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.
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.
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.
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.
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.
This multicenter study was undertaken to characterize the population of ventilator-dependent patients admitted to long-term care hospitals (LTCHs) with weaning programs, and to report treatments, ...complications, weaning outcome, discharge disposition, and survival in these patients.
Observational study with concurrent data collection.
Twenty-three LTCHs in the United States.
Consecutive ventilator-dependent patients admitted over a 1-year period: March 1, 2002, to February 28, 2003.
A total of 1,419 patients were enrolled in the Ventilation Outcomes Study. Median age of patients was 71.8 years (range, 18 to 97.7 years). Patients averaged 6.9 procedures and treatments during the LTCH hospitalization; median length of stay was 40 days (range, 1 to 365 days). Seven of the 10 most frequent complications treated at the LTCH were infections; congestive heart failure and diabetes mellitus were the most common comorbidities requiring treatment. Outcomes of weaning attempts, scored at LTCH discharge, were 54.1% weaned, 20.9% ventilator dependent, and 25.0% deceased. Median time to wean (n = 766) was 15 days (range, 7 to 30 days). Discharge disposition included 28.8% to home, 49.2% to rehabilitation and extended-care facilities, and 19.5% to short-stay acute hospitals. Nearly one third of patients were known to be alive 12 months after admission to the LTCH.
Patients admitted to LTCHs for weaning attempts were elderly, with acute-on-chronic diseases, and continued to require considerable medical interventions and treatments. The frequency and type of complications were not surprising following prolonged and aggressive ICU interventions. In the continuum of critical care medicine, more than half of ventilator-dependent survivors of catastrophic illness transferred from the ICU were successfully weaned from prolonged mechanical ventilation in the setting of an LTCH.
Functional exercise capacity has been shownto be a strong predictor of survival following pulmonaryrehabilitation. This study evaluated whether questionnaire-ratedfunctional status is also predictive ...of survival.
Following pulmonary rehabilitation, patients withadvanced chronic lung disease were evaluated for survival, 6-min walkdistance, and questionnaire-rated functional status. The latter wasmeasured using the pulmonary functional status scale, which hassubscores of functional activities, psychological status, and dyspnea. Information on survival was available on 149 patients.
The mean age was 69 years, and 45% of patientswere male. Eighty-nine percent had a diagnosis of COPD, and their, FEV1 was 37 ± 18% of predicted. Ninety-one (61%) weremarried. The 3-year survival for the group was 85%. Age, gender, bodymass index, and primary diagnosis were not related to survival. Variables strongly associated with increased survival followingpulmonary rehabilitation included a higher postrehabilitation, Functional Activities score, a longer postrehabilitation 6-min walkdistance, and being married (vs widowed, single, or divorced). Diseaseseverity variables associated with survival included an initialreferral to outpatient pulmonary rehabilitation, no supplemental oxygenrequirement, and a higher percent-predicted FEV1.
Indicators of functional status are strongpredictors of survival in patients with advanced lungdisease.
Understanding the long-term effects of severe COVID-19 illness on survivors is essential for effective pandemic recovery planning. Therefore, we investigated impairments among hospitalized adults ...discharged to long-term acute care hospitals (LTACHs) for prolonged severe COVID-19 illness who survived 1 year.
The Recovery After Transfer to an LTACH for COVID-19 (RAFT COVID) study was a national, multicenter, prospective longitudinal cohort study.
We included hospitalized English-speaking adults transferred to one of nine LTACHs in the United States between March 2020 and February 2021 and completed a survey.
None.
Validated instruments for impairments and free response questions about recovering. Among 282 potentially eligible participants who provided permission to be contacted, 156 (55.3%) participated (median age, 65; 38.5% female; 61.3% in good prior health; median length of stay of 57 d; 77% mechanically ventilated for a median of 26 d; 42% had a tracheostomy). Approximately two-thirds (64%) had a persistent impairment, including physical (57%), respiratory (49%; 19% on supplemental oxygen), psychiatric (24%), and cognitive impairments (15%). Nearly half (47%) had two or more impairment types. Participants also experienced persistent debility from hospital-acquired complications, including mononeuropathies and pressure ulcers. Participants described protracted recovery, attributing improvements to exercise/rehabilitation, support, and time. While considered life-altering with 78.7% not returning to their usual health, participants expressed gratitude for recovering; 99% returned home and 60% of previously employed individuals returned to work.
Nearly two-thirds of survivors of among the most prolonged severe COVID-19 illness had persistent impairments at 1 year that resembled post-intensive care syndrome after critical illness plus debility from hospital-acquired complications.
Abstract
Objective:
Compare clinical outcomes and costs in a study group of long-term acute care hospital (LTCH) patients with a control group of LTCH-eligible patients in an acute care hospital. ...LTCHs were created to provide post-acute care services not available at other post-acute settings. This is based on the premise that these patients would otherwise have stayed at acute care hospitals as high-cost outliers. The LTCH hospital is intended to deliver care to patients more efficiently, however, there are little documented clinical and financial data regarding the comparative clinical outcomes and costs for patients.
Methods:
Retrospective medical and billing record review of patients from the following groups: (1) LTCH study comprising patients admitted directly from an acute care hospital to the study LTCH and discharged from the LTCH from September 2004 through August 2006; (2) a control group of LTCH-eligible, medically complex patients treated and discharged from an acute care hospital in FY 2002. The control group was selected from approximately 500 patients who had at least one of the ten most common principle diagnosis DRGs of the study LTCH with >30-day length of stay at the referring hospital and met NALTH admitting guidelines.
Results:
Discharge disposition is an important outcome measure of the quality of care of medically complex patients. The in-hospital mortality rate trended lower and home discharge was 3 times higher for the LTCH study group than for the control group. As a possible result, SNF discharge of LTCH patients was approximately half that of the control group. Both mean patient cost per day and mean total cost per patient were significantly higher in the control group than in the LTCH study group.
Conclusions:
The patients in the LTCH study group had both better clinical outcomes and lower cost of care than the control group.
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