Functional Outcomes, Goals, and Goal Attainment Amongst Chronically Critically Ill Long-Term Acute Care Hospital Patients.

Abstract

RATIONALE\nChronically critically ill patients admitted to a long-term acute care hospital (LTACH) setting are a vulnerable population of intensive care unit survivors. Little is known of the goals and functional outcomes achieved by patients after rehabilitation in the LTACH setting.\n\n\nOBJECTIVES\nWe sought to examine patient goals and functional outcomes, including swallowing function, amongst ICU survivors admitted to an LTACH with a tracheostomy.\n\n\nMETHODS\nProspective observational cohort study of chronic critically ill LTACH patients.\n\n\nRESULTS\nFifty elderly subjects with a median duration of intubation prior to 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 PTSD, 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 exam, 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 able to speak, 88% able to eat and drink, yet only 21% were walking and 18% were 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 MRC score (p=0.002), as well as the EuroQOL domains of mobility (p=0.008) and self-care (p=0.04).\n\n\nCONCLUSIONS\nGoal attainment during this period of recovery was variable. The ability to speak, eat and drink, frequently identified as goals by these patients, were achieved, while 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.