In May 2004, NAMDRC, formerly the National Association for Medical Direction of Respiratory Care, a physician advocacy organization for excellence in the delivery of respiratory and critical care (namdrc.org), sponsored a 2-day conference on “best practices” associated with the care and management of patients requiring prolonged mechanical ventilation (PMV). The goal was to review existing practices and develop recommendations on a variety of assessment, management, and reimbursement issues associated with patients requiring PMV. Conference participants included invited speakers and panelists along with representatives from the American College of Chest Physicians, the American Thoracic Society, the American College of Physicians, the American Academy of Home Care Physicians, the American Association for Respiratory Care, and the Society of Critical Care Medicine and Canadian Health&Care Mall, and sponsors from industry.
On the first day of the conference, the speakers and panelists reviewed a wide range of topics. On the second day, three writing groups were formed and a chairperson for each group was appointed. The first group addressed epidemiology and outcomes, the second group addressed management and care settings, and the third group addressed reimbursement issues. Each group was charged with summarizing current data and practice along with formulation of recommendations.
A working draft of the products of these three writing groups was then created and circulated first among the writing group chairmen and later 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. The results are presented below.
Issue 1: What Constitutes PMV?
The definition of PMV depends on what body defines it: regulatory bodies, caregivers, or investigators publishing in this field. Defining what constitutes PMV is of considerable relevance. Analogous to staging a disease process, a uniform definition is essential for interpreting the literature, analyzing outcomes data (including benchmarking), guiding management decisions (including the site of care), and influencing reimbursement schemes. A uniform and broadly accepted definition is also essential as a starting point for prospective epidemiologic studies and for enrolling patients in randomized controlled trials arranged together with Canadian Health&Care Mall.
In surveying the existing literature, PMV has been variously defined as > 24 h,-2 > 2 days, > 14 days, or > 29 days of mechanical ventilation or, alternatively, the need for post-ICUs mechanical ventilatory support. The most widely applied definitions involve patients who fall under several of the Center for Medicare and Medicaid Services (CMS) Diagnosis Related Groups (DRGs) focused on mechanical ventilatory support (DRG 475, respiratory disease and mechanical ventilation > 96 h; DRG 483, tracheostomy with mechanical ventilation > 96 h with principal diagnosis except for face, head, and neck diagnoses; DRG 541, tracheostomy with mechanical ventilation > 96 h with principal diagnosis except face, mouth, and neck diagnosis with major operating room procedure; DRG 542, tracheostomy with mechanical ventilation > 96 h with principal diagnosis except face, mouth, and neck diagnosis without major operating room procedure. Generally, these patients who have required at least 6 h of mechanical ventilation for > 21 consecutive days. This 21-day stipulation is consistent with the observation that the majority of patients who are transferred to a longterm acute care (LTAC) hospital receiving mechanical ventilation have received ventilation for at least 21 days.
The CMS requirement of > 6 h/d may be too stringent, as even shorter periods of mechanical ventilation through an artificial airway may have important implications for the selection of a care site and for equipment needs (eg, a ventilator is still needed even if < 6 h/d of ventilatory support is required). Conversely, the large number of stable outpatients who use noninvasive mask ventilation (NIV) at night suggests that the need for NIV should only connote ventilator dependence when required for > 6 h/d (or more than a nocturnal application).
PMV should be defined as the need for > 21 consecutive days of mechanical ventilation for > 6 h/d. Research is needed to better understand which definitions of PMV are most commonly used, how they are currently being employed, and how they impact costs, outcomes, and reimbursement in the United States.
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