Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a
doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED" and in last week’s episode I answered another question from our readers and the question was
My Brother had Bypass surgery and a Cardiac Arrest in ICU. Can he recover?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my Kaye as part of my 1:1 consulting and advocacy service! Kaye’s
husband had a heart surgery and is on tracheostomy in the ICU and is asking why the doctors are immediately transferring him to a skilled nursing facility without removing his tracheostomy.
My Tracheostomized Husband is in the ICU. Can it Be Removed in a Skilled Nursing Facility?
Eric: Hello.
Patrik: Oh, hi is that Eric?
Eric: Yes, Patrik how are you?
Patrik: Very good thank you. How are you?
Erik: I’m good thank you.
Patrik: Thank you for your time.
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Erik: Yes no problem. Thanks for taking the time. So, Kaye actually has most of the information. Do you think I can try to conference call her in?
Patrik: Yeah, absolutely… absolutely.
Erik: Okay. Give me just a minute I’ll try to get her on.
Patrik: Sure, Sure.
Erik: Okay thanks.
Patrik: Thank you.
Eric: Hi Patrik.
Patrik: Yes.
Eric: Yes, Hi Patrik, Kaye is on the phone. She’s at the hospital right now.
Patrik: Right okay-
Kaye: Hi Patrik.
Patrik: Hello Kaye. How are you?
Kaye: I’m hanging in here. And you, how are you?
Patrik: I’m really good, I’m really good. So, I read through your email earlier this weekend, and that’s the starting point for me. I obviously got your message this morning that they’re trying to send your husband into long-term acute care but now their turning back.
Eric: Now their turning back, and they want to send him to just skilled nursing. We don’t think that’s good enough.
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Patrik: Oh.
Eric: We think that the next step should be long-term acute care.
Patrik: Yes, what has changed?
Eric: I’ll let Kaye fill you in on that one.
Kaye: Well, pretty much, what they are telling me right now since he is not on the intravenous, which is IV because they’re not giving him any IV at this point. He takes medications orally right now. So, he takes Digoxin. My husband had open heart surgery. So he
takes Digoxin to control his heart rhythm.
Patrik: He has A-fib?
Kaye: He has A-fib, yeah.
Patrik: Yeah. Mm-hmm (affirmative).
Kaye: He has a pacemaker, but it is still very random. His score is 80, 81, 92, 90, 014, 100, 99, 91 in this range.
Patrik: Right.
Kaye: His blood pressure is a little more as well. They’re giving him diuretics because he’s too swollen. His blood pressure is approximately around 96/54. It was like this before.
Patrik: Right.
Kaye: Now, his potassium is low, and they’re giving him potassium because he is taking diuretics.
Patrik: Mm-hmm (affirmative). Yep, Mm-hmm (affirmative). I’m all with you so far.
Kaye: I’m sorry?
Patrik: I’m all with you so far.
Kaye: Okay. His haemoglobin is in the low range 8, but they’re saying that considering my husband’s situation and having cirrhosis, it’s okay.
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Patrik: Okay. When you’re saying your husband has cirrhosis, they’re referring to liver cirrhosis?
Kaye: One more time?
Patrik: When you’re saying your husband has cirrhosis, you are referring to liver cirrhosis?
Kaye: He has it. He has it right now.
Eric: Cirrhosis of the liver, which has been caused by the Hep C.
Patrik: Okay, okay.
Kaye: He’s taking medication for the Hep C.
Patrik: So, this is nothing new? This is longstanding?
Eric: Yes.
Patrik: Okay, okay.
Kaye: Hello.
Patrik: I said the liver cirrhosis.
Kaye: I’m down here in the wrong spot. Hello?
Patrik: Yeah, I can hear you.
Eric: We can hear you Kaye.
Kaye: Can you hear me, hello?
Eric: We can hear you.
Patrik: Yep.
Kaye: I cannot hear. It’s horrible. Hello?
Eric: Yeah.
Patrik: Yeah.
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Kaye: Patrik, can you hear me?
Patrik: Yes, I can hear you. I can hear you.
Kaye: Okay. Perfect. I found a spot. I’m staying here.
Patrik: The liver cirrhosis and the hepatitis C are nothing new. This is longstanding.
Kaye: Apparently, he had it all his life, but we found out about this last year.
Patrik: Okay, okay. That’s okay. Can I just ask a few things before we move on?
Kaye: Sure.
Patrik: In your email this week, Eric, you were saying that obviously they’re referring him to long-term acute care, and they are confident your brother will recover. That to me is the most important question now that I’m asking. Were they confident that your brother would be able to be weaned off the ventilator at LTACH?
Kaye: They were very confident that he will be weaned off. At this point right now, he is actually off the ventilator, and he is breathing with the oxygen mask over it.
Patrik: Okay, yep.
Kaye: Tomorrow they will be doing swallowing tests to see how he can swallow and drink water.
Patrik: Yep. Mm-hmm (affirmative).
Kaye: He is actually right now talking to me with the trach. He talks to me. I can hear him.
Patrik: Does he have a speaking valve?
Kaye: Yeah, they put a little valve in there. Right, so he can talk.
Patrik: Okay.
Kaye: Yeah.
Patrik: That means he is off the ventilator for most of the day?
Kaye: He is off of the ventilator for approximately one week.
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Patrik: Okay. Is he back on the ventilator today or what’s changed?
Kaye: No, he is still off of the ventilator. At night, what they do is they put T-
Patrik: The T- Piece?
Kaye: Yeah. T- Piece.
Patrik: Okay. That’s very encouraging. So that’s been happening over the last week?
Kaye: Yes.
Patrik: Okay, okay. That to me is very good news. I didn’t realise from your email that he was off the ventilator. That to me is very good news. From that perspective, they would have every reason to send him to LTACH because he doesn’t need to be weaned off the ventilator.
They need to focus on his recovery, on his rehabilitation, and they need to focus on getting the tracheostomy removed, right? They wouldn’t be doing that in a skilled nursing home. There’s no way.
Kaye: This is why I’m freaking out to be honest with you. Who will be monitoring all these things?
Eric: He just said something that I think makes a lot of sense. You just answered our question that we had. You’re saying that he cannot go to skilled nursing with a trach?
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Patrik: Well, he probably could, but I’ll tell you from my experience what happens. When patients go from ICU to long-term acute care, and for whatever reason they can’t get weaned off the ventilator there, then they go on to skilled nursing. Now, the reason for that often is that the insurance stops paying for whatever time frame they have. Often now it’s six months or so sometimes after 12 months in LTACH. They stop paying irrespective of the outcome. Then they send them to a skilled nursing facility because they couldn’t achieve their goals in LTACH.
It sounds to me like your husband is a lot closer to achieving his goals already. Are you with me there?
Eric: Yeah, we are with you there, and that’s what I was wondering. As of this morning, they were saying he’s going to LTACH. Then, as of this afternoon, they’re saying he’s not going to LTACH and that he is going to skilled nursing.
Kaye: All this time, Patrik, they were telling me LTACH, LTACH, LTACH. He has so many issues. He’s had so many issues. She calls me today at 1 o’clock and she says, “Guess what? He did not meet the criteria to go to the LTACH. So, guess what? He’s qualified to go to the skilled nursing.” I said, “What?”
Patrik: Could this be an insurance issue?
Eric: I’m starting to think that. We would really like to see him go to LTACH because we’ve seen the LTACH facility, and it really is fantastic. You know what
skilled nursing is like and we do too. He is not going to have the level of care that we would want him to have.
Kaye: At all, at all.
Patrik: Yeah, yeah, yeah.
Kaye: Over there, at skilled nursing, one nurse has approximately eight or nine patients. Patrik, what does it mean?
Patrik: Horrible, horrible. When I deal with similar situations, the situation often is, and I don’t want to go too much into what is happening with other clients, but the reality is if I get similar inquires, it’s often about, “Hey, we want to keep my husband in ICU because he is meant to go to LTACH. We don’t think he’s ready.”
However, given that your husband is off the ventilator for a week now, he is way more ahead of many other patients that they want to send to LTACH. Many other patients that get sent to LTACH are not off the ventilator, right?
Kaye: Right.
Patrik: I still believe the best place to wean a patient off the ventilator is ICU. That’s what I believe, but your husband seems to have taken that step already which is good news.
Eric: Yes.
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Patrik: That’s really good news.
Eric: Yes.
Kaye: You know Patrik, if they would wean him off of the trach right now and tell us go for the skilled facility, I would probably have to say okay, but going with this trach in his neck, to the skilled nurse facility, I don’t have enough confidence in those facilities.
Patrik: No, of course not and you shouldn’t. It could be an insurance issue. It could be an issue that LTACH might not have a bed.
Kaye: They do.
Patrik: They do, okay? I think that’s your quickest way. Keep talking to LTACH if you can. If you are talking to a nurse manager there or to a bed manager, that could be one way to exert yourself to keep talking to them and keep that door open. For the hospital, it doesn’t really make a difference where your husband is going. That’s why I think it’s an insurance issue.
Eric: Yeah. We’re actually 100% it’s the insurance. We are trying to figure out what the criteria is for them denying it.
Patrik: Okay.
Kaye: What is the criteria, Patrik? When they say the word criteria, they say to me that-
Patrik: Go on, what are they saying?
Eric: Well, Patrik-
Patrik: What are they saying?
Kaye: They say because he’s not on the-
Eric: Ventilator.
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Kaye: Ventilator, yeah and no IV.
Eric: But Patrik, may I just say this real quick? Patrik, he is not walking. I mean he is not walking.
Kaye: Not at all.
Patrik: No.
Eric: He cannot get up. I just wonder if that should be a criteria of sending him to LTACH.
Patrik: Yeah, yeah, absolutely yes. I understand he is off the ventilator now, but the reality is that the patients who go from ICU to LTACH are usually not walking because they are on a ventilator, they’re still immobile.
Eric: Right, right.
Patrik: That is the criteria to go from ICU to LTACH, to be immobile, bed-bound and also to be ventilator dependent. What’s kind of unusual about … The surgery was done on the 12th of July so about a month ago.
Eric: Yes.
Patrik: Right. So, you’re within-
Eric: Just over a month.
Patrik: So, you’re within the time frames. If it had been done on the 12th of June, I would say, “Okay, two months in ICU.” Maybe they have some clause in the insurance policy about we don’t go to LTACH after two months of ICU because already so much money has been spent, but that doesn’t seem to be the case, right?
Eric: Right.
Patrik: So yes.
Kaye: That’s what confuses me, maybe because he doesn’t have any IV medications and he is not on a vent perhaps that is the main thing to qualify to go to the LTACH.
Patrik: The-
Kaye: I think that is about enough.
Patrik: I think the most important thing about LTACH really is the rehabilitation part, right? In your husband’s case, he is off the ventilator already. I can’t stress this enough as this is really good news. Now the focus should be on
rehabilitation. That includes mobilisation, getting out of bed.
Kaye: Let me ask you, Patrik. If he’s not mobile-
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Patrik: Yeah, yeah, of course, I understand. I understand he’s not mobile, but that doesn’t mean he cannot be mobile in the future.
Kaye: Yeah.
Patrik: Right? I understand your husband is 82. I understand he’s had big surgery. I understand all of that, but that’s what those rehabilitation facilities are there for, right? To rehabilitate people. I’m not saying this is possible, but if they don’t try, it’s
never going to happen if they don’t try.
Kaye: I already told the case managers here at the hospital that I’m curious what the opinion is, and I would love to have a family meeting with doctors, sit down and have ideas of why they think he is okay to go. I already called the medical insurance, case manager there, and I want to know why he was denied, and I want to know what are the criteria to be qualified?
Patrik: Yeah, absolutely.
Kaye: I did that. Now I have a question, Patrik. If he’s not mobile, is it harder to get off of the trach?
Patrik: Yeah, the more mobile, the better. The more mobile the better. The reality is … Okay, let me ask a few questions. Have they been sitting your husband out of bed in a recliner chair for example in ICU?
Kaye: I’m sorry. Did I understand your question correctly? You said what do they do after that, I’m sorry?
Patrik: Have they-
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Eric: Yes, Patrik, yes, they’ve been putting him in a cardiac chair.
Patrik: Okay.
Kaye: Yes, at the edge of the bed. Yeah and I exercise with him every time and he starts moving slowly, but he cannot stand up. He cannot stand up, and he cannot sit on his own on the edge of the bed.
Patrik: How-
Kaye: He sits sometimes on the bench.
The 1:1 consulting session will continue in next week’s episode.
