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Abstract & Commentary
Outcomes After Prolonged Mechanical Ventilation: Not as Favorable as One Might Wish
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: In this single-center study of what happened to 126 consecutive patients who survived an ICU admission requiring prolonged mechanical ventilation, 56% of them were alive after 1 year, but only 11 of these were functioning independently. On average, the patients spent 74% of all post-discharge days in the hospital, in a postacute care facility, or at home receiving paid home health care.
Source: Unroe M, et al. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: A cohort study. Ann Intern Med 2010;153:167-175.
Unroe and associates prospectively enrolled 126 consecutive survivors of prolonged mechanical ventilation, along with their surrogates, and followed them for 1 year after discharge from the ICU. All patients were managed in one of the ICUs at Duke University Medical Center (adult general surgical, trauma, neurologic, cardiothoracic surgery, cardiac, and medical ICUs). Entry criteria included age > 18 years, English fluency, an identifiable surrogate decision-maker, and hospital discharge after an ICU stay that involved either at least 21 days of ventilatory support, or tracheostomy after at least 4 days ventilated. The investigators interviewed patients, surrogates, and the primary ICU physicians that had managed them, within 48 hours of study eligibility, with respect to the expectations for survival and eventual functional independence among each of these groups. Patients and surrogates were interviewed again 3 and 12 months later with respect to health care utilization and quality of life. Quality of life was determined via the EuroQol-5D instrument, which has been validated for this purpose in critical illness survivors and their surrogates. Data on resource utilization were obtained from the medical records, billing records, and participant interviews.
Eighty percent of eligible patients and/or surrogates during the study period agreed to participate and were enrolled. The included patients' mean age was 55 years (range, 19-85 years), with 60% male, 53% white, 38% black, and 9% other ethnicity. The primary ICU admission diagnosis was respiratory failure in 23% of patients, neurologic in 23%, trauma 21%, postoperative 21%, septic shock 8%, and cardiac 4%. Median ventilator days were 27 and hospital days 39 prior to discharge. Complete follow-up data were obtained for all 126 patients.
Twenty-three patients (18%) died in the hospital after discharge from the ICU, and all of them were still receiving mechanical ventilation at the time of death. Of the 103 initial survivors, 74% were discharged to a postacute care facility. At 1 year, 70 patients (56%) were still alive, although only 11 (9%) were independently functioning (that is, were at home without paid health care assistance), and only 19 (27%) had good quality of life. Both ICU physicians and surrogates substantially overestimated the likelihood of recovery and eventual independence. During the 1-year follow-up there were 457 transitions in care location (median 4 per patient), and 150 hospital readmissions among 68 of the 103 initial hospital survivors. The average patient spent 74% of all days alive (95% confidence interval, 68%-80%) in a hospital or postacute care facility, or was receiving home health care. Only 3 patients were both initially discharged to their home and remained there during the 1-year follow-up; only 3 of 54 previously employed patients ever returned to work. Mean total 1-year health care cost was $306,135 per patient, 73% of which was for the initial acute-care hospitalization. The 1-year costs did not differ by health outcome.
As hospital medicine becomes more and more compartmentalized, with emergency physicians, intensivists, and hospitalists each focusing on their own practice context and less and less continuity with other disciplines, it is easy to lose track of patients once one's own "task" is done. In the day-to-day life of an intensivist, getting patients out of the unit alive tends to become a main de facto object of the game. This study's findings are sobering and discouraging with respect to the feelings of "mission accomplished" one may have on bringing a prolonged, complicated case through successfully to ICU discharge. The findings also emphasize something else familiar to intensivists: Many if not most patients who transfer out after prolonged mechanical ventilation are likely to be readmitted, and often more than once, in the weeks and months that follow.
This study looked only at patients cared for in a single hospital in North Carolina, and thus the generalizability of the findings in other regions and patient populations is uncertain. However, its results are both clear and consistent with those of other studies of outcomes and costs in "chronic critical illness." Prolonged mechanical ventilation is common in critical care and its prevalence may well increase in the future. Although results may generally be somewhat better in certain patient categories such as younger individuals and those with trauma who were previously fully functional prolonged mechanical ventilation is highly resource-intensive and associated with generally poor long-term functional outcomes among patients who survive to leave the ICU. The need for better prognostication, earlier in the course of illness, and also for more accurate appreciation and communication of the likely course and outcome, among all who are involved in managing the patients and making decisions on their behalf, seems clear. Unfortunately, how these things are to be achieved is less apparent at present.