Complex Ventilator Patients: Four insights on challenges and protocols to reduce readmissions

Managing critically ill, medically complex ventilator patients with multiple comorbidities poses significant challenges related to throughput, length of stay, readmissions and risk of hospital-acquired conditions.

During Becker's Hospital Review's 12th Annual Meeting in Chicago, Special Care Unit led a roundtable discussion on best practices for hospitals interested in developing an in-house, multidisciplinary ventilator-weaning unit. The panelists were:

• Sam Nimah, Chief Executive Officer, Special Care Unit

• Phillip R. Morris, RN, BSN, Chief Business Development Officer, Special Care Providers

• Elizabeth Turnipseed, MD, Vice Chair Clinical Affairs/Chief of Medical Staff, UAB Hospital in Birmingham, Ala.

SCU Chief Business Development Officer, Phillip Morris, and SCU Care Manager, Tamika Moody, at Becker's 12th Annual Meeting.

Four insights:

1. Traditional approaches to managing complex ventilator patients can lead to negative outcomes. When these patients stay in the intensive care unit, care coordination suffers. "In many short-term acute care hospitals, complex patients are scattered across multiple ICUs," Dr. Turnipseed said. "Providers spend a lot of time traveling between units and in so doing, they miss opportunities to overlap with other critical care team members. This contributes to provider burnout and reduced efficiency. Due to complex logistics and a lack of coordinated, multidisciplinary care, patients suffer worse outcomes."
   

2. Yet, long-term acute care hospitals (LTACHs) aren't the answer for this patient population. When ventilator patients transfer to LTACHs, both readmission and mortality rates tend to be high, according to the presenters.
   

3. Multidisciplinary vent-weaning units in short-term acute care hospitals have demonstrated success. Special Care Unit consolidates ventilator patients in small, highly specialized units within hospitals. "Our high-touch units have nine to 12 beds," Mr. Morris said. "They are seamlessly embedded in the hospital. Patients simply transfer into the unit — there's no need for discharge and readmission." The patient to nurse ratio is typically 3:1, while the ratio of patients to personal care assistants is 5-6:1. One or more registered respiratory therapists work every day and every shift. Physical therapists and occupational therapists work with patients six days a week, or as frequently as patients can tolerate, according to Mr. Morris. "Intensivists love this concept because we can decompress the ICU," he said. "Hospitalists love it because when they come onto the unit, all the disciplines are there."
   

4. UAB Hospital has seen positive results among its complex ventilator patients. UAB Hospital is a Level 1 Trauma Center and a large teaching hospital. "One of the things that piqued our interest about the Special Care Unit model was having a place distinct from our ICUs that could manage patients as a step-down capability," Dr. Turnipseed said. "It offered a way to decant the ICU and bring in additional patients who were critically ill."

In 2016, the organization partnered with Special Care Unit to create a vent-weaning unit. UAB Hospital set an annual ventilator wean target rate of 75 percent and has surpassed that figure by achieving an 84.5 percent wean rate. In terms of 30-day readmission rates for this patient population, UAB Hospital established a target of 10 percent and the unit has seen readmissions of 5.8 percent.

The Special Care Unit approach is a win for patients and health systems alike. "We believe that getting these complex, sick patients healthy in the short-term acute care hospital setting is the key to success," Mr. Nimah said. "From an economic perspective, we can provide hospitals in the right markets with significant savings and revenue improvement."