How Guideline Changes Are Improving Access to Specialized Ventilator Care at LTACHs

Sean Muldoon, MD, SVP and Chief Medical Officer at Kindred Hospitals, discusses how MCG Health’s guideline revisions are improving ventilated patients’ access to LTACHs and why this is important for their recovery.

Read the full transcript:

Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

On this episode, Dr Sean Muldoon shares how ensuring access to specialty care at long-term acute care hospitals (LTACHs) can improve patient outcomes.

Hello everyone. My name is Sean Muldoon. I am the chief medical officer for Kindred Hospitals, which is a national group of long-term acute care hospitals.

Can you tell us what a long-term acute care hospital is, and who LTACHs provide care for?

It's really in the name. I’m going to focus on the A—acute. We are licensed, certified, and accredited as an acute care hospital. The standards you're used to, in terms of delivery of care, staffing, and services, are the same as in the largest hospital.

We are, however, a niche that has stood the test of time as a place for that small group of patients who don't follow all the usual recovery rules and timelines. It's not long-term care, but it is longer-term care.

Thank you, Dr Muldoon. The timing of an admission to LTACHs is complicated because the patients are complicated. Two proprietary sets of guidelines are available from InterQual and Milliman. I understand there have been updates in these, so can you tell us how this might affect access to care?

Ultimately, the decision to make a transfer from one site to another is a physician-to-physician decision. However, there's often a mechanical process for these, and there's some screening done by non-physicians.

There are 2 proprietary sets of guidelines to help with that: one by Milliman and one by InterQual. Both have been updated this spring with particular attention to the mechanically ventilated patient, because that seems to be the group for whom LTACHs are most suitable and for whom there are fairly stiff consequences for making an error in transfer appropriateness.

The guidelines were updated with a cooperative effort between payers, clinicians, researchers, and the provider group. There were some significant changes made that are worth just mentioning briefly. You can go to the guidelines and see the details. Let's start with the Milliman care guidelines first.

They removed the long overdue requirement that the person had 21 days of mechanical ventilation. This reflects a much better understanding. I was the author of the paper that is misquoted to say there's anything magic about 21 days. Then they quantified the idea of what 3 failed weaning attempts meant. Both are improvements.

The guidelines on weaning attempts focus on what the research has shown to be a pretty good predictor: the spontaneous breathing trial, which is very short. You put patients on a T-Piece or CPAP, measure respiratory rate and title volume, and there's a cutoff number. The doctors are very familiar with this, so payers can ask someone for more of those details.

The other part was that there was nothing magic about 21 days. Many researchers think of prolonged mechanical ventilation starting at 7 days. Being that there wasn't any consensus, they simply removed that.

Why is it important that longer-term ventilated patients have access to specialized care?

Part of this is philosophical and part is empirically supported with the data. The philosophical part is, "Do you think that you can get a wide variety of care in a single place? Do you think that people should be placed in settings where that is the specialty? Are you offered general hospitals everywhere, or are you more in tune with the focused factory?"

The focused factory has a fair amount of empirical support for it. That is why LTACHs have stood the test of time, both from a regulatory and payment perspective.

There are some neat studies that are showing a couple phenomena. One very interesting study looked at 13,000 LTACH ventilated patients and asked the question, "Does it matter when you go to the LTACH to start your specialized care?"

After looking at 13,000 of these admissions, they concluded it looks like earlier is better. For every day you delay going to the LTACH, the odds ratio that you will wean changes by 12%. They didn't find any mortality difference, but the probability of getting off the ventilator was better the earlier that you went.

This is consistent with what CMS found 10 or 15 years ago. For people who went to an LTACH rather than bypassed them, there was not inferiority. They did better or the same, both from a cost and a clinical outcome perspective, if they went to an LTACH. So there are several things that support using an LTACH if you're in this category, because it increases the chances that you're going to do well.

How can earlier access to LTACH care help patients on prolonged ventilator support?

You want to go into a place where the nurses are used to you, where the rehab therapists say, "You know, I don't care if you've got tubes, lines, and drains that are on mechanical ventilator. We're getting up, we're going to start our rehab. We're not afraid of them. We're used to safely manipulating the lines, tubes, and drains." Then you also get a philosophy that is much different.

Whereas in the ICU, it's, "Figure it out, keep you alive, and give you everything you need." And once you get to an LTACH, the goal is, "What do we need to take away so that you can get out of here?" While the mechanical ventilator may be the obvious one, there’s also a lot of other things: the complicated infections, getting the gut working again, getting your brain working again, getting you back on a sleep-wake cycle, all those things that have been really disrupted over the course of this persistent critical illness.

We have to wind down that care, so to that end, we spend a lot of time with what we call patient-centered goal-directed care plans. Do the patient and family understand what you're working with and what you're facing? Palliative care becomes an aspect of care that's in the background of every care plan in a long-term acute care hospital.

Is there anything that you feel we missed today that you wanted to add?

I hope it's been helpful to our audience, particularly those in managed care. If they would like some more details, there are plenty of people around to provide them with those.

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