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Improving Ventilated Patient Outcomes through Timely Discharge to LTACHs

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

Executive Summary

  • Timely discharge of patients on prolonged ventilation to long-term acute care hospitals (LTACHs), which specialize in ventilator liberation, can help improve outcomes
  • Healthcare guidelines have been revised to reflect a more comprehensive understanding of when a ventilator patient would benefit from LTACH care, focusing particularly on breathing trials
  • Expertise in ventilator care, an interdisciplinary care team approach, and specialized rehabilitation are key components that allow LTACHs like Kindred Hospitals to aid in ventilator patient recovery

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 timeframe.2 These patients often benefit from specialized pulmonary and ventilator care provided by LTACHs. Because LTACHs, which are licensed as acute care hospitals, have a particular expertise in ventilator liberation, timely discharge of such patients to an LTACH can help improve outcomes and expedite recovery. 

This article highlights the latest clinical guidelines for LTACH discharge of ventilated patients, and the unique aspects of LTACH care that can help improve outcomes.

Ventilator Liberation Strategies and Guidelines

Liberation strategies – which may include direct extubation, spontaneous breathing trials (SBTs), or tracheostomy collars trials – have changed over time and vary across the globe.3 There is additional variability around when a patient on a ventilator should transition to another setting, such as an LTACH. 

Earlier thinking had led healthcare groups to primarily base a recommendation for LTACH discharge around a specific number of ventilator days. However, contemporary standards, including the most recent edition of the MCG Health guidelines, reflect a more comprehensive evaluation of the need for prolonged weaning, focusing in particular on the outcomes of SBTs4

This change is supported by a number of recent studies that found that SBTs are considered a best practice for liberation and that delaying discharge of ventilated patients from the STACH to an LTACH may negatively influence the probability of liberation.5,6 

Unique Aspects of LTACH Care That Can Improve Outcomes

There are three key aspects of LTACH care that allow them to 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 the LTACH admissions, receive expert treatment from a team led by pulmonologists and respiratory therapists. 

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.8

Interdisciplinary care teams

Medically complex patients with multiple comorbidities often require a team of specialists who can address the different facets of their conditions. At an LTACH, physicians, respiratory therapists, dieticians, 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.9

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.10

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 2 days.11 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.12

How Kindred Hospitals Can Help

Kindred Hospitals has provided quality care for 30 years, and continue to introduce initiatives that improve care, such as:

  • The Joint Commission Certification in Respiratory Failure and in Sepsis across most hospitals
  • Early Mobility Program which incorporate mobilization as early as is safe, even for patients on ventilators, allowing for a quicker, more complete recovery. 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.13
  • AfterCare Program, in which specially trained RNs follow up with patients post-discharge to discuss durable medical equipment and medication needs and education, primary care provider appointments, and any additional post-discharge services needed

If you have a medically complex patient in need of acute care after a hospital stay, call a Kindred Clinical Liaison for a patient assessment. Our Clinical Liaison team will help you determine whether an LTACH stay is appropriate for your patient. If you are unsure of who your Kindred representative is, please feel free to contact us via recoveratkindred.com and speak with a Registered Nurse who can assist.


References

  1. https://pubmed.ncbi.nlm.nih.gov/23963122/
  2. https://www.karger.com/Article/FullText/510085
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988370/ Ventilator Management Long-Term Acute Care Hospital (LTACH) Guideline (GRG-049). 2022. In General Recovery Care. 26th Edition.
  4. https://pubmed.ncbi.nlm.nih.gov/27818331/
  5. https://www.karger.com/Article/FullText/510085
  6. http://medpac.gov/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf
  7. https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-021-01454-1
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526935/
  9. https://pubmed.ncbi.nlm.nih.gov/22875526/
  10. https://clinicaltrials.gov/ct2/show/NCT04381338
  11. https://www.atsjournals.org/doi/full/10.1164/rccm.201610-2076ST
  12. Early Mobility Program participants at Kindred Hospitals through July 2021
By Sean R. Muldoon, MD, MPH, FCCP, Chief Medical Officer, Kindred Hospitals