Chronic ventilator facilities (CVFs) are meant to be “protected” environments for the treatment of patients who require prolonged mechanical ventilation. Numerous words are included under the umbrella of CVFs: long-term acute care facilities, respiratory special care units, chronic ventilator-dependent units, regional weaning centers, ventilator-dependent rehabilitation hospitals, prolonged respiratory care units, noninvasive respiratory care units, high-dependency units, and respiratory intensive care units. And this is without even considering nursing homes and hospice care.
A 16-year study showed that the number of acute care hospital beds in the United States has decreased over time, but the number of critical care beds has increased progressively in both absolute and proportional terms. Indeed, the total number of non–critical care beds decreased by 31%, whereas critical care beds increased by 26%1; nevertheless, admissions to an intensive care unit (ICU) are very strongly influenced by bed shortages. Most beds in an ICU are occupied by patients requiring mechanical ventilation. A subset of patients receiving mechanical ventilation may have weaning difficulties, so that the duration of ventilation may be abnormally prolonged (commonly defined as greater than 15 days). Several reports indicate that these ICU patients are affected by complex cardiopulmonary disease or multisystem problems and have a relatively poor outcome.2–6
Of 6,469,674 hospitalizations in six American states, 180,326 (2.8%) received invasive mechanical ventilation. A total of 44.6% had at least one major comorbidity condition. The most common comorbidities were diabetes (13.2%) and pulmonary disease (13.2%), and only 30.8% of patients were discharged to home from the hospital, while the others ultimately required care in a skilled care facility.7
Increased life expectancy has dramatically increased the age of patients requiring critical care. Medical ICU admission is associated with a high long-term mortality even in healthy elderly patients, while most of the oldest survivors undergo prolonged mechanical ventilation, which is often a marker not only of respiratory system insufficiency, but also a multisystems insufficiency caused by many factors, including a chronic underlying disease, infections, malnutrition, complications, invasive procedures, and medications.8,9
Prolonged mechanical ventilation is not just a “medical” problem; it also has social and economic impact. Costs for mechanical ventilation in the United States are estimated to be $27 billion, representing 12% of all hospital costs. Incidence, mortality, and cumulative population costs rise significantly with age.7 Each year in the United States, approximately 300,000 patients receive prolonged life support in an ICU, and this number is likely to double within a decade, with associated costs of more than $50 billion.10
These patients, once discharged from the ICU, have a readmission rate of 67% and spend an average of 74% of all days alive in a hospital or in an acute care facility, or receiving home health care. Indeed, patients who survive for 1 year are left with a serious burden of pervasive and persistent disability despite aggressive care that cost ...