PURPOSE: We have observed recurrent admissions of individual ventilator patients from eight local SNFs to our hospital. They all had long hospital stays and weaning was seldom attempted during these admissions. The only diagnosis provided for most of them was Chronic Ventilator Dependence (CVD-code V-4611). To investigate these issues, joint ventilator rounds were conducted by Pulmonary Medicine and Respiratory Therapy from April through November 2009 evaluating the weaning potential of all patients with admission diagnoses of CVD.
METHODS: Design: Prospective collection of demographics, lung and muscle function, weaning attempts and outcomes of all mechanically ventilated patients on medical-surgical floors. Medical stability, pulmonary mechanics and spontaneous breathing trials(SBTs) were used to assess weaning potential.
RESULTS: Of 81 patients evaluated, 71 were maintained in SNFs as having CVD. 21 of them had good weaning potential. They were 74±12 years old, m/f=15/6, with a mean length of stay of 20±19 days. Their pulmonary compliance was 43±15ml/cmH2O and Raw was 19±6cmH2O/l/s. On SBTs, RR=27±6b/m and Vt=334±160ml with SaO2=99% on 38%O2. 6 had weaning attempts requested by their physicians and all were successfully weaned. Of these, 4 were replaced on mechanical ventilation immediately on return to their SNF “by protocol”, without evaluation. Only 12 had pulmonary consultation during admission. NYSDOH publications show that reimbursement for mechanically ventilated patients in Bronx/Queens SNFs is $649±58/day versus $247±31/day for non-ventilated patients.
CONCLUSION: 1)Many patients considered to have CVD can breathe spontaneously, but are seldom evaluated for weaning. 2)There are potential procedural and financial barriers to weaning in custodial ventilator units. 3)Current coding practice impedes usable record keeping in ventilator units. 4)These results are generalizable in view of the variety of SNFs and practitioners caring for these patients.
CLINICAL IMPLICATIONS: 1)All CVD patients should have periodic SBTs regardless of duration of mechanical ventilation. 2)Any patient weaned offsite should be evaluated by a physician before being returned to mechanical ventilation. 3)Reimbursement policies for mechanically ventilated patients should be revised. 4)Nursing home records should communicate pathologic diagnoses in order to facilitate treatment.
DISCLOSURE: William Marino, No Financial Disclosure Information; No Product/Research Disclosure Information