Four-year experience with a unit for long-term ventilation (Respiratory Special Care Unit) at the Cleveland Clinic Foundation

Background: In the context that special weaning units have been advocated a s effective alternatives to the ICU for weaning selected patients, we initi ated a Respiratory Special Care Unit (ReSCU) at the Cleveland Clinic Hospit al in August 1993. The goals of the ReSCU were the following: (1) to wean v entilator-dependent patients when possible; and (2) when weaning was not po ssible, to optimize patient and family instruction for patients going home with ventilatory support. This study presents our 4-year experience with 21 2 patients managed in the ReSCU and analyzes clinical features associated w ith favorable clinical outcomes. Methods: The features of the ReSCU include six private beds in a pulmonary inpatient ward staffed by nurses with special pulmonary; expertise; 24-h re spiratory therapy supervision; bedside and central noninvasive monitoring ( ie, continuous pulse oximetry, end tidal capnometry, and ventilator alarms) ; and a multidisciplinary approach involving dietitians, physical therapist s, occupational therapists, social workers, and speech pathologists. All Re SCU patients were cared for primarily by a pulmonary/critical care attendin g physician and fellow, with consultative input solicited as deemed necessa ry. The criteria for admission to the ReSCU included hemodynamic stability; absence of an arrhythmia requiring telemetry; and in the attending physici an's judgment, the ability to benefit from the ReSCU. Results: Between August 23, 1993, and August 31, 1997, 212 patients were ad mitted to the ReSCU. The median age was 68 years old; 55% were women; 86% w ere white; and 55% were transferred from the medical ICU. Underlying reason s for ventilator dependence were ARDS from a nonsurgical cause (33%), ARDS following surgery (18%), status post-cardiothoracic surgery (13%), status p ost-thoracic surgery (12%), and COPD (12%). The median length of ReSCU stay was 17 days (interquartile range, 10 to 29 days). Eighteen percent (n 38) died during the hospitalization. Among the 174 survivors, complete ventilat or independence was achieved in 127 patients (60% of the 212 patient cohort ), 28 patients were ventilator dependent (13% of 212 patients), and the rem aining 19 patients (9%) required partial ventilatory support. Univariate an alysis regarding the association of baseline characteristics with death ide ntified lower albumin and transferrin levels, increasing age, and the physi cian's estimate of lower weaning likelihood as significant correlates of de ath. In contrast, achieving complete ventilator independence was associated with a higher serum albumin level, a nonmedical ICU referral source, a cau se of respiratory failure other than COPD, and a physician's estimate of hi gher weaning likelihood. To analyze the financial impact of the ReSCU, we a ssumed that ReSCU patients would have otherwise stayed in the medical ICU a nd compared the charges (ICU vs ReSCU) with, for a subset of patients, the true costs of ReSCU vs ICU care. Analyses of both charges and cost differen ces showed similar savings associated with ReSCU care ($13,339 per patient [charges] and $10,694 per patient [costs]). Conclusions: We conclude the following: (1) the rate of achieving complete ventilator independence in the ReSCU was high; and (2) based on our achievi ng clinical outcomes, which are comparable to the most favorable rates repo rted in other series from ventilator units, we conclude that the ReSCU can be an effective and cost-saving alternative to the ICU for carefully select ed patients.