RESUMO
BACKGROUND: Chronic ventilator use in Tennessee nursing homes surged following 2010 increases in respiratory care payment rates. Tennessee's Medicaid program implemented multiple policies between 2014 and 2017 to promote ventilator liberation in 11 nursing homes, including quality reporting, on-site monitoring, and pay-for-performance incentives. METHODS: Using repeated cross-sectional analysis of Medicare and Medicaid nursing home claims (2011-2017), hospital discharge records (2010-2017), and nursing home quality reports (2015-2017), we examined how service use changed as Tennessee implemented policies designed to promote ventilator liberation in nursing homes. We measured the annual number of nursing home patients with ventilator-related service use; discharge destination of ventilated inpatients and percent of nursing home patients liberated from ventilators. RESULTS: Between 2011 and 2014, the number of Medicare SNF and Medicaid nursing home patients with ventilator use increased more than sixfold. Among inpatients with prolonged mechanical ventilation, discharges to home decreased as discharges to nursing homes increased. As Tennessee implemented policy changes, ventilator-related service use moderately declined in nursing homes from a peak of 198 ventilated Medicare SNF patients in 2014 to 125 in 2017 and from 182 Medicaid patients with chronic ventilator use in 2014 to 145 patients in 2017. Nursing home weaning rates peaked at 49%-52% in 2015 and 2016, but declined to 26% by late 2017. Median number of days from admission to wean declined from 81 to 37 days. CONCLUSIONS: This value-based approach demonstrates the importance of designing payment models that target key patient outcomes like ventilator liberation.
Assuntos
Reembolso de Incentivo , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Desmame do Respirador/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Masculino , Medicaid , Pessoa de Meia-Idade , Instituições de Cuidados Especializados de Enfermagem/economia , Tennessee , Estados Unidos , Desmame do Respirador/economiaRESUMO
OBJECTIVES: An integrated delivery system with a prospective payment program (IPP) for prolonged mechanical ventilation (PMV) was launched by Taiwan's National Health Insurance (NHI) due to the costly and limited ICU resources. This study aimed to analyze the effectiveness of IPP and evaluate the factors associated with successful weaning and survival among patients with PMV. METHODS: Taiwan's NHI Research Database was searched to obtain the data of patients aged ≥17 years who had PMV from 2006 to 2010 (N=50,570). A 1:1 propensity score matching approach was used to compare patients with and without IPP (N=30,576). Cox proportional hazards modeling was used to examine the factors related to successful weaning and survival. RESULTS: The related factors of lower weaning rate in IPP participants (hazard ratio [HR]=0.84), were older age, higher income, catastrophic illness (HR=0.87), and higher comorbidity. The effectiveness of IPP intervention for the PMV patients showed longer days of hospitalization, longer ventilation days, higher survival rate, and higher medical costs (in respiratory care center, respiratory care ward). The 6-month mortality rate was lower (34.0% vs. 32.9%). The death risk of IPP patients compared to those non-IPP patients was lower (HR=0.91, P<0.001). CONCLUSIONS: The policy of IPP for PMV patients showed higher survival rate although it was costly and related to lower weaning rate.
Assuntos
Sistema de Pagamento Prospectivo/estatística & dados numéricos , Respiração Artificial/economia , Desmame do Respirador/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doença Catastrófica , Comorbidade , Feminino , Humanos , Renda , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde , Avaliação de Programas e Projetos de Saúde , Pontuação de Propensão , Respiração Artificial/mortalidade , Taiwan , Desmame do Respirador/economiaRESUMO
BACKGROUND: Respiratory failure is among the most common primary causes of or complications of critical illness, and although mechanical ventilation can be lifesaving, it also engenders substantial risk of morbidity and mortality to patients. Three decades of research suggests that the duration of invasive mechanical ventilation can be reduced substantially, reducing morbidity and mortality. Mean duration of ventilation reported in recent international studies suggests a quality chasm in management of this common critical illness. METHODS: This is a selective review of the literature and synthesis with precepts of medical professionalism and ethics. CONCLUSIONS: To the extent that daily wake-up-and-breathe reduces morbidity, mortality, and length of stay, failure to deploy this strategy is, by definition, malpractice (ie, poor practice). Practical measures are offered to close this quality chasm.
Assuntos
Cuidados Críticos/normas , Imperícia , Respiração Artificial/normas , Insuficiência Respiratória/terapia , Desmame do Respirador/normas , Cuidados Críticos/economia , Estado Terminal , Medicina Baseada em Evidências , Humanos , Morbidade , Mortalidade , Qualidade da Assistência à Saúde , Respiração Artificial/economia , Desmame do Respirador/economiaRESUMO
PURPOSE: To evaluate the efficacy of a quality improvement (QI) program for protocol-directed weaning from mechanical ventilation. METHODS: This was a prospective, cluster randomized controlled trial. The study consisted of a baseline phase and a QI phase. Fourteen intensive care units (ICUs) in Beijing, China, were randomized into the QI group and non-QI group. The QI group received a QI program to improve the compliance with protocol-directed weaning during the QI phase. RESULTS: A total of 444 patients were enrolled in the non-QI group (193 for the baseline, 251 for the QI phase) and 440 in the QI group (199 for the baseline, 241 for the QI phase). During the QI phase in the QI group, compared with the non-QI group, total duration of mechanical ventilation decreased from 7.0 to 3.0 days (p = 0.003), the time before the first weaning attempt decreased from 3.63 to 1.96 days (p = 0.003), length of ICU stay decreased from 10.0 to 6.0 days (p = 0.004), length of hospital stay decreased from 23.0 to 19.0 days (p < 0.001). These differences were also significant in the QI group when the QI phase was compared with the baseline phase. In addition, there was a significant reduction in the percentage of mechanical ventilation exceeding 21 days (p = 0.001) when the baseline phase was compared with the QI phase in the QI group. CONCLUSIONS: The QI program involving protocol-directed weaning is associated with beneficial clinical outcomes in mechanically ventilated patients.
Assuntos
Unidades de Terapia Intensiva/economia , Tempo de Internação/economia , Guias de Prática Clínica como Assunto , Melhoria de Qualidade/economia , Respiração Artificial/economia , Desmame do Respirador/economia , Desmame do Respirador/normas , Idoso , Idoso de 80 Anos ou mais , Pequim , Feminino , Humanos , Unidades de Terapia Intensiva/normas , Masculino , Avaliação de Programas e Projetos de Saúde , Estudos ProspectivosRESUMO
PURPOSE: Utilization of intensive care services by patients with malignancy has risen during the past several decades. Newer cancer therapies have improved overall survival and outcomes. Patients with respiratory failure from central airway obstruction related to tumor growth were previously viewed as inappropriate candidates for ventilator support. However, an increasing number of reports suggest that interventional pulmonary (IP) procedures may benefit such patients. METHODS: We reviewed the literature for case reports or case series from the past 20 years regarding the use of IP procedures for the treatment of respiratory failure from malignancy-associated central airway obstruction. RESULTS: As a whole, IP procedures were greater than 60 % successful in liberating patients from mechanical ventilation. Moreover, IP procedures served to palliate respiratory symptoms, prolong overall survival, allow for additional cancer treatments, and reduce hospitalization costs. Nevertheless, it remains unclear who may benefit the most from these procedures. CONCLUSIONS: Although data are limited, IP procedures are generally safe and should be considered for appropriate patients with respiratory failure from malignancy-associated central airway obstruction as a potential means of liberation from mechanical ventilation.
Assuntos
Obstrução das Vias Respiratórias/etiologia , Obstrução das Vias Respiratórias/terapia , Neoplasias/complicações , Respiração Artificial/estatística & dados numéricos , Obstrução das Vias Respiratórias/economia , Obstrução das Vias Respiratórias/cirurgia , Hospitalização/economia , Humanos , Metástase Neoplásica , Insuficiência Respiratória/economia , Insuficiência Respiratória/terapia , Stents/economia , Desmame do Respirador/economia , Desmame do Respirador/estatística & dados numéricosRESUMO
BACKGROUND: This study investigated prognosis among patients under prolonged mechanical ventilation (PMV) through exploring the following issues: (1) post-PMV survival rates, (2) factors associated with survival after PMV, and (3) the number of days alive free of hospital stays requiring mechanical ventilation (MV) care after PMV. METHODS: This is a retrospective cohort study based on secondary analysis of prospectively collected data in the national health insurance system and governmental data on death registry in Taiwan. It used data for a nationally representative sample of 25,482 patients becoming under PMV (> = 21 days) during 1998-2003. We calculated survival rates for the 4 years after PMV, and adopted logistic regression to construct prediction models for 3-month, 6-month, 1-year, and 2-year survival, with data of 1998-2002 for model estimation and the 2003 data for examination of model performance. We estimated the number of days alive free of hospital stays requiring MV care in the immediate 4-year period after PMV, and contrasted patients who had low survival probability with all PMV patients. RESULTS: Among these patients, the 3-month survival rate was 51.4%, and the 1-year survival rate was 31.9%. Common health conditions with significant associations with poor survival included neoplasm, acute and unspecific renal failure, chronic renal failure, non-alcoholic liver disease, shock and septicaemia (odd ratio < 0.7, p < 0.05). During a 4-year follow-up period for patients of year 2003, the mean number of days free of hospital stays requiring MV was 66.0 in those with a predicted 6-month survival rate < 10%, and 111.3 in those with a predicted 2-year survival rate < 10%. In contrast, the mean number of days was 256.9 in the whole sample of patients in 2003. CONCLUSIONS: Neoplasm, acute and unspecific renal failure, shock, chronic renal failure, septicemia, and non-alcoholic liver disease are significantly associated with lower survival among PMV patients. Patients with anticipated death in a near future tend to spend most of the rest of their life staying in hospital using MV services. This calls for further research into assessing PMV care need among patients at different prognosis stages of diseases listed above.
Assuntos
Estado Terminal/economia , Atestado de Óbito , Cobertura do Seguro/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Taxa de Sobrevida/tendências , Desmame do Respirador/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estado Terminal/epidemiologia , Estado Terminal/terapia , Análise Discriminante , Feminino , Humanos , Expectativa de Vida , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde , Avaliação de Resultados em Cuidados de Saúde/normas , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Alta do Paciente/tendências , Estudos Retrospectivos , Taiwan/epidemiologia , Fatores de Tempo , Desmame do Respirador/estatística & dados numéricos , Desmame do Respirador/tendênciasRESUMO
INTRODUCTION: The number of patients requiring prolonged mechanical ventilation (PMV) is likely to increase. Transferring patients to specialised weaning units may improve outcomes and reduce costs. The aim of this study was to establish the incidence and outcomes of PMV in a UK administrative health care region without a dedicated weaning unit, and model the potential impact of establishing a dedicated weaning unit. METHODS: A retrospective cohort study was undertaken using a database of admissions to three intensive care units (ICU) in a UK region from 2002 to 2006. Using a 21 day cut-off to define PMV, incidence was calculated using all ICU admissions and ventilated ICU admissions as denominators. Outcomes for the PMV cohort (mortality and hospital resource use) were compared with the non-PMV cohort. Length of ICU stay beyond 21 days was used to model the effect of establishing a weaning unit in terms of unit occupancy rates, admission refusal rates, and healthcare costs. RESULTS: Out of 8290 ICU admission episodes, 7848 were included in the analysis. Mechanical ventilation was required during 5552 admission episodes, of which 349 required PMV. The incidence of PMV was 4.4 per 100 ICU admissions, and 6.3 per 100 ventilated ICU admissions. PMV patients used 29.1% of all general ICU bed days, spent longer in hospital after ICU discharge than non-PMV patients (median 17 vs 7 days, P < 0.001) and had higher hospital mortality (40.3% vs 33.8%, P = 0.02). For the region, in which about 70 PMV patients were treated each year, a weaning unit with a capacity of three beds appeared most cost efficient, resulting in an occupancy rate of 73%, admission refusal rate at 21 days of 36%, and potential cost saving of £344,000 (418,000) using UK healthcare tariffs. CONCLUSIONS: One in every sixteen ventilated patients requires PMV in our region and this group use a substantial amount of health care resource. Establishing a weaning unit would potentially reduce acute bed occupancy by 8-10% and could reduce overall treatment costs. Restructuring the current configuration of critical care services to introduce weaning units should be considered if the expected increase in PMV incidence occurs.
Assuntos
Cuidados Críticos/economia , Unidades de Terapia Intensiva/economia , Regionalização da Saúde/economia , Respiração Artificial/economia , Desmame do Respirador/economia , Adulto , Idoso , Cuidados Críticos/organização & administração , Estado Terminal , Feminino , Recursos em Saúde/economia , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Regionalização da Saúde/organização & administração , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Reino UnidoRESUMO
OBJECTIVE: To investigate the effects of weaning protocols on the total duration of mechanical ventilation, mortality, adverse events, quality of life, weaning duration, and length of stay in the intensive care unit and hospital. DESIGN: Systematic review. DATA SOURCES: Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL, LILACS, ISI Web of Science, ISI Conference Proceedings, Cambridge Scientific Abstracts, and reference lists of articles. We did not apply language restrictions. Review methods We included randomised and quasi-randomised controlled trials of weaning from mechanical ventilation with and without protocols in critically ill adults. Data selection Three authors independently assessed trial quality and extracted data. A priori subgroup and sensitivity analyses were performed. We contacted study authors for additional information. RESULTS: Eleven trials that included 1971 patients met the inclusion criteria. Compared with usual care, the geometric mean duration of mechanical ventilation in the weaning protocol group was reduced by 25% (95% confidence interval 9% to 39%, P=0.006; 10 trials); the duration of weaning was reduced by 78% (31% to 93%, P=0.009; six trials); and stay in the intensive care unit length by 10% (2% to 19%, P=0.02; eight trials). There was significant heterogeneity among studies for total duration of mechanical ventilation (I(2)=76%, P<0.01) and duration of weaning (I(2)=97%, P<0.01), which could not be explained by subgroup analyses based on type of unit or type of approach. CONCLUSION: There is evidence of a reduction in the duration of mechanical ventilation, weaning, and stay in the intensive care unit when standardised weaning protocols are used, but there is significant heterogeneity among studies and an insufficient number of studies to investigate the source of this heterogeneity. Some studies suggest that organisational context could influence outcomes, but this could not be evaluated as it was outside the scope of this review.
Assuntos
Estado Terminal/terapia , Desmame do Respirador/métodos , Adulto , Protocolos Clínicos/normas , Custos e Análise de Custo , Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Estado Terminal/economia , Estado Terminal/mortalidade , Mortalidade Hospitalar , Humanos , Tempo de Internação , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Viés de Seleção , Fatores de Tempo , Desmame do Respirador/economia , Desmame do Respirador/mortalidadeRESUMO
Up to 20% of patients requiring mechanical ventilation will suffer from difficult weaning (the need of more than 7 days of weaning after the first spontaneous breathing trial), which may depend on several reversible causes: respiratory and/or cardiac load, neuromuscular and neuropsychological factors, and metabolic and endocrine disorders. Clinical consequences (and/or often causes) of prolonged mechanical ventilation comprise features such as myopathy, neuropathy, and body composition alterations and depression, which increase the costs, morbidity and mortality of this. These difficult-to-wean patients may be managed in two type of units: respiratory intermediate-care units and specialized regional weaning centers. Two weaning protocols are normally used: progressive reduction of ventilator support (which we usually use), or progressively longer periods of spontaneous breathing trials. Physiotherapy is an important component of weaning protocols. Weaning success depends strongly on patients’ complexity and comorbidities, hospital organization and personnel expertise, availability of early physiotherapy, use of weaning protocols, patients’ autonomy and families’ preparation for home discharge with mechanical ventilation.
Assuntos
Respiração Artificial , Insuficiência Respiratória/terapia , Desmame do Respirador/métodos , Cuidados Críticos , Custos de Cuidados de Saúde , Humanos , Alta do Paciente , Modalidades de Fisioterapia , Recuperação de Função Fisiológica , Respiração Artificial/efeitos adversos , Respiração Artificial/economia , Testes de Função Respiratória , Insuficiência Respiratória/economia , Insuficiência Respiratória/fisiopatologia , Músculos Respiratórios/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Desmame do Respirador/efeitos adversos , Desmame do Respirador/economiaRESUMO
BACKGROUND: Respiratory intermediate care units (RICU) are hospital locations to treat acute and acute on chronic respiratory failure. Dedicated weaning centers (WC) are facilities for long-term weaning. AIM: We propose and describe the initial results of a long-term weaning model consisting of sequential activity of a RICU and a WC. METHODS: We retrospectively analysed characteristics and outcome of tracheostomised difficult-to wean patients admitted to a RICU and, when necessary, to a dedicated WC along a 18-month period. RESULTS: Since February 2008 to November 2009, 49 tracheostomised difficult-to wean patients were transferred from ICUs to a University-Hospital RICU after a mean ICU length of stay (LOS) of 32.6 +/- 26.6 days. The weaning success rate in RICU was 67.3% with a mean LOS of 16.6 +/- 10.9 days. Five patients (10.2%) died either in the RICU or after being transferred to ICU, 10 (20.4%) failed weaning and were transferred to a dedicated WC where 6 of them (60%) were weaned. One of these patients was discharged from WC needing invasive mechanical ventilation for less than 12h, 2 died in the WC, 1 was transferred to a ICU. The overall weaning success rate of the model was 79.6%, with 16.3% and 4.8% in-hospital and 3-month mortality respectively. The model resulted in an overall 39 845 +/- 22 578 euro mean cost saving per patient compared to ICU. CONCLUSION: The sequential activity of a RICU and a WC resulted in additive weaning success rate of difficult-to wean patients. The cost-benefit ratio of the program warrants prospective investigations.
Assuntos
Unidades de Terapia Intensiva/economia , Tempo de Internação/economia , Insuficiência Respiratória/economia , Desmame do Respirador/economia , Idoso , Análise Custo-Benefício , Feminino , Humanos , Itália , Masculino , Modelos Econômicos , Avaliação de Resultados em Cuidados de Saúde , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Traqueostomia/mortalidade , Resultado do Tratamento , Desmame do Respirador/mortalidade , Desmame do Respirador/normasRESUMO
AIM: To analyse the diagnosis-related characteristics and the costs of treating patients with difficult/prolonged weaning from mechanical ventilation we have undertaken a retrospective observational study. METHODS: The study has considered all the patients admitted to our weaning unit of a regional Rehabilitation department during 3 consecutive periods since the opening date. Characteristics of the admitted patients and the DRG-related cares delivered have been recorded. A cost analysis has been obtained over time. RESULTS: The number of beds allocated to this unit (from 4 in the 1st period to 6 in the 2nd and 3rd periods) and the number of patients cared for (from 32 to 43 and to 65, respectively) increased over time. In particular, the COPD to non-COPD patient ratio (from 2.2 to 1.3 and to 1.0) and the DRG/patient weight (from 3.0 +/- 0.3 to 3.1 +/- 0.2 and to 3.3 +/- 0.2 point) changed significantly (p < 0.05). The daily reimbursement per patient from the public health care system only slightly increased, whereas the operating margin (reimbursement less costs) per patient significantly improved (from -304, to +17 and +55 Euro/pt/day, respectively, p < 0.05) due to a gradual restriction in the variable costs. Length of stay, mortality rate and weaning rate did not change over time. CONCLUSION: The weaning centre is a hospital area where economic burdens should be carefully evaluated. Given the actual reimbursement received on a national level for these patients, variable costs might be better spread, thus optimising the burdens without losing out on clinical outcomes.
Assuntos
Unidades de Cuidados Respiratórios/economia , Desmame do Respirador/economia , Estudos de Coortes , Custos e Análise de Custo , Humanos , Itália , Tempo de Internação/economia , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/economia , Doença Pulmonar Obstrutiva Crônica/terapia , Mecanismo de Reembolso/economia , Estudos RetrospectivosRESUMO
PURPOSE: To compare the Therapeutic Intervention Scoring System (TISS) 28 in difficult to wean patients before and after transfer to a weaning center. PATIENTS AND METHODS: Using TISS-28, the authors investigated the difference between regular intensive care units (ICUs) and the respiratory ICU (RICU) of their hospital in difficult to wean patients after long-term mechanical ventilation (MV). Special emphasis was placed on the appropriateness of TISS-28 to cover the specific weaning activities. 63 tracheotomized patients ventilated for more than 14 days were included. RESULTS: In total, 15.9% of patients were not weaned, 20.6% of population was successfully weaned with noninvasive ventilation (NIV), and 63.5% of patients was successfully weaned without NIV. The transfer of patients from other ICUs to a weaning facility resulted in a significant reduction of total TISS-28 from 29.5 to 23.8 points (p<0.001) on average. CONCLUSION: The high weaning success rate in a specialized facility is associated with a significant reduction of TISS-28 scores. The use of TISS-28 in a weaning center for patients with prolonged MV to measure workload does not adequately mirror the efforts by physicians, nurses, physiotherapists, and other health-care personnel.
Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Unidades de Terapia Intensiva/economia , Assistência de Longa Duração/economia , Unidades de Cuidados Respiratórios/economia , Desmame do Respirador/economia , APACHE , Idoso , Feminino , Alemanha , Custos Hospitalares/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/economia , Avaliação de Processos e Resultados em Cuidados de Saúde , Equipe de Assistência ao Paciente/economia , Transferência de Pacientes/economia , Mecanismo de Reembolso/economiaRESUMO
OBJECTIVE: To describe the outcome of patients admitted to a new private facility for chronically ventilated patients in the Ashdod area of Israel. METHODS: On arrival, all patients were placed on Adaptive Support Ventilation (ASV) at 90% of target minute ventilation for lean body weight, reducing progressively in weekly decrements of 10% down to 60% of target minute ventilation if adequate spontaneous ventilation was maintained by the patient. RESULTS: Almost half (12/27) of these patients admitted in the first 12 months following establishment of the facility were successfully weaned from mechanical ventilation within 2 weeks to 2 months of admission. CONCLUSIONS: The cost effectiveness of this form of closed loop mechanical ventilation in achieving weaning automatically, without the need for respiratory therapists or continuous attendance by intensive care specialists to conduct weaning trials is demonstrated by these results.
Assuntos
Desmame do Respirador/métodos , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Feminino , Humanos , Israel , Masculino , Pessoa de Meia-Idade , Desmame do Respirador/economiaRESUMO
Weaning patients from ventilation can be a costly and time-consuming intervention. This article describes how a protocol was designed and introduced into the critical care unit of a district general hospital in 2003. A step-by-step approach was used based on that outlined by the Modernisation Agency and The National Institute for Clinical Excellence. The purpose of the project was to improve the weaning process in the unit by devising a protocol, which would give structure to weaning and help maintain continuity. It was hoped that the changes in practice would also reduce ventilator time and improve patient outcomes. A multi-professional group interested in weaning worked together to formulate a protocol, which was duly implemented into the unit. After implementation, the protocol was audited and subsequently adopted by the unit. Although it was agreed that the structure and the continuity of weaning had improved, reducing weaning times and patient outcomes was difficult to measure. This article explains how the protocol came to be written and how it was implemented into the unit.
Assuntos
Protocolos Clínicos , Cuidados Críticos/métodos , Guias de Prática Clínica como Assunto , Respiração Artificial/enfermagem , Desmame do Respirador/métodos , Algoritmos , Pesquisa em Enfermagem Clínica , Controle de Custos , Cuidados Críticos/economia , Cuidados Críticos/normas , Árvores de Decisões , Educação Continuada em Enfermagem/organização & administração , Inglaterra , Hospitais de Distrito , Hospitais Gerais , Humanos , Avaliação em Enfermagem , Auditoria de Enfermagem , Recursos Humanos de Enfermagem Hospitalar/educação , Seleção de Pacientes , Projetos Piloto , Técnicas de Planejamento , Comitê de Profissionais/organização & administração , Fatores de Tempo , Gestão da Qualidade Total/organização & administração , Desmame do Respirador/economia , Desmame do Respirador/enfermagem , Desmame do Respirador/normasRESUMO
In this controlled, randomised cross-over trial on 26 intensive care patients, we compared the effects on haemodynamic and respiratory profiles of continuous positive airway pressure delivered through the Hamilton Galileo ventilator or a Drager CF 800 device. We also compared the nursing time saved using the two approaches when weaning patients from mechanical ventilation. We did not find significant differences in haemodynamics, respiratory rate, physiological dead space, oxygen saturation and carbon dioxide production between the continuous positive airway pressure generated by the Galileo and Drager machines. However, there was a 10-fold reduction in nursing time using the Galileo ventilator compared with the Drager generator. We conclude that continuous positive airway pressure delivered through the Galileo ventilator is as efficient as a Drager device but consumes less nursing time.
Assuntos
Pressão Positiva Contínua nas Vias Aéreas/instrumentação , Ventiladores Mecânicos , Adulto , Idoso , Pressão Sanguínea , Pressão Positiva Contínua nas Vias Aéreas/economia , Pressão Positiva Contínua nas Vias Aéreas/enfermagem , Cuidados Críticos , Estudos Cross-Over , Feminino , Frequência Cardíaca , Custos Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Fenômenos Fisiológicos Respiratórios , Desmame do Respirador/economia , Desmame do Respirador/enfermagemRESUMO
BACKGROUND: Among the most resource intensive and challenging of medical needs is the treatment of patients requiring long-term or chronic mechanical ventilation. Expenditures are significant, and definitions of "successful weaning," are often inconsistent. A weaning program was initiated for patients referred to a stand-alone nursing home ventilator unit. METHODS: Weaning entailed standardized weaning protocols, enhanced socialization, a multidisciplinary approach to care, empowerment of staff to initiate weaning, and aggressive utilization of noninvasive positive pressure ventilation (NPPV) in selected patients. RESULTS: Sixty-eight (67%) of 102 patients were successfully weaned during a six-year period. NPPV facilitated successful weaning in 27 (26%) of 102 patients. Of the 28 chronic ventilator-dependent patients admitted with a neuromuscular etiology for respiratory failure, NPPV was utilized in 73% (8/11) of the successfully weaned patients. Total variable costs per ventilator per patient per day for the years 1998-2000 were $319.79, $302.75, and $297.59. Six-year cost savings for referring hospitals were estimated at $18.5 million. DISCUSSION: Incentives were aligned between the hospital, nursing home, and physicians to develop a financially stable model. Developing an off-site nursing home ventilator unit resulted in significant cost savings to the referring hospitals and positively affected patient flow.
Assuntos
Unidades de Terapia Intensiva , Casas de Saúde , Transferência de Pacientes , Garantia da Qualidade dos Cuidados de Saúde , Desmame do Respirador , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/estatística & dados numéricos , Pessoa de Meia-Idade , Casas de Saúde/economia , Casas de Saúde/estatística & dados numéricos , Equipe de Assistência ao Paciente , Transferência de Pacientes/economia , Respiração com Pressão Positiva , Desmame do Respirador/economia , Desmame do Respirador/métodos , WisconsinRESUMO
BACKGROUND: Patients requiring mechanical ventilation for prolonged periods typically are sicker and have more comorbid illnesses than do patients who can be weaned more rapidly. As a result, the weaning process is often complex, requiring shared decision making by a skilled, multidisciplinary team. Unfortunately, many of the structures used in critical care units to plan and evaluate care do not lend themselves to collaborative management of patients. OBJECTIVE: To evaluate the effect of a collaborative weaning plan on outcomes, including duration of mechanical ventilation, for patients treated with mechanical ventilation for 7 days or more. METHODS: A collaborative weaning plan (weaning board and flow sheet) was introduced into the medical intensive care unit at the University of California Los Angeles, Medical Center. A historical design was used to compare outcomes before and after the plan was used. The primary outcome variable was duration of mechanical ventilation. Other outcomes studied included length of stay in the unit, cost, prevalence of complications (ie, reventilation, readmission to the intensive care unit), and mortality rate. RESULTS: The collaborative weaning plan decreased duration of ventilation by 4.9 days (P=.02) and decreased median length of stay in the unit by 4.5 days (P=.004). The median cost per stay in the unit decreased from $50462 to $37330 (P=.004). The prevalence of complications did not differ significantly between groups. CONCLUSIONS: Collaborative structures (eg, weaning boards, flow sheets) are useful in decreasing duration of mechanical ventilation for patients receiving long-term ventilation.
Assuntos
Cuidados Críticos/organização & administração , Planejamento de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Desmame do Respirador/métodos , APACHE , Adulto , Distribuição de Qui-Quadrado , Comportamento Cooperativo , Tomada de Decisões Gerenciais , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Prognóstico , Fatores de Tempo , Resultado do Tratamento , Desmame do Respirador/efeitos adversos , Desmame do Respirador/economiaRESUMO
OBJECTIVE: The process of weaning from mechanical ventilation can be complex, requiring collaborative care planning by members of the healthcare team. Improved outcomes have been demonstrated to result from collaborative decision-making processes (e.g., when ventilator teams were utilized). The purpose of this study was to evaluate the effect of a collaborative weaning plan (CWP) on length of time on mechanical ventilation, length of stay in the intensive care unit (ICU), and cost. DESIGN: A new, collaborative weaning plan in the form of a weaning board and flowsheet was introduced into a medical intensive care unit (MICU) setting. A pre- and post-quasi-experimental design using historical controls was used to test the hypotheses. Attempts to control for the effects of history were made by collecting data related to patient, staffing, and organizational variables that could independently effect outcome. SETTING: MICU in a west coast teaching hospital. PATIENTS: Critically ill patients receiving mechanical ventilation for 3 days or greater. INTERVENTION: Implementation of a collaborative weaning plan. MEASUREMENTS: Outcomes studied included length of stay in the MICU, length of time patients were mechanically ventilated in the MICU, cost per MICU stay, and the incidence of complications (e.g., reventilation, readmission to the ICU, and mortality rate). MAIN RESULTS: The CWP decreased length of stay in the MICU by 3.6 days (p =.03) and length of ventilator time by 2.7 days (p =.06). There were no significant differences between groups related to cost or incidence of complications. CONCLUSIONS: These results support the usefulness of collaborative structures (such as weaning boards/flowsheets) in decreasing ICU length of stay.
Assuntos
Comportamento Cooperativo , Cuidados Críticos/organização & administração , Relações Interprofissionais , Planejamento de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Desmame do Respirador/métodos , APACHE , Adulto , Idoso , Tomada de Decisões Gerenciais , Feminino , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Prontuários Médicos , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Prognóstico , Fatores de Tempo , Resultado do Tratamento , Desmame do Respirador/efeitos adversos , Desmame do Respirador/economiaRESUMO
STUDY OBJECTIVE: Economic forces have precipitated intense interest in cost-saving practices for patients undergoing coronary artery bypass grafting (CABG). While several preoperative variables have been implicated in higher costs, few studies have included perioperative factors. This study evaluated the predictive power of a preoperative mortality risk measurement (Parsonnet score) and of early extubation (< or = 6 h from ICU admission) in determining ICU and hospital costs. DESIGN: Multivariate correlational design. SETTING: University hospital in a large metropolitan area. PATIENTS: All patients (n = 116) undergoing isolated CABG during a 6-month period were studied after the introduction of a clinical pathway. MEASUREMENTS AND RESULTS: Clinical data were collected. Costs data were obtained retrospectively from the institutional data system and were derived from individual patient charges by application of department-specific cost-to-charge ratios. In multivariate logistic regression, Parsonnet score (per point odds ratio [OR], 1.09; confidence interval [CI], 1.03 to 1.17), in-hospital coronary angiography (OR, 3.51; CI, 1.23 to 10.01), delayed extubation (OR, 4.59; CI, 1.29 to 16.29), and presence of arrhythmia (OR, 3.50; CI, 1.15 to 10.64) were independent predictors of ICU costs. Only Parsonnet score (OR, 1.09; CI, 1.03 to 1.15) and cardiopulmonary bypass time (OR, 1.01; CI, 1.00 to 1.02) were independent predictors of hospital costs. CONCLUSIONS: The Parsonnet score is a useful indicator of both ICU and hospital costs. Early extubation is associated with decreased ICU costs, but is not independently predictive of hospital costs.