Long-term Acute Care Hospitals Research Articles

Reducing Pressure Injuries in a High-Risk Long-Term Acute Care Hospital

Reducing Pressure Injuries in a High-Risk Long-Term Acute Care Hospital

Trajectories of Serious Illness Communication During Long-term Acute Care Hospital Admissions (GP151)

Trajectories of Serious Illness Communication During Long-term Acute Care Hospital Admissions (GP151)

One-Year Recovery Among Survivors of Prolonged Severe COVID-19: A National Multicenter Cohort.

Understanding the long-term effects of severe COVID-19 illness on survivors is essential for effective pandemic recovery planning. Therefore, we investigated impairments among hospitalized adults discharged to long-term acute care hospitals (LTACHs) for prolonged severe COVID-19 illness who survived 1 year. The Recovery After Transfer to an LTACH for COVID-19 (RAFT COVID) study was a national, multicenter, prospective longitudinal cohort study. We included hospitalized English-speaking adults transferred to one of nine LTACHs in the United States between March 2020 and February 2021 and completed a survey. None. Validated instruments for impairments and free response questions about recovering. Among 282 potentially eligible participants who provided permission to be contacted, 156 (55.3%) participated (median age, 65; 38.5% female; 61.3% in good prior health; median length of stay of 57 d; 77% mechanically ventilated for a median of 26 d; 42% had a tracheostomy). Approximately two-thirds (64%) had a persistent impairment, including physical (57%), respiratory (49%; 19% on supplemental oxygen), psychiatric (24%), and cognitive impairments (15%). Nearly half (47%) had two or more impairment types. Participants also experienced persistent debility from hospital-acquired complications, including mononeuropathies and pressure ulcers. Participants described protracted recovery, attributing improvements to exercise/rehabilitation, support, and time. While considered life-altering with 78.7% not returning to their usual health, participants expressed gratitude for recovering; 99% returned home and 60% of previously employed individuals returned to work. Nearly two-thirds of survivors of among the most prolonged severe COVID-19 illness had persistent impairments at 1 year that resembled post-intensive care syndrome after critical illness plus debility from hospital-acquired complications.

Reducing Hospitalizations and Multidrug-Resistant Organisms via Regional Decolonization in Hospitals and Nursing Homes

Infections due to multidrug-resistant organisms (MDROs) are associated with increased morbidity, mortality, length of hospitalization, and health care costs. Regional interventions may be advantageous in mitigating MDROs and associated infections. To evaluate whether implementation of a decolonization collaborative is associated with reduced regional MDRO prevalence, incident clinical cultures, infection-related hospitalizations, costs, and deaths. This quality improvement study was conducted from July 1, 2017, to July 31, 2019, across 35 health care facilities in Orange County, California. Chlorhexidine bathing and nasal iodophor antisepsis for residents in long-term care and hospitalized patients in contact precautions (CP). Baseline and end of intervention MDRO point prevalence among participating facilities; incident MDRO (nonscreening) clinical cultures among participating and nonparticipating facilities; and infection-related hospitalizations and associated costs and deaths among residents in participating and nonparticipating nursing homes (NHs). Thirty-five facilities (16 hospitals, 16 NHs, 3 long-term acute care hospitals [LTACHs]) adopted the intervention. Comparing decolonization with baseline periods among participating facilities, the mean (SD) MDRO prevalence decreased from 63.9% (12.2%) to 49.9% (11.3%) among NHs, from 80.0% (7.2%) to 53.3% (13.3%) among LTACHs (odds ratio [OR] for NHs and LTACHs, 0.48; 95% CI, 0.40-0.57), and from 64.1% (8.5%) to 55.4% (13.8%) (OR, 0.75; 95% CI, 0.60-0.93) among hospitalized patients in CP. When comparing decolonization with baseline among NHs, the mean (SD) monthly incident MDRO clinical cultures changed from 2.7 (1.9) to 1.7 (1.1) among participating NHs, from 1.7 (1.4) to 1.5 (1.1) among nonparticipating NHs (group × period interaction reduction, 30.4%; 95% CI, 16.4%-42.1%), from 25.5 (18.6) to 25.0 (15.9) among participating hospitals, from 12.5 (10.1) to 14.3 (10.2) among nonparticipating hospitals (group × period interaction reduction, 12.9%; 95% CI, 3.3%-21.5%), and from 14.8 (8.6) to 8.2 (6.1) among LTACHs (all facilities participating; 22.5% reduction; 95% CI, 4.4%-37.1%). For NHs, the rate of infection-related hospitalizations per 1000 resident-days changed from 2.31 during baseline to 1.94 during intervention among participating NHs, and from 1.90 to 2.03 among nonparticipating NHs (group × period interaction reduction, 26.7%; 95% CI, 19.0%-34.5%). Associated hospitalization costs per 1000 resident-days changed from $64 651 to $55 149 among participating NHs and from $55 151 to $59 327 among nonparticipating NHs (group × period interaction reduction, 26.8%; 95% CI, 26.7%-26.9%). Associated hospitalization deaths per 1000 resident-days changed from 0.29 to 0.25 among participating NHs and from 0.23 to 0.24 among nonparticipating NHs (group × period interaction reduction, 23.7%; 95% CI, 4.5%-43.0%). A regional collaborative involving universal decolonization in long-term care facilities and targeted decolonization among hospital patients in CP was associated with lower MDRO carriage, infections, hospitalizations, costs, and deaths.

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

Regional impact of multidrug-resistant organism prevention bundles implemented by facility type: A modeling study.

Emerging multidrug-resistant organisms (MDROs), such as carbapenem-resistant Enterobacterales (CRE), can spread rapidly in a region. Facilities that care for high-acuity patients with longer stays may have a disproportionate impact on this spread. We assessed the impact of implementing preventive interventions, directed at a subset of facilities, on regional prevalence. We developed a deterministic compartmental model, parametrized using CRE and patient transfer data. The model included the community and healthcare facilities within a US state. Individuals may be either susceptible or infectious with CRE. Individuals determined to be infectious through admission screening, periodic prevalence surveys (PPSs), or interfacility communication were placed in a state of lower transmissibility if enhanced infection prevention and control (IPC) practices were in place at a facility. Intervention bundles that included PPS and enhanced IPC practices at ventilator-capable skilled nursing facilities (vSNFs) and long-term acute-care hospitals (LTACHs) had the greatest impact on regional prevalence. The benefits of including targeted admission screening in acute-care hospitals, LTACHs, and vSNFs, and improved interfacility communication were more modest. Daily transmissions in each facility type were reduced following the implementation of interventions primarily focused at LTACHs and vSNFs. Our model suggests that interventions that include screening to limit unrecognized MDRO introduction to, or dispersal from, LTACHs and vSNFs slow regional spread. Interventions that pair detection and enhanced IPC practices within LTACHs and vSNFs may substantially reduce the regional burden.

Abstract TP271: A Retrospective Analysis of Demographic and Clinical Variables Within a Single Center Young Stroke Cohort

Introduction: Despite significant efforts to increase public awareness of cerebrovascular disease, the incidence of stroke and transient ischemic attack (TIA) in young adults has remained elevated, representing a major public health concern. We sought to better characterize our young stroke population in order to gain insight as to where targeted interventions could be beneficial in community outreach and support of affected patients. Methods: We conducted a retrospective study evaluating young adults (under 50 years of age) presenting to a single urban academic medical center with acute ischemic stroke or TIA between 2013 and 2022. Demographic information and clinical variables (including past medical history, Trial of Org 10172 in Acute Stroke Treatment [TOAST] classification of stroke etiology, and discharge disposition) were extracted from the electronic medical record and descriptive statistics were calculated. Results: A total of 408 patients were reviewed. Within this study population, the median age was 43 years (IQR 38-47 years) and 235 (57.6%) were men. The median initial National Institutes of Health Stroke Scale upon presentation was 3 (IQR 1-7). The most common stroke risk factors were tobacco use (44.6%), pre-existing cardiovascular disease (26.2%), and other substance use (23.8%). The most common TOAST classification upon discharge was Stroke of Undetermined Etiology (32.9%). Most patients (244, 59.8%) were discharged directly to home from the hospital, although 140 (34.3%) were transitioned to another facility, including acute rehabilitation facilities (95, 23.3%), skilled nursing facilities (22, 5.4%), and long-term acute care hospitals (11, 2.7%). Conclusion: Our study highlights that the continued high incidence of stroke in the young may be at least partially attributable to a high prevalence of traditional cardiovascular risk factors, thus emphasizing the importance of smoking cessation counseling and early treatment of hypertension in the primary care setting. In addition, while most young patients will present with minor stroke symptoms, a significant portion are unable to return directly to home upon discharge from the hospital.

Concurrent transmission of multiple carbapenemases in a long-term acute-care hospital.

We investigated concurrent outbreaks of Pseudomonas aeruginosa carrying blaVIM (VIM-CRPA) and Enterobacterales carrying blaKPC (KPC-CRE) at a long-term acute-care hospital (LTACH A). We defined an incident case as the first detection of blaKPC or blaVIM from a patient's clinical cultures or colonization screening test. We reviewed medical records and performed infection control assessments, colonization screening, environmental sampling, and molecular characterization of carbapenemase-producing organisms from clinical and environmental sources by pulsed-field gel electrophoresis (PFGE) and whole-genome sequencing. From July 2017 to December 2018, 76 incident cases were identified from 69 case patients: 51 had blaKPC, 11 had blaVIM, and 7 had blaVIM and blaKPC. Also, blaKPC were identified from 7 Enterobacterales, and all blaVIM were P. aeruginosa. We observed gaps in hand hygiene, and we recovered KPC-CRE and VIM-CRPA from drains and toilets. We identified 4 KPC alleles and 2 VIM alleles; 2 KPC alleles were located on plasmids that were identified across multiple Enterobacterales and in both clinical and environmental isolates. Our response to a single patient colonized with VIM-CRPA and KPC-CRE identified concurrent CPO outbreaks at LTACH A. Epidemiologic and genomic investigations indicated that the observed diversity was due to a combination of multiple introductions of VIM-CRPA and KPC-CRE and to the transfer of carbapenemase genes across different bacteria species and strains. Improved infection control, including interventions that minimized potential spread from wastewater premise plumbing, stopped transmission.

Content Validity Testing of a Novel Cognitive Screen, the Gaylord Occupational Therapy Cognitive (GOT-Cog), to Improve Inpatient Occupational Therapy Treatment Planning.

No single cognitive screen adequately captures all cognitive domains that are important for inpatient occupational therapy treatment planning. To quantify the content validity of a novel 22-item cognitive screen, the Gaylord Occupational Therapy Cognitive (GOT-Cog) screen, developed to better inform inpatient occupational therapy treatment planning. Delphi-style expert panel review. Long-term acute care hospital. The first panel was attended by four occupational therapists, two speech-language pathologists, one physician assistant, and two neuropsychologists; the second, by four occupational therapists, one speech-language pathologist, and one physician assistant. Each Delphi panel discussed the relevance, essentiality, and clarity of each item. After each discussion, panelists completed a content validity survey to summarize their evaluation of each item. On the basis of panelists' survey responses, item- and scale-level relevance, essentiality, and clarity were quantified by calculating the respective content validity index (CVI), content validity ratio (CVR), and content clarity index (CCI). Universal agreement (UA) and κ statistics were also calculated, as appropriate. Upon presenting the initial 23-item instrument covering 10 cognitive domains to the first Delphi panel, several questions were added, removed, or rewritten, resulting in a 22-item instrument representing nine domains. After the second panel, several questions were again rewritten, and the domains reorganized. All scale-level metrics improved, including CVI (from 0.87 to 1.0), UA (0.52 to 1.0), CVR (0.43 to 0.94), and CCI (2.26 to 2.92). GOT-Cog displays overall excellent content validity and can proceed to construct validity testing. Plain-Language Summary: By reporting on the content validity of the Gaylord Occupational Therapy Cognitive screen, this brief report begins the necessary process of evaluating the measure's overall validity and reliability.

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.

Days at Home After Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients.

Days at home (DAH) represents an important patient-oriented outcome that quantifies time spent at home after a medical event; however, this outcome has not been fully evaluated for low-surgical-risk patients undergoing transcatheter aortic valve replacement (TAVR). We sought to compare 1- and 2-year DAH (DAH365 and DAH730) among low-risk patients participating in a randomized trial of TAVR with a self-expanding bioprosthesis versus surgical aortic valve replacement (SAVR). Using Medicare-linked data from the Evolut Low Risk trial, we identified 619 patients: 606 (322 TAVR/284 SAVR) and 593 (312 TAVR/281 SAVR) were analyzed at 1 and 2 years, respectively. DAH was calculated as days alive and spent outside a hospital, inpatient rehabilitation, skilled nursing facility, long-term acute care hospital, emergency department, or observation stay. Mean DAH was compared using the t test. The mean (SD) age and female sex were 74.7 (5.1) and 74.3 (4.9) years and 34.6% (115/332) and 30.3% (87/287) in TAVR and SAVR, respectively. Postprocedural discharge to rehabilitation occurred in ≤3.0% (≤10/332) in TAVR and 4.5% (13/287) in SAVR. The mean DAH365 was comparable in TAVR versus SAVR (352.2±45.4 versus 347.8±39.0; difference in days, 4.5 [95% CI, 2.3-11.2]; P=0.20). DAH730 was also comparable in TAVR versus SAVR (701.6±106.0 versus 699.6±94.5; difference in days, 2.0 [-14.1 to 18.2]; P=0.81). Secondary outcomes DAH30 and DAH90 were higher in TAVR (DAH30, 26.0±3.6 versus 20.7±6.4; difference in days, 5.3 [4.5-6.2]; P<0.001; DAH90, 85.1±8.3 versus 78.7±13.6; difference in days, 6.4 [4.6-8.2]; P<0.001). In the Evolut Low Risk trial linked to Medicare, low-risk patients undergoing TAVR spend a similar number of days at home at 1 and 2 years compared with SAVR. Days spent at home at 30 and 90 days were higher in TAVR. In contrast to higher-risk patients studied in prior work, there is no clear advantage of TAVR versus SAVR for DAH in the first 2 years after AVR in low-surgical-risk patients.

2197. Impact of an INtake FOrm for Restricted Medications to (INFORM) better antibiotic use within a long-term acute care hospital system

Abstract Background Long-term Acute Care Hospitals (LTACHs) are uniquely positioned to treat patients with a high severity of illness for a long period of time. Despite this, there are substantial barriers to providing antimicrobial stewardship in this setting including limited resources and lack of patient data from transferring facilities. Methods This multi-center retrospective, quasi-experimental study evaluated the use of broad-spectrum antibiotics (BSAbx) over 3 timeframes in 43 LTACHs and rehabs within the Post Acute Medical System. Despite implementation of a restriction policy in June 2018, use remained high for ceftolozane/tazobactam (C/T), ceftazidime/avibactam (CZA), and meropenem/vaborbactam (MEV). In July 2020, the system antimicrobial stewardship committee created an INtake FOrm for Restricted Medications (INFORM) that required submission of pertinent clinical information for each patient receiving one of the target antibiotics as well as systematic review by an ID pharmacist. An electronic version of the INFORM was implemented in April 2022. Study timeframes included baseline (BL: July 2019-June 2020), phase 1 (P1: July 2020-March 2022), and phase 2 (P2: April 2022-March 2023). The primary objective was to determine if there was a difference in the combined use of C/T, CZA, and MEV measured as cost/acute patient day (APD) across the three timeframes. Secondary analyses included post-hoc analyses between these groups, and an evaluation of C/T, CZA, MEV with the addition of imipenem/cilastatin/relebactam (I/C/R). Results There was a significant reduction in antimicrobial use across intervention periods (mean cost/APD BL=2.5, P1=1.3, P2=0.8, p=0.045 using ANOVA, Figure 1). Sub-hoc analyses showed a significant difference for BL:P1 (p=0.02) and BL:P2 (p&amp;lt; 0.01), but not for P1:P2 (p=0.6). Even when adding I/C/R to control for any shifts in utilization to this agent after it was approved by the FDA, there was a statistically significant reduction across the intervention periods (p&amp;lt; 0.01 using ANOVA, Figure 2). Figure 2: Cost/Acute Patient Day for C/T, CZA, MEV vs. I/C/R over time C/T = ceftolozane/tazobactam, CZA = ceftazidime/avibactam, MEV = meropenem/vaborbactam, I/C/R = imipenem/cilastatin/relebactam Conclusion Completion of both the paper and electronic INFORM reduced C/T, CZA, and MEV use from baseline, showing that the systematic collection and review of patient data by an ID pharmacist reduced use of these BSAbx in a system of LTACHs and rehabs. Disclosures All Authors: No reported disclosures

Patient Outcomes After Long-Term Acute Care Hospital Closures

Long-term acute care hospitals (LTCHs) are common sites of postacute care for patients recovering from severe respiratory failure requiring mechanical ventilation (MV). However, federal payment reform led to the closure of many LTCHs in the US, and it is unclear how closure of LTCHs may have affected upstream care patterns at short-stay hospitals and overall patient outcomes. To estimate the association between LTCH closures and short-stay hospital care patterns and patient outcomes. This retrospective, national, matched cohort study used difference-in-differences analysis to compare outcomes at short-stay hospitals reliant on LTCHs that closed during 2012 to 2018 with outcomes at control hospitals. Data were obtained from the Medicare Provider Analysis and Review File, 2011 to 2019. Participants included Medicare fee-for-service beneficiaries aged 66 years and older receiving MV for at least 96 hours in an intensive care unit (ie, patients at-risk for prolonged MV) and the subgroup also receiving a tracheostomy (ie, receiving prolonged MV). Data were analyzed from October 2022 to June 2023. Admission to closure-affected hospitals, defined as those discharging at least 60% of patients receiving a tracheostomy to LTCHs that subsequently closed, vs control hospitals. Upstream hospital care pattern outcomes were short-stay hospital do-not-resuscitate orders, palliative care delivery, tracheostomy placement, and discharge disposition. Patient outcomes included hospital length of stay, days alive and institution free within 90 days, spending per days alive within 90 days, and 90-day mortality. Between 2011 and 2019, 99 454 patients receiving MV for at least 96 hours at 1261 hospitals were discharged to 459 LTCHs; 84 LTCHs closed. Difference-in-differences analysis included 8404 patients (mean age, 76.2 [7.2] years; 4419 [52.6%] men) admitted to 45 closure-affected hospitals and 45 matched-control hospitals. LTCH closure was associated with decreased LTCH transfer rates (difference, -5.1 [95% CI -8.2 to -2.0] percentage points) and decreased spending-per-days-alive (difference, -$8701.58 [95% CI, -$13 323.56 to -$4079.60]). In the subgroup of patients receiving a tracheostomy, there was additionally an increase in do-not-resuscitate rates (difference, 10.3 [95% CI, 4.2 to 16.3] percentage points) and transfer to skilled nursing facilities (difference, 10.0 [95% CI, 4.2 to 15.8] percentage points). There was no significant association of closure with 90-day mortality. In this cohort study, LTCH closure was associated with changes in discharge patterns in patients receiving mechanical ventilation for at least 96 hours and advanced directive decisions in the subgroup receiving a tracheostomy, without change in mortality. Further studies are needed to understand how LTCH availability may be associated with other important outcomes, including functional outcomes and patient and family satisfaction.

Economic and Humanistic Burden Among Medicare-Aged Women With Fragility Fracture in the United States.

Describe patient characteristics, health care resource utilization, costs, and humanistic burden of women with Medicare insurance with incident fragility fracture who were admitted to post-acute-care (PAC). Retrospective cohort study using 100% Medicare Fee-for-Service (FFS) data. Community-dwelling female Medicare beneficiaries with incident fragility fracture January 1, 2017, to October 17, 2019, resulting in PAC admission to a skilled nursing facility (SNF), home-health care, inpatient-rehabilitation facility, or long-term acute-care hospital. Patient demographic/clinical characteristics were measured during 1-year baseline. Resource utilization and costs were measured during baseline, PAC event, and PAC follow-up. Humanistic burden was measured among SNF patients with linked Minimum Data Set assessments. Multivariable regression examined predictors of PAC costs after discharge and changes in functional status during SNF stay. A total of 388,732 patients were included. Compared with baseline, hospitalization rates were 3.5, 2.4, 2.6, and 3.1 times higher and total costs 2.7, 2.0, 2.5, and 3.6 times higher for SNF, home-health, inpatient-rehabilitation, and long-term acute-care, respectively, following PAC discharge. Utilization of dual-energy X-ray absorptiometry (DXA) and osteoporosis medications remained low: 8.5% to 13.7% received DXA during baseline vs 5.2% to 15.6% following PAC; 10.2% to 12.0% received osteoporosis medication during baseline vs 11.4% to 22.3% following PAC. Dual eligibility for Medicaid (ie, low income) was associated with 12% higher costs; Black patients had 14% higher costs. Activities of daily living scores improved 3.5 points during SNF stay, but Black patients had 1.22-point lower improvement than White patients. Pain intensity scores showed small improvement (-0.8 points). Women admitted to PAC with incident fracture had high humanistic burden with little improvement in pain and functional status and significantly higher economic burden after discharge compared with baseline. Disparities in outcomes related to social risk factors were observed, with consistently low utilization of DXA and osteoporosis medications even after fracture. Results indicate a need for improved early diagnosis and aggressive disease management to prevent and treat fragility fractures.

120.7: Establishing and maximizing the potential for organ donation in a long-term acute care hospital system.

120.7: Establishing and maximizing the potential for organ donation in a long-term acute care hospital system.

Severity-of-Illness Scores and Discharge Disposition in Patients Admitted to Long-Term Acute Care Hospitals.

After an intensive care unit (ICU) admission, nearly 20% of survivors of chronic critical illness require admission to a long-term acute care hospital (LTACH) for continued subspecialty care. The effect of the burden of medical comorbidities on discharge disposition after LTACH admission remains unclear. A retrospective cohort study was performed involving patients with chronic critical illness who were discharged from the medical ICU and admitted to an LTACH between 2016 and 2018. The patients' Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), Nutrition Risk in the Critically Ill (NUTRIC), and Charlson Comorbidity Index (CCI) scores at the time of LTACH admission were calculated from electronic medical records. The mean scores on each instrument were compared by discharge disposition. A total of 156 patients were admitted to the LTACH from the medical ICU between 2016 and 2018. They had a mean (SD) age of 61.5 (13.3) years, a mean (SD) body mass index of 28.1 (8.3), a median (IQR) ICU stay of 16.3 (1-108) days, and a median (IQR) LTACH stay of 38.2 (1-227) days. Patients who were discharged home had lower mean (SD) APACHE II (14.6 [5.0] vs 18.2 [5.4], P = .01), SOFA (3.3 [2.1] vs 4.6 [2.1], P = .03), NUTRIC (3.3 [1.4] vs 4.6 [1.4], P = .001), and CCI (4.3 [2.5] vs 6.1 [2.8], P = .02) scores on admission to the LTACH than those who were not discharged home. Severity-of-illness scores on admission to an LTACH can be used to predict patients' likelihood of being discharged home.

Upper airway and tracheostomy management in patients with COVID-19: A long-term acute care hospital (LTACH)

ObjectiveDescribe the tracheostomy and ventilation management of patients admitted due to COVID-19 as facilitated by speech language pathologists (SLPs) and otolaryngologists within the long-term acute care hospital (LTACH) setting. Study designRetrospective cohort study. SettingLong-term acute care hospital. Subjects and methodsA retrospective chart review was conducted on all patients admitted to RML Specialty Hospital for respiratory failure secondary to COVID-19 from April 1, 2020 to November 30, 2021. Demographic information, laryngeal findings, and tracheostomy management was reviewed. Descriptive statistics and chi-square analysis were performed. ResultsAmongst the 213 subjects, 80.0 % arrived on mechanical ventilation. 23.0 % required otolaryngology consultation during LTACH stay due to poor Passy Muir Valve (PMV) or tracheostomy capping tolerance. 35 (71.4 %) of those consulted had abnormal laryngeal findings on exam with subglottic/tracheal stenosis and laryngeal edema being most common at 38.8 % and 20.4 %, respectively. 28.6 % of those with laryngeal findings were decannulated by discharge. Mechanical ventilator weaning and decannulation success were 86.6 % and 62.5 %, respectively. No association (p > 0.05) between number of intubations and abnormal laryngeal findings were found. No association (p > 0.05) between number of intubations or prone-positioning and decannulation success at discharge were found. ConclusionLTACHs can serve a specific role in upper airway rehabilitation and tracheostomy care in the post COVID-19 period. SLPs and otolaryngologists should be involved in the care of these patients to help facilitate decannulation and return to normal laryngeal function.

Characteristics and Outcomes of Tracheostomized Patients With and Without COVID-19.

To create a study evaluating the impact of COVID-19 on tracheostomized patients by comparing clinical outcomes and weaning parameters in COVID-19 positive and negative cohorts. A retrospective observational cohort study of 604 tracheostomized patients hospitalized in 16 ICUs in New York City between March 9, 2020, and September 8, 2021. Patients were stratified into two cohorts: 398 COVID-19 negative (COVID-ve) and 206 COVID-19 positive (COVID+ve) patients. Clinical characteristics, outcomes, and weaning parameters (first pressure support [PS], tracheostomy collar [TC], speech valve placement, and decannulation) were analyzed. COVID+ve had fewer comorbidities including coronary artery disease, congestive heart failure, malignancy, chronic kidney disease, liver disease, and HIV (p < 0.05). Higher Fio2 (53% vs 44%), positive end-expiratory pressure (PEEP) (7.15 vs 5.69), Pco2 (45.8 vs 38.2), and lower pH (7.41 vs 7.43) were observed at the time of tracheostomy in COVID+ve (p < 0.005). There was no statistical difference in post-tracheostomy complication rates. Longer time from intubation to tracheostomy (15.90 vs 13.60 d; p = 0.002), tracheostomy to first PS (2.87 vs 1.80 d; p = 0.005), and TC placement (11.07 vs 4.46 d; p < 0.001) were seen in COVID+ve. However, similar time to speech valve placement, decannulation, and significantly lower 1-year mortality (23.3% vs 36.7%; p = 0.001) with higher number of discharges to long-term acute care hospital (LTACH) (23.8% vs 13.6%; p = 0.015) were seen in COVID+ve. Patients with COVID-19 required higher Fio2 and PEEP ventilatory support at the time of tracheostomy, with no observed change in complication rates. Despite longer initial weaning period with PS or TC, similar time to speech valve placement or decannulation with significantly lower mortality and higher LTACH discharges suggest favorable outcome in COVID-19 positive patients. Higher ventilatory support requirements and prolonged weaning should not be a deterrent to pursuing a tracheostomy.

Clinician-initiated written communication for families of patients at a long-term acute care hospital

ObjectiveTo assess the experience of families and clinicians at a long term acute care hospital (LTACH) after implementing a written communication intervention. MethodsWritten communication templates were developed for six clinical disciplines. LTACH clinicians used templates to describe the condition of 30 mechanically ventilated patients at up to three time points. Completed templates were the basis for written summaries that were sent to families. Impressions of the intervention among families (n = 21) and clinicians (n = 17) were assessed using a descriptive correlational design. Interviews were analyzed using thematic content analysis. ResultsWe identified four themes during interviews with families: Written summaries 1) facilitated communication with LTACH staff, 2) reduced stress related to COVID-19 visitor restrictions, 3) facilitated understanding of the patient condition, prognosis, and goals and 4) facilitated communication among family members. Although clinicians understood why families would appreciate written material, they did not feel that the intervention addressed their main challenge – overly optimistic expectations for patient recovery among families. ConclusionWritten communication positively affected the experience of families of LTACH patients, but was less useful for clinicians. InnovationUse of written patient care updates helps LTACH clinicians initiate communication with families.

A hospital within a hospital: An innovative pharmacy model to improve the continuum of care.

To describe the implementation of a contracted pharmacy service model for a co-located long-term acute care hospital (LTAC). Historically, most LTACs have been free-standing healthcare facilities, but there is an increased trend towards the co-located LTAC ("hospital within a hospital") model. Co-located LTACs represent a solution for the management of patient throughput within a health system, with optimized bed capacity at the host hospital, increased revenue under a prospective payment system, and reduced readmission rates. A co-located LTAC will likely share resources with the host hospital, including ancillary departments such as pharmacy services, through a contractual model. Operationalization of pharmacy services in a co-located LTAC presents unique challenges in the integration of pharmacy services. Pharmacy leaders at Houston Methodist collaborated with executive leadership and other healthcare disciplines to expand services from a free-standing LTAC to a co-located LTAC at the academic medical center location. The contracted pharmacy service operationalization processes in the co-located LTAC comprised licensure and regulations, accreditation, information technology enhancements, a staffing model, operations/distribution services, clinical services, and a defined quality reporting structure. Admissions from the host hospital to the LTAC consisted of patients requiring long-term antibiotic administrations, pre- and post-organ transplant care, complex wound care, oncologic-related treatment, and neurological rehabilitation for strengthening and continued care. The framework described here offers guidance to health-system pharmacy departments to support establishment of a co-located LTAC. The case study outlines challenges, considerations, and processes for implementation of a successful contracted pharmacy service model.