Revised MCG Health Guidelines: Reducing Readmissions of Ventilated Patients Through Timely Discharges to LTACHs

An estimated 20% to 40% of patients in the ICU experience severe respiratory insufficiency, requiring the support of mechanical ventilation.¹ While most patients rely on this intervention for only a short time, approximately 20% of patients need ventilator support for a longer time.²

Studies show that timely discharge of these patients to long-term acute care hospitals (LTACHs), which specialize in ventilator liberation, can help improve outcomes and reduce readmissions, ultimately relieving costly demands on the health care system. Based on these findings, health care guidelines have been revised to promote patient transfer to LTACHs as soon as clinically appropriate. 

This article highlights how the MCG Health Clinical Indications for Admission to LTACHs have been revised based on the latest clinical research showing the benefits of timely discharge of ventilated patients to LTACHs.

The Importance of Ventilator Liberation Strategies

While mechanical ventilation is a life-saving intervention, long-term use can pose significant health risks and increase rates of readmission.

One primary concern of prolonged ventilation is bacterial infection, which can cause ventilator-associated pneumonia.³ Lung injury is another risk, which may result from overdistention and mechanical stress of the alveoli.⁴ Patient immobility can also increase risk of skin pressure injuries and blood clots and lead to muscle loss and depression.⁵ As a consequence of these risks, both readmission and mortality rates increase as the duration of mechanical ventilation increases.⁶

Furthermore, the resources required for managing mechanical ventilation and addressing ventilator-related adverse events in addition to costly readmissions make long-term ventilation a financial concern for the entire health care system.

Therefore, it is important that health care systems have liberation strategies in place, including the utilization of downstream partners with ventilator expertise, so ventilator-dependent patients can receive the most effective and cost-efficient care available.

New Health Care Guidelines Incorporate Latest Clinical Research on Liberation

Liberation strategies—which may include direct extubation, spontaneous breathing trials (SBTs) or tracheostomy collars trials—have changed over time and vary across the globe.⁷ There is additional variability around when a patient on a ventilator should transition to another setting, such as an LTACH.

In an effort to establish consistency, medical professionals have collaborated to synthesize the most up-to-date clinical research and publish guidelines for the treatment and transition of ventilated patients. MCG Health is one health care group that offers unbiased care recommendations based on the latest evidence.⁸ 

Historically, MCG Health’s Clinical Indications for Admission to LTACH included 21 ventilator days. However, in March 2022, MCG published revised guidelines that replace the 21-day indication with a less arbitrary and more clinical indication—3 failed SBTs.⁹

This change is supported by several recent studies that found that: 1) SBTs are considered a best practice for evaluating clinical necessity of long-term ventilation, and 2) delaying discharge of ventilated patients to an LTACH may negatively influence the probability of liberation.^10,2 

Based on these updated guidelines, payers should consider providing ventilated patients access to the specialized care available at LTACHs as soon as clinically appropriate.  

Unique Aspects of LTACH Care That Can Improve Outcomes

There are 3 key aspects of LTACH care that help patients on prolonged ventilation regain breathing independence and mobility.

Expertise in Ventilator Care

Critical pulmonary care and ventilator weaning are core competencies of LTACHs, which make them advantageous settings for ventilator-supported patients. These patients, which make up more than 25% of LTACH admissions, receive expert treatment from a team led by pulmonologists and respiratory therapists.¹¹  

As such, discharging these patients to the LTACH in a timely fashion can help improve outcomes. In fact, one study found that a 1-day delay in LTACH discharge after intubation is associated with an 11.6% reduction in the odds of weaning.¹²

Interdisciplinary Care Teams

Medically complex patients with multiple comorbidities often require a team of specialists who can address the different facets of their conditions. In an LTACH, physicians, respiratory therapists, dieticians, bedside nurses, and others formally collaborate as an interdisciplinary care team to develop comprehensive treatment plans. This level of collaboration can improve outcomes by reducing the risk of miscommunication, which can be a primary cause of adverse events.¹³

The benefit of interdisciplinary care team collaboration is particularly clear when looking at patients requiring mechanical ventilation. One case study found an association between long-term liberation plans led by a multidisciplinary team and reductions in mortality and time on ventilator.¹⁴

Specialized Rehabilitative Care

Early and comprehensive rehabilitation is also essential for patients with multiple chronic conditions and acute illnesses. Rehabilitation services provided at an LTACH are led by physical therapists, respiratory therapists, occupational therapists, and speech-language pathologists and are integrated with specialized acute care to help patients achieve the fastest and most complete recovery possible.

Early mobilization is especially important for critical pulmonary patients. One case study showed improving access of ventilated patients to pulmonary rehabilitation in an acute care setting could reduce time on ventilation by 2 days.¹⁵ Studies such as these have contributed to the recommendation by the American Thoracic Society and American College of Chest Physicians to implement early mobilization protocols for ventilated patients.¹⁶

How Kindred Hospitals Can Help

Kindred Hospitals have provided quality care for 30 years, and continue to introduce initiatives that improve care, such as pursuit of Certification in Respiratory Failure from The Joint Commission and the establishment of their Move Early Program. This program incorporates mobilization as early as is safe, even for patients on ventilators. In fact, 82% of Kindred’s ventilated patients are able to reach a high level of mobility, as defined by Johns Hopkins High Level of Mobility Scale.¹⁷

Kindred Hospitals partner with health plans to provide the highest quality of care, improve patient outcomes, and lower costs for their sickest and most vulnerable patient population. Kindred currently supports the following products:

• Medicare Advantage
• Commercial
• Managed Medicaid
• Veterans Affairs
• Worker’s Compensation

Visit kindredmanagedcare.com to request a conversation about how Kindred Hospitals’ level of service can help manage your critically complex patients.

References:

1. Wunsch H, Wagner J, Herlim M, Chong DH, Kramer AA, Halpern SD. ICU occupancy and mechanical ventilator use in the United States. Crit Care Med. 2013;41(12):2712-9. doi:10.1097/CCM.0b013e318298a139
2. Schönhofer B, Geiseler J, Dellweg D, et al. Prolonged weaning: S2k guideline published by the German Respiratory Society. Respiration. 2020;99(11):982-1083. doi:10.1159/000510085
3. Haribhai S, Mahboobi SK. Ventilator Complications. Treasure Island (FL): StatPearls Publishing; 2022.
4. Chen ZL, Song YL, Hu ZY, Zhang S, Chen YZ. An estimation of mechanical stress on alveolar walls during repetitive alveolar reopening and closure. J Appl Physiol (1985). 2015;119(3):190-201. doi:10.1152/japplphysiol.00112.2015
5. Complications of ventilator use. WebMD. Updated August 9, 2021. Accessed July 26, 2022. https://www.webmd.com/lung/ventilator-complications#2
6. Lee HW, Cho YJ. The impact of mechanical ventilation duration on the readmission to intensive care unit: a population-based observational study. Tuberc Respir Dis (Seoul). 2020;83(4):303-311. doi:10.4046/trd.2020.0024
7. Burns KEA, Rizvi L, Cook DJ, et al. Ventilator weaning and discontinuation practices for critically ill patients. JAMA. 2021;325(12):1173-1184. doi:10.1001/jama.2021.2384
8. MCG Health. Company overview. MCG Health. Accessed July 26, 2022. https://www.mcg.com/about/company-overview/
9. Ventilator Management Long-Term Acute Care Hospital (LTACH) Guideline (GRG-049). 2022. General Recovery Care. 26th Edition.
10. Ouellette DR, Patel S, Girard TD, et al. Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society clinical practice guideline: inspiratory pressure augmentation during spontaneous breathing trials, protocols minimizing sedation, and noninvasive ventilation immediately after extubation. Chest. 2017;151(1):166-180. doi:10.1016/j.chest.2016.10.036
11. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. March 2021. Accessed July 26, 2022. https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf
12. Demiralp B, Koenig L, Xu J, Soltoff S, Votto J. Time spent in prior hospital stay and outcomes for ventilator patients in long-term acute care hospitals. BMC Pulm Med. 2021;21(104). doi:10.1186/s12890-021-01454-1
13. Manojlovich M, Adler-Milstein J, Harrod M, et al. The effect of health information technology on health care provider communciation: a mixed-method protocol. JMIR Res Protoc. 2015;4(2):e72. doi:10.2196/resprot.4463
14. Black CJ, Kuper M, Bellingan GJ, Batson S, Matejowsky C, Howell DCJ. A multidisciplinary team approach to weaning from prolonged mechanical ventilation. Br J Hosp Med (Lond). 2012;73(8):462-466. doi: 10.12968/hmed.2012.73.8.462
15. Masiero S, Venturin A, Tiberio I, et al. Rehabilitation for people with COVID-19 in ICU (COVID_REHAB). ClinicalTrials.gov Identifier: NCT04381338. 
16. Schmidt GA, Girard TD, Kress JP, et al. Official executive summary of an American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline: Liberation from Mechanical Ventilation in Critically Ill Adults. Am J Respir Crit Care Med. 2017;195(1):115-119. doi:10.1164/rccm.201610-2076ST
17. Early Mobility Program participants at Kindred Hospitals through July 2021.