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Long-Term Acute Care: Where Does It Fit in the Health Care Continuum?

July 2016
American Journal of Critical Care 25(4):364-367

July 2016
25(4):364-367

DOI:10.4037/ajcc2016766

Authors:

Christina Canfield

Cleveland Clinic

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Commentary

LONG-TERM ACUTE CARE:

WHERE DOES IT FIT IN THE

HEALTH CARE CONTINUUM?

By Taryn Miller, RN, DNP, NEA-BC, Christina Canﬁeld, RN, MSN, ACNS-BC, CCRN-E, Thomas Buckingham,

RN, BSN, MBA, Gary Johnston, RN, MSN, FNP-C, CCRN-K, Samuel Hammerman, MD, MMM, CPE, Gloria

Skinner, RN, MSN, and John Tote, RN, MSN, CCRN

As technological advancements have been

introduced into the intensive care

environment, the volume of patients

surviving the acute illness or trauma

phase has increased. Many of these

patients become chronically critically ill. Chronic

critical illness, a term ﬁrst used in 1985, refers to

the subset of patients requiring prolonged mechani-

cal ventilation, those who experience multisystem

organ failure, and those patients referred to as the

“damaged survivors of critical care.”1 In addition to

their multiple organ system failures, these patients

experience profound muscle weakness, debilitation

and require periods of prolonged recovery. Recovery

of the chronically critically ill has been described

as slow; occurring over weeks or months.2

Care of this population requires a skill set that

blends critical care expertise with rehabilitation.

The need for acute nursing and medical care extends

signiﬁcantly beyond the expected length of stay as

seen in a traditional hospital environment. Extended

acute care may be provided in specialized hospitals

called long-term acute care hospitals (LTACHs). Long-

term acute care hospitals specialize in the care of

high acuity patients who become chronically criti-

cally ill and require medical treatment beyond the

normal length of stay in a short-stay acute care

hospital and beyond the scope of practice of inpa-

tient rehabilitation or skilled nursing facilities.2

Background

Long-term acute care hospitals were formally

established in the 1980s, and are deﬁned by the US

Centers for Medicare and Medicaid Services as

acute care hospitals with an average length of stay

greater than 25 days.3 The Centers for Medicare

and Medicaid Services also requires patients transi-

tioning to LTACHs to have spent 3 or more days in

an intensive care unit (ICU) immediately preced-

ing their admission or to have required mechanical

ventilation for more than 96 hours. These hospitals

may be located within the walls of a short-term

acute care hospital or they can be a free-standing

facility. An LTACH is a fully functioning acute

care hospital, not a skilled nursing facility or an

inpatient rehabilitation facility. Categorized as a

postacute care facility, an LTACH provides care for

patients with higher acuity needs than an inpatient

rehabilitation facility or skilled nursing facility.

Within the postacute care provider category, LTACHs

provide the highest level of clinical expertise and

require the greatest use of human and equipment

resources in the provision of care to this fragile

patient population. Improved outcomes may be

related to the LTACHs’ multidisciplinary approach

to care, which includes physicians, nurses, respira-

tory therapists, physical therapists, pharmacists, dieti-

cians, and case managers.5

Care provided at an LTACH focuses on contin-

ued medical stabilization, management of critical

infusions, optimizing respiratory status, and facilita-

tion of functional recovery. Consideration for trans-

fer to an LTACH should occur early in a critically

ill patient’s ICU stay to afford the patient the opti-

mal chance for recovery. Of note, access to many

of the same services as a short-term acute care

hospital, such as hemodialysis, radiology, and lab-

oratory services, allows for the continued intense

level of care these patients require. A smoother

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“ The ultimate goal in caring for these patients

is the restoration of normal function.

”

transition of care, avoidance of delays in discharge,

and enhanced utilization of ICU resources are

advantages of early LTACH identiﬁcation.5 More

than one-third of the 5 million patients admitted

to ICUs every year will require mechanical ventila-

tion and up to 25% of these patients will require

ventilation beyond 7 days with subsequent trache-

ostomy placement.6 LTACHs provide highly special-

ized evidence-based care intended to improve

long-term outcomes for these patients and offer the

ideal environment for development and implemen-

tation of specialized strategies for liberation from

prolonged mechanical ventilation. Collaboration

among the interdisciplinary team focuses on decreas-

ing the potential for ventilator-associated events,

improving progressive mobility, preventing infec-

tion, maintaining adequate nutrition, and enhanc-

ing communication and strategic weaning strategies.

Identiﬁcation of Patients

Patients are identiﬁed for transfer to an LTACH

through a comprehensive referral process. Although

patients are frequently referred directly out of the

ICU, they may also transfer from a step-down or

complex medical-surgical setting. Physicians and

case managers identify patients who will beneﬁt

from an LTACH stay before transitioning them to a

lower level of care. Patients requiring acute dialysis,

liberation from mechanical ventilation, complex

wound management, management of 1 or more

infectious disease processes, and those who require

frequent administration or adjustment of intrave-

nous medications may all be eligible for admission

to an LTACH. Clinical liaisons, skilled in the

assessment of chronically critically ill patients, work

with the short-term acute care hospital’s case man-

agement team to coordinate the admission and

assure continuity of care between settings. Handoff

occurs between physicians, advanced practice nurses,

bedside nurses, and respiratory therapists prior to

patient transfer.

Patients requiring intense or frequent nursing

care and assessments may be placed in a high

observation or special care unit within the facility,

and lower acuity patients may be placed in a

medical-surgical unit. The clinical team is geared

toward the management and clinical resolution of

the chronically critically ill patient’s complex medi-

cal issues. Interventions are carefully considered

for possible unintended negative consequences.

The LTACH environment provides adequate tech-

nology to assess and sustain care (eg, ventilators,

electrocardiogram monitors, intravenous equipment).

This is coupled with careful, coordinated attention

and intervention by clinicians with specialized skills.

The ultimate goal in caring for these patients is the

restoration of normal function with an emphasis

on mobility and weight bearing, effective nutrition,

management of current organ dysfunction, and pre-

vention of additional complications.

Interventions Provided

Interventions such as central venous catheter

insertion, percutaneous endoscopic gastrostomy

tube insertion, bronchoscopy, or colonoscopy may

also be performed in an LTACH. Additionally,

LTACHs are equipped to manage acute physiologic

decompensation such as respiratory failure, sepsis,

and acute pulmonary edema. Patients experiencing

an acute decompensation may be transferred to a

higher level of care within the facility for more

intense management. Clinicians at LTACHs are

skilled at endotracheal intubation and management

of rapid response calls and cardiopulmonary arrest.

LTACHs do not provide therapies such as percuta-

neous coronary intervention or extracorporeal

membrane oxygenation. Patients requiring these

therapies are transferred back to a short-term acute

care hospital.

Many LTACHs maintain an afﬁliation or connec-

tion with providers at short-term acute care hospitals.

This afﬁliation allows for continuity of care and

exchange of key patient information. The relation-

ship may be maintained via dual privileging of phy-

sicians and midlevel providers or through a shared

medical record. Physicians assess the patients’ prog-

ress daily and adjust their treatment plan accordingly.

About the Authors

Taryn Miller is clinical leadership development special-

ist, Thomas Buckingham is executive vice president,

Gary Johnston is regional chief nursing ofﬁcer, Samuel

Hammerman, is chief medical ofﬁcer, and Gloria Skinner

is senior vice president and chief nursing ofﬁcer at Select

Medical, Mechanicsburg, Pennsylvania. Christina Canﬁeld

is clinical program manager and John Tote is nurse man-

ager, eHospital, Cleveland Clinic, Cleveland Ohio.

Corresponding author: Taryn Miller, RN, DNP, NEA-BC, clinical

leadership development specialist, LTACH division, Select

Medical, 4714 Gettysburg Road, Mechanicsburg, PA 17055

(tarymiller@selectmedical.com).

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skillful therapeutic communication. Patients and

their families are often hesitant to leave the ICU

environment and require much reassurance that

their needs will be met during the LTACH stay.

Goals of care are set with patients and their families

during care conferences held with the interdisciplin-

ary team at the beginning of their stay. Care confer-

ences allow the clinical team, the patient, and the

family to collaborate on care delivery and also allow

the patient and their family to express their prefer-

ence and desire for a discharge plan. The goals of

LTACH must frequently be reinforced. Physical ther-

apy, occupational therapy, and speech therapy con-

tribute signiﬁcantly in the LTACH setting to the

patient’s progression, however there is no deﬁned

amount of time that they must be able to participate

in therapy sessions. Therapy interventions are ﬂuid

and dependent upon close collaboration with the

medical, nursing, and respiratory teams. The therapy

plan is decided based upon the daily assessment

and the patient’s medical condition. Collaboration,

cooperation, and communication are intrinsic to

the patient’s outcome in the LTACH space.

The interdisciplinary team continuously eval-

uates patient progress and develops a plan for the

next transition in care. This plan for transition is

generated collaboratively with patients and their

families while considering the available and/or

required resources. Whereas some patients may be

discharged home from an LTACH, many will tran-

sition to inpatient rehabilitation, skilled nursing,

or hospice care. The decision to transfer to the next

level of care is based on the patient’s medical sta-

bility and potential for rehabilitation. In contrast

to LTACHs, inpatient rehabilitation facilities have a

therapy driven model in which the patients must be

able to tolerate 3 hours of therapy at a minimum.

Focused on Return to Normalcy

The successful recovery of a critically ill patient

is deﬁned by the entire episode of care and thus

the transition of patients who are chronically criti-

cally ill out of the intensive care environment to an

LTACH once they have reached the end of the acute

phase of their illness is an important step in their

healing. The LTACH environment, with a focus on

the patient’s return to normalcy through the imple-

mentation of evidence-based protocols, has produced

positive patient outcomes.

Highly skilled clinicians, who comprise the inter-

disciplinary team, work closely together on a treatment

“ The nurse is an integral member

of the interdisciplinary team.

”

Consultations for specialty physicians, such as, but

not limited to, pulmonologists, infectious disease

experts, nephrologists, gastroenterologists, urologists,

cardiologists, and neurologists are also available.

Advancements in telemedicine further connect pro-

viders at referring hospitals to their patients and

allow for virtual consults and, at times, assessment

and management of care.

The Long-Term Acute Care Hospital Team

A care environment and clinical team geared

to the management and clinical resolution of these

issues as a group, such as that provided in an

LTACH, is essential for returning the patient to true

recovery. This patient population is very fragile, so

every intervention must be carefully considered

for possible unintended negative consequences.

The environment must provide adequate technol-

ogy to sustain care and carefully coordinated atten-

tion and intervention by clinicians with specialized

skills. To reiterate, the goal in caring for these

patients must be the restoration of normal function

with emphasis on mobility and weight bearing,

effective nutrition, management of current organ

dysfunction and prevention of additional compli-

cations. This is difﬁcult to achieve in the modern

ICU, which is geared toward technology and inter-

ventions that limit mobility, and which does not

have clinicians with specialized knowledge of this

phase of critical illness. Once more, transfer to a

more specialized environment such as an LTACH,

can decrease anxiety and delirium, promote sleep,

and possibly ameliorate future cognitive impair-

ment and posttraumatic stress disorder.

Nurses who work at LTACHs must demonstrate

a high degree of competence in caring for patients

with multiple complex medical problems. Nurses

maintain Acute Cardiac Life Support certiﬁcation

and many also hold certiﬁcation as Critical Care

Registered Nurses. Advanced training in the imme-

diate management and stabilization of critically ill

patients may be provided; Fundamentals of Critical

Care Support training may be offered to nurses, as

well. The nurse is an integral member of the interdis-

ciplinary team and actively participates in developing,

implementing and evaluating the individualized

and continuing care plan for each patient.

Caring for patients and their families who have

experienced an unexpected prolonged hospital stay

presents its own unique set of challenges and nurs-

ing care of the patient admitted to an LTACH involves

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plan that encompasses the patients’ and families’

goals for healing. Unlike inpatient rehabilitation

facilities and skilled nursing facilities, the care

provided at an LTACH is driven by their continued

acute medical needs. LTACHs provide high quality

care to the chronically critically ill patient popula-

tion and will continue to partner with ICUs to

assure these patients are transitioning seamlessly

to the best level of care possible, helping to ensure

successful clinical outcomes.

FINANCIAL DISCLOSURES

None reported.

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REFERENCES

1. Girard K, Rafﬁn TA. The chronically critically ill: to save or

let die? Respir Care. 1985;30:328-347.

2. MacIntyre N. Chronic critical illness: the growing challenge

to health care. 49th Respiratory Care Journal Conference,

“The Chronically Critically Ill Patient,” September 2011,

Florida. Respir Care. [serial online]. 2012;57(6):1021-1027.

3. Kahn JM, Barnato AE, Lave JR, et al. A comparison of free-

standing versus co-located long-term acute care hospitals.

PLoS One. 10(10):e0139742. doi:10.1371/journal.pone.0139742.

4. Centers for Medicare and Medicaid Services. Long-term

hospital PPS. April 16, 2013. Available at https://www.cms

.gov/Medicare/Medicare-Fee-for-Service-Payment/LongTerm-

CareHospitalPPS/index.html. Accessed November 10, 2015.

5. Szubski C, Tellez A, Barsoum W, et al. Predicting discharge

to a long-term acute care hospital after admission to an

intensive care unit. Am J Crit Care. 2014;23(4):e46-e53.

6. Critical care statistics. Society of Critical Care Medicine. http://

www.sccm.org/Communications/Pages/CriticalCareStats.aspx.

Accessed March 2, 2016.

To purchase electronic or print reprints, contact American

Association of Critical-Care Nurses, 101 Columbia, Aliso

Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050

(ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

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Skinner and John Tote

Taryn Miller, Christina Canfield, Thomas Buckingham, Gary Johnston, Samuel Hammerman, Gloria