Time spent in prior hospital stay and outcomes for ventilator patients in long-term acute care hospitals.
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ABSTRACT: Background
Long-term acute care hospitals (LTACHs) treat mechanical ventilator patients who are difficult to wean and expected to be on mechanical ventilator for a prolonged period. However, there are varying views on who should be transferred to LTACHs and when they should be transferred. The purpose of this study is to assess the relationship between length of stay in a short-term acute care hospital (STACH) after endotracheal intubation (time to LTACH) and weaning success and mortality for ventilated patients discharged to an LTACH.Methods
Using 2014-2015 Medicare claims and assessment data, we identified patients who had an endotracheal intubation in STACH and transferred to an LTACH with prolonged mechanical ventilation (defined as 96 or more consecutive hours on a ventilator). We controlled for age, gender, STACH stay procedures and diagnoses, Elixhauser comorbid conditions, and LTACH quality characteristics. We used instrumental variable estimation to account for unobserved patient and provider characteristics.Results
The study cohort included 13,622 LTACH cases with median time to LTACH of 18 days. The unadjusted ventilator weaning rate at LTACH was 51.7%, and unadjusted 90-day mortality rate was 43.7%. An additional day spent in STACH after intubation is associated with 11.6% reduction in the odds of weaning, representing a 2.5 percentage point reduction in weaning rate at 18 days post endotracheal intubation. We found no statistically significant relationship between time to LTACH and the odds of 90-day mortality.Conclusions
Discharging ventilated patients earlier from STACH to LTACH is associated with higher weaning probability for LTACH patients on prolonged mechanical ventilation. Our findings suggest that delaying ventilated patients' discharge to LTACH may negatively influence the patients' chances of being weaned from the ventilator.
SUBMITTER: Demiralp B
PROVIDER: S-EPMC7990091 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:PURPOSE:We sought to examine variation in long-term acute care hospital (LTACH) quality based on 90-day in-hospital mortality for patients admitted for weaning from mechanical ventilation. METHODS:We developed an administrative risk-adjustment model using data from Medicare claims. We validated the administrative model against a clinical model using data from LTACHs participating in a 2002 to 2003 clinical registry. We then used our validated administrative model to assess national variation in 90-day in-hospital mortality rates in LTACHs from 2013. RESULTS:The administrative risk-adjustment model was derived using data from 9447 patients admitted to 221 LTACHs in 2003. The model had good discrimination (C statistic=0.72) and calibration. Compared to a clinically derived model using data from 1163 patients admitted to 14 LTACHs, the administrative model generated similar performance estimates. National variation in risk-adjusted mortality was assessed using data from 20,453 patients admitted to 380 LTACHs in 2013. LTACH-specific risk-adjusted mortality rates varied from 8.4% to 48.1% (median: 24.2%, interquartile range: 19.7%-30.7%). CONCLUSIONS:LTACHs vary widely in mortality rates, underscoring the need to better understand the sources of this variation and improve the quality of care for patients requiring long-term ventilator weaning.
| S-EPMC6014911 | biostudies-literature
Project description:BackgroundQuality care depends on effective communication between caregivers, but it is unknown whether time spent communicating is associated with communication outcomes.ObjectiveTo assess the association between time spent communicating, agreement on plan of care, and patient satisfaction.DesignTime-motion study with cross-sectional survey.SettingAcademic medical center.ParticipantsPhysicians, patients, and nurses on a hospital medicine service.MeasurementsHospitalists' forms of communication were timed with a stopwatch. Physician-nurse agreement on the plan of care and patient satisfaction with physician communication were assessed via survey.ResultsEighteen hospitalists were observed caring for 379 patients. On average, physicians spent more time per patient on written than verbal communication (median: 9.2 min. vs. 6.3 min, p<0.001). Verbal communication was greatest with patients (mean time 5.3 min, range 0-37 min), then other physicians (1.4 min), families (1.1 min), nurses (1.1 min), and case managers (0.4 min). There was no verbal communication with nurses in 30% of cases. Nurses and physicians agreed most about planned procedures (87%), principal diagnosis (74%), tests ordered (73%), anticipated discharge date (69%) and least regarding medication changes (59%). There was no association between time spent communicating and agreement on plan of care. Among 123 patients who completed surveys (response rate 32%), time physicians spent talking to patients was not correlated with patients' satisfaction with physician communication (Pearson correlation coefficient = 0.09, p=0.30).ConclusionsHospitalists vary in the amount of time they spend communicating, but we found no association between time spent and either patient satisfaction or nurse-physician agreement on plan of care.
| S-EPMC3270236 | biostudies-literature
Project description:BackgroundMechanical ventilation (MV) via tracheostomy is performed commonly for patients who are in long-term acute care hospitals (LTACHs) after respiratory failure. However, the outcome of MV in COVID-19-associated respiratory failure in LTACHs is not known.Research questionWhat is the ventilator liberation rate of patients who have received tracheostomy with COVID-19-associated respiratory failure compared with those with respiratory failure unrelated to COVID-19 in LTACHs?Study design and methodsIn this retrospective cohort study, we examined mechanically ventilated patients discharged between June 2020 and March 2021. Of 242 discharges, 165 patients who had undergone tracheostomy arrived and were considered for ventilator liberation. One hundred twenty-eight patients did not have COVID-19 and 37 patients were admitted for COVID-19.ResultsThe primary outcome of the study was ventilator liberation; secondary outcomes were functional recovery, length of stay (LOS) at the LTACH, and discharge disposition. After controlling for demographics, the number of comorbidities, hemodialysis, vasopressor need, thrombocytopenia, and the LOS at the short-term acute care hospital, our results indicated that patients with COVID-19 showed a higher adjusted ventilator liberation rate of 91.4% vs 56.0% in those without COVID-19. Functional ability was assessed with the change of Functional Status Score for the Intensive Care Unit (FSS-ICU) between admission and discharge. The adjusted mean change in FSS-ICU was significantly higher in the COVID-19 group than in the non-COVID-19 group: 9.49 (95% CI, 7.38-11.6) vs 2.08 (95% CI, 1.05-3.11), respectively (P < .001). Patients with COVID-19 experienced a shorter adjusted LOS at the LTACH with an adjusted hazard ratio of 1.57 (95% CI, 1.0-2.46; P = .05) compared with patients without COVID-19. We did not observe significant differences between the two groups regarding discharge location, but a trend toward need for lower level of care was found in patients with COVID-19.InterpretationOur study suggests that patients with COVID-19 requiring MV and tracheostomy have a higher chance for recovery than those without COVID-19.
| S-EPMC8875856 | biostudies-literature
Project description:ImportanceNon-ventilator-associated hospital-acquired pneumonia (NV-HAP) is a common and deadly hospital-acquired infection. However, inconsistent surveillance methods and unclear estimates of attributable mortality challenge prevention.ObjectiveTo estimate the incidence, variability, outcomes, and population attributable mortality of NV-HAP.Design, setting, and participantsThis cohort study retrospectively applied clinical surveillance criteria for NV-HAP to electronic health record data from 284 US hospitals. Adult patients admitted to the Veterans Health Administration hospital from 2015 to 2020 and HCA Healthcare hospitals from 2018 to 2020 were included. The medical records of 250 patients who met the surveillance criteria were reviewed for accuracy.ExposuresNV-HAP, defined as sustained deterioration in oxygenation for 2 or more days in a patient who was not ventilated concurrent with abnormal temperature or white blood cell count, performance of chest imaging, and 3 or more days of new antibiotics.Main outcomes and measuresNV-HAP incidence, length-of-stay, and crude inpatient mortality. Attributable inpatient mortality by 60 days follow-up was estimated using inverse probability weighting, accounting for both baseline and time-varying confounding.ResultsAmong 6 022 185 hospitalizations (median [IQR] age, 66 [54-75] years; 1 829 475 [26.1%] female), there were 32 797 NV-HAP events (0.55 per 100 admissions [95% CI, 0.54-0.55] per 100 admissions and 0.96 per 1000 patient-days [95% CI, 0.95-0.97] per 1000 patient-days). Patients with NV-HAP had multiple comorbidities (median [IQR], 6 [4-7]), including congestive heart failure (9680 [29.5%]), neurologic conditions (8255 [25.2%]), chronic lung disease (6439 [19.6%]), and cancer (5,467 [16.7%]); 24 568 cases (74.9%) occurred outside intensive care units. Crude inpatient mortality was 22.4% (7361 of 32 797) for NV-HAP vs 1.9% (115 530 of 6 022 185) for all hospitalizations; 12 449 (8.0%) were discharged to hospice. Median [IQR] length-of-stay was 16 (11-26) days vs 4 (3-6) days. On medical record review, pneumonia was confirmed by reviewers or bedside clinicians in 202 of 250 patients (81%). It was estimated that NV-HAP accounted for 7.3% (95% CI, 7.1%-7.5%) of all hospital deaths (total hospital population inpatient death risk of 1.87% with NV-HAP events included vs 1.73% with NV-HAP events excluded; risk ratio, 0.927; 95% CI, 0.925-0.929).Conclusions and relevanceIn this cohort study, NV-HAP, which was defined using electronic surveillance criteria, was present in approximately 1 in 200 hospitalizations, of whom 1 in 5 died in the hospital. NV-HAP may account for up to 7% of all hospital deaths. These findings underscore the need to systematically monitor NV-HAP, define best practices for prevention, and track their impact.
| S-EPMC10196873 | biostudies-literature
Project description:Previous studies have shown that more active older adults have better cognition and brain health based on a variety of structural neuroimaging measures. Nevertheless, the effects of maintaining physical activity (PA) over an extended period of time on future changes in older adults' cognition and brain structure are unknown. Participants were 141 initially well-functioning community-dwelling older adults (aged 70-79 years at baseline; 60% female; 42% black) studied over a 13-year period. PA (self-reported time spent walking) was assessed annually from years 1 to 10. Magnetic resonance imaging with diffusion tensor was performed at years 10 and 13. Time spent walking decreased on average by 8.4% annually from year 1 to year 10. Independent of initial time spent walking, demographics, and APOE e4 status, better maintenance of time spent walking over the decade predicted less reduction in hippocampal volume (p = 0.03), smaller increases in global gray matter mean diffusivity and white matter axial diffusivity (p < 0.01), and maintenance of general cognitive performance (p < 0.01). Maintenance of cognitive performance was associated with smaller increases in white matter axial diffusivity (p < 0.01). PA at baseline and at year 10, as well as changes in PA over a 5-year period, was less predictive of future changes in brain structure and cognition. Thus, how PA levels change over longer periods of aging may be an important contributor to cognitive and neural protection.
| S-EPMC5564417 | biostudies-literature
Project description:RationaleThe National Quality Forum recently endorsed in-hospital mortality and intensive care unit length of stay (LOS) as quality indicators for patients in the intensive care unit. These measures may be affected by transferring patients to long-term acute care hospitals (LTACs).ObjectivesTo quantify the implications of LTAC transfer practices on variation in mortality index and LOS index for patients in academic medical centers.MethodsWe used a cross-sectional study design using data reported to the University HealthSystem Consortium from 2008-2009. Data were from patients who were mechanically ventilated for more than 96 hours.Measurements and main resultsUsing linear regression, we measured the association between mortality index and LTAC transfer rate, with the hospital as the unit of analysis. Similar analyses were conducted for LOS index and cost index. A total of 137 hospitals were analyzed, averaging 534 transfers to LTAC per hospital during the study period. Mean±SD in-hospital mortality was 24±6.4%, and observed LOS was 30.4±8.2 days. The mean LTAC transfer rate was 15.7±13.7%. Linear regression demonstrated a significant correlation between transfer rate and mortality index (R2=0.14; P<0.0001) and LOS index (R2=0.43; P<0.0001).ConclusionsLTAC hospital transfer rate has a significant impact on reported mortality and LOS indices for patients requiring prolonged acute mechanical ventilation. This is an example of factors unrelated to quality of medical care or illness severity that must be considered when interpreting mortality and LOS as quality indicators.
| S-EPMC3361349 | biostudies-literature
Project description:Little is known about the long-term outcomes in elderly survivors of in-hospital cardiac arrest. We determined rates of long-term survival and readmission among survivors of in-hospital cardiac arrest and examined whether these outcomes differed according to demographic characteristics and neurologic status at discharge.We linked data from a national registry of inpatient cardiac arrests with Medicare files and identified 6972 adults, 65 years of age or older, who were discharged from the hospital after surviving an in-hospital cardiac arrest between 2000 and 2008. Predictors of 1-year survival and of readmission to the hospital were examined.One year after hospital discharge, 58.5% of the patients were alive, and 34.4% had not been readmitted to the hospital. The risk-adjusted rate of 1-year survival was lower among older patients than among younger patients (63.7%, 58.6%, and 49.7% among patients 65 to 74, 75 to 84, and ?85 years of age, respectively; P<0.001), among men than among women (58.6% vs. 60.9%, P=0.03), and among black patients than among white patients (52.5% vs. 60.4%, P=0.001). The risk-adjusted rate of 1-year survival was 72.8% among patients with mild or no neurologic disability at discharge, as compared with 61.1% among patients with moderate neurologic disability, 42.2% among those with severe neurologic disability, and 10.2% among those in a coma or vegetative state (P<0.001 for all comparisons). Moreover, 1-year readmission rates were higher among patients who were black, those who were women, and those who had substantial neurologic disability (P<0.05 for all comparisons). These differences in survival and readmission rates persisted at 2 years. At 3 years, the rate of survival among survivors of in-hospital cardiac arrest was similar to that of patients who had been hospitalized with heart failure and were discharged alive (43.5% and 44.9%, respectively; risk ratio, 0.98; 95% confidence interval, 0.95 to 1.02; P=0.35).Among elderly survivors of in-hospital cardiac arrest, nearly 60% were alive at 1 year, and the rate of 3-year survival was similar to that among patients with heart failure. Survival and readmission rates differed according to the demographic characteristics of the patients and neurologic status at discharge. (Funded by the American Heart Association and the National Heart, Lung, and Blood Institute.).
| S-EPMC3652256 | biostudies-literature
Project description:BackgroundMost studies on out-of-hospital cardiac arrest have focused on immediate survival. However, little is known about long-term outcomes and resource use among survivors.Methods and resultsWithin the national CARES registry, we identified 16 206 adults 65 years or older with an out-of-hospital cardiac arrest between 2005 and 2010. Among 1127 patients who were discharged alive, we evaluated whether 1-year mortality, cumulative readmission incidence, and follow-up inpatient costs differed according to patients' race, sex, initial cardiac arrest rhythm, bystander delivery of cardiopulmonary resuscitation, discharge neurological status, and functional status (hospital discharge disposition). Overall 1-year mortality after hospital discharge was 31.8%. Among survivors, there were no long-term mortality differences by sex, race, or initial cardiac arrest rhythm, but worse functional status and severe neurological disability at discharge were associated with higher mortality. Moreover, compared with first responders, cardiopulmonary resuscitation delivered by bystanders was associated with 23% lower mortality (hazard ratio 0.77 [confidence interval 0.58-1.02]). Besides mortality, 638 (56.6%) patients were readmitted within the first year, and the cumulative readmission incidence was 197 per 100 patient-years. Mean 1-year inpatient costs were $23 765±41 002. Younger age, black race, severe neurological disability at discharge, and hospital disposition to a skilled nursing or rehabilitation facility were each associated with higher 1-year inpatient costs (P for all <0.05).ConclusionAmong elderly survivors of out-of-hospital cardiac arrest, nearly 1 in 3 patients die within the first year. Long-term mortality and inpatient costs differed substantially by certain demographic factors, whether cardiopulmonary resuscitation was initiated by a bystander, discharge neurological status, and hospital disposition.
| S-EPMC4943267 | biostudies-literature
Project description:IntroductionMedicines used at Danish public hospitals are purchased through tendering. Together with drug shortage, tendering result in drug changes, known to compromise patient safety, increase medicine errors and to be resource demanding for healthcare personnel. Details on actual resources required in the clinic setting to manage drug changes are unknown. The aim of the study is to explore time spend by hospital personnel in a drug change situation when dispensing medicine to in- and outpatients in a hospital setting in the Capital Region of Denmark.MethodA time and motion study, using direct observation combined with time-registration tools, such as eye-tracking, video recording and manual time tracking. Data were obtained from observing nurses and social and health care assistants with dispensing authority while dispensing or extraditing medicine before and after the implementation of drug changes in two clinical setting; a cardiology ward and a rheumatology outpatient clinic.ResultsHospital personnel at the cardiology inpatient ward spent 20.5 seconds on dispensing a drug, which was increased up to 28.4 seconds by drug changes. At the rheumatology outpatient clinic, time to extradite medicine increased from 8 minutes and 6 seconds to 15 minutes and 36 seconds by drug changes due to tender. Similarly, drug changes due to drug shortage prolonged the extradition time to 16 minutes and 54 seconds. Statistical analysis reveal that drug changes impose a significant increase in time to dispense a drug for both in- and outpatients.ConclusionClinical hospital personnel spent significantly longer time on drug change situations in the dispensing of medicine to in- and outpatients in a hospitals. This study emphasizes that implementing drug changes do require extra time, thus, the hospital management should encounter this and ensure that additional time is available for the hospital personnel to ensure a safe drug dispensing process.
| S-EPMC7906352 | biostudies-literature
Project description:Hospital length of stay (LOS) after burn injury is commonly estimated as 1 day per percent burn, but LOS often exceeds that estimate. The purpose of this study is to develop a novel method for estimating burn hospital LOS at any time during hospitalization. The authors used the American Burn Association National Burn Repository from 2000 to 2009 to directly estimate the median residual LOS (MRLOS) of patients hospitalized for burn injuries and who survived to discharge. The MRLOS is the median of how many more days a burn patient will be hospitalized given that the person has been in hospital for a specified time period. The authors also estimated the 25th and 75th percentiles of residual life and quantified the relationship between MRLOS and LOS with ordinary least squares for all burn patients, by burn size and by presence of inhalation injury. MRLOS increased with increasing LOS, confirming that discharge estimates change over time. Patients with inhalation injury had longer MRLOS than patients without inhalation injury in the first 100 hospital days. Patients with large burns (>25%) had large MRLOS consistent with prolonged hospitalization, but patients with small burns (<25%) also had steadily increasing MRLOS during hospitalization (ie, the longer the patient was in the hospital, the longer the predicted LOS regardless of initial LOS estimate). Estimating remaining hospital LOS at any time during admission has been problematic; MRLOS can be used to provide an estimate of remaining hospital LOS and resource utilization to families, administrators, and other medical professionals.
| S-EPMC5014656 | biostudies-literature