Critical Care Plus: No Hard Figures Yet, But LTACs Have Anecdotal Lead
Therapist-driven protocols, appropriate care levels make the difference
By Julie Crawshaw, CRC Plus Editor
The number of us long-term acute care (ltac) hospitals increased from 203 in 1997 to 270 in 2001, and constitute a rapidly growing segment of Medicare payments. Sean Muldoon, MD, says there isn’t denominator data on rate of ventilator-dependent patients who go to specialized ventilator units. Muldoon is Chief Clinical Officer for Kindred Health Care hospital division, which has a network of about 60 long-term acute care hospitals in which ventilator-dependent patients constitute a large part of the population. Though there is no reliable census of ventilator-dependent patients, Muldoon says that Kindred’s ventilator-dependent patient admissions continue to rise year after year.
The number of LTACs in the United States began to grow in the post-prospective DRG era, when short-term acute care hospitals recognized that many ventilator-dependent patients needed care beyond what they were geared to provide. LTAC growth appreciated in response to the same political forces that led to rapid expansion of skilled nursing facilities, sub-acute units and acute rehab hospitals.
Though across the Atlantic many hospitals maintain specialized respiratory wards with a few high-intensity, ICU-type beds for specific acute COPD exacerbation, the more common US model is a separately licensed and owned "hospital within a hospital" (HIH) located on the same campus as its host hospital. Muldoon observes that one barrier preventing US hospitals from adopting the European model is a set of regulations-designed to keep down costs-that prevent frequent transfer of patients to and from the host hospital to the HIH. Under the current DRG prospective payment system, short-term acute hospitals have little financial incentive to create a unit designed for very expensive long-term patients.
Muldoon notes that even though they may not require the full gamut of ICU services, the overwhelming majority of ventilator-dependent patients here are in an ICU because there isn’t any other place for them in traditional hospitals. Such patients, who can be treated LTAC or ventilator unit and receive the level of care specific to their needs, tie up a valuable resource and receive a level of care higher than what they truly need.
Do LTACs Produce Better Outcomes?
Do LTACs produce better outcomes than outcome short-term acute care units? The answer requires a large randomized or retrospective trial that hasn’t yet been done, Muldoon says. Though unable to state from a purely scientific point of view that outcomes are better in long-term than in short-term facilities, Muldoon says that from a process point of view, LTACs have designed themselves specifically around the needs of this sub-section of ventilated patients in a way that short-term hospitals can’t. "Published studies have used widely varied selection criteria that make valid comparisons impossible," Muldoon says. "We don’t have any direct comparison between long-term and short-term acute care, but a growing body of literature supports the notion that focusing on sub-sets of patients produces better outcomes than low-volume providers, especially when the facility providing care is staffed by specialists."
Curtis F. Veal, MD, medical director of Kindred Hospital-Seattle, a long-term acute care ventilator unit, says that data published several years ago indicated that long-term outcomes for patients sick enough to end up in an LTAC is so poor as to raise the question of whether the facilities should even exist.
But anecdotally, Veal says he can do a better job weaning a difficult patient in the LTAC venue than in a short-term ICU because long-term wards put more therapist-driven protocols in place. Physicians, Veal notes, often visit the ICU twice a day and may not observe the little changes that occur over a longer period of time. They might abort efforts to wean a patient who could make some headway two hours after their visit.
Plus which, Veal observes, LTAC’s have tools and techniques not found in most ICUs, like the Passey-Muir valve used to enhance speech in patients who have had tracheostomies and are embarking on a longer, slower process of weaning than what physicians like to see in a short-term patient. "I believe that I’m more effective in weaning difficult patients from a ventilator in the LTAC than in a short-term ICU," Veal says. "And I think more contemporary data will bear out my anecdotal impression."
Patients’ quality of life should be better outside of ICU, Veal says. "If I interviewed my patients before and after transfer I expect they would say that by and large they are happier with what they’re doing—being able to speak, getting up, walking while being ventilated as they recover," he says. "While we can do all these things in short-term acutes, we don’t because we’re geared differently. It’s not that you don’t have intermittent setbacks, episodes of sepsis and nosocomial pneumonia in LTAC facilities, but you do have more of a focus on returning to health than you do on just putting out fires."
Cost-Effectiveness: One Clear LTAC Benefit
One LTAC benefit is increased cost-effectiveness. An ICU nurse never has more than three patients, Veal points out, but a good ICU nurse can take care of six patients in a long-term unit and not feel like it’s an awful day.
Because most LTAC’s are for profit, the cost-effectiveness is built into the system. If the government were to adopt this model for its own delivery of care as opposed to having it owned by companies, Veal thinks that the government could save some of the taxpayer’s money. "I think it’s an example of doing what really is necessary without cutting corners too close," he says.
Weaning success is obviously a big part of cost-effectiveness, Muldoon says. Kindred tracks weaning-success metrics through a sophisticated risk-adjusted methodology that compares its patients to the LTAC base population, calculating and observing to expected ratio on a number of outcomes that include weaning success. The technique prevents Kindred from benefiting from changing patient acuity while reviewing wean-success over time. "Our success rate is 20% higher than the LTAC base population of a few years ago," Muldoon says.
LTACs Emphasize Multi-Disciplinary Approach
Another advantage Veal perceives in his own unit is a greater emphasis on multi-disciplinary, collaborative approach to patient care. "We like to think we do that everywhere, but the fact is we don’t get together on a regular basis with everybody each one about the patients," he says. "In a short-term facility you’re taking care of patients who come in one day and leave three days later. There’s a lot of turnover, which takes attention away from long-term care." Also, in the United States the COPD patient spends a few days in the ICU and is then transferred to a medical ward, which often means being taken care of by a completely different team of caregivers.
Many of the published studies on NPPV in COPD come from Britain, where specialized respiratory wards are common. Prospective randomized controlled trials performed outside the ICU have shown varying results, according to the British Thoracic Society (BTS) Standards of Care Committee. One multi-center British trial found reductions in the need for intubation from 27% to 15% and in-hospital mortality from 20% to 10% but suggested that operator expertise is more likely than any other factor to determine the success or failure of NPPV outside the ICU.1
But the BTS committee also reports that if an acute non-invasive service is not provided, the shortage of ICU beds means that some patients will die because facilities to ventilate them invasively are unavailable. Trials have also shown that NPPV can be set up and successfully administered in ICU, respiratory and general wards.
In 1997, NPPV was available in 48% of UK hospitals surveyed. Lack of staff training and insufficient funds were the two reasons most commonly cited by facilities where respiratory ward service had not been set up. Wisia Wedzicha, MD, Professor of Respiratory Medicine at St. Bartholomew’s Hospital/London, says she is a great supporter of treating COPD patients with non-invasive ventilation on respiratory specialist wards. "There are issues of training, monitoring and cover," Wedzicha says. "One of the problems in the UK is that there are fewer staff around during the night. But the biggest advantage is that you can rehabilitate the patient faster on a ward because it’s more relaxed."
One of the biggest problems Wedzicha sees with NPPV is getting the patient to accept the mask and achieving synchrony between patient and machine." In an ideal world, Wedzicha adds, it would be nice to teach patients who are at risk of deteriorating how to use these masks.
Wedzicha believes that non-invasive ventilation can be successfully used on wards if all medical staff must be appropriately trained. She has found it takes about 15-16 hours of training followed by regular two-hour maintenance every three months before staff can be considered capable.
Monitoring equipment is less sophisticated in specialty wards than in ICUs, Wedzicha says, plus which there are fewer nurses and no backup when things go wrong. "You don’t have intubation on the ward—if something goes wrong have to call in a team," Wedzicha says. "You’ve got to regularly monitor your figures. Once a patient is established on ventilation the nursing input lessens considerably."
Wedzicha also believes that respiratory ward outcomes beat ICU outcomes because care is focused and there is more specific expertise. "If patients are very ill and need higher dependency care, then it is better to use intensive care as other interventions that may be needed are close at hand," she points out.
Wedzicha’s own unit is highly specialized and has more staff members who know how to do NPPV. She cautions that hospitals that want to open a respiratory unit need guidelines, such as the BTS guidelines below, for which she was a reviewer.
BTS guidelines for establishing training programs for non-invasive ventilation should include:
- Understanding of the normal respiratory anatomy and physiology;
- Understanding of the pathophysiology of respiratory failure;
- Understanding of treatment options available to the relevant patient population;
- Awareness of signs demonstrating worsening respiratory failure;
- Understanding of the operation, maintenance and troubleshooting of NIV equipment;
- Knowledge of patient interfaces and selection criteria used in non-invasive ventilation;
- Ability to interpret all relevant data (saturation monitor, blood gas analysis, etc) and to assess patient response to NPPV and act accordingly in treatment failure;
- Knowledge of existing literature;
- Practical experience in a facility offering NPPV;
- Competency assessment
In addition, BTS advises regularly auditing NPPV services for their organizational features, such as identifying responsible parties for initiating the therapy, and for process and outcome of patients with acute hypercapnic respiratory failure secondary to COPD.2 An example of an audit form tested in several British centers can be found in appendix 2 of the article referenced below. It’s available online at www.brit-thoracic.org.uk/guide/acquire_guide.html.
Contact info: Sean Muldoon (502) 596-7175; Curtis Veal (206) 329-1760; Wisnia Wedzicha 011 44 208 656 6140.
References
1. British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax. 2002;57:192-211.
2. Ibid.
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