Ventilator Care on a General Ward?!

Abstract

To the Editor. In the February 1998 issue of Pediatrics, Ambrosio et al1 reported on the safety of ventilation-dependent children outside of the intensive care unit (ICU). Caution should be used when moving these children out of the ICU and to a general pediatric ward. I agree that using valuable ICU resources would improve by moving these medically stable patients to a non-ICU setting. However, the “general pediatric ward” they describe is atypical of most pediatric wards. With the specialized nursing and respiratory therapy staff; time spent in didactic teaching (80 hours); high nurse-to-patient ratios (1:2 to 1:3); and level of monitoring (continuous cardiorespiratory monitors, pulse oximetry, and end-tidal CO2 monitors), what the authors depict as a general ward is actually a step-down or intermediate care unit. Without such staffing and monitoring these patients would be at great risk on the general wards of most hospitals and certainly would have a much different safety profile than that reported in the article.The authors mention the cost of hospitalization. True, the cost of an ICU bed per day is in excess of $1000, but that is only if a critically ill patient occupies that bed. As we know, in light of the recent changes in reimbursement, patient charges are based on the level of care provided and not the location within the hospital. Therefore, these patients should incur the same costs whether they are in the ICU or an intermediate care unit. The ability to move these patients out of the ICU setting does free up ICU beds and resources for more appropriate, critically ill children. This in turn will allow higher reimbursement per ICU bed.We must also remember that the majority of ventilator-dependent children are either in chronic care facilities or have some level of skilled nursing in the home. Caring for these children on a ward with nursing ratios less than 1:2 to 1:3 would be decreasing their level of care and potentially putting them at risk.I agree with the authors that medically stable ventilator-dependent children can be and should be cared for outside the ICU. However, it must be done in a safe environment with the appropriate physicians, support staff, and equipment. This can be best delivered in a step-down or intermediate care unit, not the typical general pediatric ward.In Reply. We agree with Dr Straumanis that moving ventilator-dependent children from an intensive care unit (ICU) to the general ward should be done with caution and only under strict guidelines and supervision by appropriate services. For this reason, we published our guidelines in our article.1The majority of our almost 200 ventilator-dependent children are not in chronic care facilities but are in home environments. Their “skilled nursing” home care (if they have any) is usually a nurse with an LVN degree. The hospital wards, where our home-ventilator patients are placed, adjust their staffing and coverage for our patients based on the patient needs, just as they would for other nonventilator-dependent patients. On all our patient wards, young children are placed on continuous cardiopulmonary monitors and all have access to continuous pulse oximetry monitoring as well. The end-tidal CO2monitor is the only additional piece of equipment that we insist the ventilator-dependent patients have on the hospital ward.Hence, while we agree with Dr Straumanis that stable ventilator-dependent children can be cared for outside the ICU when there are appropriate physicians, support staff, and equipment, we do not agree that this care “can be best delivered in a step-down or intermediate care unit, not the typical general pediatric ward” in our institution. Where these patients receive hospital care outside the ICU in other hospitals will depend on where the appropriate services are located. If the equipment and appropriate personnel are not available anywhere else except in an intermediate care unit or in an intensive care unit, then that is where these patients should be placed.