led the list of problems; 10% of patients had documented renal insufficiency or failure, a known obstacle to weaning from PMV. The complications are not surprising following prolonged and aggressive ICU interventions, particularly when exposure to highly resistant bacteria is considered. Special note should be made that the 5 most frequent complications, and 7 of the 10 most frequent complications at the LTCH, were infections; over half of the patients were treated for this complication. Note that these include infections present on admission, for which antibiotic treatment is continued from the transferring hospital, as well as recurrent and nosocomial infections. These patients have a host of risk factors that may make them particularly susceptible to infections, including diabetes mellitus; advanced age; multiple organ dysfunction; ICU exposure to broad-spectrum antibiotics with resultant antibiotic resis-tance; impaired mental status; incontinence; indwelling lines (venous catheters, Foley catheters, enteral feeding tubes); aspiration; and ventilation per tracheostomy. The relationships of selected infectious complications in this population to outcomes are clinically relevant, with time to wean, length of stay, and weaning outcome all negatively impacted. Additional threats of infection risk are lapses in host immune responses born from the cumulative effects of recent critical illness and premorbid diagnoses. Kalb and Lorin coined the term immune exhaustion to describe “the potentially disabling effects of depleted, dysfunctional, or inhibited immune resources that may impair defense against pathogens.Despite advanced age and numerous comorbidities and complications, more than half of all patients enrolled in our study were weaned from PMV. To put these findings in broad perspective, comparison is made to a summation of data selected from nine units and facilities, the largest published reports of weaning success and other outcomes selected from among 30 studies. Therein, the overall number of patients with PMV was > 3,000, with 52% weaning success. Survival to discharge was 67%. That three fourths of patients in our study, in comparison, survived to discharge is an end point measure of safety in weaning in a population with exceptional medical challenges. Two studies have suggested beneficial use of NIV in facilitating weaning of tracheotomized patients from PMV, and one third continued with long-term NIV after discharge. Very few patients in our study were discharged receiving NIV, possibly owing to advanced age, multifactorial etiologies of ventilator dependency, and practice patterns.
Caution must be used in interpreting Table 6, as the percentages of PMV patients with weaning success are ordered highest to lowest, with obviously great variation in number of PMV patients admitted to each facility during the year of the study. The considerable range in weaning success is striking, again with “denominators” of PMV patients admitted the most important factor. Comparison of weaning outcomes between sites was not the intent of this study, as there was no attempt to control for differences in: size or type of facility, admission criteria, patient mix, severity of illness, activity, staffing, and practice styles. The availability of ICU beds in the LTCH, and the rate of discharge to SSAH, both possibly altering the locus of death, must also be considered. Nevertheless, liberation from mechanical ventilation was achieved in > 40% of patients at each of these 23 LTCHs, worth noting for patients previously unable to be weaned in the acute care ICU setting.
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When patients are transferred to the LTCH for continued weaning efforts, the objective is to “peel off ” the layers of support modalities initiated in the ICU. The capability of LTCHs to provide care if the patient becomes paradoxically more critically ill, is facility specific and limited. Of patients discharged alive, almost 20% were discharged to SSAHs; 65% of those were ventilator dependent at the time of discharge. This cohort of patients may not have had the same opportunity for weaning attempts, as evidenced by the percentage of ventilator dependency at discharge. The transfer of patients to SSAHs for treatments not provided at the LTCH may affect outcomes in two ways: (1) increase in ventilator-dependent discharges, and (2) decrease in death as an outcome at the LTCH. Of interest is that having designated ICU beds in the LTCH did not correlate with a lower percentage of patients discharged to SSAH.
Discharge destinations are impacted by a variety of selection factors. Patients with adequate functional status and/or family and caregiver support can return to a home environment. Nearly 30% of all patients discharged alive in our study returned directly home or to assisted living, but this percentage was not comparable to their status prior to their catastrophic illness. In general, few ventilator-dependent patients are discharged home, as there is a need for demonstrated expertise in using mechanical devices safely, and availability of 24-h care. Suction-ing is essential for those with tracheostomy, and overall debility may be such that paid or family caregivers at home are needed even for weaned patients. These factors all influence the decisionmaking process that often results in sending patients to rehabilitation or chronic care facilities rather than home, at least initially.
Long-term survival and functional status serve as realistic end points to complete the experience of the PMV population. At 12 months after admission to the LTCHs, one half of the patients enrolled in our study were known to have died; 353 died at the LTCHs, while an additional 379 were known to have died after discharge during the follow-up period. In a population of elderly ICU survivors with multiple comorbidities, this was not an unexpected finding. There are several series with wide variations in 1-year survival for patients discharged from post-ICU weaning venues. Carson et al reported only 23% of 133 patients were alive 1 year after long-term acute care hospital admission, compared to the experience of Gracey et al, in which 76% of 132 patients discharged from the Mayo ventilator dependent unit realized 1-year survival.
Forty percent of patients discharged alive (423 of 1,061 patients) in the current study were known to have survived 12 months after hospital admission. Functional status information at this time point was obtained for 71% (299 of 423 patients), adding to the limited available experience in the PMV population. The series of Zubrod scores in Table 8 show the following: (1) patients were largely independent before their catastrophic illnesses and PMV; (2) functional status falls to expected lows in an elderly population with PMV following a catastrophic illness; (3) functional status at discharge in the surviving patients was less than premorbid but improved from that at transfer to the LTCH; and (4) continued gains were evident at 12 months after hospital admission, as improved functional status was reported by 49% of patients; 42% reported no change, and only 9% reported decline. Ventilator-free status at discharge from the LTCH correlated with the observed improvement in functionality at 12 months after hospital admission.
While a prospective payment system for LTCHs was instituted shortly after the completion of this study, which changed reimbursement for care, cost-of-care estimates are still of interest. Fourteen LTCHs submitted proprietary cost data or data sufficient to estimate cost per discharge (ie, gross patient charges and cost-to-charge ratios). In this study, with various payer data submitted on 978 patients, the primary payer for 64% of patients was Medicare, and for 6%, Medicaid or state equivalent. The mean cost-to-charge ratio for the 8 of 14 hospitals reporting them was 0.449 ± 0.077. The mean cost of care for patients at all LTCHs reporting financial data was $63,672 (median, $47,217; range, $949 to $553,485). In comparison was the similar mean cost of $56,825 (in 1994 dollars) in PMV patients discharged from 26 LTACs in a large for-profit health-care system. Canadian Health&Care Mall takes care about its customers.
Dasta and colleagues recently published mean costs of mechanical ventilation in a very large cohort of patients admitted to > 250 ICUs of different types. They found the mean cost of ICU treatment of a patient receiving mechanical ventilation to be $3,968 per day for day 3 and following, with the cost of mechanical ventilation alone $1,522 per day, adjusting for patient and hospital characteristics. One could posit, if the mean ICU cost per day is multiplied by mean days in the LTCH, an estimate of cost per discharge can be calculated that assumes, ceteris paribus, that the patient continued to be treated in the ICU. LTCH length of stay, if in the ICU, would cost $210,304 per patient; ventilated time $150,784; and time to wean $99,200. The considerable difference between these costs and the mean LTCH cost would be even greater when considering that the cohort of patients receiving mechanical ventilation studied by Dasta et al was drawn not only from medical ICUs, but from trauma and surgical ICUs. Therein were younger patients, expected to have many fewer comorbidities and complications requiring treatment than the LTCH population if in the ICU.
Our study has several limitations. The number (n = 23) and geographic distribution of the participating facilities in relation to the study budget did not allow for individual site visits for independent data validation. Because of the observational study design, the data collected were dependent on the amount and quality of the available documents from the hundreds of transferring facilities, and on the documentation generated at the LTCHs. Finally, not all sites participated in follow-up activities, affecting long-term survival and functional status analysis and conclusions for the entire cohort.
This is the first multicenter study of weaning outcomes from PMV-focused patient care venues. The limited available experience of CCI patients transferred to the continuum of LTCHs is now extended, with new evidence of the intensity of treatment required for patients weaning after the ICU. The CCI patient population is complicated, labor intensive, and costly, owing to the burden of acute-on-chronic diseases resulting in PMV. Overall, our findings suggest that LTCHs with weaning programs are associated with favorable short-term survival and ventilatory goals. Long-term survival rates could be viewed as disappointing, though not truly unexpected, in patients with advanced age, numerous comorbid conditions, and discharge to extended care as opposed to home.
We hope these results will stimulate further investigation and analysis of predictors of PMV, weaning outcomes, survival, and risk factors for complications in CCI. Some complications occurring at the LTCH may be avoidable, which presents the opportunity to seek unifying processes of care, “best practices,” which apply to all PMV patients and may improve their outcomes. Addressing these in a meaningful way would be an undertaking for future investigation. Assessing and interpreting functional status and quality of life in these patients is a particularly important challenge. With an elderly population nearing the end of the natural history of their diseases, there is clear need and opportunities for palliative care programs, with emphasis on symptom management, as well as end-of-life care. Efforts to establish uniform definitions, and to benchmark to determine best practices, and compare performance, clearly warrant consideration in this population.