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 Dad is in ICU on a Ventilator with Tracheostomy. Is it True that My Dad Can Go Home with Services like Intensive Care at Home?
You can check out last week’s question by clicking on the link here.
This is another episode of your questions answered and in today’s episode, I want to answer a question that we get so frequently that it’s really time to look into this into more depth. It is actually a case study that is actually a real case study from a client. However, the question is a question that I really want to answer on a more general level.
The question today is,
ICU vs Intensive Care at Home vs LTAC?
So let me break this down today for you, so that you have all the answers and that you can make informed decisions, get peace of mind, control, power, and influence when it comes to these very important and also often life or death decisions that you need to make when your loved one is in ICU with ventilation and tracheostomy.
So let me read out this email from Zia and she writes.
My 67-year-old dad was sent to the emergency department after being ill for about 12 days at home, we were told on the phone due to no hospital visitations regulations at the moment because of the COVID several hours later, that he was severely dehydrated and
in acute renal failure. He was admitted to the ICU and intubated and two more COVID tests were performed all coming back negative, even though we told them the
first text test was negative.
Honestly, I think they were treating him as a COVID patient initially which is why he was intubated. They claim to “protect his airway”. Several days later, they recognized a clot on his leg and he had a DVT which became a PE, PE stands for pulmonary embolism. Something he has had in another state eight years ago. So it actually wasn’t in his chart.
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Anyway, currently he has a tracheostomy and all the hospital wants to do is to transfer him to an LTAC. They called this morning saying they had found a bed for him in an LTAC facility, and they need consent from us as a family. We, as a family, didn’t give consent and I came across your websites intensive care hotline and intensive care
at home and we’d love to hear your input in regards to weaning him off the ventilator.
I have had several discussions and finally we are at the place where he gets taken off the ventilator for a few hours a day, goes on a CPAP mode or room air, and then back on the ventilator to get him to rest. According to the ICU team, we don’t want him in an LTAC. I’m concerned about infections and even bed sores and lack of quality care. I would much rather engage a service like intensive care at home.
If my dad can’t come off the ventilator, I’m really looking forward to your thoughts and advice.
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Well, Zia, thank you so much for writing in, and let’s break this down for you today. I’m not surprised that your dad initially was treated as a COVID patient in the ER or in the emergency department and then he went into ICU, got intubated to protect his airway.
At the moment my understanding is that in ICU, patients get intubated much quicker than usual because it diminishes exposure for staff and protect actually the staff when patients are intubated, it’s sort of, gets less droplets into the air that are potentially COVID positive.
So then, he obviously had to do tracheostomy, he couldn’t come off the ventilator for whatever reason. It sounds to me like the DVT and the PE contributed to your dad, not coming off the ventilator. It’s a shame that it wasn’t picked up that he had a PE in the past because they could have potentially heparinized him early on and potentially prevented the DVT.
So in any case, he’s now having a tracheostomy, he is now having CPAP trials and room air trials and it looks like, he’s slowly moving towards getting off the ventilator, but it also sounds like he’s not there yet. And it sounds like the ICU was entertaining the thought of getting him to LTAC as the next step and obviously you have done your research. You have found that intensive care at home is an option. So, let’s look at the next step.
First of all, if someone is in ICU and is close of coming off the ventilator and the tracheostomy, they should not be leaving intensive care. The best place to wean somebody off the ventilator, especially when it’s short term is intensive care.
Why do I say that? I say that confidently because ventilation and tracheostomy is a specialist skill that can only be found in intensive care or with a service like intensive care at home but I’ll come into intensive care at home in a moment. Let’s just focus on ICU for a minute.
In ICU, you have intensive care doctors, you have intensive care trained nurses, in the United States and Canada you’ve got respiratory therapists. In other countries such as Australia or the UK, you don’t have respiratory therapists, but you don’t really need them because ICU doctors and ICU nurses can manage the weaning process in ICU quite confidently. So in your dad’s case, it sounds like he’s not too far away from getting off the ventilator. Therefore he
should stay in ICU until he’s off the ventilator. End of story, period.
So I have seen so many patients in ICU being weaned off the ventilator and the tracheostomy that an LTAC is just bringing patients down really and why do I say that? So you go from intensive care where you have intensive care trained doctors, intensive care trained nurses that go through a specialist training that are used to looking after patients on ventilation that are used to looking after tracheostomies and that takes years of training and exposure to it
confidently.
So when patients go to LTAC, the most important reason patients get to go to LTAC is, number one, ICU needs to empty their beds because ICU beds are in high demand, that’s number one.
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Number two. It’s purely to save money for the funding bodies and when patients go to LTAC, it’s not based on clinical needs, it’s simply because patients need to empty the ICU or ICUs need to empty their hospital beds because they are in high demand. And then when patients do go to LTAC, they often bounce back to ICU simply because they’re not ready to go to LTAC.
Also, why do they bounce back to ICU? Well, number one, because they’re often not ready, number two, when patients go to LTAC, it’s not staffed by ICU doctors and ICU nurses. It’s often staffed by general RN’s, general registered nurses that have no ventilation and tracheostomy training.
Now you look at the reviews for LTACs, they are shocking reviews, they’re negative reviews because you’re simply going from an environment of highly trained doctors and nurses to an environment where you don’t have highly trained doctors and nurses, often have one doctor for 30 patients. You often have one non-ICU RN for five patients. So there is no quality in LTAC, there is no quality care, outcomes are pretty poor and if patients then deteriorate and go back
to ICU, they often don’t go back to ICU to the ICU where they came from.
So what is important when patients are critically ill, it is important to focus on consistency of care. Now, a patient that’s critically ill is already outside of their comfort zone. Their families are already out of the comfort zone and they don’t need the disruption of a care episode during critical illness.
So what that means is, when patients go to LTAC, they often go to LTAC far away from their home. They often go away to LTACs two hours away from their home and families can’t really visit them. Now, when patients are critically ill, they need to be around their families and not far away. So, those are the reasons why someone should stay in ICU after a tracheostomy and mechanical ventilation.
Now, if a patient can’t be weaned off the ventilator and the tracheostomy, the only genuine alternative for that is really intensive care at home. That is the only genuine alternative, because basically you can continue the care episode from intensive care. You can continue that at home with 24-hour intensive care nurses and having the intensive care doctor that is a genuine alternative. It cuts the cost of an ICU bed by about 50% and patients and families are
where they should be.
It’s a much more patient and family friendly and holistic care environment. And it’s not two hours away from the original ICU. Like most of LTACs are.
So, intensive care at home really is a win-win situation and it cuts the cost of an ICU bed by 50%. And it provides the same level of quality care at home. Patients can be weaned off the ventilator at home. They are close to an ICU where they really need to, but I mean, the goal of intensive care at home is certainly to keep patients at home predictably and get them their care episodes at home, including weaning mechanical ventilation.
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So, that really is the difference between ICU, LTAC and INTENSIVE CARE AT HOME. To sum it up again, ICU, definitely for the short term and if somebody can be weaned off the ventilator, ventilation- free and tracheostomy-free, they should do that in ICU.
If ventilation and tracheostomy is needed in the long run, then definitely intensive care at home. Whereas LTAC really is a no go on all levels and you can see that when you Google online reviews for LTACs, they are pretty shocking.
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So I hope that answers the question for more information about intensive care at home.
Check out intensivecareathome.com.
Thank you for tuning into this week’s blog and into this week’s “Your Questions Answered”.
Kind regards,
Patrik
