Financial Implications of Ventilator Care

Immediate extubation after aortic valve surgery using high thoracic epidural analgesia or opioid-based analgesia

OBJECTIVE

Fast-track anesthesia has gained widespread use in cardiac centers around the world. No study has been published focusing on immediate extubation after aortic valve surgery. This study examines the feasibility and hemodynamic stability of immediate extubation after simple or combined aortic valve surgery using either thoracic epidural analgesia or opioid-based analgesia.

DESIGN

Prospective audit, pilot study.

SETTING

Single-institution university medical center.

PARTICIPANTS

Adult patients undergoing aortic valve replacement (N = 45).

INTERVENTIONS

Forty-five patients undergoing aortic valve surgery with an ejection fraction of more than 30% were included in this prospective audit. Induction of anesthesia was done using fentanyl, 2 to 4 mug/kg, propofol, 1 to 2 mg/kg, and endotracheal intubation facilitated by rocuronium; anesthesia was maintained using sevoflurane titrated according to bispectral index (BIS [BIS target: 50]). Perioperative analgesia was provided by high thoracic epidural analgesia (TEA group, bupivacaine 0.125%, 6 to 14 mL/h) or fentanyl, up to 10 microg/kg, followed by patient-controlled analgesia with morphine (OPIOID group).

MEASUREMENTS AND MAIN RESULTS

Success of extubation within 30 minutes after surgery was recorded. Hemodynamic data during surgery were compared by using an analysis of variance test; p < 0.05 was considered as showing a significant difference. Data presented as median (25th-75th percentile). In the TEA group, patients underwent simple aortic valve replacement (N = 21) or combined aortic valve surgery (N = 14), with additional coronary artery bypass grafting (N = 10) and replacement of the ascending aorta (Bentall, N = 4). In the OPIOID group, patients underwent simple aortic valve replacement (N = 5) or combined aortic valve surgery (N = 5), with additional aortocoronary bypass grafting (N = 2), replacement of the ascending aorta (Bentall, N = 2), and reconstruction of the mitral valve (N = 1). All 45 patients were extubated within 15 minutes after surgery. There was no need for reintubation; pain scores were lower in the TEA group than in the OPIOID group immediately after surgery and at 6 hours, 24 hours, and 48 hours after surgery. For the TEA group and OPIOID group, the pain scores were 0 (0-2), 0 (0-2), 0 (0-1.5), and 0 (0-0) and 5 (4-5.75), 4 (3-4.5), 4 (3.25-4), and 1 (0-2.5), respectively. During and up to 6 hours after surgery, there was no significant hemodynamic difference between the TEA and OPIOID groups. Eighteen of 45 patients needed temporary pacemaker activation. There were no epidural hematoma or neurologic complications related to TEA.

CONCLUSION

Immediate extubation is feasible after aortic valve surgery using either high thoracic epidural analgesia or opioid-based analgesia; both techniques maintain hemodynamic stability throughout surgery. TEA provides superior pain control.

Rates and characteristics of intensive care unit admissions and intubations among asthma-related hospitalizations

BACKGROUND

A life-threatening attack of asthma that leads to intensive care unit (ICU) admission, intubation, or both identifies patients at high risk of subsequent morbidity and mortality and represents a major cost burden.

OBJECTIVE

To assess the rates, characteristics, and costs of ICU admissions and intubations among asthma-related hospitalizations.

METHODS

This analysis was performed using a database of 215 hospitals representing more than 3 million annual inpatient visits. Asthma-related hospital admissions were identified by a primary diagnosis code for asthma during 2000. Logistic regression was used to estimate the odds ratios (ORs) for predictors of ICU admission, intubation, and in-hospital mortality. Ordinary least squares regression was used to estimate adjusted mean costs and length of stay.

RESULTS

Of 29,430 admissions with a primary diagnosis of asthma, 10.1% were admitted to the ICU and 2.1% were intubated. The risk of in-hospital death was significantly greater in patients who were intubated but not admitted to the ICU (OR, 96.20; 95% confidence interval [CI], 50.24-184.20), those who were admitted to the ICU and intubated (OR, 62.69; 95% CI, 38.17-102.96), and patients with more severe comorbidities (OR, 1.53; 95% CI, 1.38-1.70). On average, intubated patients stayed in the hospital 4.5 days longer and incurred more than $11,000 in additional costs; patients admitted to the ICU stayed 1 day longer and accounted for $3,000 in additional costs vs standard admissions.

CONCLUSIONS

The inpatient mortality, morbidity, and cost burden of life-threatening asthma in the United States is considerable. This study characterizes patients with asthma at risk of ICU admissions and intubations. Appropriate recognition and treatment are needed to prevent these severe and potentially life-threatening events.

Subjective Perceptions and Physiological Variables During Weaning From Mechanical Ventilation

• Background As costs related to mechanical ventilation increase, clear indicators of patients’ readiness to be weaned are needed. Research has not yet yielded a consensus on physiological variables that are consistent correlates of weaning outcomes. Subjective perceptions rarely have been examined for their contribution to successful weaning.

• Objective To explore the subjective perceptions of dyspnea, fatigue, and self-efficacy and selected physiological variables in patients being weaned from mechanical ventilation.

• Methods Data were collected prospectively on 68 patients being weaned from mechanical ventilation. Subjective perceptions were measured by using 3 visual analog scales; physiological variables were measured by using the Burns Weaning Assessment Program and a patient profile. Weaning outcomes were recorded 24 hours after data collection.

• Results Participants were primarily white women and required mechanical ventilation for a mean of less than 4 days. Participants reported mild dyspnea, moderate fatigue, and high weaning self-efficacy. High Pao2, low Paco2, stable hemodynamic status, adequate cough and swallow reflexes, no metabolic changes, and no abdominal problems were associated with complete weaning (P = .05). Subjective perceptions were associated with physiological variables but not with weaning outcomes.

• Conclusions Multidimensional assessment of both primary and secondary indicators of readiness to be weaned is necessary for timely, efficient weaning from mechanical ventilation. Primary assessments include physiological variables related to gas exchange, hemodynamic status, diaphragmatic expansion, and airway clearance. Secondary assessments include perceptions related to key physiological variables. Additional research is needed to determine the predictive value of physiological variables and perceptions of dyspnea, fatigue, and self-efficacy.

Long-term survival and health status after prolonged mechanical ventilation after cardiac surgery

OBJECTIVE

To determine hospital mortality, weaning from mechanical ventilation, long-term survival, and functional health status in patients receiving > or =7 days of mechanical ventilation after cardiac surgery.

DESIGN

Retrospective chart review and prospective patient interviews.

SETTING

A university-affiliated, tertiary care medical center.

PATIENTS

A total of 124 patients that received > or =7 days of mechanical ventilation after cardiac surgery.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Hospital and long-term death, liberation from mechanical ventilation, and functional health status.

MEASUREMENTS AND MAIN RESULTS

A total of 19 (15%) patients died in hospital. Of the 105 survivors, 104 (99%) were completely weaned from mechanical ventilation. Patients who died in the hospital were more likely to have had a preoperative stroke or to have a new postoperative stroke, more likely to have postoperative renal failure, and less likely to have chronic obstructive pulmonary disease. Kaplan-Meier survival was 59% at 5 yrs and expected median survival was 6.2 yrs. Patients who died anytime after discharge were more likely to have preoperative renal dysfunction or stroke, took longer to be weaned from mechanical ventilation and to be discharged, and were more likely to have postoperative complications such as stroke or renal dysfunction. Also, they were more likely to be too debilitated to walk or eat. By multivariate analysis, admitting creatinine, aortic valve surgery, number of ventilator days, and discharged on tube feedings remained significant predictors of mortality. A total of 40 of 53 survivors were interviewed. Participants were similar to nonparticipants (p > .10 for all characteristics). A few (16%) had limitations of their activities of daily living (eating, dressing, bathing), and most had limitations of moderate activity (60%) and vigorous activity (94%). Only 36% could climb stairs or walk uphill without limitations, 54% could walk a block, and 41% had no limitations in house or job work. Half the participants had no body pain; 38% had moderate and 4% severe pain. Most (59%) described their general health as good to excellent. Only 10% said it was poor.

CONCLUSION

Patients' chances of being liberated from mechanical ventilation are excellent. Their long-term survival and health status are good.

The impact of long-term acute-care facilities on the outcome and cost of care for patients undergoing prolonged mechanical ventilation

OBJECTIVES

To compare the 6-month mortality rate of chronically ventilated patients treated either exclusively in a traditional acute-care hospital or transferred during hospitalization to a long-term acute-care facility. To analyze the hospital cost of care and estimate the amount of uncompensated care incurred by acute-care hospitals under the Medicare prospective payment diagnostic related groups system.

DESIGN

Retrospective chart review and questionnaire.

SETTING

Fifty-four acute-care referral hospitals and 26 longterm acute-care institutions.

PATIENTS

A total of 432 ventilated patients selected from 3,266 patients referred but not transferred to a study long-term acute-care facility and 1,702 ventilated patients from 4,174 patients referred and then subsequently transferred to the long-term acute-care facility. Six-month outcomes were determined for the subgroup of patients > or =65 yrs old (279 and 1,340 patients, respectively). Hospital charges were available for 192 of the 279 nontransferred patients who were > or =65 yrs old and 1,332 of the 1,340 transferred patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The 6-month mortality rate was 67.4% for the 279 nontransferred patients and 67.2% for the 1,340 transferred patients. On multiple regression analysis, variables associated with the 6-month mortality rate included initial admitting diagnosis, age, the acute physiology score, and presence of decubitus ulcer. After controlling for these variables, there was no significant difference in 6-month mortality rate, but admission to the long-term acute-care facility was associated with a longer mean survival time. Average total hospital costs for the 192 nontransferred patients was $78,474, and estimated Medicare reimbursement was $62,472, resulting in an average of $16,002 of uncompensated care per patient. Estimated costs for the long-term acute-care facility admissions were $56,825.

CONCLUSIONS

Patients undergoing prolonged ventilation have high hospital and 6-month mortality rates, and 6-month outcomes are not significantly different for those transferred to long-term acute-care facilities. These patients generate high costs, and acute-care hospitals are significantly underreimbursed by Medicare for these costs. Acute-care hospitals can reduce the amount of uncompensated care by earlier transfer of appropriate patients to a long-term acute-care facility.

Research methodology issues related to interviewing the mechanically ventilated patient

Difficulties conducting research in vulnerable or frail patient populations limit the data-based information on which to base practice in these populations. Although there are many challenges in this type of research, they are not insurmountable, and, in an effort to encourage others interested in studying vulnerable patient populations, we discuss the methodological process used to prospectively study one vulnerable group. Interviews about perceptions of weaning, fatigue, mood, and sleep/rest states were conducted with 20 patients who were chronically critically ill and required long-term mechanical ventilation. Illness severity and communication difficulties were primary considerations in the design, development, and implementation of the study. Ethical considerations, informed consent, sample representation, and data collection issues are discussed.

Patterns in costs and outcomes for patients with prolonged mechanical ventilation undergoing tracheostomy: an analysis of discharges under diagnosis-related group 483 in New York State from 1992 to 1996

OBJECTIVE

To analyze the costs and discharge status for patients with prolonged mechanical ventilation undergoing tracheostomy.

DESIGN

Retrospective analysis of a statewide database.

PATIENTS

All patients (n = 37,573) >18 yrs of age who had prolonged mechanical ventilation (procedure code 96.72) and were discharged from the hospital between 1992 and 1996 with a final DRG code of 483.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Rates of change in discharges and hospital reimbursements and the cost per survivor were examined by case payment groups and discharge year. A direct relation between volume and reimbursement rate was seen over time, although the patient age distributions remained relatively stable. The greatest increase in volume was from 1995 to 1996. For most years, there was a consistent inverse relation between age and survival, with older survivors being more likely to be discharged to residential healthcare facilities and younger patients more likely to be discharged home. There was a consistent direct relation between age and cost per survivor, mainly the result of improved survival rather than decreased reimbursements in later years.

CONCLUSIONS

More controlled reimbursements and improved overall survival rates for DRG 483 have contributed to the improved cost per survivor among all age groups over the period. Given the greater proportion of elderly that do not survive or who are placed into residential healthcare facilities, more scrutiny is needed concerning the use of DRG 483 resources so that care is better coordinated for these patients in the inpatient and postacute care settings.

The ventilator: selection of mechanical ventilators

A comprehensive ventilator selection process can be a time-consuming and an overwhelming task. The needs assessment becomes the primary driving tool in the design of the selection process. From the needs assessment, the evaluation can be planned and organized according to the facility requirements, time constraints, and resources. The strategy can expand to an extensive project or have a succinct and condensed design. The needs assessment determines the criteria for the selection, whether it be cost, ventilator specifications, educational needs, manufacturer support needs, maintenance requirements, accessory items, or combinations of any item. Once the data have been collected, it must be analyzed and critiqued. How this examination is performed can be expansive or scaled down according to the facility's resources. Important items in the selection must be maintained and used more extensively in the decision, whereas less important items take a backseat in the operation. The final selection comes from the culmination of the entire process.

Provision of long-term mechanical ventilation

When patients suffer prolonged mechanical ventilation, physicians are faced with a series of decisions beginning in the intensive care unit (ICU) and extending into a broadening spectrum of post-ICU levels of care. This article reviews current thinking and outcome data on when and how to perform the tracheostomy, as well as when and where the patient should be transferred from the ICU for continued weaning efforts or support. Decannulation after success in weaning and continuation of ventilation at home are also addressed.

Clinical and economic outcome of mechanically ventilated patients in New York State during 1993: analysis of 10,473 cases under DRG 475

STUDY OBJECTIVES

To examine and describe the relationship between age and disposition in patients undergoing mechanical ventilation.

DESIGN

Retrospective analysis of a statewide database.

SETTING

All acute-care hospitals in New York State.

PATIENTS

All patients (n=10,473) aged > or = 18 years discharged from hospital during 1993 with a final diagnosis related group (DRG) coding of 475.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The final disposition, according to six codes (other acute-care facility, residential health-care facility, other health-care facility, home, home health-care services, and death) were examined for the whole population. Cost per case was assumed to equal the average statewide Medicaid rate. An inverse relationship between survival rate and age was observed and this resulted in an age-related increased cost per survivor. Also, survivors in older age groups have an increasing rate of hospital discharge to residential health-care facilities.

CONCLUSION

Patients who undergo mechanical ventilation are expensive to care for. The older they are, the less satisfactory is the outcome both from clinical and economic perspectives.

Patient perception of fatigue while undergoing long-term mechanical ventilation: incidence and associated factors

OBJECTIVE

To describe a chronically critically ill population of patients receiving long-term ventilatory assistance, including patient perception of fatigue and the associated factors of nutritional status, depression, and sleep-rest.

DESIGN

Prospective, descriptive correlational design.

SETTING

Two tertiary care, university-affiliated medical centers.

SUBJECTS

Twenty subjects who were undergoing mechanical ventilation for at least 7 days and who were in the process of weaning.

RESULTS

Descriptive, correlational, and t test statistics were used in the data analysis. There was a 100% prevalence rate of fatigue, and with a 10-cm visual analogue scale, 45% of the subjects rated their fatigue as severe (> or = 6.0 cm) in intensity. The sample's mean serum albumin was 2.7 gm/dl, and mean hemoglobin was 10.1 gm/dl, but there were no statistically significant relationships between fatigue and nutritional status. Subjects' depression scores were in the moderate range, and they evaluated their sleep as fragmented and only moderately effective. Fatigue and depression were strongly correlated (r = 0.61; p = 0.004); there were no statistically significant relationships between fatigue and the sleep-rest scales.

CONCLUSIONS

The descriptive findings suggest that patients receiving long-term ventilatory assistance are undernourished and experience fatigue, depressed mood state, and disruptions of their sleep-rest patterns.

Clinical and economic outcome of patients undergoing tracheostomy for prolonged mechanical ventilation in New York state during 1993: analysis of 6,353 cases under diagnosis-related group 483

OBJECTIVE

To examine and describe the relation between age and disposition in patients undergoing tracheostomy.

DESIGN

Retrospective analysis of a statewide database.

SETTING

All acute care hospitals in New York state.

PATIENTS

All patients (n = 6,353) > or = 18 yrs of age who were discharged from the hospital during 1993 with a final diagnosis-related groups code of 483.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The final disposition, according to six disposition codes (other acute care facility, residential healthcare facility, other healthcare facility, home, home healthcare services, and death) was examined for the entire population. Cost per case was assumed to equal the average statewide Medicaid rate. An inverse relation between survival rate and age was observed, which resulted in an age-related increased cost per survivor. Also, survivors in older age groups had an increased rate of discharge to residential healthcare facilities. There was a negative, albeit less marked, effect of older age on the rates of survivors discharged to home and to other healthcare facilities.

CONCLUSIONS

Care of patients who undergo tracheostomy for prolonged mechanical ventilation is expensive. The older the patient, the less satisfactory the outcome from an economic, clinical, and possibly social perspective.