The Unweanable Patient: Outcomes of Long-Term Acute Care
The Unweanable Patient: Outcomes of Long-Term Acute Care
Abstract & Commentary
Synopsis: Among ventilator-dependent patients transferred from ICUs to long-term acute care facilities, 77% die within a year and only 8% are fully functional at one-year follow-up.
Source: Carson SS, et al. Outcomes after long-term acute care. Am J Respir Crit Care Med 1999;159: 1568-1573.
Carson and associates determined the premorbid status, clinical characteristics, and outcomes after one year for all 133 mechanically ventilated patients transferred from ICUs in acute care hospitals to a long-term acute care (LTAC) hospital in the Chicago area during a one-year period. In addition to determining the patients’ outcomes both during their LTAC stay and at one year, Carson et al used specific patient variables to develop a predictive model for one-year survival.
The patients were 71 ± 12 years old (77% were older than 65), and 52% of them were women. The diagnoses leading to "chronic critical illness" and unweanability from ventilatory support included acute lung injury in 31%, chronic lung disease (16%), cardiac disease (16%), disorders of the central nervous system (15%), and multiple organ failure (10%). Mechanical ventilation had continued for from 9 to 123 days (median, 25 days) in the ICU of the referring hospital prior to transfer to the LTAC center, and all of the patients had undergone tracheotomy.
Mean length of stay in the LTAC facility was 63 days. Sixty-six patients (50%) died at the LTAC hospital, and 51% of the survivors (34 patients) were discharged to a skilled nursing facility or nursing home. Successful weaning occurred in 51 patients (38%). Of the 67 (50%) patients who were discharged from the LTAC facility, 47 (70%) had been liberated from ventilatory support and 20 (30%) remained on the ventilator. Thirty study patients (23%) were still alive one year after transfer to the LTAC facility, most of these having returned to their own homes. Two patients still required mechanical ventilation, neither of them at home. Of the entire 133-patient group, only 11 (8%) were oriented, ambulatory, and independent at one year.
Carson et al’s predictive model for survival among patients transferred from acute care hospitals to LTAC facilities showed that the patients could be separated into two roughly equal-sized groups with different outcomes. Patients younger than 65 years old, and those 75 or younger who were functionally independent prior to original hospitalization had a 56% one-year mortality (95% confidence interval; 41-71%). Patients 75 or older and patients 65-75 who had not previously been independent experienced 95% mortality in the first year (95% CI, 84-99%; P < 0.001). Patients in the high-risk group spent, on average, only 7% of the one-year follow-up period in their own homes, the rest of this time being spent in the LTAC (71%), nursing homes (13%), or acute-care hospitals (9%).
COMMENT BY LESLIE A. HOFFMAN, RN, PhD
There are approximately 200 LTAC hospitals nationwide, with annual revenues estimated at more than $3 billion (Chan L, et al. N Engl J Med 1997;337:978). LTAC hospitals admit patients who are sufficiently stable to be transferred from the acute care setting but still have complex medical problems, including the need for mechanical ventilation. Patients admitted to LTAC hospitals are diagnosis-related groups (DRG) exempt, thus care can be reimbursed by Medicaid, Medicare, or private insurers.
Despite the increasing capacity of these institutions (currently 15,000 beds), little is known about outcomes in patients transferred to LTAC hospitals. Findings of this study indicated a 50% chance of survival in patients who required mechanical ventilation at admission. This percentage is comparable to that reported for patients who required mechanical ventilation but were cared for entirely in acute care hospitals. Other LTAC hospitals have reported survival rates as high as 91%, but the patients in these series were carefully selected for their rehabilitation potential (Mayo Clin Proc 1997;72:13-19). The LTAC hospital from which this sample was recruited had no selection criteria for prognosis or illness severity, beyond being able to undergo transfer and having a tracheostomy.
The important finding of this study was that in this unselected patient population, distinct patient characteristics, identifiable before transfer, were significant predictors of a poorer prognosis. Patients who were older than 75 years of age or patients who were older than 65 years but not functionally independent at admission to the acute care hospital had a 95% mortality at one year. Further, these high-risk patients spent 92% of the year hospitalized, either in a LTAC hospital, nursing home, or acute care hospital.
To obtain functional status data, patients or families were surveyed by case managers at admission to the LTAC hospital using a short (6-item) instrument that assessed the patient’s prior mental status, physical capabilities, ability to manage activities of daily living, and living arrangements, and included a general statement of the patient’s functional dependence or independence. Such an assessment would be easy to accomplish and require little time.
Findings of this study suggest that selected characteristics (e.g., age and prehospital functional status) may identify patients with an extremely poor prognosis before they are transferred to an LTAC hospital. Further efforts to identify the subset of patients likely to benefit from this expensive, extended care are needed. Larger studies that include multiple institutions should test these and other predictors. If results of this study are representative, such information can be of value in assisting clinicians when discussing care options with family members in decision-making regarding what level of support is appropriate for their family member.
COMMENT BY DAVID J. PIERSON, MD, FACP, FCCP
Prior to 1983, the prospects for transferring a "chronically critically ill," ventilator-dependent patient out of the ICU were close to nil. In 1983, however, an exemption from Medicare prospective payment was created by the Health Care Financing Administration (HCFA) to apply to such patients, which permitted institutions other than acute-care hospitals to care for them without losing money. In fact, LTAC has since become big business: according to sources cited by Carson et al, and as mentioned above by Dr. Hoffman, LTAC hospitals generated revenues of more than $3 billion during 1997.
Today’s availability of alternative sites for managing "chronically critically ill" patients is both good news and bad news—good news for the acute-care hospital ICU, which loses enormous amounts of money caring long-term for ventilator-dependent patients, but perhaps not such good news for the patients themselves or their loved ones. While one hears individual success stories about patients whose care in a LTAC facility enabled them to recover from prolonged critical illness and return to the bosom of their families, according to this study the outlook for the majority of patients is far from encouraging. Care in a LTAC facility is expensive (even if perhaps less so than ICU care in an acute-care hospital), and prolongation of an inevitably fatal illness by such care would seem to be in neither the patients’ nor society’s best interests.
The trick is to be able to identify accurately those patients who will not survive their present critical illness, even with an additional period of care in a specialized facility. Severity-of-illness scores such as the various generations of the APACHE system have proven helpful in studying the epidemiology of critical illness but cannot be relied upon when dealing with an individual case. Carson et al have brought us a bit closer to being able to predict the outcome for patients in the specific category studied here—that is, middle-aged and elderly patients with prolonged critical illness requiring mechanical ventilation after two weeks or more in the ICU. If an elderly patient in that clinical setting is known not to have been functionally independent because of preexisting health conditions before the onset of the present illness, the current study suggests that that person’s likelihood of a return to independence is remote, even after care in a LTAC facility. This and (hopefully) similar studies may enable us to move closer to a scheme of care for the "chronically critically ill" that maximizes the likelihood of meaningful long-term survival while at the same time greatly reducing the number of instances in which continued intensive care has virtually no chance of restoring health.
Among patients transferred to a long-term acute care facility after prolonged mechanical ventilation in the ICU, survival at one year is less than 5% for patients who:
a. are older than 75 years old.
b. are 65-75 years old and were not functionally independent prior to the acute illness.
c. Both of the above
d. Neither of the above
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