Sharing secrets to success in ventilator weaning
Dr. Vasudeva Raju
Post-acute care facilities must excel at weaning patients off ventilators. After all, what hospital wants to transfer a patient to a facility with mediocre weaning success rates, after its staff has worked very hard to help its patient recover throughout a lengthy ICU stay? What managed care plan wants to pay indefinitely for a patient on a ventilator at an average facility when a different facility can get the patient off the ventilator — and save dollars —more quickly? What post-acute facility can survive bad word of mouth from families who transfer Mom to a different facility where she is successfully weaned? Let's also not forget the patient, whose quality of life will be better breathing solo.
At the Long-Term Acute Care Hospital at NYC Health + Hospitals/Carter, we consistently help more patients who need prolonged mechanical ventilation to be weaned off the ventilator (64%) than the industry average (50%). Certain factors have allowed our 201-bed post-acute care facility to achieve greater success, despite the complexity of our patient population.
To clarify, by “prolonged mechanical ventilation” I mean the need for mechanical ventilation for in excess of 21 days and for six or more hours per day (as opposed to ventilator support following scheduled surgery or other routine care, which is routinely suspended within 72 hours). Patients who need prolonged mechanical ventilation often have extended stays in an intensive care unit — often in a coma (induced or otherwise) — and have usually received a tracheostomy to support ongoing ventilator use. Factors that can make weaning more challenging include a patient's advanced age, the presence or absence of comorbid conditions, respiratory muscle strength, and lung mechanics.
Referring hospitals, managed care plans, and post-acute care facilities should understand that not all facilities perform with the same success. As a long-term acute care hospital with greater success, we want to share three factors that contribute to this success in weaning more patients off mechanical ventilators.
The first factor is the availability of weaning services seven days a week, as opposed to just weekdays at many facilities. In our care, weaning activities are timed to correspond with the patient's recovery stages, rather than the traditional work week. Close collaboration among the respiratory therapist, pulmonologist, and internist — all on staff — allows for customized care to fit the patient's capacity. Weaning is not “one size fits all,” and the team approach, supported by state-of-the-art ventilators, helps patients move from pre-weaning (when the strengthening of respiratory muscles is critical) through weaning, with greater success.
Second, because many patients have comorbidities, it is fairly common for secondary health issues to pop up and become immediate priorities, which can set back progress on respiratory recovery. The solution at NYC Health + Hospitals/Carter is to have physician presence 24/7, so that comorbidities can be aggressively treated, reducing the chances of respiratory setbacks.
Third, speed in tackling comorbidities requires speed in information to guide clinical decision-making. The facility's on-site lab and radiology services provide a level of support available to only a subset of post-acute care facilities. These services make a difference.
Social workers and discharge planners should help families who are deciding where to place a loved one to know the right questions to ask:
- What is your facility's success rate in weaning patients off ventilators?
- Are weaning services conducted seven days a week?
- Is a physician on site round-the-clock?
Not every facility has this level of commitment, but every facility should.
Vasudeva Raju, M.D., is chief medical officer at NYC Health + Hospitals/Carter, a 365-bed post-acute care facility in New York City. Opened in 2013, this 400,000-square-foot facility — a part of the nation's largest public health system — features a 201-bed Long-Term Acute Care Hospital, designed, equipped, and staffed to provide specialized clinical support around the clock, and a 164-bed skilled nursing facility that admits residents whose medical needs require management and care that cannot be provided at home.