Department of Speech Pathology, Good Shepherd Penn Partners, Philadelphia, Pennsylvania.
Department of Pulmonary Medicine, and.
Ann Am Thorac Soc. 2021 Dec;18(12):2041-2048. doi: 10.1513/AnnalsATS.202011-1412OC.
Chronically critically ill patients admitted to a long-term acute care hospital (LTACH) setting are a vulnerable population of intensive care unit (ICU) survivors. Little is known of the goals and functional outcomes achieved by patients after rehabilitation in the LTACH setting. We sought to examine patient goals and functional outcomes, including swallowing function, among ICU survivors admitted to an LTACH with a tracheostomy. This was a prospective observational cohort study of chronic critically ill LTACH patients. Fifty older subjects with a median duration of intubation before tracheostomy of 13 days were enrolled. ICU-acquired weakness and cognitive impairment were present in 40 (80%) and 36 (72%) patients, as measured by the Medical Research Council scale and Montreal Cognitive Assessment, respectively. Mental health problems were also common, with 16 (32%) patients experiencing moderate to severe anxiety, 9 (18%) experiencing moderate to severe depression, and 11 (22%) reporting symptoms consistent with post-traumatic stress disorder, according to the Hospital Anxiety and Depression Scale and Post-Traumatic Stress Syndrome 10-Questions Inventory, respectively. Pharyngeal dysfunction, as measured by Fiberoptic Endoscopic Evaluation of Swallow examination, was present in 37 (74%) patients. Patient goals, in decreasing order of frequency, included eating and drinking, speaking, walking, returning home, and toileting. By LTACH discharge, goal attainment was variable, with 97% of those who ranked speaking as important being able to speak and 88% of those who ranked eating and drinking as important being able to eat and drink but with only 21% being able to walk and only 18% being able to self-toilet. Discharge to the home or acute rehabilitation setting, achieved in 52% of the population, was associated with greater strength, as measured by the total Medical Research Council score ( = 0.002) as well as by the European 5-dimension, 5-level health-related quality of life instrument domains of mobility ( = 0.008) and self-care ( = 0.04). Goal attainment during this period of recovery was variable. The ability to speak, eat, and drink, frequently identified as goals by these patients, were achieved, whereas functional goals such as walking were rarely achieved. These findings highlight the importance of identifying patient goals and setting realistic expectations informed by functional assessments when rehabilitating this vulnerable patient population in the LTACH and subsequent post-acute care settings.
慢性危重症患者入住长期急性护理医院 (LTACH) 是重症监护病房 (ICU) 幸存者中的一个脆弱群体。对于在 LTACH 接受康复治疗的 ICU 幸存者，他们的目标和功能结局（包括吞咽功能）知之甚少。我们旨在研究 ICU 幸存者入住 LTACH 合并气管造口术后的患者目标和功能结局，包括吞咽功能。这是一项慢性危重症 LTACH 患者的前瞻性观察队列研究。共纳入 50 名中位气管切开前插管时间为 13 天的老年患者。采用医学研究委员会量表和蒙特利尔认知评估分别评估 40 名（80%）和 36 名（72%）患者存在 ICU 获得性肌无力和认知障碍。根据医院焦虑和抑郁量表和创伤后应激综合征 10 项问卷，16 名（32%）患者存在中度至重度焦虑，9 名（18%）患者存在中度至重度抑郁，11 名（22%）患者报告存在创伤后应激障碍症状，心理健康问题也很常见。咽功能障碍，采用纤维内镜吞咽评估进行测量，37 名（74%）患者存在该障碍。患者目标按频率降序排列，包括进食、说话、行走、回家和如厕。到 LTACH 出院时，目标实现情况各不相同，97%的将说话列为重要目标的患者能够说话，88%的将进食和饮水列为重要目标的患者能够进食和饮水，但只有 21%的患者能够行走，只有 18%的患者能够自行如厕。52%的患者出院到家庭或急性康复环境，与更强的力量相关，这可以通过总医学研究委员会评分（ = 0.002）以及欧洲五维五分健康相关生活质量量表的移动（ = 0.008）和自我护理（ = 0.04）领域来衡量。在此期间的康复过程中，目标的实现情况各不相同。这些患者经常将说话、进食和饮水列为目标，而像行走这样的功能目标则很少实现。这些发现强调了在 LTACH 和随后的急性后护理环境中康复这些脆弱患者群体时，确定患者目标并根据功能评估设定现实期望的重要性。
