Prolonged mechanical ventilation costs

Dewar DM, Kurek CJ, Lambrinos J, et al. Patterns in costs and outcomes for patients with prolonged mechanical ventilation undergoing tracheostomy an analysis of discharges under diagnosis-related group 483 in New York State from 1992 to 1996. Crit Care Med 1999 27(12) 2640-2647. 

Seneff MG, Wagner D, Thompson D, et al. The impact of long-term acute-care facilities on the outcome and cost of care for patients undergoing prolonged mechanical ventilation. Crit Care Med 2000 28 342-350. 

This chapter addresses the importance of integrating the process of rehabilitation within the milieu of critical care. A conceptual model will be presented to show how rehabilitation can be organized within the ICU, incorporating the whole of the patient s journey irrespective of their length of stay (LOS) within the ICU. The chapter will focus on those patients who require prolonged mechanical ventilation (PMV), i.e., >21 days and will be presented from a U.K. perspective. Case examples from my own critical care practice will be used to demonstrate how a rehabilitation framework of care impacts upon patient mortality, quahty of care, and ICU costs. Finally, recommendations will be made for future practice. 

Recent advances in intensive care have resulted in an increased salvage of critically ill patients a number of patients have become dependent upon mechanical ventilation as a chronic form of life support (1). The increased use of prolonged mechanical ventilation (PMV) has led to greater intensive care unit (ICU) bed use, resource consumption, and costs (2,3). It is important to characterize such patients to define treatment goals and expectations, to establish ventilatory care units for their specialized care, and to provide prognostic information for overall survival, morbidities, and health-related quality of life. The goals of this chapter are to provide definitions of PMV, to characterize the patient population requiring this modality of treatment, and to briefly describe a multidiscipUnaiy approach to treatment. 

Figure 1 Potential sites of care for patients requiring PMV. Sites toward the bottom of the figure have fewer medical resources and lower costs but allow greater patient independence and a higher quality of life. Abbreviation PMV, prolonged mechanical ventilation. Source From Make BJ, Hill NS, Goldberg AI, et al. Mechanical ventilation beyond the intensive care unit report of a consensus conference of the American college of chest physicians. Chest 1998 113 295S.

As a consequence of their growing numbers, prolonged care of a VAI (>30 days) in the ICU has rapidly increased the costs to the health care system in the United States, it has been estimated that patients requiring prolonged mechanical ventilation (PMV) account for as much as 40% of the ICU budget (5). Nevertheless, in 1995, a U.S. survey of 300 randomly selected acute care units reported that over 11,000 patients had received PMV at a cost of 9 million per day. Of these patients, 17% were awaiting placement outside the ICU, and 12% remained in ICU as they could not be reimbursed for care elsewhere (6). Although... 

The fourth item covers various other costs resulting from a lack of mechanical reliability. An example of costly remedial measures being employed as a result of minor mechanical difficulties has already been quoted in the section on seals, in which extensive ventilation systems were installed as a result of leakage of toxic fumes. As another example in this category, the user may be forced to consider installing additional spare equipment, or additional facilities for stockpiling product, if particularly severe and prolonged problems are experienced. 

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