One-Year Trajectories of Care and Resource Utilization for Recipients of Prolonged Mechanical Ventilation

Abstract

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.

Long-Term Consequences of Critical Illness: A New Opportunity For High-Impact Critical Care Nurses

“…11 • 50% of ICU survivors require caregiver assistance 1 year after ICU discharge. 2,12,13 The support required may range from assistance with activities of daily living to full care.…”

“…2,12 In these studies, the definition of prolonged mechanical ventilation varied and ranged from longer than 4 days to longer than 7 days.…”

“…Currently, a tremendous amount of research is being done around the world to understand the risk factors for long-term consequences of critical illness developing. Risk factors that have been identified include [2][3][4][5][6][7][8][9][10][11][12][13] • age more than 65 years • sepsis • mechanical ventilation • heavy sedation, delirium • hypoglycemia • hypoxia Reducing the risk factors may mitigate the long-term consequences that ICU patients and their families suffer. Early physical and occupational therapy started while patients are in the ICU and are hemodynamically stable can improve physical function.…”

“…[2][3][4][5][6][7][8][9][10][11][12][13] • Encourage patients to do cycling exercises and range-of-motion activities within the first few days of admission, even those patients we once thought were appropriately left in a pharmacologically comatose state. 2,4 • Reduce the use of benzodiazepines and, instead, use other sedating agents and nonpharmacological measures to combat anxiety and discomfort imposed by critical illness.…”

“…2,4 • Reduce the use of benzodiazepines and, instead, use other sedating agents and nonpharmacological measures to combat anxiety and discomfort imposed by critical illness. [2][3][4][5][6][7][8][9][10][11][12][13] • Work hand-in-hand with therapists to move patients who are receiving mechanical ventilation, patients who had once stayed in bed and at most achieved a head-of-bed-elevated position, out of bed and onto tilt-tables or chairs. [2][3][4][5][6][7][8][9][10][11][12][13] • Help create a diary for a patient so that the patient's family can have a working document to later slowly move the patient past the delusions and misconceptions that gather in the muddled mind during critical illness.…”