Long-term Acute Care Hospital Setting Research Articles

Guillain-Barre in the long-term acute care hospital setting: Ventilation does not prolong stay

Objective Guillain-Barre Syndrome (GBS) is a rare acute inflammatory demyelinating polyneuropathy, resulting in loss of muscle function and potentially respiratory failure requiring prolonged mechanical ventilation. Data describing the demographics and outcomes of patients with severe GBS requiring prolonged ventilation in the long-term acute care hospital (LTACH) setting is limited. We hypothesized that patients with GBS requiring prolonged mechanical ventilation require longer lengths of stay in an LTACH and are discharged with poorer functional status than GBS patients who do not require mechanical ventilation. Design, Setting, and Participants We conducted a retrospective study of GBS patients admitted over a 9-year period at an independent, large LTACH and compared ventilated versus non-ventilated GBS patients’ lengths of stay and functional ability at the time of admission and discharge. Interventions Not Applicable Main Outcome Measures and Results We found no significant difference in mean (standard error of means) lengths of stay between ventilated and non-ventilated GBS patients admitted to an LTACH (48.4 (± 8.0) vs. 38.8 (± 5.7) days, P 0.37). We also found that ventilated patients with GBS were discharged from an LTACH with similar functional ability than non-ventilated GBS patients (4.5 vs. 4.0, P 0.43 on 10 ft walk; 4.7 vs. 4.5 on P 0.70; 5.0 vs. 4.2, P 0.21 on 150 ft walk). Conclusion These findings suggest that GBS patients suffering from prolonged mechanical ventilation may expect similar lengths of stay in an LTACH as non-ventilated GBS patients and a similar or greater rate of functional improvement during their stay. These data support admission of chronically ventilated GBS patients to an LTACH for ongoing care after their acute care without the anticipation of greater length of stay or less rehabilitation outcomes with respect to non-ventilated GBS patients. Keywords: Guillain-Barre Syndrome, Assisted Ventilation, Pulmonary Rehabilitation, LTACH, Critical Care

Caregiver Engagement in Serious Illness Communication in a Long-Term Acute Care Hospital Setting

Context Prolonged management of critical illnesses in long-term acute care hospitals (LTACH) makes serious illness communication (SIC), a clinical imperative. SIC in LTACH is challenging as clinicians often lack training and patients are typically unable to participate—making caregivers central. Objectives This qualitative descriptive study characterized caregiver engagement in SIC encounters, while considering influencing factors, following the implementation of Ariadne Labs’ SIC training at a LTACH in the Northeastern United States. Methods Clinicians’ documented SIC notes (2019-2020) were analyzed using directed content analysis. Codes were grouped into four categories generated from two factors that influence SIC—evidence of prognostic understanding (yes/no) and documented preferences (yes/no)—and caregiver engagement themes identified within each category. Results Across 125 patient cases, 251 SIC notes were analyzed. In the presence of prognostic understanding and documented preferences, caregivers acted as upholders of patients’ wishes (29%). With prognostic understanding but undocumented preferences, caregivers were postponers of healthcare decision-making (34%). When lacking prognostic understanding but having documented preferences, caregivers tended to be searchers, intent on identifying continued treatment options (13%). With poor prognostic understanding and undocumented preferences, caregivers were strugglers, having difficulty with the clinicians or family unit over healthcare decision-making (21%). Conclusion The findings suggest that two factors—prognostic understanding and documented preferences—are critical factors clinicians can leverage in tailoring SIC to meet caregivers’ SIC needs in the LTACH setting. Such strategies shift attention away from SIC content alone toward factors that influence caregivers’ ability to meaningfully engage in SIC to advance healthcare decision-making.

The association between beta-natriuretic peptide (BNP) serum levels and liberation from mechanical ventilation.

Prolonged time on mechanical ventilation is associated with multiple consequences for both the patient and medical facility. Based on anecdotal evidence that sustained elevation of beta-natriuretic protein (BNP) during a patient's stay in a long-term acute care hospital (LTACH) was associated with failure to wean from prolonged mechanical ventilation, we investigated if there is an association between a decrease in BNP levels during one's stay and successful weaning from prolonged mechanical ventilation. We performed a retrospective study of 66 patient records revealing no correlation between lowering BNP levels and probability of liberating a patient from prolonged mechanical ventilation in an LTACH environment where the probability of liberation from mechanical ventilation is high (> 85%). BNP measurements by itself does not appear to be a helpful tool in the likelihood of liberation from mechanical ventilation AUC = 0.61 (CI: 0.48-0.72). In an LTACH setting with high success rates of liberation from mechanical ventilation, it does not appear to be necessary to trend BNP measurements in attempts to liberate patients from prolonged mechanical ventilation.

Context Matters: Caregiver Engagement in Serious Illness Communication in the Long-Term Acute Care Hospital Setting (GP757)

Context Matters: Caregiver Engagement in Serious Illness Communication in the Long-Term Acute Care Hospital Setting (GP757)

Occupational and Physical Therapy Strategies for the Rehabilitation of COVID-19-Related Guillain-Barré Syndrome in the Long-term Acute Care Hospital Setting: Case Report.

BackgroundAlthough several reports have described the diagnosis and treatment of patients with COVID-19-associated Guillain-Barré syndrome (GBS), there is a paucity of literature describing the occupational and physical therapy (OT and PT) strategies used in the long-term acute care hospital (LTACH) setting to rehabilitate these patients.ObjectiveTo expand this body of literature, we present a case report highlighting the treatment strategies used to rehabilitate and discharge an individual from an independent LTACH facility, following diagnosis and treatment of COVID-19-related GBS at a regional ACH.MethodsA 61-year-old male was admitted to an LTACH for the rehabilitation of GBS following COVID-19 infection and intravenous immunoglobulin treatment. Rehabilitation in the LTACH setting uses a variety of skilled treatment interventions to meet patient-driven goals and maximize their function to the highest level possible in preparation of their discharge to a subacute or homecare setting. In this case, this was accomplished through individual OT and PT sessions, OT/PT cotreatment sessions, and targeted group therapy sessions focused on leg, arm, and fine motor coordination exercises.ResultsWith the OT and PT standard of care, the patient’s improvement was demonstrated by several outcome measures, including manual muscle testing, range of motion, grip strength, and the activity measure for postacute care. The patient was successfully rehabilitated and returned to the community after presenting with COVID-19-associated GBS.ConclusionsThis report highlights the complex rehabilitation needs patients require to regain independence after diagnosis of COVID-19-associated GBS.

Prevalence of Diaphragmatic Dysfunction in the Long-Term Acute Care Setting and Its Effects on Ventilator Weaning Outcomes: A Retrospective Cohort Study.

To determine the prevalence of undiagnosed diaphragmatic dysfunction in a long-term acute care hospital setting in patients on prolonged mechanical ventilation and its association with weaning outcomes. This is a single-center, retrospective cohort study including 451 patients on prolonged mechanical ventilation admitted to a long-term acute care hospital facility between 2012 and 2017. Diaphragmatic dysfunction was assessed using fluoroscopy. Three hundred nineteen patients on prolonged mechanical ventilation were assessed for diaphragmatic dysfunction. Nine patients were diagnosed with diaphragmatic dysfunction before admission. Eighty (72.7%) without diaphragmatic dysfunction were successfully weaned and 30 (27.3%) failed to wean, whereas 51 participants (31.9%) with diaphragmatic dysfunction were successfully weaned and 109 (68.1%) failed to wean (P < 0.001). When analyzing days to wean, the median was 13 days for those with no diaphragmatic dysfunction, 19 days with unilateral diaphragmatic dysfunction, and 28 days with bilateral diaphragmatic dysfunction (P < 0.001). Weaning success was not statistically associated with generalized neuromuscular disorders, age, sex, body mass index, smoking history, or diabetes. Diaphragmatic dysfunction was found to be strongly associated with time to wean and weaning success in the long-term acute care hospital setting. Very few patients despite being on prolonged mechanical ventilation were diagnosed with diaphragmatic dysfunction before long-term acute care hospital admission. Given this information, early diagnosis of diaphragmatic dysfunction among prolonged mechanical ventilation patients in the long-term acute care hospital setting is paramount in preventing secondary complications associated with mechanical ventilation.

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

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.

Medical Device-Related Pressure Injuries in Long-term Acute Care Hospital Setting.

The purpose of this study was to examine the epidemiology of medical device-related pressure injuries (MDRPIs) in 3 long-term acute care hospitals (LTACHs). Retrospective descriptive study. The sample comprised 304 adult inpatients at 3 geographically diverse LTACHs: Spaulding Hospital for Continued Medical Care, Drake Center, and Bethesda Hospital. The facilities are located in the Northeastern, Southeastern, and Midwestern United States. Hospital-acquired pressure injury (HAPI) data and MDRPI data were collected and reported for the 3 LTACHs from July 1, 2009, to June 30, 2010. Data were collected by the wound nurses at 2 of the facilities on a daily or weekly basis and quarterly at the remaining site. One hundred forty-two MDRPIs occurred during data collection, representing an occurrence rate of (47%). The proportion of MDRPIs and HAPIs at each of the LTACHs was 38%, 50%, and 47%, respectively. The most commonly reported medical devices causing pressure injury were respiratory devices, splints and braces, and tubing. The MDRPI rate identified in the LTACH setting was higher than rates reported in the literature. This study's findings confirm the importance of monitoring MDRPIs in order to implement appropriate prevention strategies.

Adapting the ABCDEF Bundle to Meet the Needs of Patients Requiring Prolonged Mechanical Ventilation in the Long-Term Acute Care Hospital Setting: Historical Perspectives and Practical Implications.

When robust clinical trials are lacking, clinicians are often forced to extrapolate safe and effective evidence-based interventions from one patient care setting to another. This article is about such an extrapolation from the intensive care unit (ICU) to the long-term acute care hospital (LTACH) setting. Chronic critical illness is an emerging, disabling, costly, and yet relatively silent epidemic that is central to both of these settings. The number of chronically critically ill patients requiring prolonged mechanical ventilation is expected to reach unprecedented levels over the next decade. Despite the prevalence, numerous distressing symptoms, and exceptionally poor outcomes associated with chronic critical illness, to date there is very limited scientific evidence available to guide the care and management of this exceptionally vulnerable population, particularly in LTACHs. Recent studies conducted in the traditional ICU setting suggest interprofessional, multicomponent strategies aimed at effectively assessing, preventing, and managing pain, agitation, delirium, and weakness, such as the ABCDEF bundle, may play an important role in the recovery of the chronically critically ill. This article reviews what is known about the chronically critically ill, provide readers with some important historical perspectives on the ABCDEF bundle, and address some controversies and practical implications of adopting the ABCDEF bundle into the everyday care of patients requiring prolonged mechanical ventilation in the LTACH setting. We believe developing new and better ways of addressing both the science and organizational aspects of managing the common and distressing symptoms associated with chronic critical illness and prolonged mechanical ventilation will ultimately improve the quality of life for the many patients and families admitted to LTACHs annually.

Outcomes of a ventilator-associated pneumonia bundle on rates of ventilator-associated pneumonia and other health care-associated infections in a long-term acute care hospital setting

Long-term trends in ventilator-associated pneumonia (VAP) rates, and other health care-associated infections, were examined prior to, during, and after introduction of a VAP bundle in a long-term acute care hospital setting. VAP incidence rate declined in a step-wise fashion and reached a null value. Incidence rates of bacteremia from any cause declined in a similar fashion. The incidence rates of vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus colonization or infection rates also decreased, but that of Clostridium difficile infection did not. VAP in the long-term acute care hospital setting can be controlled over time with implementation of Centers for Disease Control and Prevention-based VAP bundle. This outcome also may decrease certain other health care-associated infections.

Antipsychotic Prescribing Patterns, and the Factors and Outcomes Associated with Their Use, among Patients Requiring Prolonged Mechanical Ventilation in the Long-Term Acute Care Hospital Setting

Administration of scheduled antipsychotic therapy to mechanically ventilated patients to prevent or treat delirium is common, despite the lack of evidence to support its use. Among long-term acute care hospital (LTACH) patients requiring prolonged mechanical ventilation (PMV), the frequency of scheduled antipsychotic therapy use, and the factors and outcomes associated with it, have not been described. To identify scheduled antipsychotic therapy prescribing practices, and the factors and outcomes associated with the use of antipsychotics, among LTACH patients requiring PMV. Consecutive patients without major psychiatric disorders or dementia who were admitted to an LTACH for PMV over 1 year were categorized as those receiving scheduled antipsychotic therapy (≥24 hours of use) and those not receiving scheduled antipsychotic therapy. Presence of delirium, use of psychiatric evaluation, nonscheduled antipsychotic therapy, and scheduled antipsychotic therapy-related adverse effects were extracted and compared between the 2 groups and when significant (p ≤ 0.05), were entered into a regression analysis using generalized estimating equation techniques. Among 80 patients included, 39% (31) received scheduled antipsychotic therapy and 61% (49) did not. Baseline characteristics, including age, sex, illness severity, and medical history, were similar between the 2 groups. Scheduled antipsychotic therapy was administered on 52% of LTACH days for a median (interquartile range [IQR]) of 25 (6-38) days and, in the antipsychotic group, was initiated at an outside hospital (45%) or on day 2 (1-6; median [IQR]) of the LTACH stay (55%). Quetiapine was the most frequently administered scheduled antipsychotic (77%; median dose 50 [37-72] mg/day). Use of scheduled antipsychotic therapy was associated with a greater incidence of psychiatric evaluation (OR 5.7; p = 0.01), delirium (OR 2.4; p = 0.05), as-needed antipsychotic use (OR 4.1; p = 0.005) and 1:1 sitter use (OR 7.3; p = 0.001), but not benzodiazepine use (p = 0.19). Among LTACH patients requiring PMV, scheduled antipsychotic therapy is used frequently and is associated with a greater incidence of psychiatric evaluation, delirium, as-needed psychotic use, and sitter use. Although scheduled antipsychotic therapy-related adverse effects are uncommon, these effects are infrequently monitored.

Epidemiology of Ventilator-Associated Pneumonia in a Long-Term Acute Care Hospital

To characterize the epidemiology and microbiology of ventilator-associated pneumonia (VAP) in a long-term acute care hospital (LTACH). Retrospective study of prospectively identified cases of VAP. Single-center, 207-bed LTACH with the capacity to house 42 patients requiring mechanical ventilation, evaluated from April 1, 2006, through January 31, 2008. Data on the occurrence of VAP were collected prospectively as part of routine infection surveillance at Radius Specialty Hospital. After March 2006, Radius Specialty Hospital implemented a bundle of interventions for the prevention of VAP (hereafter referred to as the VAP-bundle approach). A case of VAP was defined as a patient who required mechanical ventilation at Radius Specialty Hospital for at least 48 hours before any symptoms of pneumonia appeared and who met the Centers for Disease Control and Prevention criteria for VAP. Sputum samples were collected from a tracheal aspirate if there was clinical suspicion of VAP, and these samples were semiquantitatively cultured. During the 22-month study period, 23 cases of VAP involving 19 patients were associated with 157 LTACH admissions (infection rate, 14.6%), corresponding to a rate of 1.67 cases per 1,000 ventilator-days, which is a 56% reduction from the VAP rate of 3.8 cases per 1,000 ventilator-days reported before the implementation of the VAP-bundle approach (P< .001). Microbiological data were available for 21 (91%) of 23 cases of VAP. Cases of VAP in the LTACH were frequently polymicrobial (mean number +/- SD, 1.78+/-1.0 pathogens per case of VAP), and 20 (95%) of 21 cases of VAP had at least 1 pathogen (Pseudomonas species, Acinetobacter species, gram-negative bacilli resistant to more than 3 antibiotics, or methicillin-resistant Staphylococcus aureus) cultured from a sputum sample. LTACH patients with VAP were more likely to have a neurological reason for ventilator dependence, compared with LTACH patients without VAP (69.6% of cases of VAP vs 39% of cases of respiratory failure; P= .014). In addition, patients with VAP had a longer length of LTACH stay, compared with patients without VAP (median length of stay, 131 days vs 39 days; P= .002). In 6 (26%) of 23 cases of VAP, the patient was eventually weaned from use of mechanical ventilation. Of the 19 patients with VAP, 1 (5%) did not survive the LTACH stay. The VAP rate in the LTACH is lower than the VAP rate reported in acute care hospitals. Cases of VAP in the LTACH were frequently polymicrobial and were associated with multidrug-resistant pathogens and increased length of stay. The guidelines from the Centers for Disease Control and Prevention that are aimed at reducing cases of VAP appear to be effective if applied in the LTACH setting.

186: An Analysis of Darbepoetin Dosing Patterns for Treatment of Anemia at a Longterm Acute Care Hospital Setting

186: An Analysis of Darbepoetin Dosing Patterns for Treatment of Anemia at a Longterm Acute Care Hospital Setting