Non-ICU care of hemodynamically stable mechanically ventilated patients

Mortality outcomes of patients on chronic mechanical ventilation in different care settings: A systematic review

Objectives

To determine the outcomes of chronically ventilated patients outside the setting of intensive care units.

Design

Systematic review.

Setting and participants

Studies evaluating patients on chronic invasive mechanical ventilation in different care settings.

Methods

A systematic literature search of the PubMed, Embase, Cochrane Library, CINAHL (EBSCOhost), LILACS and Scopus databases from inception to March 27, 2020. Studies reporting mortality outcomes of patients ≥18 years of age on chronic invasive mechanical ventilation in intensive care units and other care settings were eligible for inclusion.

Results

Sixty studies were included in the systematic review. Mortality rates ranged from 13.7% to 77.8% in ICUs (n = 17 studies), 7.8%-51.0% in non-ICUs including step-down units and inpatient wards (n = 26 studies), and 12.0%-91.8% in home or nursing home settings (n = 19 studies). Age was associated with mortality in all care settings. Weaning rates ranged from 10.0% to 78.2% across non-ICU studies. Studies reporting weaning as their primary outcome demonstrated higher success rates in weaning. Home care studies reported low incidences of ventilator failure. None of the studies reported ventilator malfunction as the primary cause of death.

Conclusions and implications

Mortality outcomes across various settings were disparate due to methodological and clinical heterogeneity among studies. However, there is evidence to suggest non-ICU venues of care as a comparable alternative to ICUs for stable, chronically ventilated patients, with the additional benefit of providing specialized weaning programs. By synthesizing the global data on managing chronically ventilated patients in various care settings, this study provides health care systems and providers alternative venue options for the delivery of prolonged ventilatory care in the context of limited ICU resources.

Mechanical ventilation patterns and trends over 20 years in an Israeli hospital system: policy ramifications

Background

Mechanical ventilation is a life supporting modality increasingly utilized when caring for severely ill patients. Its increasing use has extended the survival of the critically ill leading to increasing healthcare expenditures. We examined changes in the hospital-wide use of mechanical ventilation over 20 years (1997–2016) in two Israeli hospitals to determine whether there were specific patterns (e.g. seasonality, weekday vs. weekend) and trends (e.g. increases or decreases) among various hospital departments and units.

Methods

Retrospective analysis of prospectively collected data on all mechanically ventilated patients over 20-years in a two-hospital Israeli medical system was performed. Data were collected for each hospital unit caring for ventilated patients. Time-series analysis examined short and long-term trends, seasonality and intra-week variation.

Results

Over two decades overall ventilator-days increased from 11,164 (31 patients/day) in 1997 to 24,317 (67 patients/day) in 2016 mainly due to more patients ventilated on internal medicine wards (1997: 4 patients/day; 2016: 24 patients/day). The increases in other hospital areas did not approach the magnitude of the internal medicine wards increases. Ventilation on wards reflected the insufficient number of ICU beds in Israel. A detailed snapshot over 4 months of patients ventilated on internal medicine wards (n = 745) showed that they tended to be elderly (median age 75 years) and that 24% were ventilated for more than a week. Hospital-wide ventilation patterns were the weighted sum of the various individual patient units with the most noticeable pattern being peak winter prevalence on the internal medical wards and in the emergency department. This seasonality is not surprising, given the greater incidence of respiratory ailments in winter.

Conclusions

Increased mechanical ventilation plus seasonality have budgetary, operational and staffing consequences for individual hospitals and the entire healthcare system. The Israeli healthcare leadership needs to plan and support expanding, equipping and staffing acute and chronic care units that are staffed by providers trained to care for such complex patients.

Electronic supplementary material

The online version of this article (10.1186/s13584-019-0291-y) contains supplementary material, which is available to authorized users.

Factors influencing weaning from mechanical ventilation in neurological and neurosurgical early rehabilitation patients

BACKGROUND

Studies analyzing risk factors of weaning failure in neurological and neurosurgical early rehabilitation (NNER) patients are rare.

AIM

The aim of this study was to identify clinical factors influencing the weaning of NNER patients.

DESIGN

An observational, retrospective data analysis of a German multicenter study was performed.

SETTING

German neurological early rehabilitation centers.

POPULATION

Inpatient ventilated NNER patients (N.=192) were enrolled in the study.

METHODS

Demographical data, main diagnosis, medical devices, special medical care and assessment instruments of functional abilities, consciousness and independence in activities of daily living were accrued and compared between patients with and without successful weaning. The prognostic power of factors associated with weaning success/failure was analyzed using binary logistic regression.

RESULTS

In total, 75% of the patients were successfully weaned. Colonization with multi-drug resistant bacteria and the need for dialysis were independent predictors of weaning failure. Successfully weaned patients had a shorter length of stay, better functional outcome, and lower mortality than non-successfully weaned patients.

CONCLUSIONS

Successfully weaned patients differ from patients with weaning failure in several clinical variables. All these variables are associated with the morbidity of the patient, indicating that the weaning process is strongly influenced by disease burden.

CLINICAL REHABILITATION IMPACT

Functional abilities, level of consciousness, independence in activities of daily living, colonization with multi-drug resistant bacteria, need for dialysis and disease duration might help to predict the weaning process of NNER.

[Prolonged weaning during early neurological and neurosurgical rehabilitation : S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]

Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".

Chronic Critical Illness: The Limbo Between Life and Death

The entity of chronic critical illness (CCI) has shown a rise in the past decades for popularity and prevalence. CCI is loosely defined as the group of patients who require the intensive care setting for weeks to months; its hallmark is prolonged mechanical ventilation. The outcomes of chronically critically ill patients have been dismal and have not improved over time; 1-year survival hovers at approximately 50%. Given the high mortality, prognostic variables are important when making medical decisions. CCI encompasses a syndrome that includes altered pathophysiology across a variety of organ systems. Another crucial element of CCI is the symptom burden that patients experience which include feelings of dyspnea, difficulty communicating and pain. This patient population necessitates the combined efforts of multiple care teams and the early integration of palliative and critical care. Future directions need to include improving the symptom management and communication for patients with CCI.

Prospective observational cohort study of patients with weaning failure admitted to a specialist weaning, rehabilitation and home mechanical ventilation centre

OBJECTIVES

According to National Health Service England (NHSE) specialist respiratory commissioning specification for complex home ventilation, patients with weaning failure should be referred to a specialist centre. However, there are limited data reporting the clinical outcomes from such centres.

SETTING

Prospective observational cohort study of patients admitted to a UK specialist weaning, rehabilitation and home mechanical ventilation centre between February 2005 and July 2013.

PARTICIPANTS

262 patients admitted with a median age of 64.2 years (IQR 52.6-73.2 years). 59.9% were male.

RESULTS

39.7% of patients had neuromuscular and/or chest wall disease, 21% were postsurgical, 19.5% had chronic obstructive pulmonary disease (COPD), 5.3% had obesity-related respiratory failure and 14.5% had other diagnoses. 64.1% of patients were successfully weaned, with 38.2% weaned fully from ventilation, 24% weaned to nocturnal non-invasive ventilation (NIV), 1.9% weaned to nocturnal NIV with intermittent NIV during the daytime. 21.4% of patients were discharged on long-term tracheostomy ventilation. The obesity-related respiratory failure group were most likely to wean (relative risk (RR) for weaning success=1.48, 95% CI 1.35 to 1.77; p<0.001), but otherwise weaning success rates did not significantly vary by diagnostic group. The median time-to-wean was 19 days (IQR 9-33) and the median duration of stay was 31 days (IQR 16-50), with no difference observed between the groups. Weaning centre mortality was 14.5%, highest in the COPD group (RR=2.15, 95% CI 1.19 to 3.91, p=0.012) and lowest in the neuromuscular and/or chest wall disease group (RR=0.34, 95% CI 0.16 to 0.75, p=0.007). Of all patients discharged alive, survival was 71.7% at 6 months and 61.8% at 12 months postdischarge.

CONCLUSIONS

Following NHSE guidance, patients with weaning delay and failure should be considered for transfer to a specialist centre where available, which can demonstrate favourable short-term and long-term clinical outcomes.

Reinstitution of mechanical ventilation within 14 days as a poor predictor in prolonged mechanical ventilation patients following successful weaning

Although many parameters were investigated about weaning and mortality in critical patients in intensive units, no studies have yet investigated predictors in prolonged mechanical ventilation (PMV) patients following successful weaning. A cohort of 142 consecutive PMV patients with successful weaning in our respiratory care center was enrolled in this study. Successful weaning is defined as a patient having smooth respiration for more than 5 days after weaning. The results showed as follows: twenty-seven patients (19%) had the reinstitution within 14 days, and 115 patients (81%) had the reinstitution beyond 14 days. Renal disease RIFLE-LE was associated with the reinstitution within 14 days (P = 0.006). One year mortality rates showed significant difference between the two groups (85.2% in the reinstitution within 14 days group versus 53.1% in the reinstitution beyond 14 days; P < 0.001). Kaplan-Meier analysis showed that age ≥70 years (P = 0.04), ESRD (P = 0.02), and the reinstitution within 14 days (P < 0.001) were associated with one-year mortality. Cox proportional hazards regression model showed that only the reinstitution within 14 days was the independent predictor for mortality (P < 0.001). In conclusion, the reinstitution within 14 days was a poor predictor for PMV patients after successful weaning.

Outcomes of prolonged mechanic ventilation: a discrimination model based on longitudinal health insurance and death certificate data

BACKGROUND

This study investigated prognosis among patients under prolonged mechanical ventilation (PMV) through exploring the following issues: (1) post-PMV survival rates, (2) factors associated with survival after PMV, and (3) the number of days alive free of hospital stays requiring mechanical ventilation (MV) care after PMV.

METHODS

This is a retrospective cohort study based on secondary analysis of prospectively collected data in the national health insurance system and governmental data on death registry in Taiwan. It used data for a nationally representative sample of 25,482 patients becoming under PMV (> = 21 days) during 1998-2003. We calculated survival rates for the 4 years after PMV, and adopted logistic regression to construct prediction models for 3-month, 6-month, 1-year, and 2-year survival, with data of 1998-2002 for model estimation and the 2003 data for examination of model performance. We estimated the number of days alive free of hospital stays requiring MV care in the immediate 4-year period after PMV, and contrasted patients who had low survival probability with all PMV patients.

RESULTS

Among these patients, the 3-month survival rate was 51.4%, and the 1-year survival rate was 31.9%. Common health conditions with significant associations with poor survival included neoplasm, acute and unspecific renal failure, chronic renal failure, non-alcoholic liver disease, shock and septicaemia (odd ratio < 0.7, p < 0.05). During a 4-year follow-up period for patients of year 2003, the mean number of days free of hospital stays requiring MV was 66.0 in those with a predicted 6-month survival rate < 10%, and 111.3 in those with a predicted 2-year survival rate < 10%. In contrast, the mean number of days was 256.9 in the whole sample of patients in 2003.

CONCLUSIONS

Neoplasm, acute and unspecific renal failure, shock, chronic renal failure, septicemia, and non-alcoholic liver disease are significantly associated with lower survival among PMV patients. Patients with anticipated death in a near future tend to spend most of the rest of their life staying in hospital using MV services. This calls for further research into assessing PMV care need among patients at different prognosis stages of diseases listed above.

Profile and consequences of children requiring prolonged mechanical ventilation in three Brazilian pediatric intensive care units

OBJECTIVE

To describe the characteristics of children submitted to prolonged mechanical ventilation (MV), and evaluate their mortality, and associated factors as well as the potential impact at admissions to the pediatric intensive care unit (PICU).

METHODS

We conducted a retrospective study enrolling all children admitted to three Brazilian PICUs between January 2003 and December 2005 submitted to MV > or =21 days. The three selected PICUs were located in university-affiliated hospitals. From the medical charts were reported anthropometric data, diagnosis, ventilator parameters on the 21st day, length of MV, length of stay in the PICU, specific interventions (e.g., tracheostomy), and outcome.

RESULTS

One hundred eighty-four children (190 admissions) were submitted to prolonged MV (2.5% of all admissions to these 3 Brazilian PICUs), with a median age of 6 months. The mortality rate was 48% and the median time on MV was 32 days. Tracheostomy was performed on only 19% of the patients and, on average after 32 days of intubation. Mortality was associated with peak inspiratory pressure >25 cm H2O (odds ratio = 2.3; 1.1-5.1), fraction of inspired oxygen >0.5 (odds ratio = 6.3; 2.2-18.1), and vasoactive drug infusion (odds ratio = 2.6; 1.1-5.9) on the 21st day of MV. Seventy-six children (1% of the all admissions) were dependent on MV without other organ failures were 830 PICU admissions and were potentially prevented.

CONCLUSIONS

A small group of children admitted to the PICU requires prolonged MV. The elevated mortality rate is associated with higher ventilatory parameters and vasoactive drug support on the 21st day of MV. Stable children requiring prolonged MV in the PICU potentially prevent additional admissions of a large number of acute and unstable patients.

Predictors of successful weaning from prolonged mechanical ventilation in Taiwan

BACKGROUND

For adult patients on prolonged mechanical ventilation (PMV, >/=21 days), successful weaning has been attributed to various factors. The purpose of this study was to describe patient outcomes, weaning rates and factors in successful weaning at a hospital-based respiratory care center (RCC) in Taiwan.

METHODS AND RESULTS

This was a retrospective observational study performed in a 24-bed RCC over six years. A total of 1307 patients on PMV were included in the study. The overall survival rate was 62%. Fifty-six percent of patients were successfully weaned. Unsuccessfully weaned patients had higher MICU transfer rates, higher Acute Physiology and Chronic Health Evaluation II scores, longer duration of RCC stay, higher rates of being bed-ridden prior to admission, increased hemodialysis rates, higher modified Glasgow Coma Scale scores, higher rapid shallow breathing index, lower inspiratory pressure at residual volume (PImax) and lower blood urea nitrogen (BUN) and creatinine levels. Factors found to be associated with unsuccessful weaning were length of RCC stay (OR=1.04, P<0.001), modified GCS score (OR=0.93, P<0.046), PImax (OR=0.97, P<0.001), serum albumin concentration (OR=0.62, P<0.023) and BUN level (OR=1.01, P<0.002).

CONCLUSION

High rates of ventilator independence can be achieved in an RCC setting as an alternative to ICU care. Factors associated with unsuccessful weaning included longer duration of RCC stay, elevated BUN levels and lower modified GCS scores, serum albumin and PImax levels.

Weaning units: lessons from North America?

In the United Kingdom over 5% of critical care beds are occupied by stable patients weaning from mechanical ventilation. In North America, diagnosis related groups (DRGs) were introduced over a decade ago. These provided an economic impetus to develop more cost effective regional weaning centres. The imminent introduction of Payment By Results may encourage similar developments in the UK. The evidence for weaning centres is reviewed and detailed organisational and outcome data from two North American centres presented. These units differ from UK critical care units in terms of nurse : patient ratios and types and numbers of ancillary staff. Limited data, mostly from North America, suggest that weaning centres may be better at improving outcome in ventilator-dependent patients compared with standard critical care. The existing evidence is not conclusive and highlights the need for UK-based studies on organisational approaches to the provision of weaning and longer term critical care.

Long-Term Acute Care: A Review of the Literature

Long-term acute care (LTAC) represents a rapidly growing category of Medicare providers, but little is known about its quality, outcomes, and cost-effectiveness. Its defining characteristic, as set by Medicare, is an average length of stay of greater than 25 days. Modern LTAC emerged in the early 1980s as a setting for the weaning of ventilator-dependent patients. The industry has developed greatly in the last few years, with for-profit corporations dominating the field, and as Medicare expenditures have grown, new payment systems have emerged to limit spiraling costs. Although LTAC is mainly known for providing chronic ventilator weaning, the case mix is varied. The majority of outcome studies in this setting have been done on pulmonary patients, with fewer data available on nonventilator patients. This article analyzes studies of LTAC that are currently available, discusses some of the public policy issues surrounding this level of care, and suggests a research agenda, including a role for the field of geriatrics.

Ventilator-Dependent Survivors of Catastrophic Illness Transferred to 23 Long-term Care Hospitals for Weaning From Prolonged Mechanical Ventilation

STUDY OBJECTIVES

This multicenter study was undertaken to characterize the population of ventilator-dependent patients admitted to long-term care hospitals (LTCHs) for weaning from mechanical ventilation.

DESIGN

Observational study with concurrent data collection. Characteristics of the LTCHs were also surveyed.

SETTING

Twenty-three LTCHs in the United States.

PATIENTS

Consecutive ventilator-dependent patients admitted over a 1-year period: March 1, 2002, to February 28, 2003.

RESULTS

A total of 1,419 patients were enrolled in the Ventilation Outcomes Study. Median age of the patients was 71.8 years old (range, 18 to 97.7 years), with an equal gender distribution. The premorbid domicile was home or assisted living in 86.5%; "good" premorbid functional status (Zubrod score 0-2) was assessed in 77%. There was a history of smoking in 59% (mean, 57 +/- 42 pack-years [+/- SD]); premorbid diagnoses averaged 2.6 per patient. Patients came to the LTCH after mean of 33.8 +/- 29 days at the transferring hospital; mean time to tracheotomy was 15.0 +/- 10 days. A medical illness led to ventilator dependency in 60.8% of patients; a surgical procedure led to ventilatory dependency in 39.2%. On admission to the LTCH, the median acute physiology score of APACHE (acute physiology and chronic health evaluation) III was 35 (range, 4 to 115); > 90% of patients had at least three penetrating indwelling tubes/catheters; 42% of patients had stage 2 or higher pressure ulceration.

CONCLUSIONS

This is the first multicenter study to characterize ventilator-dependent survivors of catastrophic illness admitted to the post-ICU venue of LTCHs for weaning from prolonged mechanical ventilation (PMV). Overall, our findings suggest that ventilator-dependent patients admitted to LTCHs for weaning will continue to require considerable medical interventions and treatments, owing to the burden of acute-on-chronic diseases resulting in PMV.

Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference

Patients requiring prolonged mechanical ventilation (PMV) are rapidly increasing in number, as improved ICU care has resulted in many patients surviving acute respiratory failure only to then require prolonged mechanical ventilatory assistance during convalescence. This patient population has clearly different needs and resource consumption patterns than patients in acute ICUs, and specialized venues, management strategies, and reimbursement schemes for them are rapidly emerging. To address these issues in a comprehensive way, a conference on the epidemiology, care, and overall management of patients requiring PMV was held. The goal was to not only review existing practices but to also develop recommendations on a variety of assessment, management, and reimbursement issues associated with patients requiring PMV. Formal presentations were made on a variety of topics, and writing groups were formed to address three specific areas: epidemiology and outcomes, management and care settings, and reimbursement. Each group was charged with summarizing current data and practice along with formulation of recommendations. A working draft of the products of these three groups was then created and circulated among all participants. The document was reworked with input from all concerned until a final product with consensus recommendations on 12 specific issues was achieved.

Determinants of time-to-weaning in a specialized respiratory care unit

BACKGROUND

As the decision-making process in long-term respiratory care units often depends on time-based outcomes, we sought to identify independent predictors of time-to-weaning (TTW) in a hospital-based specialized respiratory care unit.

METHODS

Characteristics that were identified in previous studies as predictors of weaning success in ICUs and long-term ventilator units were prospectively collected on 113 consecutive admissions to our unit. TTW analyses were performed with Kaplan-Meier curves, log rank test, and Cox proportional regression.

RESULTS

The TTW was shorter in patients with static lung compliance (Cst) of > 20 mL/cm H(2)O, a normal creatinine level (0.6 to 1.4 mg/dL), a rapid shallow breathing index (RSBI) of < or = 105, intact skin, and in those patients from a surgical referral source. We found an interaction between RSBI and Cst (p = 0.02) such that patients with an RSBI of < or = 105, regardless of Cst, had a median TTW of 11 days, those with an RSBI of > 105 and a Cst of > 20 had a median TTW of 31 days, and those with an RSBI of > 105 and a Cst of < or = 20 mL/cm H(2)O had not reached a median TTW by 60 days (p = 0.007 [log rank for linear trend]). In a Cox-proportional hazard model, both this categorization model of RSBI and Cst, and renal function had a significant impact on TTW.

CONCLUSIONS

In a multivariate model incorporating the variables reviewed, only the lung parameters (RSBI combined with Cst) and renal function remained independently associated with TTW.

The enhanced postoperative care system

The perioperative care system is a continuum that includes preoperative patient evaluation, operating room scheduling, the operation itself, and postoperative care. This costly fast-paced system requires its various components to function efficiently and interact effectively. This review explores the interrelation between the operational elements of the enhanced care postoperative care system (intensive care units, intermediate care units, postanesthesia care units, and monitored floor beds) and other perioperative care activities. This care system provides patients with enhanced (from routine floor) nursing and medical care, continuous physiological monitoring, and sophisticated treatments (eg, continuous infusion of vasoactive substances). A management, rather than clinical, approach is used to provide insight into the operations of the perioperative care system so that bottlenecks to patient flow may be identified and eliminated. Emphasis is placed on the need to switch from a "fiefdom" mentality, where each component of the system acts independently and defensively, to systems thinking, in which complex interrelated patterns are identified, analyzed, and optimized.

Outcomes, cost and long term survival of patients referred to a regional weaning centre

BACKGROUND

Regional weaning centres provide cost effective care for patients who have undergone prolonged mechanical ventilation. There are few published European data on outcomes in these patients.

METHODS

Patients admitted for weaning to the Lane Fox Respiratory Unit (LFU) between January 1997 and December 2000 were identified. The proportion weaned from mechanical ventilation, in-hospital mortality, and subsequent survival after discharge were examined.

RESULTS

A total of 153 patients had been ventilated for a median of 26 days before transfer. The daily cost per patient stay was 1350. Fifty eight patients (38%) were fully weaned, 42 (27%) died, and 53 (35%) required ventilatory support at discharge from hospital of whom 36 (24%) required only nocturnal ventilation. Univariate analysis showed increasing age (OR 1.06, p<0.001), length of ICU stay (OR 1.02, p = 0.001), APACHE II predicted risk of death score (OR 1.02, p = 0.05), and a surgical cause for admission (OR 4.04) were associated with mortality. Neuromuscular/chest wall conditions were associated with low mortality (OR 0.36) but low likelihood of weaning from ventilation (OR 0.28). Female sex (OR 2.13, p = 0.03) and COPD (OR 2.81) were associated with successful weaning. Overall survival at 3 years from admission was 47%. Long term survival was lowest in patients with COPD.

CONCLUSIONS

Most patients survived to leave hospital, the majority having been liberated from ventilatory support. Survivors were younger and spent less time ventilated in the referring ICU. The underlying diagnosis determined success of weaning, hospital survival, and long term outcome.

Shifting Care of Chronic Ventilator-Dependent Patients from the Intensive Care Unit to the Nursing Home

BACKGROUND

Among the most resource intensive and challenging of medical needs is the treatment of patients requiring long-term or chronic mechanical ventilation. Expenditures are significant, and definitions of "successful weaning," are often inconsistent. A weaning program was initiated for patients referred to a stand-alone nursing home ventilator unit.

METHODS

Weaning entailed standardized weaning protocols, enhanced socialization, a multidisciplinary approach to care, empowerment of staff to initiate weaning, and aggressive utilization of noninvasive positive pressure ventilation (NPPV) in selected patients.

RESULTS

Sixty-eight (67%) of 102 patients were successfully weaned during a six-year period. NPPV facilitated successful weaning in 27 (26%) of 102 patients. Of the 28 chronic ventilator-dependent patients admitted with a neuromuscular etiology for respiratory failure, NPPV was utilized in 73% (8/11) of the successfully weaned patients. Total variable costs per ventilator per patient per day for the years 1998-2000 were $319.79, $302.75, and $297.59. Six-year cost savings for referring hospitals were estimated at $18.5 million.

DISCUSSION

Incentives were aligned between the hospital, nursing home, and physicians to develop a financially stable model. Developing an off-site nursing home ventilator unit resulted in significant cost savings to the referring hospitals and positively affected patient flow.

Long-term outcomes for patients discharged from a long-term hospital-based weaning unit

BACKGROUND

Because little attention has been given to the long-term outcomes of patients in hospital-based ventilator weaning units, we undertook this assessment of 5-year outcomes of patients discharged from the Respiratory Special Care Unit (ReSCU) of the Cleveland Clinic Hospital.

METHODS

The ReSCU consists of six private beds on a pulmonary specialty ward. Features of the unit include noninvasive monitoring with signal output at each bedside and at a central monitoring station. The unit is staffed by nurses with specific pulmonary rehabilitation expertise and has 24-h respiratory therapist supervision. Ongoing prospective data collection in the ReSCU includes monitoring weaning success, demographic features, hospital discharge status, and hospital discharge disposition. Long-term outcomes were ascertained using a review of hospital medical records and direct inquiry to patients and/or family members.

RESULTS

Between August 22, 1993, and August 22, 1996, 162 individuals were admitted to the ReSCU, with 7 persons having repeat admissions during separate hospital admissions. Seventeen percent of these persons (n = 27) died during the hospitalization, while 83% were discharged from the index hospitalization (ie, the hospital stay during which the patient was first admitted to the ReSCU). Kaplan-Meier (KM) mortality rate estimates were as follows: 1 month, 11% (95% confidence interval [CI], 6 to 15%); 1 year, 57% (95% CI, 49 to 65%); 2 years, 68% (95% CI, 61 to 75%); 3 years, 73% (95% CI, 66 to 80%); 4 years, 76% (95% CI, 69 to 83%); and 5 years, 81% (95% CI, 75 to 87%). The 5-year KM mortality rate estimates considered by year of ReSCU admission were as follows: 1993, 92% (95% CI, 77 to 100%); 1994, 84% (95% CI, 73 to 95%); 1995, 87% (95% CI, 77 to 96%); and through August 22, 1996, 66% (95% CI, 51 to 81%).

CONCLUSIONS

In this population requiring prolonged inpatient ventilatory support, moderately high acute mortality rates are consistent with data from other series. In this analysis of longer-term follow-up rates, the 5-year survival rates are low, with higher mortality rates within the first 2 years and a slower decline in survival thereafter.

Risk assessment for inpatient survival in the long-term acute care setting after prolonged critical illness

OBJECTIVE

The past decade has witnessed growth in the long-term acute care (LTAC) hospital industry. There are no reliable risk assessment models that can adjust outcomes across such facilities with different criteria for admitting patients. Variation in reported outcomes makes it difficult to determine whether a patient, or group of patients, may benefit from such care. This study sought to determine the extent to which survival in the LTAC setting is associated with age, race, residual organ system failures (OSFs), or APACHE (acute physiology and chronic health evaluation) III scores at the time of admission to LTAC.

DESIGN

Retrospective medical record review.

SETTING

Four freestanding facilities of a LTAC hospital.

PATIENTS

A sample of 300 hospital admissions weighted to represent the study hospital population.

MEASUREMENTS

Inpatient survival modeled as a function of age, APACHE III score calculated within 72 h prior to LTAC admission, and residual OSFs present on admission to LTAC.

RESULTS

Logistic regression analysis shows age and OSF were most predictive of inpatient survival (receiver operating characteristic curve area = 0.81). APACHE III score was not predictive of survival in the multivariate model.

CONCLUSIONS

Survival in LTAC is primarily associated with age and OSFs, which should be used to adjust for patient populations among LTAC settings when comparing outcomes. Our model identifies a group of patients with the poorest likelihood of survival in the LTAC setting, and may be used to facilitate dialogue with patients and family in cases where continued aggressive care is least effective.

The need for a regional weaning centre, a one-year survey of intensive care weaning delay in the Northern Region of England

Over a period of one year, a weekly telephone survey identified 161 stable patients with weaning delay (defined as patients ventilated for at least 6 h per day for more than 2 weeks) in intensive care units in the Northern Region of England. Their median age was 69 years (range 21-88 years). Sixty patients (37%) were admitted with medical conditions, 89 (55%) were postoperative patients, whereas 12 (8%) were surgical but required non-operative admission. One hundred and thirty (89%) were weaned and discharged from the intensive care unit during the year. Twenty-two (14%) died and two were transferred to the home ventilation service. Seven patients remained ventilated in intensive care at the end of the study period. Twenty patients (12%) required more than 28 days of respiratory support. These patients occupied on average 6.0% of available intensive care unit beds in the region. This study suggests that in the Northern Region of England there are a significant number of stable but ventilator-dependent patients occupying intensive care beds.

Effect of continuous lateral rotational therapy on the prevalence of ventilator-associated pneumonia in patients requiring long-term ventilatory care

OBJECTIVE

To evaluate the role of continuous lateral rotational therapy on the development of ventilator-associated pneumonia in patients requiring long-term mechanical ventilation.

DESIGN

Prospective control study.

SETTING

Chronic ventilator unit in tertiary care hospital.

METHODS

Thirty-seven patients requiring long-term mechanical ventilation were assigned to receive either continuous lateral rotational therapy or conventional therapy.

RESULTS

Patients receiving continuous lateral rotational therapy had a significantly lower prevalence of pneumonia (17.6%) as compared with control patients (50%, p<.05). The development of pneumonia after being entered into the study was also significantly delayed in continuous lateral rotational therapy patients, 29 +/- 8 days vs. 12 +/- 2 days in controls (p <.05). However, unit mortality, total ventilator days, and the number of patients successfully weaned were not significantly different between groups.

CONCLUSION

In patients requiring long-term ventilator care, continuous lateral rotational therapy reduced the prevalence of pneumonia but did not seem to affect mortality or the period of mechanical ventilation.

Nutrition support of the chronically critically ill patient

Providing nutrition and metabolic support to the CCI patient is based on the rational application of scientifically derived data and clinical experience with this unique population. Much of the data presented has been extrapolated from the critically ill ICU patients and the chronically ill hospitalized or nursing home patient, as there are limited data solely based on an experience with the CCI [table: see text] patient population. The key principles are: (1) primacy of protein provision and avoidance of overfeeding energy, (2) use of combined modality (enteral, parenteral, and oral) nutrition to meet needs as required, (3) use of adjunctive agents to promote nitrogen retention when needed, and (4) recognition of and adjustment for altered nutrient requirements (Table 3).

The epidemiology and costs of chronic critical illness

CCI patients are patients who have suffered acute illness or injury and require life support or care in an ICU setting for periods of weeks or months. These patients account for between 5% and 10% of ICU admissions, and they appear to be increasing in number. Over half of the patients are over age 65. Patients with underlying premorbid conditions who suffer complications of acute illness are at highest risk for becoming CCI. These patients have poor short-term and long-term survival, although survival may be improving for some types of CCI patients as the medical system adapts to their specific needs. Long-term survival is associated with age and premorbid condition or functional status. Survivors have significant functional limitations, but their reported quality of life is generally good. CCI patients consume a disproportionate share of ICU and hospital resources, and significant additional resources are required for continued recovery or care after discharge. Specialized units have been evolving to manage these patients at lower costs than in acute ICUs, and with similar outcomes. Further refinement of the definition of CCI is an important objective, and should pave the way to better design of outcomes studies. Efforts should continue to learn how to identify patients at high risk for CCI and poor outcome so that expensive resources can be managed effectively, and patient-provider decision making can be better informed.

Liberation from prolonged mechanical ventilation

After weaning from PMV, patients are usually far from ready to resume normal activities. A prolonged recovery period after catastrophic illness is the rule, with multidisciplinary rehabilitation and discharge planning efforts. Following such efforts, reports of success of restorative care are institutional and population specific. That all PMV patients are not "chronically critically ill" introduces selection factors that make comparisons between institutions even more difficult. Half of the authors' patients were able to go home in past years [14], although more recently, with patients admitted more debilitated and more ill, the percent returning home has gradually declined to the low 20% range. Bagley et al [11] report discharge to home in 31% of patients weaned. Gracey et al [6,133], treating younger, postsurgical patients, have reported the highest discharge to home rate, 57%; over 70% were eventually discharged to home after first being transferred to a rehabilitation unit. On the other hand, the few reports of survival 1 or more years after discharge are in the 50% range at best (Table 2). Carson and colleagues [9] report a 23% 1-year survival in 133 PMV patients. Their premorbid functional status and age analysis showed younger and more independent patients having a better mortality (56%), and older and more dependent patients having a 95% mortality at 1 year. Nasraway et al [25] report a 1-year mortality of 50.5% in 97 patients transferred from five ICUs to multiple ECFs. Most of these patients would probably meet criteria for PMV, with median time mechanically ventilated 33 days, and 71 ventilator dependent at the time of ICU discharge. A report from 25 Vencor Hospitals [134] not included in Table 2 because weaning outcome was not reported, examines mortality and cost in patients > 65 years of age primarily referred for failure to wean from mechanical ventilation (91% of the cohort of 1619 patients.) There was a 58% in-hospital mortality by day 102 (28 days in the acute care hospital before referral, 74 days in the LTAC afterward), and a 67% mortality in postdischarge follow-up to day 180. Results of functional status studies and quality-of-life (QQL) measures, some using validated instruments, are now being reported in small series of PMV patients. These will merit consideration as important as weaning outcome, disposition, and survival data, as they accumulate to round out the treatment results in this population. Using a proprietary instrument, Carson et al [9] found 42% of 1-year survivors, that is, 8% of study patients, functionally independent at 1 year after discharge. Nasraway [25], using a single-question QQL assessment, and a validated functionality measurement, found 11.5% of his original cohort at home, breathing independently, with a "fair or better" QOL and good physical functionality. In a preliminary report from Dr. Criner's VRU, objective physical improvement was demonstrated in rehabilitation after PMV, using a functional independence measure scale [89]. A full report from the same unit, using a Sickness Impact Profile score makes it clear that PMV had no independent adverse effect on QOL several years later [135]. The 46 patients (25 of whom, with mean age 59 years, responded to the follow-up questionnaire), followed for 24 months after the catastrophic episode, scored their QOL based on their underlying chronic diseases, if any. The older patients, status postsurgical illness, predominantly cardiac surgery, rated their QOL better than younger patients with acute or chronic diseases. Similar findings have been reported in a recent ICU study, reporting QOL after prolonged intensive care [136]. Those who work to liberate PMV patients from mechanical ventilation, a satisfying end in many ways, have demonstrated that this post-ICU critical care activity is usually safe, and successful, although only in observational studies. Will multicenter studies in PMV patients liberated from mechanical ventilation yield facility benchmark, weaning outcome, and survival data that warrant continuation of these activities on a cost-per-outcome basis? That remains to be seen. Assessing and interpreting QOL and functionality findings in these patients, many with underlying chronic diseases resulting in long convalescence and rehabilitation, is a particularly important challenge. The authors are participating in a multicenter study that will yield some of these data; no doubt others will also address these questions. In the mean time, "No one in our society is willing to put Grandma out on an iceberg because she's no longer contributing. Someone needs to take care of these people" [137].

Post-ICU weaning from mechanical ventilation: the role of long-term facilities

A review of the largest observational studies on post-ICU weaning from prolonged mechanical ventilation yields evidence that more than half of such patients can be successfully liberated from mechanical ventilation. Success is likely to fall within a 3-month window, with late successes and partial ventilator independence still possible thereafter. There is a uniformity of practice in finishing difficult weaning with self-breathing trials of increasing duration.

Predicting mortality in patients suffering from prolonged critical illness: an assessment of four severity-of-illness measures

STUDY OBJECTIVES

Investigators have been using severity-of-illness indexes such as APACHE II (acute physiology and chronic health evaluation score II) to describe patients with prolonged critical illness. However, little is known about the utility of these indexes for this patient population. We evaluated the ability of four severity-of-illness indexes to predict mortality rates in 182 patients with prolonged critical illness.

DESIGN

Retrospective inception cohort study.

SETTING

A single, urban, long-term, acute-care hospital in Chicago.

PATIENTS

One hundred eighty-two patients transferred from 37 acute-care hospital ICUs.

MEASUREMENTS AND RESULTS

We assessed four indexes: the acute physiology and chronic health evaluation II, the simplified acute physiology score II, the mortality prediction model II, and the logistic organ dysfunction system using variables measured on admission to the long-term acute-care hospital ICU. We found that none of these indexes distinguished well between the patients who lived and the patients who died (area under ROC [receiver operating characteristics] curve < 0.70 for all), nor did they assign correct probabilities of death to individual patients (Hosmer-Lemeshow goodness-of-fit statistics, p < 0.01 for all).

CONCLUSIONS

Investigators and clinicians should use caution in using severity-of-illness measures developed for acutely ill patients to describe critically ill patients admitted to long-term care units. As clinical practice and research focus more on these latter patients, development of adequately performing severity-of-illness measures appropriate to this patient population will be needed.

Respiratory intensive care units in Italy: a national census and prospective cohort study

BACKGROUND

In Italy, respiratory intensive care units (RICUs) provide an intermediate level of care between the intensive care unit (ICU) and the general ward for patients with single organ respiratory failure. Because of the lack of official epidemiological data in these units, a two phase study was performed with the aim of describing the work profile in Italian RICUs.

METHODS

A national survey of RICUs was conducted from January to March 1997 using a questionnaire which comprised over 30 items regarding location, models of service provision, staff, and equipment. The following criteria were necessary for inclusion of a unit in the survey: (1) a nurse to patient ratio ranging from 1:2.5 to 1:4 per shift; (2) availability of adequate continuous non-invasive monitoring; (3) expertise for non-invasive ventilation (NIV) and for intubation in case of NIV failure; (4) physician availability 24 hours a day. Between November 1997 and January 1998 a 3 month prospective cohort study was performed to survey the patient population admitted to the RICUs.

RESULTS

Twenty six RICUs were included in the study: four were located in rehabilitation centres and 22 in general hospitals. In most, the reported nurse to patient ratio ranged from 1:2 to 1:3, with 36% of units reporting a ratio of 1:4 per shift. During the study period 756 consecutive patients of mean (SD) age 68 (12) years were admitted to the 26 RICUs. The highest proportion (47%) were admitted from emergency departments, 19% from other medical wards, 18% were transferred from the ICU, 13% from specialist respiratory wards, and 2% were transferred following surgery. All but 32 had respiratory failure on admission. The reasons for admission to the RICU were: monitoring for expected clinical instability (n=221), mechanical ventilation (n=473), and weaning (n=59); 586 patients needed mechanical ventilation during their stay in the RICU, 425 were treated with non-invasive techniques as a first line of treatment (374 by non-invasive positive pressure, 51 by iron lung), and 161 underwent invasive mechanical ventilation (63 intubated, 98 tracheostomies). All but 48 patients had chronic respiratory disease, mainly chronic obstructive pulmonary disease (COPD; n=451). More than 70% of patients (n=228) had comorbidity, mainly consisting of heart disorders. The median APACHE II score was 18 (range 1--43). The predicted inpatient mortality risk rate according to the APACHE II equation was 22.1% while the actual inpatient mortality rate was 16%. The mean length of stay in the RICU was 12 (11) days. The outcome in most patients (79.2%) admitted to RICUs was favourable.

CONCLUSIONS

Italian RICUs are specialised units mainly devoted to the monitoring and treatment of acute on chronic respiratory failure by non-invasive ventilation, but also to weaning from invasive mechanical ventilation. The results of this study provide a useful insight into an increasingly important field of respiratory medicine.

Weaning from prolonged mechanical ventilation

The development of weaning failure and need for PMV is multifactorial in origin, involving disorders of pulmonary mechanics and complications associated with critical illness. The underlying disease process is clearly important when discussing mechanisms of ventilator dependence; interventions therefore must be tailored to individual patients. Unfortunately, the main conclusion that can be drawn from the sum of the studies investigating patients on PMV to date is that an evidence-based approach to weaning is not possible and more research needs to be done. New studies need to incorporate severity-of-illness scores and an assessment of principal and comorbid conditions to allow for comparison of the findings from different centers. The best approach to a patient requiring PMV after exclusion of easily treatable conditions is not known. The literature regarding both acute and chronic cases suggests that a systematic approach to weaning involving the participation of multiple caregivers, including nurses, physicians, and respiratory, physical, and speech therapists facilitates liberation from MV. Although a gradual decrement in ventilator support would seem prudent, Scheinhorn et al have begun to identify a subpopulation of patients who can tolerate an acceleration of the weaning process. Given the known complications associated with MV, it is crucial that further research be performed to identify patients as soon as they are capable of breathing spontaneously. The literature demonstrates through multiple studies that satisfactory patient outcomes are attainable and can be achieved at LTAC facilities in a more cost-effective manner than in an ICU setting. The trend toward the concentration of patients into specialized regional weaning centers should facilitate the research process and continue to improve outcomes in this population.

Chronic ventilator dependence in elderly patients

Long-term ventilator dependence is the need for mechanical ventilation for more than 6 h/d for more than 21 days. Long-term ventilator dependence complicates 9% to 20% of the episodes of mechanical ventilation treated in the intensive care units of acute care hospitals; it is associated with an average mortality rate of 40%. Unlike acute respiratory failure, the risk for which does not increase with age, long-term ventilator dependence falls disproportionately to patients aged 70 years or older. During the past 2 decades, a profusion of care sites for patients with long-term ventilator dependence has evolved, largely as the product of the prospective payment system for health services introduced by the Health Care Financing Administration in 1983. The outcome of long-term ventilator dependence in elderly patients across this health care continuum is addressed.

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.

The distribution of costs of care in mechanically ventilated patients with chronic obstructive pulmonary disease

OBJECTIVES

To delineate the costs of care of patients with Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure and to compare them with those of other mechanically ventilated patients.

DESIGN

A post hoc analysis of a prospective investigation.

SETTING

Medical and coronary intensive care units (ICUs) of an 804-bed, university-based hospital.

PATIENTS

A total of 300 mechanically ventilated patients, 44 with COPD and 256 others, were included.

MEASUREMENTS AND MAIN RESULTS

Despite similar lengths of ICU stay (9 days) and mechanical ventilation (5.5 days COPD vs. 5 days other, p = .11), ICU respiratory care costs for patients with COPD were $2,422 ($1,157-$6,110) [median U.S. dollars (interquartile range)] vs. $1,580 ($738-$3,322) for the others (p = .01). Ventilator costs for COPD patients were $1,795 ($943-$5,782) vs. $1,574 ($613-$3,112) (p = .12). Total hospitalization respiratory care costs for COPD patients were higher, $4,064 ($2,422-$9,572) vs. $2,342 ($1,186-$4,591), (p = .0001), and 74.4% of the median difference in cost between COPD patients and others was accounted for by spontaneous nebulizers (p = .001), metered dose inhalers (p = .01), and pulse oximetry (p = .02). By using multiple linear regression analyses, we found that COPD remained associated with higher respiratory costs (p<.05). Respiratory Care was the third largest category of hospital costs after beds (27%) and pharmacy expenses (25%), and it comprised approximately 14% of total cost. Total hospital costs were large for both groups, but did not differ between COPD and the others [$24,217 ($16,211-$58,834) vs. $27,672 ($15,692-$53,766), respectively (p = .96)]. Linear regression analyses showed that only Acute Lung Injury score was significantly related to total ICU and hospital costs of care (p<.05).

CONCLUSIONS

Costs of ICU and non-ICU respiratory care for patients with COPD are higher than costs of care for other mechanically ventilated patients. Although the increased cost of bronchodilators and oximetry in these patients may serve as target areas for reductions in respiratory care costs, it may also be true that these modalities of therapy and management are necessary and need to be used with even greater intensity to achieve better outcomes. The predominant contributions of bed and pharmacy costs in all of our patients with respiratory failure support research efforts addressing these aspects of care.

Four-year experience with a unit for long-term ventilation (respiratory special care unit) at the Cleveland Clinic Foundation

BACKGROUND

In the context that special weaning units have been advocated as effective alternatives to the ICU for weaning selected patients, we initiated a Respiratory Special Care Unit (ReSCU) at the Cleveland Clinic Hospital in August 1993. The goals of the ReSCU were the following: (1) to wean ventilator-dependent patients when possible; and (2) when weaning was not possible, to optimize patient and family instruction for patients going home with ventilatory support. This study presents our 4-year experience with 212 patients managed in the ReSCU and analyzes clinical features associated with favorable clinical outcomes.

METHODS

The features of the ReSCU include six private beds in a pulmonary inpatient ward staffed by nurses with special pulmonary expertise; 24-h respiratory therapy supervision; bedside and central noninvasive monitoring (i.e., continuous pulse oximetry, end tidal capnometry, and ventilator alarms); and a multidisciplinary approach involving dietitians, physical therapists, occupational therapists, social workers, and speech pathologists. All ReSCU patients were cared for primarily by a pulmonary/critical care attending physician and fellow, with consultative input solicited as deemed necessary. The criteria for admission to the ReSCU included hemodynamic stability; absence of an arrhythmia requiring telemetry; and in the attending physician's judgment, the ability to benefit from the ReSCU.

RESULTS

Between August 23, 1993, and August 31, 1997, 212 patients were admitted to the ReSCU. The median age was 68 years old; 55% were women; 86% were white; and 55% were transferred from the medical ICU. Underlying reasons for ventilator dependence were ARDS from a nonsurgical cause (33%), ARDS following surgery (18%), status post-cardiothoracic surgery (13%), status post-thoracic surgery (12%), and COPD (12%). The median length of ReSCU stay was 17 days (interquartile range, 10 to 29 days). Eighteen percent (n = 38) died during the hospitalization. Among the 174 survivors, complete ventilator independence was achieved in 127 patients (60% of the 212 patient cohort), 28 patients were ventilator dependent (13% of 212 patients), and the remaining 19 patients (9%) required partial ventilatory support. Univariate analysis regarding the association of baseline characteristics with death identified lower albumin and transferrin levels, increasing age, and the physician's estimate of lower weaning likelihood as significant correlates of death. In contrast, achieving complete ventilator independence was associated with a higher serum albumin level, a nonmedical ICU referral source, a cause of respiratory failure other than COPD, and a physician's estimate of higher weaning likelihood. To analyze the financial impact of the ReSCU, we assumed that ReSCU patients would have otherwise stayed in the medical ICU and compared the charges (ICU vs ReSCU) with, for a subset of patients, the true costs of ReSCU vs. ICU care. Analyses of both charges and cost differences showed similar savings associated with ReSCU care ($13,339 per patient [charges] and $10,694 per patient [costs]).

CONCLUSIONS

We conclude the following: (1) the rate of achieving complete ventilator independence in the ReSCU was high; and (2) based on our achieving clinical outcomes, which are comparable to the most favorable rates reported in other series from ventilator units, we conclude that the ReSCU can be an effective and cost-saving alternative to the ICU for carefully selected patients.

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.

Options for long-term ventilatory support

Long-term mechanical ventilator support for patients with chronic respiratory failure is becoming more common. This article reviews the common causes for chronic ventilator dependence, and offers an approach to weaning these patients from the ventilator. In addition, the details for preparing these patients for prolonged mechanical ventilation outside of the acute-care hospital setting are discussed. Appropriate education of the patient's caregivers is key to the success of long-term ventilatory support outside of the acute-care hospital.