For most LTV patients, the ICU should not be the end point in their continuum of care. There are many examples of successfully transitioned patients who are enjoying improved quality of life in alternate care settings. It is important to have meaningful engagement of the patient and family regarding potential next steps. A medically stable, ventilator-dependent patient can be transitioned successfully from the ICU to home, supportive housing or a long-term health care facility. At this stage in the patient’s care, there is a need to ensure that the patient and caregivers are comfortable with leaving the ICU and that there are appropriate rehabilitation services to accept these patients.
A successful transition requires careful planning, and plenty of patient and family education.
Factors to Consider Prior to Initializing Mobilization Program or Protocol (daily assessment) Physician should be consulted before starting mobilization if any of the following conditions exist
- CNS impairment • Unarousable, no response to voice or physical stimulation •
- Deep sedation, no response to voice, but movement or eye opening to physical stimulation
- Pulls or removes tube(s) or catheters; aggressive • Combative, violent, danger to staff
- Poor Oxygenation • SaO2 < 88% • FIO2 > 0.6 & PEEP > 10 cm H2O 3. Tachypnea
- Respiratory Rate > 40 per minute 4. Acidemia • Most recent Arterial pH < 7.25
- Mean Arterial Pressure < 55 mmHg [MAP = diastolic + 1/3(systolic-diastolic)]
- Mean Arterial Pressure > 140 mm Hg [MAP = diastolic + 1/3(systolic-diastolic)]
- New Venothromboembolic Disease (Deep Venous Thrombosis or Pulmonary Embolism) with duration of anticoagulation less than 36 hour
If appropriate, consider the following interventions:
- Decrease tracheostomy tube size to assist with speech and weaning
- Consult with Speech Language for the following interventions:
- Cuff deflation and speech, consider a change to a cuffless or tight-to-the-shaft tracheostomy tube to assist with speech and weanin
- Swallowing assessment
- Switch patient to chronic care ventilator
- Move patient to area with less activity such as a step-down unit
- Encourage the use of a call bell, consider modifications if necessary
- Have patient direct his/her own care
- Get patient up in chair daily and extend length of time
- Have patient dress in their own clothing rather than hospital gowns
- Establish a routine for bowel/bladder, plan of care, regular day/night routine
- Have Physiotherapy consult for range of motion and ambulation
- Consider taking the patient out of the ICU for short periods of time with staff and/or family
- Have Occupational Therapy consult for initiation of wheel chair prescription (if appropriate)
- Initiate ADP/VEP forms to expedite Ministry funded equipment (once discharge plan is developed)
- Investigate private insurance coverage and capacity for private caregiver support
- Encourage family and caregivers to review LTVCOE e-learning modules.
- Educate the family/caregivers on “bagging”, suctioning and trouble shooting.
- Involve the patient as much as possible, have the caregivers demonstrate these skills with the support of the healthcare professional
- Provide the patient with a written copy of the prescribed ventilator settings, including alarm and Fi02 setting. For prescribed ventilator settings “templates”
- Provide the patient with a written care plan including a list of emergency contact name and telephone numbers.