Background Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about their patterns of care as they transition from the acute hospital to post-acute care facilities or the associated resource utilization. Objectives To describe one-year trajectories of care and resource utilization for prolonged mechanical ventilation patients. Design One-year prospective cohort study. Setting 5 ICUs at Duke University Medical Center. Participants 126 prolonged mechanical ventilation patients as well as their 126 surrogates and 54 ICU physicians were enrolled consecutively during one year. Prolonged mechanical ventilation was defined as ventilation for ≥4 days with tracheostomy placement or ventilation for ≥21 days without tracheostomy. Measurements Patients and surrogates were interviewed in hospital, as well as 3 and 12 months later to determine patient survival, functional status, and facility type and duration of post-discharge care. Physicians were interviewed in-hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and inter-facility transportation. We used Medicare claims data to assign costs for post-acute care. Results 103 (82%) hospital survivors experienced 457 separate transitions in post-discharge care location (median 4 [interquartile range 3, 5]), including 68 (67%) patients who were readmitted at least once. Patients spent an average of 74% (CI, 68% to 80%) of all days alive in a hospital, post-acute care facility, or receiving home health care. At one year, 11 (9%) patients had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency (n=4, 21%) or dead (n=56, 44%). Patients experiencing a poor outcome were older, had more comorbidities, and were more frequently discharged to a post-acute care facility than patients with either fair or good outcomes (all p <0.05). Costs per patient were $306,135 (SD $285,467) and total cohort costs totaled $38.1 million, for an estimated $3.5 million per one-year independently functioning survivor. Limitations The results of this single center study may not be applicable to other centers. Conclusions Prolonged mechanical ventilation patients experience multiple transitions of care, resulting in extraordinary health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support.

Although computerized algorithms and user-friendly graphic displays show promise in minimizing the time to recognition of dyssynchrony, monitoring diaphragmatic electrical activity comes closest to representing the ideal in ventilator monitoring. Further work, however, is needed to demonstrate outcomes benefit to patients and to make this a reliable and user-friendly system for clinicians.

No abstract