Effective Care Practices in Patients Receiving Prolonged Mechanical Ventilation. An Ethnographic Study

Implementation of a Quality Improvement Tool "Recover25" to Guide the Care of Patients Experiencing Prolonged Critical Illness: A Mixed-Method Feasibility Study

OBJECTIVES

Few quality improvement (QI) tools are specifically designed to manage the care of patients experiencing prolonged critical illness. This risks omissions in care. To determine the implementation feasibility and clinician acceptability of our QI tool "Recover25," we focused on actionable processes of care for patients with an ICU stay of over 7 days and their families.

DESIGN

Parallel convergent mixed-methods feasibility study conducted between February 2024 and May 2024.

SETTING

A mixed ICU in London, United Kingdom.

SUBJECTS

Patients with an ICU stay of more than 7 days, and the staff who care for them.

INTERVENTIONS

We invited representatives of all ICU professions to a weekly QI round.

MEASUREMENTS AND MAIN RESULTS

We recorded the time completed Recover25, the amount and type of actions generated following Recover25 use (i.e., what new care activities did it prompt), and the number and profession of staff attending each round. We administered the Theoretical Framework of Acceptability (TFA) questionnaire and conducted semi-structured clinician interviews. We calculated means (sds) or interquartile ranges (IQRs) (percentiles) of time to complete and a number of actions generated. We analyzed and integrated qualitative data using framework analysis informed by the TFA. "Recover 25" was used 34 times (65%) of 52 opportunities with 26 patients. Median (IQR) Recover25 completion time was 9.75 minutes (8.2-14.9 min) with a completion rate of 96% (89-100%). Recover25 usage prompted a median of 1 (IQR) (1-2) new action. There was a mean of 4 (sd 2) interprofessional team members attending each QI round. Nineteen clinicians completed 33 TFA questionnaires and 11 interviews. Recover25 was perceived as acceptable, with 94% reporting it aligned with their principles of good care, 85% perceiving it as a coherent intervention, and 67% perceiving it was effective. Interview data showed participants valued the emphasis on person-centered care and highlighted ways to improve implementation.

CONCLUSION

Recover25 was perceived as feasible to implement and acceptable by staff. Further work is needed to understand the effects on patient experience and outcomes.

Feasibility of implementing a communication board to improve communication interactions of mechanically ventilated patients in intensive care units at one Sri Lankan hospital - A pilot randomised controlled trial

OBJECTIVE

To evaluate the feasibility of implementing a communication board in intensive care units in terms of participant recruitment and retention, intervention fidelity, and ability to collect patient outcome data.

DESIGN

A prospective, two-arm, unblinded, pilot randomised controlled trial.

RESEARCH METHODOLOGY

Adult, conscious, mechanically ventilated intensive care patients were recruited between August and November 2023. All participants received routine communication practices; the intervention group also received the communication board. Prior to the study, all nurses were trained on using the communication board. Patient or proxy consent was obtained. Data were collected from patients, nurses, patients' medical records, and screening, tracking, intervention fidelity, and contamination logs.

MAIN OUTCOME MEASURES

The primary outcome data was feasibility of participant recruitment, retention, and intervention fidelity, which was recorded daily until seven days of follow-up or pre-defined trial endpoints. Secondary patient outcomes (anxiety, satisfaction, ease of communication) were assessed at recruitment and approximately 24 h after recruitment or soon after extubation, whichever occurred first.

SETTING

Two intensive care units in one Sri Lankan tertiary care hospital.

RESULTS

Of the 123 patients, 60 (75.0%) were recruited and randomised (30 control; 30 intervention). All intervention group patients received the communication board (100% intervention fidelity), and 58 (96.7%) completed the follow-up. On recruitment, 12.5% of secondary patient outcome data was missing, and 9.9% on follow-up, predominantly associated with the 10-item ease of communication scale.

CONCLUSIONS

Conducting a larger, definitive communication board trial is feasible but collecting secondary patient outcome data, especially ease of communication was challenging. Study procedures need to be refined prior to a larger trial.

IMPLICATIONS FOR CLINICAL PRACTICE

The use of communication boards in intensive care units may improve patient-centred care for ventilated patients but requires further, high quality effectiveness trials.

Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy

Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.

Adolescents with Rett syndrome at critical care pathway junctures: Examining clinicians' decision to initiate invasive long-term ventilation

BACKGROUND

The initiation of invasive long-term ventilation (I-LTV) for an adolescent with Rett Syndrome (RTT) involves many serious bioethical considerations. In moving towards a more inclusive model of patient participation, transparency surrounding the main influencing factors around this decision is important.

OBJECTIVE

We aimed to identify the main drivers influencing a clinician's decision to support initiation of I-LTV for an adolescent with RTT.

METHOD

We used an anonymous online vignette-based factorial survey. The survey was distributed internationally through eight professional multi-disciplinary organisations to reach clinicians working in paediatrics.

RESULTS

We analysed 504 RTT vignettes completed by 246 clinicians using mixed effect regression modelling. The main three significant influencing factors identified were: parental agreement with the decision to support initiation, the family's support network, and proximity to a tertiary care centre. Additional comments from participants focused on family support, and the importance of on-going communication with the family.

CONCLUSION

As the rights of those with disabilities improve and participation of adolescents in decision-making becomes more established, effective communications with the family around goals of care and particular sensitivity and reflective practice around methods of consensus building will likely contribute to a positive decision-making process at this difficult time.

Clinician views on actionable processes of care for prolonged stay intensive care patients and families: A descriptive qualitative study

OBJECTIVES

To explore clinician perspectives on key actionable processes of care that may improve outcomes and experience of patients experiencing a prolonged (over 7 days) intensive care unit stay, and their family members.

RESEARCH METHODOLOGY

A descriptive qualitative interview study in the United Kingdom. We conducted online semi-structured interviews using video conferencing software (October 2020-August 2022). We used purposive sampling ensuring participation from a broad range of professions representing the interprofessional team in the United Kingdom. We used Framework Analysis methods to group actionable processes into the six themes of person-centred care. Analyses were informed by our previous scoping review and previous interviews with former patients and family members.

FINDINGS

We interviewed 24 staff participants and identified 36 actionable processes of care under six themes of person-centred care. Processes relating to communication (both establishing an effective communication method for the patient and staff communication with the patient and family), continuity of staff and care plans, and personalising the environment and routines, and allowing flexible family visiting were most frequently articulated. These processes were perceived as having a multifaceted impact on patient and family wellbeing, for example family visiting helping patient and family emotional wellbeing and staff communication with family; and establishing an effective communication method for patients reduced their anxiety, enhanced their involvement in their care and allowed staff to include them in ward rounds more efficiently.

CONCLUSION

We identified 36 actionable processes of care from interviews with intensive care staff, with an emphasis on enhancing patient autonomy through optimising communication and involvement in decision-making, participation of family, and continuity of staff and care plans.

IMPLICATIONS FOR CLINICAL PRACTICE

These 36 actionable processes of care will contribute to future development of quality improvement tools, which will be used to standardise the care of prolonged-stay intensive care patients and their families.

Clinician-initiated written communication for families of patients at a long-term acute care hospital

Objective

To assess the experience of families and clinicians at a long term acute care hospital (LTACH) after implementing a written communication intervention.

Methods

Written communication templates were developed for six clinical disciplines. LTACH clinicians used templates to describe the condition of 30 mechanically ventilated patients at up to three time points. Completed templates were the basis for written summaries that were sent to families. Impressions of the intervention among families (n = 21) and clinicians (n = 17) were assessed using a descriptive correlational design. Interviews were analyzed using thematic content analysis.

Results

We identified four themes during interviews with families: Written summaries 1) facilitated communication with LTACH staff, 2) reduced stress related to COVID-19 visitor restrictions, 3) facilitated understanding of the patient condition, prognosis, and goals and 4) facilitated communication among family members. Although clinicians understood why families would appreciate written material, they did not feel that the intervention addressed their main challenge - overly optimistic expectations for patient recovery among families.

Conclusion

Written communication positively affected the experience of families of LTACH patients, but was less useful for clinicians.

Innovation

Use of written patient care updates helps LTACH clinicians initiate communication with families.

Patient Outcomes After Long-Term Acute Care Hospital Closures

Importance

Long-term acute care hospitals (LTCHs) are common sites of postacute care for patients recovering from severe respiratory failure requiring mechanical ventilation (MV). However, federal payment reform led to the closure of many LTCHs in the US, and it is unclear how closure of LTCHs may have affected upstream care patterns at short-stay hospitals and overall patient outcomes.

Objective

To estimate the association between LTCH closures and short-stay hospital care patterns and patient outcomes.

Design, Setting, and Participants

This retrospective, national, matched cohort study used difference-in-differences analysis to compare outcomes at short-stay hospitals reliant on LTCHs that closed during 2012 to 2018 with outcomes at control hospitals. Data were obtained from the Medicare Provider Analysis and Review File, 2011 to 2019. Participants included Medicare fee-for-service beneficiaries aged 66 years and older receiving MV for at least 96 hours in an intensive care unit (ie, patients at-risk for prolonged MV) and the subgroup also receiving a tracheostomy (ie, receiving prolonged MV). Data were analyzed from October 2022 to June 2023.

Exposure

Admission to closure-affected hospitals, defined as those discharging at least 60% of patients receiving a tracheostomy to LTCHs that subsequently closed, vs control hospitals.

Main Outcomes and Measures

Upstream hospital care pattern outcomes were short-stay hospital do-not-resuscitate orders, palliative care delivery, tracheostomy placement, and discharge disposition. Patient outcomes included hospital length of stay, days alive and institution free within 90 days, spending per days alive within 90 days, and 90-day mortality.

Results

Between 2011 and 2019, 99 454 patients receiving MV for at least 96 hours at 1261 hospitals were discharged to 459 LTCHs; 84 LTCHs closed. Difference-in-differences analysis included 8404 patients (mean age, 76.2 [7.2] years; 4419 [52.6%] men) admitted to 45 closure-affected hospitals and 45 matched-control hospitals. LTCH closure was associated with decreased LTCH transfer rates (difference, -5.1 [95% CI -8.2 to -2.0] percentage points) and decreased spending-per-days-alive (difference, -$8701.58 [95% CI, -$13 323.56 to -$4079.60]). In the subgroup of patients receiving a tracheostomy, there was additionally an increase in do-not-resuscitate rates (difference, 10.3 [95% CI, 4.2 to 16.3] percentage points) and transfer to skilled nursing facilities (difference, 10.0 [95% CI, 4.2 to 15.8] percentage points). There was no significant association of closure with 90-day mortality.

Conclusions and Relevance

In this cohort study, LTCH closure was associated with changes in discharge patterns in patients receiving mechanical ventilation for at least 96 hours and advanced directive decisions in the subgroup receiving a tracheostomy, without change in mortality. Further studies are needed to understand how LTCH availability may be associated with other important outcomes, including functional outcomes and patient and family satisfaction.

Care practices for patients requiring mechanical ventilation more than seven days in Swedish intensive care units: A national survey

OBJECTIVE

To identify care practices in Swedish intensive care units specific to patients requiring mechanical ventilation for >7 days.

RESEARCH METHODOLOGY

We conducted a national cross-sectional survey inviting all adult Swedish ICUs (n = 79). Nurse managers were invited by email to complete a questionnaire by telephone. The questionnaire included seven domains: ventilator weaning, mobilisation, communication, nutrition, symptom assessment, psychosocial support and organisational characteristics.

RESULTS

We received responses from 77 units (response rate, 97%). Weaning protocols were available in 42 (55%) units, 52 (68%) used individualised weaning strategies and 50 (65%) involved physicians and nurses in collaborative decision making. In 48 units (62%), early mobilisation was prioritised using bed cycling but only 26 (34%) units had mobilisation protocols. Most of the intensive care units (74, 96%) had nutrition protocols but only 2 (3%) had dedicated dieticians. Delirium screening tools were available in 49 (64%) ICUs, 3 (4%) assessed anxiety and none assessed dyspnoea. Nineteen (25%) units employed a primary nursing model and 11 (14%) indicated person-centred care policies. Regular case conferences, including family participation, were held by 39 (51%) units.

CONCLUSION

We found that an individualised approach to ventilator weaning, decided by physicians and nurses in collaboration, was the predominant approach, although weaning protocols were available in some intensive care units. Most units prioritised early mobilisation, though few used protocols. Nutritional protocols were widely adopted, as few units had a dedicated dietician.

Informing the standardising of care for prolonged stay patients in the intensive care unit: A scoping review of quality improvement tools

OBJECTIVES

To inform design of quality improvement tools specific to patients with prolonged intensive care unit stay, we determined characteristics (format/content), development, implementation and outcomes of published multi-component quality improvement tools used in the intenisve care unit irrespective of length of stay.

RESEARCH METHODOLOGY

Scoping review searching electronic databases, trial registries and grey literature (January 2000 to January 2022).

RESULTS

We screened 58,378 citations, identifying 96 studies. All tools were designed for use commencing at intensive care unit admission except three tools implemented at 3, 5 or 14 days. We identified 32 studies of locally developed checklists, 28 goal setting/structured communication templates, 23 care bundles and 9 studies of mixed format tools. Most (43 %) tools were designed for use during rounds, fewer tools were designed for use throughout the ICU day (27 %) or stay (9 %). Most studies (55 %) reported process objectives i.e., improving communication, care standardisation, or rounding efficiency. Most common clinical processes quality improvement tools were used to standardise were sedation (62, 65 %), ventilation and weaning (55, 57 %) and analgesia management (58, 60 %). 44 studies reported the effect of the tool on patient outcomes. Of these, only two identified a negative effect; increased length of stay and increased days with pain and delirium.

CONCLUSION

Although we identified numerous quality improvement tools for use in the intensive care unit, few were designed to specifically address actionable processes of care relevant to the unique needs of prolonged stay patients. Tools that address these needs are urgently required.

SYSTEMATIC REVIEW REGISTRATION

The review protocol is registered on the Open Science Framework, https://osf.io/, DOI 10.17605/OSF.IO/Z8MRE.

Co-designed and consensus based development of a quality improvement checklist of patient and family-centered actionable processes of care for adults with persistent critical illness

PURPOSE

Few quality improvement tools specific to patients with persistent or chronic critical illness exist to aid delivery of high-quality care. Using experience-based co-design methods, we sought consensus from key stakeholders on the most important actionable processes of care for inclusion in a quality improvement checklist.

METHODS

Item generation methods: systematic review, semi-structured interviews (ICU survivors and family) members, touchpoint video creation, and semi-structured interviews (ICU clinicians). Consensus methods: modified online Delphi and a virtual meeting using nominal group technique methods.

RESULTS

We enrolled 138 ICU interprofessional team, patients, and family members. We obtained consensus on a quality improvement checklist comprising 11 core domains: patient and family involvement in decision-making; patient communication; physical comfort and complication prevention; promoting self-care and normalcy; ventilator weaning; physical therapy; swallowing; pharmacotherapy; psychological issues; delirium; and appropriate referrals. An additional 27 actionable processes are contained within 6 core domains that provide more specific direction on the actionable process to be targeted.

CONCLUSIONS

Using a highly collaborative and methodologically rigorous process, we generated a quality improvement checklist of actionable processes to improve patient and family-centred care considered important by key stakeholders. Future research is needed to understand optimal implementation strategies and impact on outcomes and experience.

A contextual needs assessment of families with home invasive mechanical ventilation patients: A qualitative study

OBJECTIVES

With the advancement of technology the number of patients surviving critical illness has increased. Home mechanical ventilation (HMV) is a growing option for patients requiring long-term mechanical ventilation. Caring for these patients is demanding and challenging. The aim of this study was to explore family caregivers'(carers) needs when providing care to adult patients under HMV from the perspective of nurses, home care attendants, and the caregivers themselves.

METHODS

Overall, 15 participants (nine carers, three home nurses, and three home care attendants) were selected by purposive sampling. Data were collected by in-depth semi-structured interviews and structured observation. Finally, data were analyzed through conventional content analysis with MAXQDA software.

RESULTS

Three categories of carers'needs were identified, including educational needs (basic and emergencies), psychological needs, and economic needs. In addition, since the needs, feelings, and views of caregivers change over time, the noted needs were divided into three periods: Pre-discharge preparation, initial transition from hospital to home, and appropriate long-term follow-up.

CONCLUSION

The study results showed that the families of patients under invasive HMV require a standard discharge plan based on their care needs, financial concerns, and psychological screening before discharge as well as a suitable long-term follow-up plan in collaboration with a multidisciplinary treatment team, insurance providers, and home care services.

What the American Journal of Critical Care Junior Peer Reviewers Were Reading During the First Year of the Program: Caring for Patients With COVID-19

The Junior Peer Reviewer program of the American Journal of Critical Care provides mentorship in the peer review process to novice reviewers. The program includes discussion sessions in which participants review articles published in other journals to practice and improve their critical appraisal skills. The articles reviewed during the first year of the program focused on caring for patients with COVID-19. The global pandemic has placed a heavy burden on nursing practice. Prone positioning of patients with acute respiratory failure is likely to improve their outcomes. Hospitals caring for patients needing prolonged ventilation should use evidence-based, standardized care practices to reduce mortality. The burden on uncompensated caregivers of COVID-19 survivors is also high, and such caregivers are likely to require assistance with their efforts. Reviewing these articles was helpful for building the peer review skills of program participants and identifying actionable research to improve the lives of critically ill patients.

Outcomes of prolonged intensive care and rehabilitation at a specialized multidisciplinary center in Sweden

BACKGROUND

Specialized clinics may improve the outcome for patients with prolonged intensive care stays. Admission may depend on diagnosis, need of respiratory support and more. We report the results from a Swedish specialized center with a multidisciplinary team approach to continued intensive care and simultaneous rehabilitation regardless of patients' primary diagnosis or ventilator need.

METHODS

All patients admitted and discharged from 2015 to 2018 were included. Demographics, diagnoses, ventilatory support requirement, discharge destination and survival were retrieved from the center´s quality registry.

RESULTS

A total of 181 patients, mean age 61 ± 16 years, 64% men, were analyzed. A neurological diagnosis was the cause for hospitalization in 46% of patients. Of the 55 patients admitted to the center for weaning from mechanical ventilation, 89% were successfully weaned within a median of 25 (interquartile range (IQR) 16-45) days. Decannulation was intended in 117 patients of which 90% were successful within a median of 25 (IQR 13-43) days. Readmission to intensive care was 4%. Most patients were discharged to their home or to rehabilitation clinics with a lower level of care. In-clinic mortality was 3%. Survival beyond 1 and 2 years after discharge was 79% and 70%, respectively.

CONCLUSION

Patients with prolonged intensive care and complex medical needs treated at a specialized center in Sweden had weaning and decannulation rates comparable to or better than previously reported. Mortality was low, and most patients were discharged home or for further rehabilitation. This was achieved with a multidisciplinary team approach to continued intensive care and simultaneous rehabilitation.

Insights into the challenges faced by chronically critically ill patients, their families and healthcare providers: An interpretive description

OBJECTIVE

To describe and understand the challenges of patients with chronic critical illness (CCI), their families and healthcare providers during the disease trajectory.

METHODOLOGY/DESIGN

This qualitative study follows Thorne's methodology of interpretive description and was guided by the ethnographic method of observation and participation. Five cases, each comprising one patient with chronic critical illness their family members and several healthcare providers, were followed from the intensive care unit of a university hospital in Switzerland across different settings. In total, five patients with chronic critical illness, 12 family members and 92 healthcare providers (nurses, nursing students, care assistants, physiotherapists and occupational therapists and physicians) were observed.

FINDINGS

Regardless of the medical diagnoses and disease trajectories of the patients with chronic critical illness, all cases faced three main challenges: 1. Dealing with the unpredictability of the disease trajectory beyond the underlying disease. 2. Coping with the complexity of care. 3. Perceiving communication challenges despite all involved parties' dependency on it.

CONCLUSION

Unpredictability is not only a unique characteristic of the prolonged disease trajectory of patients with chronic critical illness, but also one of the main challenges of the participants. Therefore, the way unpredictability is handled is dependent on changes in the complexity of care and communication, highlighting the need for participation, information, empathy, clarity and honesty among all participants.

Actionable processes of care important to patients and family who experienced a prolonged intensive care unit stay: Qualitative interview study

AIM

To use positive deviance to identify actionable processes of care that may improve outcomes and experience from the perspectives of prolonged intensive care unit (ICU) stay survivors and family members.

DESIGN

Prospective qualitative interview study in two geographically distant settings: Canada (2018/19) and the United Kingdom (2019/20).

METHODS

Patient and family participant inclusion criteria comprised: aged over 18 years, ICU stay in last 2 years of over 7 days, able to recall ICU stay and provided informed consent. We conducted semi-structured in-person or telephone interviews. Data were analysed using a positive deviance approach.

RESULTS

We recruited 29 participants (15 Canadian; 14 UK). Of these, 11 were survivors of prolonged ICU stay and 18 family members. We identified 22 actionable processes (16 common to Canadian and UK participants, 4 Canadian only and 2 UK only). We grouped processes under three themes: physical and functional recovery (nine processes), patient psychological well-being (seven processes) and family relations (six processes). Most commonly identified physical/functional processes were regular physiotherapy, and fundamental hygiene and elimination care. For patient psychological well-being: normalizing the environment and routines, and alleviating boredom and loneliness. For family relations: proactive communication, flexible family visiting and presence with facilities for family. Our positive deviance analysis approach revealed that incorporation of these actionable processes into clinical practice was the exception as opposed to the norm perceived driven by individual acts of kindness and empathy as opposed to standardized processes.

CONCLUSION

Actionable processes of care important to prolonged ICU stay survivors and family members differ from those frequently used in ICU quality improvement (QI) tools.

IMPACT

Our study emphasizes the need to develop QI tools that standardize delivery of actionable processes important to patients and families experiencing a prolonged ICU stay. As the largest healthcare professional group, nurses can play an essential role in leading this.

Explainable Machine Learning to Predict Successful Weaning Among Patients Requiring Prolonged Mechanical Ventilation: A Retrospective Cohort Study in Central Taiwan

Objective: The number of patients requiring prolonged mechanical ventilation (PMV) is increasing worldwide, but the weaning outcome prediction model in these patients is still lacking. We hence aimed to develop an explainable machine learning (ML) model to predict successful weaning in patients requiring PMV using a real-world dataset. Methods: This retrospective study used the electronic medical records of patients admitted to a 12-bed respiratory care center in central Taiwan between 2013 and 2018. We used three ML models, namely, extreme gradient boosting (XGBoost), random forest (RF), and logistic regression (LR), to establish the prediction model. We further illustrated the feature importance categorized by clinical domains and provided visualized interpretation by using SHapley Additive exPlanations (SHAP) as well as local interpretable model-agnostic explanations (LIME). Results: The dataset contained data of 963 patients requiring PMV, and 56.0% (539/963) of them were successfully weaned from mechanical ventilation. The XGBoost model (area under the curve [AUC]: 0.908; 95% confidence interval [CI] 0.864-0.943) and RF model (AUC: 0.888; 95% CI 0.844-0.934) outperformed the LR model (AUC: 0.762; 95% CI 0.687-0.830) in predicting successful weaning in patients requiring PMV. To give the physician an intuitive understanding of the model, we stratified the feature importance by clinical domains. The cumulative feature importance in the ventilation domain, fluid domain, physiology domain, and laboratory data domain was 0.310, 0.201, 0.265, and 0.182, respectively. We further used the SHAP plot and partial dependence plot to illustrate associations between features and the weaning outcome at the feature level. Moreover, we used LIME plots to illustrate the prediction model at the individual level. Additionally, we addressed the weekly performance of the three ML models and found that the accuracy of XGBoost/RF was ~0.7 between weeks 4 and week 7 and slightly declined to 0.6 on weeks 8 and 9. Conclusion: We used an ML approach, mainly XGBoost, SHAP plot, and LIME plot to establish an explainable weaning prediction ML model in patients requiring PMV. We believe these approaches should largely mitigate the concern of the black-box issue of artificial intelligence, and future studies are warranted for the landing of the proposed model.

Respiratory Support Adjustments and Monitoring of Mechanically Ventilated Patients Performing Early Mobilization: A Scoping Review

This scoping review is aimed to summarize current knowledge on respiratory support adjustments and monitoring of metabolic and respiratory variables in mechanically ventilated adult patients performing early mobilization.

DATA SOURCES

Eight electronic databases were searched from inception to February 2021, using a predefined search strategy.

STUDY SELECTION

Two blinded reviewers performed document selection by title, abstract, and full text according to the following criteria: mechanically ventilated adult patients performing any mobilization intervention, respiratory support adjustments, and/or monitoring of metabolic/respiratory real-time variables.

DATA EXTRACTION

Four physiotherapists extracted relevant information using a prespecified template.

DATA SYNTHESIS

From 1,208 references screened, 35 documents were selected for analysis, where 20 (57%) were published between 2016 and 2020. Respiratory support settings (ventilatory modes or respiratory variables) were reported in 21 documents (60%). Reported modes were assisted (n = 11) and assist-control (n = 9). Adjustment of variables and modes were identified in only seven documents (20%). The most frequent respiratory variable was the Fio2, and only four studies modified the level of ventilatory support. Mechanical ventilator brand/model used was not specified in 26 documents (74%). Monitoring of respiratory, metabolic, and both variables were reported in 22 documents (63%), four documents (11%) and 10 documents (29%), respectively. These variables were reported to assess the physiologic response (n = 21) or safety (n = 13). Monitored variables were mostly respiratory rate (n = 26), pulse oximetry (n = 22), and oxygen consumption (n = 9). Remarkably, no study assessed the work of breathing or effort during mobilization.

CONCLUSIONS

Little information on respiratory support adjustments during mobilization of mechanically ventilated patients was identified. Monitoring of metabolic and respiratory variables is also scant. More studies on the effects of adjustments of the level/mode of ventilatory support on exercise performance and respiratory muscle activity monitoring for safe and efficient implementation of early mobilization in mechanically ventilated patients are needed.

Time spent in prior hospital stay and outcomes for ventilator patients in long-term acute care hospitals

Background

Long-term acute care hospitals (LTACHs) treat mechanical ventilator patients who are difficult to wean and expected to be on mechanical ventilator for a prolonged period. However, there are varying views on who should be transferred to LTACHs and when they should be transferred. The purpose of this study is to assess the relationship between length of stay in a short-term acute care hospital (STACH) after endotracheal intubation (time to LTACH) and weaning success and mortality for ventilated patients discharged to an LTACH.

Methods

Using 2014–2015 Medicare claims and assessment data, we identified patients who had an endotracheal intubation in STACH and transferred to an LTACH with prolonged mechanical ventilation (defined as 96 or more consecutive hours on a ventilator). We controlled for age, gender, STACH stay procedures and diagnoses, Elixhauser comorbid conditions, and LTACH quality characteristics. We used instrumental variable estimation to account for unobserved patient and provider characteristics.

Results

The study cohort included 13,622 LTACH cases with median time to LTACH of 18 days. The unadjusted ventilator weaning rate at LTACH was 51.7%, and unadjusted 90-day mortality rate was 43.7%. An additional day spent in STACH after intubation is associated with 11.6% reduction in the odds of weaning, representing a 2.5 percentage point reduction in weaning rate at 18 days post endotracheal intubation. We found no statistically significant relationship between time to LTACH and the odds of 90-day mortality.

Conclusions

Discharging ventilated patients earlier from STACH to LTACH is associated with higher weaning probability for LTACH patients on prolonged mechanical ventilation. Our findings suggest that delaying ventilated patients’ discharge to LTACH may negatively influence the patients’ chances of being weaned from the ventilator.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01454-1.

Prevalence and Intensive Care Bed Use in Subjects on Prolonged Mechanical Ventilation in Swedish ICUs

BACKGROUND

The number of patients requiring prolonged mechanical ventilation (PMV) is predicted to escalate due to an aging population. International studies on prevalence and resource utilization of this patient group exist, but data are lacking from Scandinavian ICUs, where there is a relatively low number of ICU beds in relation to population. The primary aim was to identify prevalence of admissions requiring mechanical ventilation ≥ 7-21 d and PMV > 21 d, and their use of ICU bed days in Sweden. Secondary aims were to describe patient characteristics and outcomes.

METHODS

We obtained data from the Swedish Intensive Care Registry on admissions age ≥ 18 y mechanically ventilated ≥ 7 d and used open source registry data to calculate the prevalence and use of bed days of admissions ventilated ≥ 7-21 d and PMV > 21 d.

RESULTS

Of the 39,510 ICU admissions to Swedish ICUs in 2017, those mechanically ventilated ≥ 7-21 d accounted for 1,643 (4%) admissions, and those with PMV > 21 d accounted for 307 (0.8%) admissions. Of the 109,457 ICU bed days, 22% were consumed by admissions ventilated ≥ 7-21 d and 10% by those with PMV > 21 d. The ICU mortality of both groups was 21%. Admissions with mechanical ventilation ≥ 7 d had a median age of 65 y and were predominantly male (64%).

CONCLUSIONS

Admissions to Swedish ICUs who required mechanical ventilation ≥ 7-21 d and PMV > 21 d form a relatively small proportion of all ICU admissions, but consume a significant proportion of ICU beds days. Prevalence of admissions, ICU bed days, and ICU mortality were lower than reports from other countries, but the admissions were predominantly elderly and male, in accordance with other reports.

Long-Term Acute Care Hospitals Extend ICU Capacity for COVID-19 Response and Recovery

The COVID-19 pandemic has presented novel challenges for the entire health-care continuum, requiring transformative changes to hospital and post-acute care, including clinical, administrative, and physical modifications to current standards of operations. Innovative use and adaptation of long-term acute care hospitals (LTACHs) can safely and effectively care for patients during the ongoing COVID-19 pandemic. A framework for the rapid changes, including increasing collaboration with external health-care organizations, creating new methods for enhanced communication, and modifying processes focused on patient safety and clinical outcomes, is described for a network of 94 LTACHs. When managed and modified correctly, LTACHs can play a vital role in managing the national health-care pandemic crisis.