Determinants of outcome for patients admitted to a long-term ventilator unit.ABSTRACTBackground. This prospective cohort study A cohort study is a form of longitudinal study used in medicine and social science. It is one type of study design. In medicine, it is usually undertaken to obtain evidence to try to refute the existence of a suspected association between cause and disease; failure to refute was done to identify determinants of successful weaning weaning, n the period of transition from breast feeding to eating solid foods. weaning the act of separating the young from the dam that it has been sucking, or receiving a milk diet provided by the dam or from artificial sources. from mechanical ventilation mechanical ventilation n. A mode of assisted or controlled ventilation using mechanical devices that cycle automatically to generate airway pressure. among patients admitted to the 10-bed Long-term ventilator ventilator /ven·ti·la·tor/ (ven´ti-la-tor) 1. an apparatus for qualifying the air breathed through it. 2. a device for giving artificial respiration or aiding in pulmonary ventilation. unit (LTVU) of a teaching hospital. Methods. Prospective patient surveillance and data collection were done on 472 patients admitted to the LTVU over a 4-year period (January 1996 to December 1999). Results. Multiple logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. analysis showed that the absence of home mechanical ventilation at the time of hospital admission, absence of intensive care unit (ICU ICU intensive care unit. ICU abbr. intensive care unit ICU see intensive care unit. ICU ) readmission readmission Managed care The admission of a Pt to a health care facility for a condition–eg, stroke, MI, GI bleeding, hip fracture, cancer surgery, shortly after discharge. See nth admission. Cf Admission, Discharge. , and admission to the LTVU from a nonmedical service were independently associated with successful weaning. No statistical difference between hospital survivors and nonsurvivors was associated with length of stay in the LTVU and length of stay in the hospital. Conclusions. Patients admitted to an LTVU require prolonged pro·long tr.v. pro·longed, pro·long·ing, pro·longs 1. To lengthen in duration; protract. 2. To lengthen in extent. hospitalizations and intensive resource utilization. These data suggest that improved methods for identifying patients who are unlikely to benefit from prolonged mechanical ventilation may assist physicians in their discussions with patients and family members as they consider various treatment options. MECHANICAL VENTILATION is one of the most common medical therapies provided in the hospital setting. Patients with acute respiratory failure Respiratory Failure Definition Respiratory failure is nearly any condition that affects breathing function or the lungs themselves and can result in failure of the lungs to function properly. requiring mechanical ventilation are typically cared for in an intensive care unit (ICU). However, over the past 15 years, increasing numbers of ventilator-dependent patients have been treated outside of traditional ICUs. This practice of transferring such patients to special ventilator units has arisen primarily as a means to reduce the escalating medical costs for such patients. (1,2) Additionally, it is now evident that many patients will not benefit from such care and will succumb suc·cumb intr.v. suc·cumbed, suc·cumb·ing, suc·cumbs 1. To submit to an overpowering force or yield to an overwhelming desire; give up or give in. See Synonyms at yield. 2. To die. to their underlying medical problems. (3,4) Therefore, methods are needed for identifying which patients are most likely to survive prolonged mechanical ventilation with an acceptable quality of life. We performed a prospective cohort study with two main goals. First, we determined the incidence of mortality among patients admitted to a long-term ventilator unit (LTVU). As part of this goal, we also planned to identify risk factors associated with hospital mortality for this group of patients. Second, we evaluated the rate of successful weaning from mechanical ventilation and identified predictors of successful weaning of patients from the LTVU. METHODS Study Location and Patients The study was conducted within the LTVU (10 beds) of a major academic health center (1,000 beds). During a 4-year period (January 1996 to December 1999), all mechanically ventilated ven·ti·late tr.v. ven·ti·lat·ed, ven·ti·lat·ing, ven·ti·lates 1. To admit fresh air into (a mine, for example) to replace stale or noxious air. 2. patients aged 18 years and older admitted to the LTVU were included in this investigation. The study was approved by the Washington University School of Medicine Washington University School of Medicine, located in St. Louis, Missouri, is one of the most competitive and highly regarded medical schools and biomedical research institutes in the United States. Human Studies Committee. The 10-bed LTVU is staffed by registered nurses and hospital technicians under the supervision of a clinical nurse specialist clinical nurse specialist n. A nurse who has advanced knowledge and competence in a particular area of nursing practice, such as in cardiology, oncology, or psychiatry. (J.A.). A multidisciplinary mul·ti·dis·ci·pli·nar·y adj. Of, relating to, or making use of several disciplines at once: a multidisciplinary approach to teaching. medical team including an attending physician board-certified in pulmonary pulmonary /pul·mo·nary/ (pool´mo-nar?e) 1. pertaining to the lungs. 2. pertaining to the pulmonary artery. pul·mo·nar·y adj. Of, relating to, or affecting the lungs. diseases, a respiratory therapist, a dietitian dietitian /di·e·ti·tian/ (di?e-tish´in) one skilled in the use of diet in health and disease. di·e·ti·tian or di·e·ti·cian n. A person specializing in dietetics. , a physical therapist, a social worker, and the patient's nurse made rounds each day except for weekends and holidays when the attending physician and the nursing staff made rounds. The medical treatment plan for the day was reviewed during rounds. Weaning from mechanical ventilation followed a protocol developed specifically for the LTVU. The protocol was done by respiratory therapists under the supervision of the LTVU attending physician. Data Collection Relevant clinical data were recorded weekly by a clinical nurse specialist (J.M.) from patient hard copy medical records and bedside computerized computerized adapted for analysis, storage and retrieval on a computer. computerized axial tomography see computed tomography. clinical data stations (EMTEK, EMTEK Health Care Systems Inc, Tempe, Ariz). Patient characteristics entered into the database upon admission to the LTVU included age, sex, race, marital status marital status, n the legal standing of a person in regard to his or her marriage state. , employment status, primary health insurance, hospital admission from a skilled nursing facility skilled nursing facility n. Abbr. SNF An establishment that houses chronically ill, usually elderly patients, and provides long-term nursing care, rehabilitation, and other services. or outside hospital, the presence of congestive heart failure congestive heart failure, inability of the heart to expel sufficient blood to keep pace with the metabolic demands of the body. In the healthy individual the heart can tolerate large increases of workload for a considerable length of time. , the presence of acquired nonpulmonary organ system derangements, a history of lung transplantation Lung Transplantation Definition Lung transplantation involves removal of one or both diseased lungs from a patient and the replacement of the lungs with healthy organs from a donor. surgery, home mechanical ventilation, and the presence of open wounds or decubiti. Processes of medical care recorded during patients' stay in the LTVU included the admission service (general surgery, internal medicine, pulmonary medicine, neurology neurology (n  rŏl`əjē, ny–), study of the morphology, physiology, and pathology of the human nervous system. , neurosurgery neurosurgery /neu·ro·sur·gery/ (noor´o-sur?jer-e) surgery of the nervous system. neu·ro·sur·ger·y n. Surgery on any part of the nervous system. , cardiothoracic cardiothoracic /car·dio·tho·rac·ic/ (-thah-ras´ik) pertaining to the heart and the thorax. car·di·o·tho·rac·ic n. Of or relating to the heart and the chest. , and thoracic surgery Thoracic Surgery Definition Thoracic surgery is the repair of organs located in the thorax, or chest. The thoracic cavity lies between the neck and the diaphragm, and contains the heart and lungs (cardiopulmonary system), the esophagus, trachea, pleura, ), the need for ICU readmission, duration of ICU stay before LTVU admission, duration of mechanical ventilation before transfer to the LTVU, level of mechanical ventilation support at the time of LTVU transfer (24 hours per day, less than 24 hours per day, none), treatment with corticosteroids Corticosteroids Definition Corticosteroids are group of natural and synthetic analogues of the hormones secreted by the hypothalamic-anterior pituitary-adrenocortical (HPA) axis, more commonly referred to as the pituitary gland. or total parenteral nutrition Total Parenteral Nutrition Definition Total parenteral nutrition (TPN) is a way of supplying all the nutritional needs of the body by bypassing the digestive system and dripping nutrient solution directly into a vein. , and the level of enteral enteral /en·ter·al/ (en´ter'l) enteric. en·ter·al adj. 1. Within or by way of the intestine, as distinguished from parenteral. 2. Enteric. nutritional support nutritional support, n the supply of foods and liquids necessary to advance healing and support health. at the time of LTVU admission (total daily requirements, partial daily requirements, none). The two main clinical outcomes evaluated were successful weaning from mechanical ventilation and hospital mortality. Secondary outcomes of interest also examined included the hospital length of stay, duration of stay on the LTVU, the number of ventilator days while on the LTVU, patient disposition at the time of hospital discharge (home, rehabilitation rehabilitation: see physical therapy. facility, skilled nursing facility, outside acute care hospital), total hospital costs, and total hospital charges. Financial data were provided by the business office of Barnes-Jewish Hospital
LTVU Admission Criteria admission criteria the rules for the establishment of comparable groups in any comparison of differences in the performance or responses of the group. The criteria may be permissible age group, the previous productivity, the freedom from disease and so on. Patients were admitted to the LTVU only if multiple attempts at weaning from mechanical ventilation had been unsuccessful in the ICU or if patients required home mechanical ventilation at the time of hospital admission. A tracheostomy and hemodynamic he·mo·dy·nam·ics n. (used with a sing. verb) The study of the forces involved in the circulation of blood. he stability were required, and only electrocardiographic electrocardiographic emanating from or pertaining to electrocardiography. electrocardiographic monitoring maintenance of a more or less continuous surveillance of a patient's cardiac status by means of electrocardiography. monitoring and pulse oximetry pulse oximetry Oxygen saturation measurement, SaO Critical care A method used to determine the O2 saturation–SaO2 and desaturation of blood in a continuous noninvasive fashion, through the noninvasive assessment of arterial Hb-bound were routinely available. The need for invasive hemodynamic monitoring invasive hemodynamic monitoring Cardiology Any maneuver used to measure in vivo hemodynamics: arterial line(s), pulmonary artery catheter, central venous line, and cardiac output monitoring. See Interventional cardiology. (eg, arterial arterial /ar·te·ri·al/ (-al) pertaining to an artery or to the arteries. ar·te·ri·al adj. 1. Of or relating to one or more arteries or to the entire system of arteries. 2. catheter catheter /cath·e·ter/ (kath´e-ter) 1. a tubular, flexible surgical instrument that is inserted into a cavity of the body to withdraw or introduce fluid. 2. urethral c. , pulmonary artery catheter In medicine pulmonary artery catheterization is the insertion of a catheter into a pulmonary artery. Its purpose is diagnostic; it is used to detect heart failure or sepsis, monitor therapy, and evaluate the effects of drugs. ) were contraindications to LTVU admission or indications for transfer to an ICU if the need for invasive invasive /in·va·sive/ (-siv) 1. having the quality of invasiveness. 2. involving puncture of the skin or insertion of an instrument or foreign material into the body; said of diagnostic techniques. monitoring occurred while the patient was in the LTVU. Additionally, all patients were evaluated by a clinical nurse specialist (J.M.) before LTVU admission to ensure that they were medically stable for transfer. This included an assessment for adequate treatment of infections, absence of pressor pressor /pres·sor/ (pres´or) tending to increase blood pressure. pres·sor adj. 1. Producing increased blood pressure. 2. Causing constriction of the blood vessels. agents unless the dose was stable for at least 24 hours, and stable nonpulmonary organ dysfunction dysfunction /dys·func·tion/ (dis-funk´shun) disturbance, impairment, or abnormality of functioning of an organ.dysfunc´tional erectile dysfunction impotence (2). . The need for hemodialysis hemodialysis /he·mo·di·al·y·sis/ (-di-al´i-sis) removal of certain elements from the blood by virtue of the difference in rates of their diffusion through a semipermeable membrane while being circulated outside the body; the process or continuous veno-venous hemofiltration were not contraindications to LTVU admission. Statistical Analysis Univariate analysis was used to compare variables for the groups of interest. Comparisons were unpaired and all tests of significance were two tailed. Continuous variables were compared using Student's t test for normally distributed variables and Wilcoxon's rank sum test for nonnormally distributed variables. The two data analyses compared (1) patients who successfully weaned wean tr.v. weaned, wean·ing, weans 1. To accustom (the young of a mammal) to take nourishment other than by suckling. 2. from mechanical ventilation with those patients who could not be liberated lib·er·ate tr.v. lib·er·at·ed, lib·er·at·ing, lib·er·ates 1. To set free, as from oppression, confinement, or foreign control. 2. Chemistry To release (a gas, for example) from combination. from mechanical ventilation and (2) hospital survivors with hospital nonsurvivors. Multivariate analysis multivariate analysis, n a statistical approach used to evaluate multiple variables. multivariate analysis, n a set of techniques used when variation in several variables has to be studied simultaneously. was done using multiple logistic regression analysis with models that were judged a priori a priori In epistemology, knowledge that is independent of all particular experiences, as opposed to a posteriori (or empirical) knowledge, which derives from experience. to be clinically sound.(5,6) This was necessary to avoid producing spuriously spu·ri·ous adj. 1. Lacking authenticity or validity in essence or origin; not genuine; false. 2. Of illegitimate birth. 3. Botany Similar in appearance but unlike in structure or function. significant results with multiple comparison.(7) A stepwise stepwise incremental; additional information is added at each step. stepwise multiple regression used when a large number of possible explanatory variables are available and there is difficulty interpreting the partial regression approach was used for entering new terms See suggestions for new terms. into the model with 0.05 as the limit for their acceptance or removal. Model overfitting was examined by evaluating the ratio of outcome events to the total number of independent variables in the final model, and specific testing for interactions between the individual variables was included in our analysis. Results of the logistic regression analyses are reported as adjusted odds ratios with their 95% confidence intervals confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. . All values are expressed as the mean [+ or -] standard deviation In statistics, the average amount a number varies from the average number in a series of numbers. (statistics) standard deviation - (SD) A measure of the range of values in a set of numbers. (continuous variables) or as a percentage of the group they were derived from (categorical That which is unqualified or unconditional. A categorical imperative is a rule, command, or moral obligation that is absolutely and universally binding. Categorical is also used to describe programs limited to or designed for certain classes of people. variables). All P values of .05 or less were considered to indicate statistical significance. RESULTS Patient Characteristics A total of 472 consecutive patients admitted to the LTVU were evaluated. There were 243 men (51.5%) and 229 women (48.5%). The mean age of the patients was 60.1 [+ or -] 18.1 years. Sixty-four patients (13.6%) received home ventilation ventilation, process of supplying fresh air to an enclosed space and removing from it air contaminated by odors, gases, or smoke. Proper ventilation requires also that there be a movement or circulation of the air within the space and that the temperature and before their hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun) 1. the placing of a patient in a hospital for treatment. 2. the term of confinement in a hospital. . Successful Weaning as an Outcome A total of 283 patients (60%) were successfully weaned from mechanical ventilation before hospital discharge. Tables 1 and 2 show patient characteristics and process of care variables associated with successful weaning by univariate analysis. Compared with patients who could not be weaned from mechanical ventilation, patients weaned from mechanical ventilation were statistically more likely to be employed before hospital admission, to have open wounds present while on the LTVU, to be nonmedical patients, to require longer durations of mechanical ventilation and longer lengths of ICU care before LTVU admission, and to be receiving their total nutritional needs by the enteral route. Patients weaned from mechanical ventilation were statistically less likely to be disabled before hospital admission, to require home ventilation, or to require readmission to an ICU. Multiple logistic regression analysis showed that the absence of home mechanical ventilation at the time of hospital admission (adjusted odds ratio [AOR AOR The ISO 4217 currency code for Angolan Reajustado Kwanza. ] = 30.54; 95% confidence interval [CI] = 17.69 to 52.71; P < .001), absence of ICU readmission (AOR = 3.23; 95% CI = 2.43 to 4.28; P < .001), and admission to the LTVU from a nonmedical service (AOR = 1.45; 95% CI = 1.24 to 1.70; P = .019) were independently associated with successful weaning from mechanical ventilation. Patients successfully weaned from mechanical ventilation had statistically shorter lengths of stay and fewer ventilator days while on the LTVU compared with patients who were not weaned from mechanical ventilation (Table 3). However, hospital length of stay was significantly longer for patients who were weaned from mechanical ventilation (Fig 1). Patients liberated from mechanical ventilation were also statistically more likely to survive their hospitalization and to be discharged to either a rehabilitation facility or skilled nursing facility. Mortality as an Outcome Eighty-four patients (17.8%) died during hospitalization. Older patients were statistically more likely to not survive their hospitalization than younger patients (Fig 2). Additionally, nonsurvivors were statistically more likely than survivors to be retired, to have congestive heart failure, to have nonpulmonary organ system derangements before LTVU admission, to have had lung transplantation, to require ICU readmission, and to have received corticosteroids during their hospitalization. Multiple logistic regression analysis showed that increasing age (1-year increments) (AOR = 1.03; 95% CI = 1.02 to 1.04; P = .004), the presence of acquired nonpulmonary organ system derangements (AOR = 2.16; 95% CI = 1.53 to 3.06; P = .026), and the need for ICU readmission (AOR = 6.80; 95% CI = 4.90 to 9.43; P < .001) were independently associated with hospital mortality. Hospital nonsurvivors had statistically greater total hospital costs and hospital charges compared with patients surviving their hospitalization (Table 3). A statistically significant relationship was observed between total hospital days and total hospital costs for all patients in the study cohort cohort /co·hort/ (ko´hort) 1. in epidemiology, a group of individuals sharing a common characteristic and observed over time in the group. 2. ([r.sup.2] = 0.6846; P< .001) (Fig 3). DISCUSSION [Figure 3 omitted] Our study showed that almost 18% of patients admitted to an LTVU died before hospital discharge. Increasing age, the occurrence of nonpulmonary organ system derangements, and the need for ICU readmission were found to be independent predictors of hospital mortality. Additionally, the mean total hospital costs and charges were statistically greater for hospital nonsurvivors than for hospital survivors. We also found that 40% of the patients admitted to the LTVU were not weaned from mechanical ventilation before hospital discharge or death. The absence of home mechanical ventilation at the time of hospital admission, absence of ICU readmission, and transfer to the LTVU from a nonmedical service were independently associated with successful liberation from mechanical ventilation. Mean total hospital costs and charges were also statistically greater for patients successfully weaned from mechanical ventilation. Our observed mortality rate for patients admitted to the LTVU appears comparable to other reports. Scheinhorn et al (3) examined 1,123 consecutive ventilator-dependent patients over an 8-year period at their regional weaning center. They found the 1-year survival to be 37.9% for these individuals, and more than 60% of their patients were discharged from the hospital alive. Gracey et al (8) observed a hospital mortality of 9.8% among their 132 patients requiring admission to a specialized spe·cial·ize v. spe·cial·ized, spe·cial·iz·ing, spe·cial·iz·es v.intr. 1. To pursue a special activity, occupation, or field of study. 2. ventilator-dependent unit. However, the 1-year mortality rate for their 119 hospital survivors was 76%. More recently, Carson et al (4) reported a hospital mortality rate of 50% among mechanically ventilated patients admitted to a long-term acute-care hospital. The observed differences in hospital mortality between these studies and our own experience may be explained, in part, by variations in the admission criteria for the individual long-term ventilator units resulting in case mix differences. Carson et al (4) admitted pa tients to their unit "regardless" of their severity of illness, whereas we required patients to be medically and hemodynamically stable, without the need for intensive monitoring intensive monitoring Intensive care The continuous monitoring of Pt vital signs, with electronic hookups to the nursing station; IM encompasses real time measurement of BP and ABGs via arterial lines, pulse oximetry, continuous cardiac monitoring, respiration, . Our observed mortality rate was similar to that shown in a regional rehabilitation center (22%) accepting patient referrals from acute care hospitals for patients who required prolonged ventilatory ventilatory /ven·ti·la·to·ry/ (-lah-tor?e) pertaining to ventilation. ventilatory pertaining to or emanating from pulmonary ventilation. support. (9) Previous investigators have attempted to identify risk factors for prolonged mechanical ventilation and mortality after admission to specialized long-term ventilator units. We previously reported that 76.5% of patients undergoing tracheostomy in our ICUs were subsequently transferred to the LTVU. (10) The development of nosocomial pneumonia nosocomial pneumonia An infection of lungs–bronchoalveolar unit–in a Pt who has been hospitalized ≥ 48 hrs, and directly attributable to pathogens acquired during the hospital visit Etiology Pseudomonas spp, S aureus, Legionella , administration of aerosol aerosol (âr`əsōl,–sŏl): see colloid. aerosol System of tiny liquid or solid particles evenly distributed in a finely divided state through a gas, usually air. treatments, having a witnessed aspiration aspiration /as·pi·ra·tion/ (as?pi-ra´shun) 1. the drawing of a foreign substance, such as the gastric contents, into the respiratory tract during inhalation. 2. event, and requiring reintubation were variables independently associated with tracheostomy and the need for prolonged mechanical ventilation. We believe this is the first study of patients in an LTVU to report predictors for successful weaning from mechanical ventilation. Carson et al (4) identified predictors for 1-year mortality among their patients, which included age greater than 64 years, diabetes, renal failure renal failure n. Acute or chronic malfunction of the kidneys resulting from any of a number of causes, including infection, trauma, toxins, hemodynamic abnormalities, and autoimmune disease, and often resulting in systemic symptoms, especially edema, , and poor dependent functional status before admission to the long-term acute-care hospital. Interestingly, we also identified increasing age and the presence of nonpulmonary organ system d erangements as predictors of hospital mortality (Fig 2). Kurek et al (11) also found an inverse relationship A inverse or negative relationship is a mathematical relationship in which one variable decreases as another increases. For example, there is an inverse relationship between education and unemployment — that is, as education increases, the rate of unemployment between the survival rate and increasing age for patients undergoing tracheostomy for prolonged mechanical ventilation in New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of State. Therefore, it appears that specific risk factors can be identified that predict poor outcomes for patients requiring prolonged ventilatory support. This study has several limitations. First, patients did not have follow-up after their hospital discharge. Therefore, we do not know the functional status and 1-year survival of patients after discharge from our LTVU. Second, we examined patients at a single institution. As a result, our findings may not be directly comparable with other patient populations because of differences in case mix. Third, we did not use a severity of illness marker to assess the acquity of our patients' medical condition. Unfortunately, well validated val·i·date tr.v. val·i·dat·ed, val·i·dat·ing, val·i·dates 1. To declare or make legally valid. 2. To mark with an indication of official sanction. 3. outcome prediction models This article outlines the various propagation models currently used by the wireless industry for signal transmission at both 900 MHz and 1800 MHz. We start with the foundation of free-space transmission, followed by Picquenard’s multiple knife edge diffraction model. are not available for this patient population. Finally, we did not separate the various components of the hospital costs for our patients. However, length of stay appears to be a good indicator of total costs (Fig 3) and can probably be used indirectly to estimate the medical care costs associated with various components of patients' hospitalization (eg, using lengths of stay to compare the costs associated with LTVU care between patients successfully weaned from mechanical ventilation and those not weaned). In summary, we identified predictors for successful weaning and hospital survival among patients admitted to an LTVU. These data may be helpful to clinicians caring for patients who require long-term mechanical ventilation. Such information may assist physicians in their discussions with patients and their families as they consider various treatment options in the hospital setting. Additionally, large multicenter studies are needed to support these results, to develop well-validated prediction models for successful weaning and mortality in this patient population, and to assess the quality of life for patients discharged from LTVUs. Our findings and the experience of other investigators show that patients requiring prolonged mechanical ventilation can be adequately cared for outside of the ICU. [Figure 1 omitted] [Figure 2 omitted] [Figure 3 omitted]
TABLE 1
Characteristics of the Study Cohort at Admission to the Long-Term
Ventilator Unit
Wenned From
Mechanical Ventilation
Characteristic (n = 283)
Age (years) 60.2 [+ or -] 17.2
Sex
Male 136 (18.1%)
Female 147 (51.9%)
Race
White 196 (69.3%)
Black 84 (29.7%)
Other 3 (1.0%)
Marital status
Single 59 (20.9%)
Married 150 (53.0%)
Widow 45 (15.9%)
Divorced 29 (10.2%)
Employment Status
Employed 67 (23.7%)
Unemployed 30 (10.6%)
Retired 112 (39.6%)
Disabled 36 (12.7%)
Unknown 38 (13.4%)
Primary health insurance
Private 79 (27.9%)
State 35 (12.4%)
Federal 133 (47.0%)
None 36 (12.7%)
Admission from a skilled nursing
facility or outside hospital 95 (33.6%)
Congestive heart failure 89 (31.4%)
Nonpulmonary organ failure 48 (21.0%)
[n = 229]
Lung transplantation 10 (3.5%)
Home ventilation 7 (2.5%)
Open wounds present 75 (32.6%)
[n = 230]
Decubiti present 102 (44.2%)
Not Weaned From
Mechanical Ventilation
Characteristic (n = 189) P Value
Age (years) 60.0 [+ or -] 19.4 .820
Sex
Male 107 (56.6%) .068
Female 82 (43.4%)
Race
White 146 (77.2%) .084
Black 43 (22.8%)
Other 0 (0.00%)
Marital status
Single 18 (25.4%) .458
Married 88 (16.6%)
Widow 29 (15.3%)
Divorced 24 (12.7%)
Employment Status
Employed 25 (13.2%) <.001
Unemployed 12 (6.3%)
Retired 72 (38.1%)
Disabled 71 (37.6%)
Unknown 9 (4.8%)
Primary health insurance
Private 53 (28.0%) .006
State 27 (14.3%)
Federal 102 (54.0%)
None 7 (3.7%)
Admission from a skilled nursing
facility or outside hospital 64 (33.9%) .947
Congestive heart failure 63 (33.3%) .668
Nonpulmonary organ failure 25 (18.0%) .489
[n = 139]
Lung transplantation 14 (7.4%) .061
Home ventilation 57 (30.2%) <.001
Open wounds present 26 (18.8%) .004
[n = 138]
Decubiti present 53 (38.1%) .255
Hospital Hospital
Survivors Nonsurvivors
Characteristic (n = 388) (n = 84)
Age (years) 58.7 [+ or -] 18.0 66.7 [+ or -] 17.4
Sex
Male 198 (51.0%) 45 (53.6%)
Female 190 (49.0%) 39 (46.4%)
Race
White 275 (70.9%) 67 (79.8%)
Black 110 (28.3%) 17 (20.2%)
Other 3 (0.8%) 0 (0.00%)
Marital status
Single 91 (23.5%) 16 (19.1%)
Married 196 (50.5%) 42 (50.0%)
Widow 54 (13.9%) 20 (23.8%)
Divorced 47 (12.1%) 6 (7.1%)
Employment Status
Employed 76 (19.6%) 16 (19.0%)
Unemployed 37 (9.5%) 5 (6.0%)
Retired 139 (35.8%) 45 (53.5%)
Disabled 94 (24.2%) 13 (15.5%)
Unknown 42 (10.8%) 5 (6.0%)
Primary health insurance
Private 108 (27.8%) 24 (28.6%)
State 55 (14.2%) 7 (8.3%)
Federal 187 (18.2%) 18 (57.1%)
None 38 (9.8%) 5 (6.0%)
Admission from a skilled nursing
facility or outside hospital 131 (33.8%) 28 (33.3%)
Congestive heart failure 114 (29.4%) 38 (45.2%)
Nonpulmonary organ failure 51 (16.4%) 22 (38.6%)
[n = 311] [n = 57%]
Lung transplantation 16 (4.1%) 8 (9.5%)
Home ventilation 58 (15.0%) 6 (7.1%)
Open wounds present 82 (26.5%) 19 (32.8%)
[n = 310] [n = 58]
Decubiti present 126 (40.4%) 29 (50.0%)
Characteristic P Value
Age (years) <.001
Sex
Male .673
Female
Race
White .240
Black
Other
Marital status
Single .093
Married
Widow
Divorced
Employment Status
Employed .032
Unemployed
Retired
Disabled
Unknown
Primary health insurance
Private .258
State
Federal
None
Admission from a skilled nursing
facility or outside hospital .940
Congestive heart failure .005
Nonpulmonary organ failure <.001
Lung transplantation .041
Home ventilation .058
Open wounds present .323
Decubiti present .173
Numbers in brackets represent patients for whom the data were available.
TABLE 2
Process of Care Variables
Weaned From
Mechanical Ventilation
Variable (n = 283)
Admission service
General surgery 88 (31.1%)
Medicine 155 (54.8%)
Neurology/neurosurgery 21 (7.4%)
Cardiothoracic/thoracic 19 (6.7%)
surgery
ICU readmission 48 (17.0%)
Days in IGU before LTVU 24.2 [+ or -] 15.4
admission
Days on MV before LTVU 22.7 [+ or -] 14.6
admission
MV support on admission
to LTVU
Full 170 (74.2%)
Partial 53 (23.2%)
None 6 (2.6%)
[n = 229]
Corticosteroids 14 (6.1%)
[n = 231]
TPN on admission to LTVU 18 (8.2%)
[n = 220]
Enteral tube feeding on
admission to LTVU
Total 183 (81.7%)
Partial 11 (4.9%)
None 30 (13.4%)
[n = 224]
Not Weaned From
Mechanical Ventilation
Variable (n = 189) P Value
Admission service
General surgery 18 (9.5%) <.001
Medicine 148 (78.3%)
Neurology/neurosurgery 14 (7.4%)
Cardiothoracic/thoracic 9 (4.8%)
surgery
ICU readmission 48 (25.4%) .026
Days in IGU before LTVU 17.8 [+ or -] 18.4 <.001
admission
Days on MV before LTVU 15.9 [+ or -] 16.6 <.001
admission
MV support on admission
to LTVU
Full 109 (79.0%) .522
Partial 27 (19.6%)
None 2 (1.4%)
[n = 138]
Corticosteroids 8 (5.6%) .865
[n = 142]
TPN on admission to LTVU 15 (11.0%) .368
[n = 136]
Enteral tube feeding on
admission to LTVU
Total 87 (64.0%) <.001
Partial 6 (4.4%)
None 43 (31.6%)
[n=136]
Hospital Hospital
Survivors NonSurvivors
Variable (n = 388) (n = 84)
Admission service
General surgery 94 (24.2%) 12 (14.3%)
Medicine 239 (61.6%) 64 (76.2%)
Neurology/neurosurgery 32 (8.3%) 3 (3.6%)
Cardiothoracic/thoracic 23 (5.9%) 5 (5.9%)
surgery
ICU readmission 54 (13.9%) 42 (5.0%)
Days in IGU before LTVU 21.1 + 16.9 24.1 [+ or -] 17.1
admission
Days on MV before LTVU 19.7 [+ or -] 15.9 21.1 [+ or -] 15.3
admission
MV support on admission
to LTVU
Full 229 (74.1%) 50 (86.2%)
Partial 73 (23.6%) 7 (12.1%)
None 7 (2.3%) 1 (1.7%)
[n = 309] [n = 58]
Corticosteroids 15 (4.8%) 7 (11.9%)
[n = 314] [n = 59]
TPN on admission to LTVU 25 (8.3%) 8 (14.6%)
[n = 301] [n = 55]
Enteral tube feeding on
admission to LTVU
Total 231 (75.7%) 39 (7.9%)
Partial 15 (4.9%) 2 (3.6%)
None 59 (19.4%) 14 (25.5%)
[n = 305] [n = 55]
Variable P Value
Admission service
General surgery .061
Medicine
Neurology/neurosurgery
Cardiothoracic/thoracic
surgery
ICU readmission <.001
Days in IGU before LTVU .135
admission
Days on MV before LTVU .455
admission
MV support on admission
to LTVU
Full .136
Partial
None
Corticosteroids .034
TPN on admission to LTVU .142
Enteral tube feeding on
admission to LTVU
Total .559
Partial
None
ICU=Intensive care unit, MV=mechanical ventilation, LTVU=long-term
ventilator unit, TPN=total parenteral nutrition. Numbers in brackets
represent patients for whom the data were available.
TABLE 3
Clinical Outcomes and Financial Data
Weaned From
Mechanical Ventilation
Outcome (n = 283)
Weaned From mechanical --
ventilation
Total LTVU ventilator days 10.6 [+ or -] 13.0
LTVU duration (days) 22.4 [+ or -] 19.4
Hospital length of stay (days) 53.1 [+ or -] 30.2
Death 12 (4.2)
Disposition for survivors
Home 62 (22.9)
Rehabilation facility 105 (38.7)
SNF 83 (30.6)
OSH 21 (7.8)
[n = 271]
Hospital costs $108,956 [+ or -] 60,546
Hospital Charges $243,127 [+ or -] 134,501
Not Weaned From
Mechanical Ventilation
Outcome (n = 189) P Value
Weaned From mechanical -- --
ventilation
Total LTVU ventilator days 23.3 [+ or -] 31.0 <.001
LTVU duration (days) 24.5 [+ or -] 31.6 .013
Hospital length of stay (days) 47.1 [+ or -] 45.7 <.001
Death 72 (38.1) <.001
Disposition for survivors
Home 68 (58.1) <.001
Rehabilation facility 5 (4.3)
SNF 22 (18.8)
OSH 22 (18.8)
[n = 117]
Hospital costs $ 85,905 [+ or -] 73,477 <.001
Hospital Charges $189,538 [+ or -] 157,631 <.001
Hospital Hospital
Survivors Nonsurvivors
Outcome (n = 388) (n = 84)
Weaned From mechanical 271 (69.9) 12 (14.3)
ventilation
Total LTVU ventilator days 14.3 [+ or -] 20.3 22.0 [+ or -] 31.8
LTVU duration (days) 22.8 [+ or -] 23.1 25.5 [+ or -] 32.6
Hospital length of stay (days) 49.3 [+ or -] 35.2 57.3 [+ or -] 45.2
Death -- --
Disposition for survivors
Home 130 (33.5) -
Rehabilation facility 110 (28.3) -
SNF 105 (27.1) -
OSH 43 (11.1) -
Hospital costs $ 96,258 [+ or -] $115,380 [+ or -]
65,698 70,502
Hospital Charges $214,338 [+ or -] $254,742 [+ or -]
145,238 148,130
Outcome P Value
Weaned From mechanical <.001
ventilation
Total LTVU ventilator days .060
LTVU duration (days) .359
Hospital length of stay (days) .143
Death --
Disposition for survivors
Home -
Rehabilation facility -
SNF -
OSH -
Hospital costs .018
Hospital Charges .023
LTUV = Long-term ventilator unit
SNF = skilled nursing facility
OSH = outside hospital.
Numbers in brackets represent hospital surviors.
References (1.) Cohen cohen or kohen (Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male. IL, Booth FV: cost containment cost containment, n the features of a dental benefits program or of the administration of the program designed to reduce or eliminate certain charges to the plan. and mechanical ventilation in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . New Horizons 1994; 2:283290 (2.) Gracey DR, Hardy DC, Koenig GE: The chronic ventilator-dependent unit: a lower-cost alternative to intensive care. Mayo Clin Proc 2000; 75:445-449 (3.) Scheinhorn DJ, Chao DC, Stearn-Hassenpflug M, et al: Post-ICU mechanical ventilation: treatment of 1,123 patients at a regional weaning center. Chest 1997; 111:1654-1659 (4.) Carson SS, Bach PB, Brzozowski L, et al: Outcomes after long-term acute care: an analysis of 133 mechanically ventilated patients. Am J Respir grit Care Med 1999; 159:1568-1573 (5.) Hosmer DW, Lemeshow S: Applied Logistic Regression. New York, Wiley Interscience Publication, 1st Ed, 1989, pp 25-81 (6.) SAS/STAT User's Guide. Cary, NC, SAS Institute SAS Institute Inc., headquartered in Cary, North Carolina, USA, has been a major producer of software since it was founded in 1976 by Anthony Barr, James Goodnight, John Sall and Jane Helwig. Inc, Vol 2, 1990, pp 1071-1126 (7.) Concato J, Feinstein AR, Holdford TR: The risk of determining risk with multivariable models. Ann Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine. in·tern or in·terne n. Med 1993; 118:201-210 (8.) Gracey DR, Naessens JM, Viggiano RW, et al: Outcome of patients cared for in a ventilator-dependent unit in a general hospital. Chesi 1995; 107:494-499 (9.) Merveille OC, Childers MK, Kreimid MM, et al: weaning from mechanical ventilation in a general rehabilitation center. Am J Phys Med Rehabil 1999; 78:85-86 (10.) Kollef MH, Ahrens TS, Shannon W: Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Core Med 1999; 27:1714-1720 (11.) Kurek GJ, Cohen IL, Lambrinos J, et al: Clinical and econoinic outcome of patients undergoing tracheostomy for prolonged mechanical ventilation in New York State during 1993: analysis of 6,353 cases under diagnosis-related group diagnosis-related group Managed care A prospective payment system used by Medicare and other insurers to classify illnesses according to diagnosis and treatment; DRGs are used to group all charges for hospital inpatient services into a single 'bundle' for payment 483. Crit Care Med 1997; 25:983-988 RELATED ARTICLE: KEY POINTS * Patients admitted to an LTVU require prolonged hospitalization and intensive resource utilization. * Predictors of successful wearning and hospital survival can be identified for patients admitted to an LTVU. * These predictors may be used by physicians in their discussions with patients to determine the optimal course of treatment. From the Pulmonary and Critical Care Division, Washington University School of Medicine, and the Department of Nursing, Barnes-Jewish Hospital, St. Louis, Mo. Reprint reprint An individually bound copy of an article in a journal or science communication requests to Mann H. Kollef, MD, Washington University School of Medicine, 660 S Euclid Aye, Campus Box 8052, St. Louis, MO 63110. |
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