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Revised Guidelines: Improving Ventilated Patient Outcomes Through Timely Discharges to LTACHs

Caregivers taking care of patient
 

By Sean R. Muldoon, MD, MPH, FCCP, Chief Medical Officer, Kindred Hospitals

 

An estimated 20-40% of patients in the ICU experience severe respiratory insufficiency, requiring the support of mechanical ventilation.1 While most patients rely on this intervention for only a short time, approximately 20% of patients need ventilator support for a longer time.2 Studies show that timely discharge of these patients to long-term acute care hospitals (LTACHs) which specialize in ventilator liberation can help improve outcomes and expedite recovery. Based on these findings, healthcare guidelines have been revised to promote patient transfer to LTACHs as soon as clinically appropriate.

 
 

MCG Health Clinical Indications for Admission to LTACHs have been revised based on research revealing the benefits of timely discharge of ventilated patients to LTACHs. See how Kindred Hospitals, a nationwide network of LTACHs, helps ventilated patients recover.

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The Importance of Ventilator Liberation Strategies

While mechanical ventilation is a life-saving intervention, long-term use can pose significant health risks and increase rates of readmission.

One primary concern of prolonged ventilation is bacterial infection which can cause ventilator-associated pneumonia.3 Lung injury is another risk, which may result from overdistention and mechanical stress of the alveoli.4 Additionally, patient immobility can increase risk of skin pressure injuries and blood clots and lead to muscle loss and depression.5 As a consequence of these risks, both readmission and mortality rates increase as the duration of mechanical ventilation increases.6

Therefore, it is important that providers have liberation strategies in place, including the utilization of downstream partners with ventilator expertise, so that ventilator-dependent patients can regain breathing independence and mobility as soon as possible.

New Healthcare Guidelines Incorporate Latest Clinical Research on Liberation

Liberation strategies – which may include direct extubation, spontaneous breathing trials (SBTs) or tracheostomy collars trials – have changed over time and vary across the globe.7 There is additional variability around when a patient on a ventilator should transition to another setting, such as an LTACH.

In an effort to establish consistency, medical professionals have collaborated to synthesize the most up-to-date clinical research and publish guidelines for the treatment and transition of ventilated patients. MCG Health is one healthcare group that offers unbiased care recommendations based on the latest evidence.8

Historically, MCG Health’s Clinical Indications for Admission to LTACH included 21 ventilator days. However, in March 2022, MCG published revised guidelines that replace the 21-day indication with a less arbitrary and more clinical indication - three failed SBTs.9

This change is supported by a number of recent studies that found that: 1) SBTs are considered a best practice for evaluating clinical necessity of long-term ventilation and; 2) delaying discharge of ventilated patients to an LTACH may negatively influence the probability of liberation.10,11

Based on these updated guidelines, providers should consider discharging ventilator-dependent patients to an LTACH as soon as clinically appropriate to begin receiving specialized ventilator care.

Unique Aspects of LTACH Care That Can Improve Outcomes

There are three key aspects of LTACH care that help patients on prolonged ventilation regain breathing independence and mobility.

Expertise in ventilator care

Critical pulmonary care and ventilator weaning are core competencies of LTACHs, which make them advantageous settings for ventilator-supported patients. These patients, which make up more than 25 percent of LTACH admissions, receive expert treatment from a team led by pulmonologists and respiratory therapists.12

As such, discharging these patients to the LTACH in a timely fashion can help improve outcomes. In fact, one study found that a one-day delay in LTACH discharge after intubation is associated with an 11.6% reduction in the odds of weaning.13

Interdisciplinary care teams

Medically complex patients with multiple comorbidities often require a team of specialists who can address the different facets of their conditions. In an LTACH, physicians, respiratory therapists, dietitians, bedside nurses and others formally collaborate as an interdisciplinary care team to develop comprehensive treatment plans. This level of collaboration can improve outcomes by reducing the risk of miscommunication, which can be a primary cause of adverse events.14

The benefit of interdisciplinary care team collaboration is particularly clear when looking at patients requiring mechanical ventilation. One case study found an association between long-term liberation plans led by a multidisciplinary team and reductions in mortality and time on ventilator.15

Specialized rehabilitative care

Early and comprehensive rehabilitation is also essential for patients with multiple chronic conditions and acute illnesses. Rehabilitation services provided at an LTACH are led by PTs, RTs, OTs and SLPs and are integrated with specialized acute care to help patients achieve the fastest and most complete recovery possible.

Early mobilization is especially important for critical pulmonary patients. One case study found that improving access of ventilated patients to pulmonary rehabilitation in an acute care setting could reduce time on ventilation by two days.16 Studies such as these have contributed to the recommendation by the American Thoracic Society and American College of Chest Physicians to implement early mobilization protocols for ventilated patients.17

How Kindred Hospitals Can Help

Kindred Hospitals have provided quality care for 30 years, and continue to introduce initiatives that improve care, such as pursuit of Certification in Respiratory Failure from The Joint Commission and the establishment of their Move Early Program. This program incorporates mobilization as early as is safe, even for patients on ventilators. In fact, 82% of Kindred’s ventilated patients are able to reach a high level of mobility, as defined by Johns Hopkins High Level of Mobility Scale.18

 
 

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References

  1. https://pubmed.ncbi.nlm.nih.gov/23963122/
  2. https://www.karger.com/Article/FullText/510085
  3. https://www.ncbi.nlm.nih.gov/books/NBK560535/
  4. https://pubmed.ncbi.nlm.nih.gov/26023222/
  5. https://www.webmd.com/lung/ventilator-complications#2
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7515670/
  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988370/
  8. https://www.mcg.com/about/company-overview/
  9. Ventilator Management Long-Term Acute Care Hospital (LTACH) Guideline (GRG-049). 2022. In General Recovery Care. 26th Edition.
  10. https://pubmed.ncbi.nlm.nih.gov/27818331/
  11. https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-021-01454-1
  12. http://medpac.gov/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf
  13. https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-021-01454-1
  14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526935/
  15. https://pubmed.ncbi.nlm.nih.gov/22875526/
  16. https://clinicaltrials.gov/ct2/show/NCT04381338
  17. https://www.atsjournals.org/doi/full/10.1164/rccm.201610-2076ST
  18. Early Mobility Program participants at Kindred Hospitals through July 2021