Long-Term Acute Care: Where Does It Fit in the Health Care Continuum?

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.

Characteristics and Outcomes of Tracheostomized Patients With and Without COVID-19

Outcomes of tracheostomized patients with COVID-19 are seldomly investigated with conflicting evidence from the existing literature.

OBJECTIVES

To create a study evaluating the impact of COVID-19 on tracheostomized patients by comparing clinical outcomes and weaning parameters in COVID-19 positive and negative cohorts.

DESIGN SETTING AND PARTICIPANTS

A retrospective observational cohort study of 604 tracheostomized patients hospitalized in 16 ICUs in New York City between March 9, 2020, and September 8, 2021.

MAIN OUTCOMES AND MEASURES

Patients were stratified into two cohorts: 398 COVID-19 negative (COVID-ve) and 206 COVID-19 positive (COVID+ve) patients. Clinical characteristics, outcomes, and weaning parameters (first pressure support [PS], tracheostomy collar [TC], speech valve placement, and decannulation) were analyzed.

RESULTS

COVID+ve had fewer comorbidities including coronary artery disease, congestive heart failure, malignancy, chronic kidney disease, liver disease, and HIV (p < 0.05). Higher Fio2 (53% vs 44%), positive end-expiratory pressure (PEEP) (7.15 vs 5.69), Pco2 (45.8 vs 38.2), and lower pH (7.41 vs 7.43) were observed at the time of tracheostomy in COVID+ve (p < 0.005). There was no statistical difference in post-tracheostomy complication rates. Longer time from intubation to tracheostomy (15.90 vs 13.60 d; p = 0.002), tracheostomy to first PS (2.87 vs 1.80 d; p = 0.005), and TC placement (11.07 vs 4.46 d; p < 0.001) were seen in COVID+ve. However, similar time to speech valve placement, decannulation, and significantly lower 1-year mortality (23.3% vs 36.7%; p = 0.001) with higher number of discharges to long-term acute care hospital (LTACH) (23.8% vs 13.6%; p = 0.015) were seen in COVID+ve.

CONCLUSIONS AND RELEVANCE

Patients with COVID-19 required higher Fio2 and PEEP ventilatory support at the time of tracheostomy, with no observed change in complication rates. Despite longer initial weaning period with PS or TC, similar time to speech valve placement or decannulation with significantly lower mortality and higher LTACH discharges suggest favorable outcome in COVID-19 positive patients. Higher ventilatory support requirements and prolonged weaning should not be a deterrent to pursuing a tracheostomy.

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.

Implementing a Nurse-Driven Protocol to Reduce Catheter-Associated Urinary Tract Infections in a Long-Term Acute Care Hospital

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are the second most common health care-associated infection. CAUTIs represent a serious threat to chronic critically ill patients in long-term acute care hospitals (LTACHs). Evidence-based guidelines have been shown to reduce the risk of infection in acute care settings but are not well documented in LTACHs.

METHOD

An evidence-based urinary catheter protocol was developed and implemented across three units in a large LTACH. RNs were oriented to the new protocol through online educational modules. During the evaluation period, 120 patients were admitted with a urinary catheter who qualified for chart review for CAUTI incidence. Overall catheter-days and CAUTI rates were compared, and changes in practice were noted.

RESULTS

After the education intervention, overall urinary catheter-days decreased by 10.1%, and CAUTI incidence decreased by 74% (4.82 CAUTI per 1,000 patient-days to 1.24). The absolute risk reduction was 3.58 infections per 1,000 catheter-days. The findings were statistically significant (z = 1.00, p < .03).

CONCLUSION

Significant reductions were noted in total catheter-days, and CAUTI rates improved after implementation of an education program and an evidence-based urinary catheter protocol in an LTACH. J Contin Educ Nurs. 2018;49(8):372-377.