Long-term outcomes for elderly survivors of prolonged ventilator assistance

Home return following invasive mechanical ventilation for the oldest-old patients in medical intensive care units from two US hospitals

Background:

The aging of the US population has been associated with an increase in intensive care unit (ICU) utilization and correspondingly, invasive mechanical ventilation (IMV) among the oldest-old (age ≥80 years). While previous studies have examined ICU and IMV outcomes in the elderly, very few have focused on patient-centered outcomes, specifically home return, in the oldest-old. We investigated the rate of immediate home return following IMV in the medical ICU in previously home-dwelling oldest-old patients relative to that of a comparison group of 50–70-year olds.

Methods:

Data were extracted retrospectively from patient records at Elmhurst Hospital Center in Elmhurst, NY, USA, encompassing the period from January 2009 to May 2014 and Jacobi Medical Center in the Bronx, NY, USA, from January 2010 to March 2014. Medical ICU admissions within those date ranges were screened for possible inclusion into one of two study groups based on age: ≥80 years old and 50–70 years old. The primary end point was hospital discharge: home return versus no home return (death or nonhome discharge). Cox proportional hazards’ regression models were used to estimate crude and multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for failure to return home.

Results:

A total of 375 patients were included in the analysis: 279 (74%) patients aged 50–70 years and 96 (26%) patients aged ≥80 years. Compared to 50–70-year olds, being ≥80 years old was associated with a nearly two-fold greater risk of no home return: adjusted HR: 1.96; 95% CI 1.43–2.67. The oldest-old was at significantly increased risk of both being discharged to a skilled nursing facility or subacute rehabilitation (adjusted HR: 2.19; 95% CI 1.33–3.59) as well as of dying in the hospital (adjusted HR: 1.81; 95% CI 1.21–2.71).

Conclusion:

Previously home-dwelling oldest-old are at significantly increased risk of failing to return home immediately following medical ICU admission with IMV as compared to patients aged 50–70 years. These results can help medical ICU staff establish appropriate expectations when addressing the families of their oldest patients. Further studies are needed to evaluate the potential for delayed home return among the oldest old and to assess the ability of frailty indices to predict home return within this ICU population.

Intensive care and invasive ventilation in the elderly patient, implications of chronic lung disease and comorbidities

Aims: Elderly patients have an increasing prevalence of illness that requires consideration of critical care and invasive ventilatory support. Although critical care of even the very elderly can provide value, with increasing age the potential risks of treatment and diminishing returns with respect to quality and quantity of life result in a need for careful evaluation. Variable combinations of impaired organ function, active disease and residual pathology from past disease and injury all affect critical care, with the consequence that the elderly are a very heterogeneous population. Recognizing that critical care is a limited resource, it is important to identify patients who may be at increased risk or least likely to benefit from treatment. Patients with functional impairments, nutritional deficiencies and multiple comorbidities may be at highest risk of poor outcomes. Those with very severe disease, extreme age and requirements for prolonged ventilatory support have high in-hospital mortality. Functional impairments, comorbidities and severity of illness are usually more important considerations than chronologic age. The objective of this review is to identify how common problems of the elderly affect critical care and decisions concerning use of invasive ventilatory support.

Prognosis of elderly patients subjected to mechanical ventilation in the ICU

OBJECTIVE

To analyze the prognosis of mechanically ventilated elderly patients in the Intensive Care Unit (ICU).

DESIGN AND SCOPE

Sub-analysis of a prospective multicenter observational cohort study conducted over a period of two years in 13 medical-surgical ICUs in Spain.

PATIENTS

Adult patients who required mechanical ventilation (MV) for longer than 24 hours.

INTERVENTIONS

None.

STUDY VARIABLES

Demographic data, APACHE II, SOFA, reason for MV, comorbidity, functional condition, reintubation, duration of MV, tracheotomy, ICU mortality, in-hospital mortality.

RESULTS

A total of 1661 patients were recruited. Males accounted for 67.9% (n=1127), with a mean age of 62.1 ± 16.2 years. APACHE II: 20.3 ± 7.5. Total SOFA: 8.4 ± 3.5. Four hundred and twenty-three patients (25.4%) were ≥ 75 years of age. Comorbidity and functional condition rates were poorer in these patients (p<0.001 for both variables). Mortality in the ICU was higher in the elderly patients (33.6%) than in the younger subjects (25.9%) (p=0.002). Also, in-hospital mortality was higher in those ≥ 75 years of age. No differences in duration of MV, prevalence of tracheostomy or reintubation incidence were found. Regarding the indication for MV, only the patient ≥ 75 years of age with pneumonia, sepsis or trauma had a higher in-ICU mortality than the younger patients (46.3% vs 33.1%, p=0.006; 55% vs 25.8%, p=0.002; 63.6% vs 4.5%, p<0,001, respectively). No differences were found referred to other reasons for MV.

CONCLUSION

Older patients (≥ 75 years) have significantly higher in-ICU and in-hospital mortality than younger patients without differences in the duration of mechanical ventilation. Differences in mortality were at the expense of pneumonia, sepsis and trauma.

Prolonged mechanical ventilation in critically ill patients: epidemiology, outcomes and modelling the potential cost consequences of establishing a regional weaning unit

INTRODUCTION

The number of patients requiring prolonged mechanical ventilation (PMV) is likely to increase. Transferring patients to specialised weaning units may improve outcomes and reduce costs. The aim of this study was to establish the incidence and outcomes of PMV in a UK administrative health care region without a dedicated weaning unit, and model the potential impact of establishing a dedicated weaning unit.

METHODS

A retrospective cohort study was undertaken using a database of admissions to three intensive care units (ICU) in a UK region from 2002 to 2006. Using a 21 day cut-off to define PMV, incidence was calculated using all ICU admissions and ventilated ICU admissions as denominators. Outcomes for the PMV cohort (mortality and hospital resource use) were compared with the non-PMV cohort. Length of ICU stay beyond 21 days was used to model the effect of establishing a weaning unit in terms of unit occupancy rates, admission refusal rates, and healthcare costs.

RESULTS

Out of 8290 ICU admission episodes, 7848 were included in the analysis. Mechanical ventilation was required during 5552 admission episodes, of which 349 required PMV. The incidence of PMV was 4.4 per 100 ICU admissions, and 6.3 per 100 ventilated ICU admissions. PMV patients used 29.1% of all general ICU bed days, spent longer in hospital after ICU discharge than non-PMV patients (median 17 vs 7 days, P < 0.001) and had higher hospital mortality (40.3% vs 33.8%, P = 0.02). For the region, in which about 70 PMV patients were treated each year, a weaning unit with a capacity of three beds appeared most cost efficient, resulting in an occupancy rate of 73%, admission refusal rate at 21 days of 36%, and potential cost saving of £344,000 (€418,000) using UK healthcare tariffs.

CONCLUSIONS

One in every sixteen ventilated patients requires PMV in our region and this group use a substantial amount of health care resource. Establishing a weaning unit would potentially reduce acute bed occupancy by 8-10% and could reduce overall treatment costs. Restructuring the current configuration of critical care services to introduce weaning units should be considered if the expected increase in PMV incidence occurs.

Effect of an episode of critical illness on subsequent hospitalisation: a linked data study

Healthcare utilisation can affect quality of life and is important in assessing the cost-effectiveness of medical interventions. A clinical database was linked to two Australian state administrative databases to assess the difference in incidence of healthcare utilisation of 19,921 patients who survived their first episode of critical illness. The number of hospital admissions and days of hospitalisation per patient-year was respectively 150% and 220% greater after than before an episode of critical illness (assessed over the same time period). This was the case regardless of age or type of surgery (i.e. cardiac vs non-cardiac). After adjusting for the ageing effect of the cohort as a whole, there was still an unexplained two to four-fold increase in hospital admissions per patient-year after an episode of critical illness. We conclude that an episode of critical illness is a robust predictor of subsequent healthcare utilisation.

Determinants of long-term mortality after prolonged mechanical ventilation

STUDY OBJECTIVES

The poor long-term survival of patients requiring prolonged mechanical ventilation may be due to potentially modifiable factors. We therefore sought to assess the early determinants of long-term survival after discharge from a specialized respiratory unit.

METHODS

Eighty of 113 patients (71%) admitted to a respiratory care unit from June 2001 to August 2003 survived to discharge. Mortality outcomes and dates of death were determined by review of the records and survey in April 2005 of a national Death Master File. Potential determinants of survival after discharge were collected during the admission to the unit.

RESULTS

Fifty-five percent of patients died within the first year after discharge. Age of 65 years or older, sacral ulcers, a serum creatinine >124 micromol/L, and failure to wean were each individually associated with shorter survival. Age, skin integrity, and wean status on discharge remained independent determinants of survival in a multivariable analysis. In a post-hoc analysis, chronic irreversible neurologic diseases were also independently associated with poor long-term survival.

CONCLUSIONS

Mortality after discharge from a respiratory care unit is high. Interventions that may favorably impact long-term survival in these patients could target the modifiable factors identified, including measures that facilitate weaning and prevent or treat renal dysfunction and skin breakdown.

"Oldest old" patients in intensive care: prognosis and therapeutic activity

OBJECTIVE

In view of ethical considerations and the limited resources in intensive care medicine, the present investigation aims to give a descriptive overview of the prognosis and therapeutic activity for the oldest age group of elderly patients admitted to an intensive care unit (ICU) in comparison with younger ICU patients.

PATIENTS AND METHODS

3069 patients admitted to the ICU during a seven-year period were categorized into four age groups: under 65 years (48%), 65 to 74 years (26%), 75 to 85 years (22%) and 85 years or older (5%). Type and reason for ICU admission, length of ICU stay, severity of illness as measured by the simplified acute physiology score (SAPS)-II, level of provided care as measured by the simplified therapeutic intervention scoring system (TISS)-28, and vital status at the date of ICU discharge were recorded.

RESULTS

The ICU mortality rate of patients aged 85 years or older was significantly higher than in patients under 65 (OR of mortality: 1.8, p < 0.001). Non-survivors had higher SAPS II levels (even when excluding age points) in all age groups, but higher daily average TISS points only in patients under 85. The daily average TISS score was negatively correlated to age (r = -0.03; p < 0.001) and was significantly lower in the oldest group when compared with all the younger groups (p < 0.001). The oldest patients had a significantly shorter length of stay (median: 2; interquartile range [IQR] 1-3, p < 0.001) than the younger patient groups.

CONCLUSIONS

Within the very elderly population, age is an important and independent predictor of mortality, but acute severity of illness is even more strongly associated with mortality. Consequently, age alone may be an inappropriate criterion for allocation of ICU resources.

Outcome of older critically ill patients: a matched cohort study

BACKGROUND

Admission of older patients to intensive care units is a controversial issue.

OBJECTIVE

To estimate age-associated mortality of critically ill patients.

METHODS

A prospective matched cohort study in the Medical-Surgical Intensive Care Unit of a tertiary hospital was conducted. We included 100 consecutive patients older than 70 years admitted to the intensive care unit (cases) and 100 patients younger than 70 years (controls). The matching criterion was the severity of illness at admission to the intensive care unit as estimated by the simplified acute physiological score (SAPS II) without including age in its calculation.

RESULTS

Mortality in the intensive care unit was higher, but not statistically significant, in the older group: 26% vs. 19% (p = 0.23). Patients older than 70 years had a longer duration of mechanical ventilation (median 7 vs. 3 days) and longer stay in the intensive care unit (median 8 vs. 5 days). There were no differences in organ dysfunctions, except for a higher incidence of respiratory failure in the older group (p < 0.001). The use of invasive procedures was similar in both groups. There were more orders for the withholding/withdrawal of treatment in patients older than 70 years (9 vs. 3%, p = 0.07).

CONCLUSION

In our study, age was not related with a significant higher mortality. In the older patients included in our study the survival was greater than 70% with a similar resource utilization except for a longer stay in the intensive care unit.

Influence of old age on survival after prolonged mechanical ventilation

BACKGROUND: While the proportion of elderly people in society is increasing, little is known about the influence of old age on survival after prolonged mechanical ventilation. METHODS: A retrospective follow-up study of 120 patients who had been mechanically ventilated for at least 10 days was performed with a follow-up of up to 5 years. In-hospital survival and post-hospital survival were documented. Also, the functional status of survivors was recorded. The predictive value of age and several other clinical and laboratory parameters for outcome was analyzed. RESULTS: The in-hospital survival of the 120 patients studied was 35%. While age below 50 years was associated with improved survival, age was not predictive of in-hospital survival for patients over 50 years of age. The post-hospital survival was 77% 1 year after discharge, with almost all survivors being functionally independent. Again, old age was not predictive of survival. CONCLUSIONS: For patients aged 50 years or older, patient age does not predict survival after prolonged mechanical ventilation. Even very old survivors have a reasonable life expectancy and regain full functional status.

Outcomes, cost and long term survival of patients referred to a regional weaning centre

BACKGROUND

Regional weaning centres provide cost effective care for patients who have undergone prolonged mechanical ventilation. There are few published European data on outcomes in these patients.

METHODS

Patients admitted for weaning to the Lane Fox Respiratory Unit (LFU) between January 1997 and December 2000 were identified. The proportion weaned from mechanical ventilation, in-hospital mortality, and subsequent survival after discharge were examined.

RESULTS

A total of 153 patients had been ventilated for a median of 26 days before transfer. The daily cost per patient stay was 1350. Fifty eight patients (38%) were fully weaned, 42 (27%) died, and 53 (35%) required ventilatory support at discharge from hospital of whom 36 (24%) required only nocturnal ventilation. Univariate analysis showed increasing age (OR 1.06, p<0.001), length of ICU stay (OR 1.02, p = 0.001), APACHE II predicted risk of death score (OR 1.02, p = 0.05), and a surgical cause for admission (OR 4.04) were associated with mortality. Neuromuscular/chest wall conditions were associated with low mortality (OR 0.36) but low likelihood of weaning from ventilation (OR 0.28). Female sex (OR 2.13, p = 0.03) and COPD (OR 2.81) were associated with successful weaning. Overall survival at 3 years from admission was 47%. Long term survival was lowest in patients with COPD.

CONCLUSIONS

Most patients survived to leave hospital, the majority having been liberated from ventilatory support. Survivors were younger and spent less time ventilated in the referring ICU. The underlying diagnosis determined success of weaning, hospital survival, and long term outcome.

Factors Associated With Failure of Weaning From Long-term Mechanical Ventilation After Cardiac Surgery

The purpose of this prospective, quantitative, comparative study, conducted at the 55 bed cardiothoracic intensive care unit of the Heart Institute (InCor), University of Sao Paulo Medical School, was to identify factors involved in the weaning of patients who require long-term (> 10 days) mechanical ventilation after cardiac surgery. The subjects included all patients who underwent open-heart surgery with cardiopulmonary bypass during a 10 month period from April 2000 to January 2001 (n = 946). From this group, 52 (5.7%) patients who required a tracheotomy for the management of long-term mechanical ventilation after cardiac surgery with cardiopulmonary bypass were selected. Pre-, intra- and postoperative data from patients who were not successfully weaned after reintubation and who underwent an elective tracheotomy were compared. Parameters of respiratory mechanics such as respiratory complications, oxygenation, and cardiac, renal, and neurological function were evaluated. Weaning success was defined as the ability of a patient to tolerate 48 hours without pressure or flow support from a mechanical ventilator. A patient was considered to have failed weaning if they died or remained under ventilation for more than 8 weeks. Of the 52 patients studied, 25 were successfully weaned, 21 died, and 6 remained ventilated for more than 8 weeks. We found significant statistical differences (P < 0.05) between the groups with respect to success or failure in LVEF (P = 0.0035), the need for vasoactive agents (P = 0.0018), and renal failure (P = 0.002). Parameters of respiratory mechanics and oxygenation (eg, static airway compliance, airway resistance) did not influence the success or failure of weaning. There was a significant difference in relation to the presence of pneumonia (P = 0.0086) between the two groups. Although neurological complications were more frequent in patients in the weaning success group, the failure group had lower GCS scores, which is indicative of worse prognoses. It is concluded that cardiac dysfunction, the need for dialysis, and pneumonia are determinants for weaning failure in patients undergoing long-term mechanical ventilation after cardiac surgery.

Critical care medicine as a distinct product line with substantial financial profitability: The role of business planning

OBJECTIVE

As academic health centers face increasing financial pressures, they have adopted a more businesslike approach to planning, particularly for discrete "product" or clinical service lines. Since critical care typically has been viewed as a service provided by a hospital, and not a product line, business plans have not historically been developed to expand and promote critical care. The major focus when examining the finances of critical care has been cost reduction, not business development. We hypothesized that a critical care business plan can be developed and analyzed like other more typical product lines and that such a critical care product line can be profitable for an institution.

DESIGN

In-depth analysis of critical care including business planning for critical care services.

SETTING

Regional academic health center in southern New Jersey.

SUBJECTS

None.

INTERVENTIONS

As part of an overall business planning process directed by the Board of Trustees, the critical care product line was identified by isolating revenue, expenses, and profitability associated with critical care patients.

MEASUREMENTS AND MAIN RESULTS

We were able to identify the major sources ("value chain") of critical care patients: the emergency room, patients who are admitted for other problems but spend time in a critical care unit, and patients transferred to our intensive care units from other hospitals. The greatest opportunity to expand the product line comes from increasing the referrals from other hospitals. A methodology was developed to identify the revenue and expenses associated with critical care, based on the analysis of past experience. With this model, we were able to demonstrate a positive contribution margin of dollar 7 million per year related to patients transferred to the institution primarily for critical care services. This can be seen as the profit related to the product line segment of critical care. There was an additional positive contribution margin of dollar 5.8 million attributed to the critical care portion of the hospital stay of patients admitted primarily through other product lines or the emergency room. This can be seen as the profit related to the "hospital service" segment of critical care. This represented a total contribution margin of dollar 12.8 million, approximately 24% of the institution's entire contribution margin. This information was subsequently used to develop strategic plans to promote this product line.

CONCLUSIONS

We were able to define the critical care product line, and we were able to demonstrate profitability through an analysis of revenue and expenses related to critical care services. Our experience suggests that the concept of critical care as a product line, in addition to a hospital service, may lead to a useful analysis of this new discipline. This plan provided a rational foundation for development of the operating and capital budgets for the health system.

Outcome of older patients receiving mechanical ventilation

OBJECTIVE

To determine the threshold of age that best discriminates the survival of mechanically ventilated patients and to estimate the outcome of mechanically ventilated older patients.

DESIGN

International prospective cohort study.

SETTING

Three hundred sixty-one intensive care units from 20 countries. PATIENTS AND PARTICIPANTS. Five thousand one hundred eighty-three patients mechanically ventilated for more than 12 h.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Recursive partitioning and logistic regression were used and an outcome model was derived and validated using independent subgroups of the cohort. Two age thresholds (43 and 70 years) were found, by partitioning recursive analysis, to be associated with outcome. This study focuses on the analysis of patients older than 43 years of age, divided in two subgroups: between 43 and 70 years (middle age group) and older than 70 years (elderly group). Survival in hospital was 45% (95% C.I.: 43-48) for the elderly group and 55% (53-57) for the middle age group ( p<0.001). Advanced age was not associated with prolongation of mechanical ventilation, weaning or length of stay in the ICU and in hospital ( p>0.05). Variables associated with mortality in the elderly were: acute renal failure, shock, Simplified Acute Physiology Score II and a ratio of PaO(2) to FIO(2) more than 150.

CONCLUSIONS

Older mechanically ventilated patients (age >70 years) had a lower ICU and hospital survival, but the duration of mechanical ventilation, ICU and hospital stay were similar to younger patients. Factors associated with the highest risk of mortality in patients older than 70 were the development of complications during the course of mechanical ventilation, such as acute renal failure and shock.

Geriatric critical care

Demographic compulsions are inescapable. There has been a 50% increase in life expectancy at birth for persons born in 1980 compared to those born in 1900. Not only do critical care units utilize up to a third of hospital expenditures and about 1% of GNP, the critically ill elderly consume a disproportionate amount of ICU resources. Outcome prediction models for very elderly critically ill patients have been proposed with age as one of numerous model variables; but such models have not been widely validated. Despite the burgeoning emphasis on evidence-based population approach to health care, there is insufficient research to guide the critical care clinician. There remains a modicum of subjectivity in crucial decisions that affect the elderly patient receiving intensive care. Older age is also one of the factors that lead to a physician bias in refusing ICU admission; this has recently been borne out in a multivariate analysis. Physicians generally consider their older patients' quality of life to be worse than do the patients, although other studies that have assessed the quality of live show no age-related differences among ICU survivors. Furthermore, physicians' estimations of patient quality of life significantly influence physicians' attitudes to futility of care issues, in contrast to patients' perceptions. Threshold for life-sustaining treatment in the elderly will continue to be different among the ICUs. In critical care of the elderly, geography may well be destiny. Clinical decisions will be subjected to many ethical, legal, and socioeconomic pressures. Personal and religious beliefs will inevitably influence societal expectations and clinician practices. Severity of illness has the biggest influence on outcome in a critical illness. Age alone is not a predictor of short-term or long-term outcome in the older patient who is critically ill. Critical illness in the elderly remains a fertile area for future research.

Caregivers of long-term ventilator patients: physical and psychological outcomes

STUDY OBJECTIVES

The physical and psychological effects of caregiving have been examined in several populations. To date, no one has examined the effects of caregiving on caregivers of patients receiving long-term mechanical ventilation (LTV) [patients who required > 4 days of continuous in-hospital mechanical ventilation] who reside in a home or institutional setting after hospital discharge. The purpose of this study was to describe the characteristics and examine depression, burden, overload, and physical health in this caregiver population over a 6-month period after hospital discharge.

DESIGN

This was a prospective longitudinal descriptive study of posthospital outcomes for patients receiving LTV and their caregivers.

SETTING AND PARTICIPANTS

Caregivers of 135 patients receiving LTV admitted to the ICUs of a university medical center, a Veterans Administration hospital, and small community hospital were enrolled.

MEASUREMENTS AND RESULTS

Interviews of caregivers were conducted at hospital discharge and 6 months later. Descriptive statistics, analysis of variance, and multiple regression analyses were used to analyze the data. Established tools were used to assess caregiver depression, burden, overload, and physical health. Caregivers reported a drop in physical health scores from hospital discharge to 6 months after discharge (p = 0.0001). Caregivers of patients residing in an institution reported higher depression (p = 0.039) and overload scores (p = 0.002) than did caregivers of patients residing at home 6 months after discharge; 51.2% of caregivers at discharge and 36.4% at 6 months after discharge reported symptoms consistent with some degree of depression. In addition, 12.2% of caregivers at hospital discharge and 15.6% at 6 months after discharge were classified as having symptoms consistent with severe depression. Caregiver physical health (p = 0.025) and overload (p = 0.006) made statistically significant contributions to explaining caregiver depression.

CONCLUSIONS

Caregivers of patients receiving LTV in our sample have similar characteristics to other caregiving populations. However, our sample had higher depression scores than those reported for many other caregiver groups.

Respiratory failure in elderly patients

Elderly individuals comprise an increasing proportion of the population and represent a progressively expanding number of patients admitted to the ICU. Because of underlying pulmonary disease, loss of muscle mass, and other comorbid conditions, older persons are at increased risk of developing respiratory failure. Recognition of this vulnerability and the adoption of proactive measures to prevent decompensation requiring intrusive support are major priorities together with clear delineation of patients' wishes regarding the extent of support desired should clinical deterioration occur. Further, the development of coordinated approaches to identify patients at risk for respiratory failure and strategies to prevent the need for intubation, such as the use of NIV in appropriate patients, are crucial. As soon as endotracheal intubation and mechanical ventilation are implemented strategies that facilitate the liberation of elderly patients from the ventilator are especially important. The emphasis on a team approach, which characterizes geriatric medicine, is essential in coordinating the skills of multiple health care professionals in this setting. Respiratory failure can neither be effectively diagnosed nor managed in isolation. Integration with all other aspects of care is essential. Patient vulnerability to nosocomial complications and the "cascade effect" of these problems such as the effects of medications and invasive supportive procedures all impact on respiratory care of elderly patients. For example, prolonged mechanical ventilation may be required long after resolution of the underlying cause of respiratory failure because of unrecognized and untreated delirium or residual effects of small doses of sedative and/or analgesic agents or other medications in elderly patients with altered drug metabolism. The deleterious impact of the foreign and sometimes threatening ICU environment and/or sleep deprivation on the patient's course are too often overlooked because the physician focuses management on physiologic measurements, mechanical ventilator settings, and other technologic nuances of care [40]. Review of the literature suggests that the development of respiratory failure in patients with certain disease processes such as COPD, IPF, and ARDS in elderly patients may lead to worsened outcome but it appears that the disease process itself, rather than the age of the patient, is the major determinant of outcome. Additional studies suggest that other comorbid factors may be more important than age. Only when comorbid processes are taken into account should decisions be made about the efficacy of instituting mechanical ventilation. In addition, because outcome prediction appears to be more accurate for groups of patients rather than for individual patients a well-structured therapeutic trial of instituting mechanical ventilation, even if comorbidities are present, may be indicated in certain patients if appropriately informed patients wish to pursue this course. This approach requires careful and realistic definition of potential outcomes, focus on optimizing treatment of the reversible components of the illness, and continuous communication with the patient and family. Although many clinicians share a nihilistic view regarding the potential usefulness of mechanical ventilation in elderly patients few data warrant this negative prognostication and more outcome studies are needed to delineate the optimum application of this element of supportive care. As with other interventions individualization of the decision must take into account the patient's premorbid status, concomitant conditions, the nature of the precipitating illness and its prospects for improvement, and most important, patient preferences. In this determination pursuing the course most consistent with the patient's wishes is essential and it must be appreciated that caregivers' impressions regarding the vigor of support desired by the patient are often erroneous. The SUPPORT investigators observed that clinicians often underestimated the degree of intervention desired by older patients assuming that less care would be desired [13]. Thus, as in other circumstances, effective communication and elicitation of patients' preferences regarding management options is crucial in the management of respiratory failure. The frequent discordance between patient preferences and the wishes of family members or other surrogate decision makers impose major clinical challenges and also mandates further investigation.

Evaluating ventilator weaning best practice: a long-term acute care hospital system-wide quality initiative

Long-term acute care (LTAC) hospitals and units are becoming increasingly important to the management of patients who have serious, complex critical illnesses and require mechanical ventilation for extended periods of time. Kindred Healthcare, Inc., a nation-wide system of LTAC hospitals embarked on a quality initiative to establish a Ventilator Management and Weaning Best Practice. The process steps included: measurement of performance of all hospitals in the system using a risk-adjusted methodology to evaluate clinical outcomes, identification of facilities with superior outcomes; structured evaluation of the characteristics, practices, and protocols of these Best Practice hospitals; and utilization of the information gleaned from these hospitals to establish evidence-based LTAC best practice ventilator management guidelines. Key characteristics of the Best Practice LTAC hospitals were: hospital-wide philosophy that "everybody weans"-that is, all disciplines actively participate and all patients are expected to wean; collaborative multidisciplinary plans of care; a consistent and a 24-hour-a-day approach to ventilator management and weaning; daily communication; mutual respect for the contributions of all disciplines to the weaning process; early, aggressive nutrition support and intervention by rehabilitation services; use of 24-hour in-hospital advance practice nurses, hospitalists, or physician assistants; and intervention by physiatrists.

Prolonged mechanical ventilation and tracheostomy in the elderly

Mechanical ventilation is a life-sustaining technology used with increasing frequency in the elderly population. Prolonged mechanical ventilation is associated with high morbidity, mortality, and poor functional status. Care of these complex patients requires a coordinated multidisciplinary approach to optimize outcome. To minimize mortality and morbidity and contain health care costs, it is essential to identify patients at high risk for prolonged ventilation and to implement early interventions to curtail functional decline. In this article, the incidence and outcome of prolonged mechanical ventilation is reviewed, along with interventions to promote recovery. In particular, the role of tracheostomy timing and placement is discussed.

Outcome of older patients requiring ventilatory support in intensive care: impact of nutritional status

OBJECTIVES

To determine predictors of mortality in the intensive care unit (ICU) and at 6 months after discharge; to assess the lifestyles of survivors 6 months after discharge.

DESIGN

Prospective cohort study of patients screened upon admission and 6 months after discharge from the ICU.

SETTING

The ICU of a university hospital.

PARTICIPANTS

One hundred sixteen consecutive patients age 70 and older admitted to the ICU and treated by mechanical ventilation for at least 24 hours.

MEASUREMENTS

A comprehensive medical, functional, nutritional, and social assessment was undertaken for each patient upon admission to the ICU. Functional status and residence were recorded for patients still living 6 months after discharge from the ICU.

RESULTS

Mortality in the ICU and 6 months after discharge was 31% and 52%, respectively. The predictors of in-ICU mortality on multivariate analysis were a high omega score per day in the ICU and a high simplified acute physiologic score corrected for points related to age (SAPS IIc). The predictors of mortality at 6 months were a high omega score per day in the ICU, a high SAPS IIc, and a mid-arm circumference (MAC) under the 10th percentile for the older French population in good health. Six months after discharge from the ICU, 91% of the surviving patients had the same residential status and 89% had a similar or improved functional status compared with pre-admission status.

CONCLUSIONS

Although severity of illness remains an important predictor of in-ICU mortality and mortality at 6 months after release from ICU, we found that impaired nutritional status upon admission was related to 6-month mortality. These results emphasize the need for a systematic nutritional assessment in older patients admitted to the ICU and treated by mechanical ventilation.

Long-term survival and health status after prolonged mechanical ventilation after cardiac surgery

OBJECTIVE

To determine hospital mortality, weaning from mechanical ventilation, long-term survival, and functional health status in patients receiving > or =7 days of mechanical ventilation after cardiac surgery.

DESIGN

Retrospective chart review and prospective patient interviews.

SETTING

A university-affiliated, tertiary care medical center.

PATIENTS

A total of 124 patients that received > or =7 days of mechanical ventilation after cardiac surgery.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Hospital and long-term death, liberation from mechanical ventilation, and functional health status.

MEASUREMENTS AND MAIN RESULTS

A total of 19 (15%) patients died in hospital. Of the 105 survivors, 104 (99%) were completely weaned from mechanical ventilation. Patients who died in the hospital were more likely to have had a preoperative stroke or to have a new postoperative stroke, more likely to have postoperative renal failure, and less likely to have chronic obstructive pulmonary disease. Kaplan-Meier survival was 59% at 5 yrs and expected median survival was 6.2 yrs. Patients who died anytime after discharge were more likely to have preoperative renal dysfunction or stroke, took longer to be weaned from mechanical ventilation and to be discharged, and were more likely to have postoperative complications such as stroke or renal dysfunction. Also, they were more likely to be too debilitated to walk or eat. By multivariate analysis, admitting creatinine, aortic valve surgery, number of ventilator days, and discharged on tube feedings remained significant predictors of mortality. A total of 40 of 53 survivors were interviewed. Participants were similar to nonparticipants (p > .10 for all characteristics). A few (16%) had limitations of their activities of daily living (eating, dressing, bathing), and most had limitations of moderate activity (60%) and vigorous activity (94%). Only 36% could climb stairs or walk uphill without limitations, 54% could walk a block, and 41% had no limitations in house or job work. Half the participants had no body pain; 38% had moderate and 4% severe pain. Most (59%) described their general health as good to excellent. Only 10% said it was poor.

CONCLUSION

Patients' chances of being liberated from mechanical ventilation are excellent. Their long-term survival and health status are good.

Patterns in costs and outcomes for patients with prolonged mechanical ventilation undergoing tracheostomy: an analysis of discharges under diagnosis-related group 483 in New York State from 1992 to 1996

OBJECTIVE

To analyze the costs and discharge status for patients with prolonged mechanical ventilation undergoing tracheostomy.

DESIGN

Retrospective analysis of a statewide database.

PATIENTS

All patients (n = 37,573) >18 yrs of age who had prolonged mechanical ventilation (procedure code 96.72) and were discharged from the hospital between 1992 and 1996 with a final DRG code of 483.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Rates of change in discharges and hospital reimbursements and the cost per survivor were examined by case payment groups and discharge year. A direct relation between volume and reimbursement rate was seen over time, although the patient age distributions remained relatively stable. The greatest increase in volume was from 1995 to 1996. For most years, there was a consistent inverse relation between age and survival, with older survivors being more likely to be discharged to residential healthcare facilities and younger patients more likely to be discharged home. There was a consistent direct relation between age and cost per survivor, mainly the result of improved survival rather than decreased reimbursements in later years.

CONCLUSIONS

More controlled reimbursements and improved overall survival rates for DRG 483 have contributed to the improved cost per survivor among all age groups over the period. Given the greater proportion of elderly that do not survive or who are placed into residential healthcare facilities, more scrutiny is needed concerning the use of DRG 483 resources so that care is better coordinated for these patients in the inpatient and postacute care settings.

Four-year experience with a unit for long-term ventilation (respiratory special care unit) at the Cleveland Clinic Foundation

BACKGROUND

In the context that special weaning units have been advocated as effective alternatives to the ICU for weaning selected patients, we initiated a Respiratory Special Care Unit (ReSCU) at the Cleveland Clinic Hospital in August 1993. The goals of the ReSCU were the following: (1) to wean ventilator-dependent patients when possible; and (2) when weaning was not possible, to optimize patient and family instruction for patients going home with ventilatory support. This study presents our 4-year experience with 212 patients managed in the ReSCU and analyzes clinical features associated with favorable clinical outcomes.

METHODS

The features of the ReSCU include six private beds in a pulmonary inpatient ward staffed by nurses with special pulmonary expertise; 24-h respiratory therapy supervision; bedside and central noninvasive monitoring (i.e., continuous pulse oximetry, end tidal capnometry, and ventilator alarms); and a multidisciplinary approach involving dietitians, physical therapists, occupational therapists, social workers, and speech pathologists. All ReSCU patients were cared for primarily by a pulmonary/critical care attending physician and fellow, with consultative input solicited as deemed necessary. The criteria for admission to the ReSCU included hemodynamic stability; absence of an arrhythmia requiring telemetry; and in the attending physician's judgment, the ability to benefit from the ReSCU.

RESULTS

Between August 23, 1993, and August 31, 1997, 212 patients were admitted to the ReSCU. The median age was 68 years old; 55% were women; 86% were white; and 55% were transferred from the medical ICU. Underlying reasons for ventilator dependence were ARDS from a nonsurgical cause (33%), ARDS following surgery (18%), status post-cardiothoracic surgery (13%), status post-thoracic surgery (12%), and COPD (12%). The median length of ReSCU stay was 17 days (interquartile range, 10 to 29 days). Eighteen percent (n = 38) died during the hospitalization. Among the 174 survivors, complete ventilator independence was achieved in 127 patients (60% of the 212 patient cohort), 28 patients were ventilator dependent (13% of 212 patients), and the remaining 19 patients (9%) required partial ventilatory support. Univariate analysis regarding the association of baseline characteristics with death identified lower albumin and transferrin levels, increasing age, and the physician's estimate of lower weaning likelihood as significant correlates of death. In contrast, achieving complete ventilator independence was associated with a higher serum albumin level, a nonmedical ICU referral source, a cause of respiratory failure other than COPD, and a physician's estimate of higher weaning likelihood. To analyze the financial impact of the ReSCU, we assumed that ReSCU patients would have otherwise stayed in the medical ICU and compared the charges (ICU vs ReSCU) with, for a subset of patients, the true costs of ReSCU vs. ICU care. Analyses of both charges and cost differences showed similar savings associated with ReSCU care ($13,339 per patient [charges] and $10,694 per patient [costs]).

CONCLUSIONS

We conclude the following: (1) the rate of achieving complete ventilator independence in the ReSCU was high; and (2) based on our achieving clinical outcomes, which are comparable to the most favorable rates reported in other series from ventilator units, we conclude that the ReSCU can be an effective and cost-saving alternative to the ICU for carefully selected patients.

Mechanical ventilation in a cohort of elderly patients admitted to an intensive care unit

BACKGROUND

It has been argued that life support for the elderly should be limited to conserve resources. As this population increases, so will the importance of evaluating appropriate use of mechanical ventilation in this group.

OBJECTIVE

To determine whether age has an independent effect on the outcomes of patients treated with mechanical ventilation after admission to an intensive care unit (ICU).

DESIGN

Prospective cohort study.

SETTING

University-based tertiary care medical center.

PATIENTS

63 patients 75 years of age or older and 237 patients younger than 75 years of age enrolled from medical and coronary ICUs.

MEASUREMENTS

In-hospital mortality rate, duration of mechanical ventilation, lengths of stay in the ICU and in the hospital, and cost of care.

RESULTS

Median duration of mechanical ventilation was 4.2 days (interquartile range, 2.1 to 9.3 days) for patients 75 years of age or older and 6.4 days (interquartile range, 3.4 to 11.4 days) for patients younger than 75 years of age (P = 0.14). When the length of time required to "pass" a daily screening test of weaning variables was used as an indicator of recovery from respiratory failure, elderly patients passed earlier than younger patients (risk ratio, 1.58 [95% CI, 1.13 to 2.22]; P = 0.03). The cost of ICU care was lower for older ($12,822 [CI, $9821 to $26,313] than for younger ($19,316 [CI, $9699 to $39,950]) patients (P = 0.03). Median hospital costs tended to be lower in the older group ($21,292 compared with $29,049; P = 0.17). After adjustment for ethnicity, sex, and severity of illness in a multivariate logistic regression analysis, patient age of 75 years or older was predictive of 1 less day on the ventilator (CI, -2.8 to 1.2 days). Lengths of stay in the ICU (beta-coefficient, -0.5 days [CI, -3.0 to 2.7 days]) and in the hospital (beta-coefficient, 0.3 days [CI, -3.7 to 5.5 days]) did not differ for persons 75 years of age or older after these adjustments (P > 0.1). Intensive care unit and hospital costs, however, were lower for elderly persons (P = 0.02). The in-hospital mortality rate was 38.1% among elderly patients and 38.8% among younger patients (P > 0.2); Cox proportional hazards analysis confirmed that survival did not differ between the two groups (relative risk for older patients, 0.82 [CI, 0.52 to 1.29]).

CONCLUSIONS

After adjustment for severity of illness, elderly patients spent similar time on mechanical ventilation and in the ICU and hospital but had a lower cost of care than younger patients. These outcomes are not explained by differences in mortality rate and suggest that mechanical ventilation should not be restricted in elderly patients with respiratory failure on the basis of chronologic age.

Patient perception of fatigue while undergoing long-term mechanical ventilation: incidence and associated factors

OBJECTIVE

To describe a chronically critically ill population of patients receiving long-term ventilatory assistance, including patient perception of fatigue and the associated factors of nutritional status, depression, and sleep-rest.

DESIGN

Prospective, descriptive correlational design.

SETTING

Two tertiary care, university-affiliated medical centers.

SUBJECTS

Twenty subjects who were undergoing mechanical ventilation for at least 7 days and who were in the process of weaning.

RESULTS

Descriptive, correlational, and t test statistics were used in the data analysis. There was a 100% prevalence rate of fatigue, and with a 10-cm visual analogue scale, 45% of the subjects rated their fatigue as severe (> or = 6.0 cm) in intensity. The sample's mean serum albumin was 2.7 gm/dl, and mean hemoglobin was 10.1 gm/dl, but there were no statistically significant relationships between fatigue and nutritional status. Subjects' depression scores were in the moderate range, and they evaluated their sleep as fragmented and only moderately effective. Fatigue and depression were strongly correlated (r = 0.61; p = 0.004); there were no statistically significant relationships between fatigue and the sleep-rest scales.

CONCLUSIONS

The descriptive findings suggest that patients receiving long-term ventilatory assistance are undernourished and experience fatigue, depressed mood state, and disruptions of their sleep-rest patterns.

Post-ICU mechanical ventilation: treatment of 1,123 patients at a regional weaning center

STUDY OBJECTIVES

To update our database, reporting changes in the results of weaning attempts and profile of patients transferred to us after prolonged mechanical ventilation (PMV) in the ICU.

DESIGN

Retrospective record review, with prospective recording of physiologic measurements on admission from mid-1994.

SETTING

Regional weaning center (RWC).

PATIENTS

We studied 1,123 consecutive ventilator-dependent patients transferred for attempted weaning over an 8-year period.

MEASUREMENTS AND RESULTS

Median (range) time of mechanical ventilation prior to transfer to the RWC declined from 37 (1 to 249) days in 1988 to 29 (1 to 120) days in 1996 (p<0.05). Acute physiology score of acute physiology and chronic health evaluation (APACHE) III was 32 (6 to 123) on RWC admission, equaling reported scores soon after ICU admission. Comparing other data on admission from 1988 to 1996, mean (+/-SD) serum albumin level declined from 2.92+/-0.58 to 2.43+/-0.50 g/dL, and alveolar-arterial oxygen pressure difference widened from 106+/-50 to 139+/-99 mm Hg. Prevalence of stage II or worse pressure ulceration on admission increased from 34% in 1988 to 46% in 1995. Despite these trends, there has been no significant change in patient outcome (55.9% weaned, 15.6% failed to wean, 28.8% died) or in median time to wean (29 [1 to 226] days). Overall survival at 1 year after discharge for the 8-year period is 37.9%, improving from 29% in 1988-1991 to 45% since 1992; survival in weaned patients discharged to home has improved from 45 to 59% during the respective time periods.

CONCLUSIONS

Patients are being transferred from the ICU to our RWC for attempted weaning sooner in their course of PMV. Although more severely ill on arrival than in past years, mortality is unchanged, more than half of the patients continue to be successfully weaned, and survival after RWC discharge is improved.

Clinical and economic outcome of patients undergoing tracheostomy for prolonged mechanical ventilation in New York state during 1993: analysis of 6,353 cases under diagnosis-related group 483

OBJECTIVE

To examine and describe the relation between age and disposition in patients undergoing tracheostomy.

DESIGN

Retrospective analysis of a statewide database.

SETTING

All acute care hospitals in New York state.

PATIENTS

All patients (n = 6,353) > or = 18 yrs of age who were discharged from the hospital during 1993 with a final diagnosis-related groups code of 483.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The final disposition, according to six disposition codes (other acute care facility, residential healthcare facility, other healthcare facility, home, home healthcare services, and death) was examined for the entire population. Cost per case was assumed to equal the average statewide Medicaid rate. An inverse relation between survival rate and age was observed, which resulted in an age-related increased cost per survivor. Also, survivors in older age groups had an increased rate of discharge to residential healthcare facilities. There was a negative, albeit less marked, effect of older age on the rates of survivors discharged to home and to other healthcare facilities.

CONCLUSIONS

Care of patients who undergo tracheostomy for prolonged mechanical ventilation is expensive. The older the patient, the less satisfactory the outcome from an economic, clinical, and possibly social perspective.

A comparison of nursing home-acquired pneumonia patients with patients with community-acquired pneumonia and nursing home patients without pneumonia

OBJECTIVES

To determine the factors responsible for mortality and characteristics unique to patients with nursing home acquired pneumonia (NHAP).

DESIGN

A prospective study of 71 patients with NHAP, 79 patients admitted from nursing homes for conditions other than pneumonia (NP), and 93 patients with community-acquired pneumonia (CAP).

SETTING

A teaching hospital that serves as the community hospital for the City of Halifax.

RESULTS

The 32% in-hospital mortality rate for NHAP was higher than the 14% rate for CAP (P < .05) but not significantly higher than the 23% mortality rate for NP patients. The most important determinants for long-term (52 weeks) outcome were complications during hospital stay, odds ratio for mortality 3.55, and self sufficiency at time of admission, odds ratio for mortality 0.306. While bacteremia rates were similar at 8% for NHAP, 13% for CAP, and 17% for NP, there was a trend toward a higher rate of pneumococcal bacteremia in the CAP group. CAP patients were more likely to receive ventilatory support, 13% versus 3% for NHAP and 4% for no pneumonia patients despite similar levels of hypoxemia in the two pneumonia groups.

CONCLUSIONS

The in-hospital mortality rate for NHAP is higher than that for CAP. The 1-year survival rate is determined by self-sufficiency at time of admission and absence of complications during hospital stay and is not group (e.g., nursing home) dependent.

Ventilator weaning protocols and techniques: getting the job done

Various protocols and techniques used to facilitate the weaning process are herein summarized. The protocols were derived from the literature, a survey of critical care nurses, and personal communications with individuals who use innovative methods to expedite the weaning process and reduce costs. The protocols provide a guideline for standardizing the weaning process, but they do not negate the importance of having skilled clinicians who provide continuity in implementing the protocols. The nursing profession has the opportunity to provide leadership in reducing health care costs through implementation of standardized approaches to weaning patients from mechanical ventilatory support.

Non-ICU care of hemodynamically stable mechanically ventilated patients

OBJECTIVE

To analyze a 4 1/2-year experience caring for hemodynamically stable mechanically ventilated patients on a nonmonitored respiratory care floor (RCF) for therapeutic outcome, utilization, and costs.

DESIGN

A retrospective medical records review.

SETTING

ICUs and an RCF of a university-affiliated tertiary care center.

PARTICIPANTS

Two hundred twenty-four patients requiring more than 24 h of mechanical ventilation cared for on the RCF.

RESULTS

The mean age of patients was 67 +/- 17 years. Of the admissions, 58% were from the medical ICU, 28% were from surgical ICUs, and 9.4% were from general medical floors. Patients spent 50 +/- 66 days mechanically ventilated on the RCF. Overall survival was 50.4% with 93.8% of surviving patients successfully weaned from mechanical ventilation. Survival by diagnostic group demonstrated highest probability of survival in patients with trauma and lowest in patients with multisystem failure. Of the survivors, 39% were discharged home, 34% to a rehabilitation unit, and 24% to a skilled nursing facility. Savings based on differential of costs between the ICU and RCF, primarily from reduced staffing requirements, were estimated at $4.1 million.

CONCLUSION

Use of a nonmonitored RCF for the care of hemodynamically stable mechanically ventilated patients yields acceptable therapeutic outcomes while providing the institution with increased flexibility in critical care bed management and significant financial savings.

Outcome of elderly patients requiring ventilatory support in intensive care

The objectives of the study were: 1) to evaluate mortality in elderly patients requiring ventilatory support in Intensive Care Unit (ICU) and at 6, 12 and 18 months after discharge from ICU; 2) (main objective) to determine predictors of mortality in ICU and after discharge; and 3) to assess the life-style of survivors. One hundred and ten consecutive hospitalized patients > or = 70 years were included in this retrospective study. Follow-up evaluation was conducted by telephone interview. Mortality in ICU and after discharge was the outcome variable. Fifteen parameters were recorded at admission and during hospitalization. Residence, health status, and self-sufficiency were evaluated after discharge. 1) Mortality in ICU and at 6, 12 and 18 months after discharge was 38%, 60%, 63% and 67% respectively. 2) The predictors of mortality in ICU were admission in shock, and use of major therapeutic interventions. Predictors of mortality at 6 months were admission in shock, previous impaired health status and marital status. 3) Eighteen months after discharge 92% of the surviving patients (N = 33) had the same residence, 75% had the same health status, and 78% had the same autonomy compared with pre-admission status. We concluded that shock and previous health status but not age are predictors of short- and long-term prognoses in elderly patients hospitalized in ICU for mechanical ventilation.

Investigating the impact of age on outcome of mechanical ventilation using a population of 41,848 patients from a statewide database

STUDY OBJECTIVE

To examine the impact of age on outcome from mechanical ventilation.

DESIGN

Retrospective analysis of a statewide database.

SETTING

All acute-care hospitals in New York State.

PATIENTS

All patients, aged 18 years and over, requiring mechanical ventilation during 1990 who could be identified with a mechanical ventilation procedure code (93.92) were studied. Data were obtained in aggregate form (six or more cases) from the New York State Department of Health. This process required a detailed request letter to the Statewide Planning and Cooperative System (SPARCS). Transmission of confidential information was not desired or permitted.

MEASUREMENTS AND RESULTS

Age and mortality rate (MR) fit a cuboidal regression model best (MR = -25.55 + 3.98Age - 0.072Age2 + 0.00043Age3, R2 = 0.85). Mortality rates vary significantly across various broad diagnostic groups (p < 0.01, analysis of variance [ANOVA]) and increase as a function of ICU duration (p < 0.01, ANOVA).

CONCLUSIONS

Age has an important effect on outcome from mechanical ventilation. Other factors, such as ICU duration and diagnosis, also influence outcome, and age should not be used as a sole criterion in evaluating the potential benefit of mechanical ventilation to an individual patient. Large, existing databases, such as SPARCS, may be useful in studying the application of mechanical ventilation.

Do elderly patients overutilize healthcare resources and benefit less from them than younger patients? A study of patients who underwent craniotomy for treatment of neoplasm

OBJECTIVE

Some physicians and academicians have suggested that limiting selected healthcare resources to the elderly will help curtail the rising cost of health care in the United States. In order to test this hypothesis in a specific medical context, we compared the cost of caring for younger (< 65 yrs) patients with that of caring for older (> or = 65 yrs) patients who underwent craniotomy for treatment of brain tumors.

DESIGN

Prospective collection and review of data on patients undergoing craniotomy for tumor in our institution between February 1989 and December 1991.

SETTING

University teaching hospital.

METHODS

Patients were divided into two groups: those < 65 yrs, and those > or = 65 yrs. Demographics, severity of illness, length of stay, hospital and surgical intensive care unit (ICU) costs and charges, ICU complications, procedures, and outcome variables were analyzed.

RESULTS

Of 3,265 ICU patients admitted during the study period, data on 123 (3.8%) undergoing craniotomy for brain tumor were analyzed. There were no differences between the patient groups in length of ICU stay or hospital stay, final outcome at discharge from the hospital, quality of life, or hospital or ICU costs, despite the fact that elderly patients had a greater number of procedures and complications per patient, and higher Acute Physiology and Chronic Health Evaluation II (APACHE II) severity of illness scores on admission and discharge than younger patients.

CONCLUSIONS

The assertion that the elderly may, under certain conditions, consume more healthcare resources and benefit less from them than younger patients must be tested for accuracy with regard to specific disease states. In the context of the disorder studied herein, the elderly do as well as the young. Without specific study of specific pathologic processes or surgical procedures, using age to limit access to resources remains an unsubstantiated, ideologic concept, rather than a scientifically proven cost-saving measure.

Weaning from prolonged mechanical ventilation. The experience at a regional weaning center

STUDY OBJECTIVE

The aim of this study was to describe the facility, patient population, outcome of treatment, and survival of patients transferred to a regional weaning center (RWC) after prolonged mechanical ventilation in the ICU setting.

DESIGN

Retrospective record review.

SETTING

Regional weaning center.

PATIENTS

Four hundred twenty-one consecutive ventilator dependent patients were transferred from ICU care for attempted weaning over a 36-month period.

MEASUREMENT AND RESULTS

Acute catastrophic surgical, traumatic, or septic illness resulted in ventilator dependency with much greater frequency than decompensated COPD. Of the 421 patients, 116 died and 287 survived with outcome known at discharge. Of the 287 who survived, 212 were freed from ventilator support. Patients who weaned were ventilator-dependent for 46.9 +/- 2.9 days before transfer to the RWC. Almost half of those weaned were discharged to their homes. Survival at 6 months and 1 year after discharge was 44 percent and 28 percent respectively, and it was greater for those at home than for those discharged to an extended care facility (ECF). The RWC care was approximately $1,500 per patient day less costly than ICU care, and $208 per patient day less costly than noninvasive respiratory care unit care.

CONCLUSIONS

Selected patients who become ventilator dependent for prolonged periods in the ICU may be transferred to an RWC with the expectation of successful weaning in a majority of cases.

[Surgical intensive care of the elderly]

Intensive care treatment of elderly patients is discussed controversially. Especially the success of maximal therapeutic efforts is questioned in this group. Therefore, this paper analyses prospective data of 1572 patients of a surgical intensive care unit with respect to age-related outcome. Besides the anticipated high proportion of concomitant diseases and an associated increased mortality of aged patients, there are no specific age-dependent differences. Old patients benefit from maximal therapeutic efforts to the same extent like younger patients. The authors conclude from the data that the patient's age per se should not influence the indication for intensive therapeutic interventions.

Survival following mechanical ventilation for acute respiratory failure in adult men

STUDY DESIGN

Survival following mechanical ventilation for acute respiratory failure has important implications for medical decision-making and allocation of expensive resources for critical care.

PROCEDURE

We reviewed a 5-year experience with mechanical ventilation in 383 men with acute respiratory failure and studied the impact of patient age, cause of acute respiratory failure, and duration of mechanical ventilation on survival. Survival rates were 66.6 percent to weaning, 61.1 percent to ICU discharge, 49.6 percent to hospital discharge, and 30.1 percent to 1 year after hospital discharge. When our data were combined with 10 previously reported series, mean survival rates were calculated to be 62 percent to ventilator weaning, 46 percent to ICU discharge, 43 percent to hospital discharge, and 30 percent to 1 year after discharge. Of 255 patients weaned from mechanical ventilation, 44 (17.3 percent) required an additional period of mechanical ventilation during the same hospitalization.

RESULTS

Age had a significant influence on survival to hospital discharge and on that to 1 year after hospital discharge, and the cause of acute respiratory failure had a significant influence on survival only to weaning. Survival was best in younger patients and those with COPD or postoperative respiratory failure and worst in patients resuscitated after cardiac or respiratory arrest. Increased duration of mechanical ventilation significantly reduced survival only to hospital discharge. Overall survival was significantly affected by age and cause of acute respiratory failure, but not by duration of mechanical ventilation.

CONCLUSION

We conclude that age, cause of acute respiratory failure, and duration of mechanical ventilation have specific influences on the generally poor outcome of mechanical ventilation for acute respiratory failure.

Predictors of mortality in older patients following medical intensive care: the importance of functional status

OBJECTIVE

We examined predictors of hospital and 6-month mortality in older Medical Intensive Care Unit (MICU) patients with particular attention to age and functional status. Age is generally thought to be strongly associated with intensive care outcomes, but this relationship may be confounded by age-related changes. These age-related changes may be approximated by changes in functional status (FS).

DESIGN

We conducted a retrospective chart review and collected severity of illness data using the Acute Physiology Score (APS), pre-hospitalization FS dichotomized as limited or not limited, and hospital mortality. County death records were reviewed for 6-month mortality.

SETTING

Three community hospital MICUs.

PATIENTS

Four-hundred MICU patients aged 50 and older admitted during the study period.

RESULTS

Limited FS was found in 42% of the 227 patients who had FS data in the chart. Mortality was significantly associated with APS, age, FS, immunocompromise state, comorbidity, and nursing home residence. In logistic regression analyses, while controlling for important variables, APS (P less than 0.001) and age greater than or equal to 75 with limited FS (P less than 0.05) were associated with hospital mortality. Six-month mortality predictors were APS (P less than 0.001), hospital (P less than 0.05), immunocompromised state (P less than 0.05) and age greater than or equal to 75 with limited FS (P less than 0.05).

CONCLUSIONS

We found that among patients without functional limitations, the oldest group was no more likely to die than the youngest group. Age and functional status had a significant interaction: patients older than 75 years with functional limitations were almost six times more likely to die in hospital compared to the reference group of patients between 50-64 years old without functional limitations. We conclude that functional status is an important predictor of outcome in older MICU patients.

Improving the quality and utilization of critical care

Critical care units have proliferated over the past three decades and the cost of care in these units has increased dramatically during that period. These units have flourished despite a surprising lack of adequate data to support their overall efficacy, and indeed a number of studies suggest that many patients admitted to these units are either too ill or too healthy to benefit. Dr Luce reviews recent changes in the organization and delivery of critical care and argues that the utilization and quality of critical care units can be improved through a combination of strategies. He advocates two strategies to decrease the demand for, or increase the supply of, critical care beds: more efficient use of intermediate care units and the development of clear institutional guidelines regarding the termination of treatment. In addition, although nominally eschewing the use of "formal" rationing policies, he advocates the development of admission and discharge policies to guide physicians during periods of low bed availability. Finally, he advocates greater leadership roles for professional critical care unit directors. This final suggestion has great merit but, as Dr Luce recognizes, a heightened role for critical care unit directors raises ethical and legal issues about the autonomy of both patients and physicians that need to be explored thoroughly.