Functional Outcomes, Goals, and Goal Attainment among Chronically Critically Ill Long-Term Acute Care Hospital Patients.

Abstract

Rationale: Chronically critically ill patients admitted to a long-term acute care hospital (LTACH) setting are a vulnerable population of intensive care unit (ICU) survivors. Little is known of the goals and functional outcomes achieved by patients after rehabilitation in the LTACH setting. Objectives: We sought to examine patient goals and functional outcomes, including swallowing function, among ICU survivors admitted to an LTACH with a tracheostomy. Methods: This was a prospective observational cohort study of chronic critically ill LTACH patients. Results: Fifty older subjects with a median duration of intubation before tracheostomy of 13 days were enrolled. ICU-acquired weakness and cognitive impairment were present in 40 (80%) and 36 (72%) patients, as measured by the Medical Research Council scale and Montreal Cognitive Assessment, respectively. Mental health problems were also common, with 16 (32%) patients experiencing moderate to severe anxiety, 9 (18%) experiencing moderate to severe depression, and 11 (22%) reporting symptoms consistent with post-traumatic stress disorder, according to the Hospital Anxiety and Depression Scale and Post-Traumatic Stress Syndrome 10-Questions Inventory, respectively. Pharyngeal dysfunction, as measured by Fiberoptic Endoscopic Evaluation of Swallow examination, was present in 37 (74%) patients. Patient goals, in decreasing order of frequency, included eating and drinking, speaking, walking, returning home, and toileting. By LTACH discharge, goal attainment was variable, with 97% of those who ranked speaking as important being able to speak and 88% of those who ranked eating and drinking as important being able to eat and drink but with only 21% being able to walk and only 18% being able to self-toilet. Discharge to the home or acute rehabilitation setting, achieved in 52% of the population, was associated with greater strength, as measured by the total Medical Research Council score (P = 0.002) as well as by the European 5-dimension, 5-level health-related quality of life instrument domains of mobility (P = 0.008) and self-care (P = 0.04). Conclusions: Goal attainment during this period of recovery was variable. The ability to speak, eat, and drink, frequently identified as goals by these patients, were achieved, whereas functional goals such as walking were rarely achieved. These findings highlight the importance of identifying patient goals and setting realistic expectations informed by functional assessments when rehabilitating this vulnerable patient population in the LTACH and subsequent post-acute care settings.