Objective: A small, but significant number of patients, termed the chronically, critically ill, survive critical illness, but remain dependent on (MV) for an extended period of time. One trend in healthcare is to transfer such patients to a lower level of intensive care (step-down intensive care unit [SD-ICU])) and then discharge them to long-term care settings as soon as they have recovered sufficiently to tolerate the transfer. Often such transfers occur while the patient is still dependent on MV. Little is known about how duration of time on MV impacts patient outcomes. Further, little is known about patient outcomes following transfer in regard to weaning success, impact on health-related quality of life (HRQoL), functional status, risk for readmission, disposition, or mortality. The purpose of this study was to examine selected variables (demographics, weaning success, HRQoL, functional status, hospital readmission, disposition, mortality) in patients who required > 6 days but < 14 days of MV in an acute care facility prior to transfer to a long-term care facility and those who required > 14 days of MV prior to transfer.
Design: Prospective, two-group comparative design.
Population, Sample, Setting, Years: Patients admitted to a 6-bed SD-ICU in a University-affiliated tertiary care hospital over an 11-month time period (10/00-8/01). The sample consisted of 51 patients who required MV for > 6 days.
Variables: Patient demographics, weaning status (on, off MV), HRQoL (Medical Outcomes Study Short Form 36 [SF-36]), functional status (Health Assessment Questionnaire [HAQ]), hospital readmission, residence (home, long-term care facility, acute-care facility) and mortality.
Methods: Consecutive patients who required > 6 days of MV were identified from SD-ICU admissions and informed consent obtained. Demographic data was obtained from the medical record. The SF-36 and HAQ were administered to the patient or, if unable to respond, the next-of-kin. The SF-36 was administered at baseline (SD-ICU admission) and 1-month after SD-ICU discharge. The HAQ was administered at baseline, SD-ICU discharge and 1-month after SD-ICU discharge. When completing baseline measures, the patient / next-of-kin was instructed to complete the instrument in regard to the time just prior to ICU admission. Patients were called monthly after SD-ICU discharge to determine weaning status, need for hospital readmission, place of residence and mortality. To identify the impact of varying time on MV, two groups were formed: those requiring MV for > 6 days but < 14 days or those who required MV for > 14 days. Data were analyzed using descriptive statistics, ANOVA, Student's t-tests and chi-square.
Results: At one-month, 43 (84%) of the patients enrolled in the study were alive, and 57% had successfully weaned from MV. However, only 20% of patients enrolled in the study were at home at 1-month, and 40% were readmitted at least once to an acute care hospital during this time interval. Patients on MV < 14 days were significantly more likely to be weaned at discharge from the SD-ICU (P=0.014). There were no significant differences between patients on MV < 14 days versus > 14 days in mortality (83 vs. 85%), readmission, weaning status, or place of residence. In addition, there were no significant between group differences in HRQoL or functional ability. When comparisons were made between baseline, discharge and 1-month measures of functional status, scores improved significantly from SD-ICU discharge to 1-month (P=0.041) for both groups, but remained significantly below that prior to SD-ICU admission (P=0.003) for both groups.
Conclusions: In this SD-ICU population, mortality was low and more than 50% of patients successfully weaned from ventilatory support. However, only a minority (20%) of the patients were able to return home and almost half (40%) were readmitted to an acute care hospital within this time period. Although functional ability improved from discharge to 1-month, neither group improved to pre-admission levels at 1-month.
Nursing Implications: Patients who require extended periods of MV are at high risk for readmission to an acute care facility during the initial month following hospital discharge. These findings suggest the need for intensive observation in the immediate post discharge period. Research is needed to test interventions designed to reduce hospital readmission during this interval. It is possible that patients are being transferred from acute care facilities prior to the time they are able to tolerate discharge, a potential that needs further study. Research is also needed to identify methods to assist patients to regain their prior level of functional ability.
Funded by: This study was supported by a grant from the NIH, NINR (RO1 NR5204).
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