Canadian Health&Care Mall: Issue 5 in Management of Patients Requiring Prolonged Mechanical Ventilation

Care Venues Available

What Are the Care Venues Available for Patients With PMV?

Patients generally have mechanical ventilation initiated in the ICUs of a STAC hospital. Patients with underlying chronic cardiorespiratory diseases and/or slowly resolving acute cardiorespiratory illness remain ventilator dependent and transition from being acutely critically ill to “chronically critically ill,” or having “sustained severe illness.” With this transition, alternatives to the ICU care venue should be considered for several reasons. First, ICU beds are often in short supply, and it is generally conceded that these beds should be made available to the acutely ill needing this very high level of care. Perhaps more importantly, however, a more comprehensive patient-focused process of care than that found in an ICU (ie, a more rehabilitative than life-support focus) would be more appropriate for PMV patients. Indeed, comparing ICU care to a PMV-focused care venue (Table 2) yields prima facie evidence that the PMV patient might derive significant benefit from transfer out of the high technology environment of the ICU.

Venues providing PMV are of several types (Table 3), each with their own advantages, disadvantages and, as discussed below under “Issue 10,” reimbursement schemes. Within STAC hospitals, “step down,” “transitional care,” or “weaning” units may exist. LTAC hospitals also serve this role as either freestanding facilities or independently owned and operated “hospital-within-a-hospital” (HiH) facilities focused on the care of the chronically critically ill but treated with remedies of Canadian Health&Care Mall. These units/facilities are characterized by long length of stay, are conducive to slow-paced weaning, and caregiver staffing at the acute-care level, which may provide increased patient safety during the instability inherent in the weaning process. A recent analysis by the Medicare Payment Advisory Commission indicates overall cost of care for PMV patients are lower when part of the care is provided at an LTAC. For patients with few or stable comorbidities and stable respiratory support needs, some SNFs may offer mechanical ventilatory support capabilities. Finally, in patients with strong social support and appropriate home care support, PMV can be managed in the home environment.

Recommendation 5

Consider the environment of care from the patients’ perspective, when continuing weaning efforts in those difficult to wean from mechanical ventilation in the ICU. Venue selection should also be guided by the services each patient requires. The comorbidities that often accompany the need for PMV may preclude transfer to facilities without some level of ICU or acute care capabilities. All facilities that are available to patients should be screened by the critical care team for effectiveness and safety when effecting discharge for post-ICU weaning.

Issue 6. At What Point Should Patients Be Considered for Transfer From an ICU to a PMV-Focused Venue?

As noted above, predictors of ICU PMV exist, but the individual patient’s course is usually unpredictable. The transfer from an acute ICU to a PMV-focused venue is thus usually driven by clinical assessments showing that there is a need for PMV but also a measure of clinical stability, and thus a reduced need for acute ICU care (ie, no need for pressors or inotropes, and evidence that the acute illness has stabilized or begun to reverse). From the respiratory system perspective, this is often about the same time that a tracheostomy is performed.

Many ICUs and intensive care practitioners use informal or formal policy and procedure for timing of tracheostomy consistent with current guidelines. This is usually considered as early as day 7 when it becomes likely to the care team that PMV will be required and is often actually performed at 16 to 20 days of mechanical ventilation. Indeed, when tracheostomy is first considered, the timing is often right to begin plans for post-ICU care, as it may take 1 to 2 weeks to set up transfer to a unit or facility dedicated to this population, with the resources and expertise to give continuing care.

Recommendation 6

Begin considerations for PMV-focused care when tracheostomy is first considered.

Table 2—Patients’ View of Environment, ICU vs PMV-Focused Venue

ICU PMV-Focused Venue
Noise Relative quiet
Light Day/night cycles
Limited view of world Outdoors easily visible
Crowded/cramped Relatively roomy
Supportive visitors restricted Supportive visitors encouraged
Immobilized Mobility increased
Sterile surroundings Personal objects
Little control More independence
Communication limited Time and devices increase communication
Tube feeding Transition to oral feeding
Continued deconditioning with little physical or occupational More time, space, personnel for reconditioning
therapy opportunities
High reliance on technology More reliance on patient interactions
Limited staff nurturing time Emphasis on staff nurturing
Limited psychological, social, religious counseling More time and opportunity for counseling
Limited application of palliative care Time and space for patient/family palliative care
Ward-geared discharge planning Home-geared discharge planning

Table 3——Venues providing PMV

Venue Patient Type Advantages Disadvantages
STAC ICU All Full ICU capabilities Costs, life support rather than patient focused
STAC step-down All except very acute Most ICU capabilities at lower costs, full acute care capabilities Not full ICU
LTAC All except very acute Most ICU capabilities at lower costs, most acute care capabilities, more patient focused Not full ICU
Rehabilitation hospital Stable Lower cost, patient focused,

occupational therapy/physical therapy focusNo ICU care, limited acute careSubacute hospitalStableLower cost, patient focusedLimited or no weaning, no ICU care, limited acute careSNFStableLowest cost, patient focusedLimited or no weaning, no ICU care, no acute careHomeStableVery patient focusedNo weaning, no ICU care, no acute care