Long-term weaning centres in critical care

Mapping Intimacies ◽

10.1093/med/9780199600830.003.0384 ◽

2016 ◽

Author(s):

Jeremy M. Kahn

Keyword(s):

Mechanical Ventilation ◽

Intensive Care ◽

Acute Care ◽

Patient Outcomes ◽

Prolonged Mechanical Ventilation ◽

Multidisciplinary Care ◽

Acute Care Hospitals ◽

Optimal Timing ◽

Physician Staffing ◽

Multidisciplinary Care Team

Successfully weaning patients from prolonged mechanical ventilation requires the varied expertise of a dedicated multidisciplinary care team. Traditionally, this care was provided in acute care hospitals, increasingly these patients are transferred to specialized weaning centres. These may improve patient outcomes by concentrating weaning expertise in a low-acuity environment and implementing protocols for liberation from mechanical ventilation. However, these centres might also worsen patient outcomes because they typically offer less intense nurse and physician staffing compared with traditional intensive care units. Generally, the clinical evidence is mixed, with the best studies suggesting that weaning centres offer similar outcomes as acute care hospitals, but at lower costs. Health systems also might stand to gain from dedicated weaning centres, because they can release intensive care unit beds for more acutely-ill patients. Many gaps remain in our understanding of which patients should be transferred to dedicated weaning centres, the optimal timing of transfer, and the best approach to care for patients in this highly specialized setting.

Download Full-text

Weaning Analgosedation in Patients Requiring Prolonged Mechanical Ventilation

Journal of Intensive Care Medicine ◽

10.1177/08850666211048779 ◽

2021 ◽

pp. 088506662110487

Author(s):

Stephanie Parks Taylor ◽

John M. Hammer ◽

Brice T. Taylor

Keyword(s):

Mechanical Ventilation ◽

Prolonged Mechanical Ventilation ◽

Multidisciplinary Care ◽

Potential Harm ◽

Mechanically Ventilated ◽

Multidisciplinary Care Team ◽

Clinical Trial Evidence ◽

Adults And Children ◽

Trial Evidence

Although research supports the minimization of sedation in mechanically ventilated patients, many patients with severe acute respiratory distress syndrome (ARDS) receive prolonged opioid and sedative infusions. ICU teams face the challenge of weaning these medications, balancing the risks of sedation with the potential to precipitate withdrawal symptoms. In this article, we use a clinical case to discuss our approach to weaning analgosedation in patients recovering from long-term mechanical ventilation. We believe that a protocolized, multimodal weaning strategy implemented by a multidisciplinary care team is required to reduce potential harm from both under- and over-sedation. At present, there is no strong randomized clinical trial evidence to support a particular weaning strategy in adult ICU patients, but appraisal of the existing literature in adults and children can guide decision-making to enhance the recovery of these patients.

Download Full-text

Assessing the Importance of Predictors of Successful Ventilator Weaning of Patients on Prolonged Mechanical Ventilation at Long Term Acute Care Hospitals

10.1164/ajrccm-conference.2019.199.1_meetingabstracts.a4358 ◽

2019 ◽

Author(s):

H. Dunn ◽

S. Corbridge ◽

L. Quinn ◽

K. Eldeirawi ◽

M.C. Kapella ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Care ◽

Prolonged Mechanical Ventilation ◽

Acute Care Hospitals ◽

Ventilator Weaning

Download Full-text

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

BMC Pulmonary Medicine ◽

10.1186/s12890-021-01454-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Berna Demiralp ◽

Lane Koenig ◽

Jing Xu ◽

Samuel Soltoff ◽

John Votto

Keyword(s):

Mechanical Ventilation ◽

Endotracheal Intubation ◽

Acute Care ◽

Prolonged Mechanical Ventilation ◽

Acute Care Hospitals ◽

Care Hospital ◽

Mechanical Ventilator ◽

Ventilated Patients ◽

Ventilator Patients

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

Download Full-text

Impact of the Staffing Structure of Intensive Care Units and High Care Units on In-Hospital Mortality Among Patients with Sepsis: A Retrospective Analysis of Japanese Nationwide Claims Data

10.21203/rs.3.rs-796517/v1 ◽

2021 ◽

Author(s):

Kota Nishimoto ◽

Takeshi Umegaki ◽

Takahiko Kamibayashi

Keyword(s):

Critical Care ◽

Intensive Care ◽

Hospital Mortality ◽

Intensive Care Units ◽

Acute Care ◽

Patient Outcomes ◽

Acute Care Hospitals ◽

High Care

Abstract Background: Critical care in Japan is provided in intensive care units (ICUs) and high care units (HCUs), which are categorized based on their fulfillment of different staffing criteria. Under Japan’s medical fee reimbursement system, units with higher staffing levels are eligible to receive higher reimbursements. However, the different staffing structure of these units may affect the quality of care and patient outcomes. This study aimed to analyze the impact of ICU/HCU staffing structure on in-hospital mortality among septic patients in Japan’s acute care hospitals using a nationwide claims database.Methods: We conducted a large-scale multicenter retrospective cohort study of adult septic patients (aged ≥18 years) who received critical care in acute care hospitals throughout Japan between April 2018 and March 2019. Patients were categorized into three groups according to the type of unit in which they received critical care: Type 1 ICUs (fulfilling stringent staffing criteria such as experienced intensivists and high nurse-to-patient ratios), Type 2 ICUs (fulfilling less stringent criteria), and HCUs (fulfilling the least stringent criteria). A Cox proportional hazards regression model was constructed with in-hospital mortality as the dependent variable and the ICU/HCU groups as the main independent variable of interest. Other covariates included age, emergency or non-emergency admission, major diagnostic categories, mechanical ventilation, noninvasive positive airway pressure ventilation, oxygen therapy, and renal replacement therapy.Results: We analyzed 2411 patients (178 hospitals) in the Type 1 ICU group, 3653 patients (422 hospitals) in the Type 2 ICU group, and 4904 patients (521 hospitals) in the HCU group. When compared with the HCU group, the adjusted hazard ratios for in-hospital mortality were 0.74 (95% confidence interval: 0.71–0.77; P<0.001) for the Type 1 ICU group and 0.83 (0.80–0.85; P<0.001) for the Type 2 ICU group. Emergency hospital admission had the highest hazard ratio for in-hospital mortality (hazard ratio: 4.78; P<0.001).Conclusions: ICUs that fulfill more stringent staffing criteria were associated with lower in-hospital mortality in septic patients than HCUs after adjusting for confounders. Optimizing the staffing structure of these units may contribute to the improvement of patient outcomes.

Download Full-text

The Role of Long-Term Ventilator Hospitals

10.1093/med/9780199653461.003.0004 ◽

2014 ◽

Author(s):

Jeremy M Kahn

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Acute Care ◽

Critically Ill Patients ◽

Prolonged Mechanical Ventilation ◽

Acute Care Hospitals ◽

Cost Of Care ◽

Current Evidence ◽

Chronically Critically Ill

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

Download Full-text