Mechanically Ventilated Patients
Many patients, particularly those in intensive care, will receive therapy in the form of mechanical ventilation. Some patients require mechanical ventilation postoperatively as a consequence of surgery (e.g., coronary artery bypass grafting or CABG). Others will require mechanical ventilation as a consequence of illness (e.g., chronic obstructive pulmonary disorder or COPD, COVID-19, etc.). Some patients in intensive care are either admitted in association with a postsurgical event or a preexisting ailment, while others will have been transferred due to a chronically worsening condition from another care unit within the hospital (e.g.: transfer from the general care floor post rapid response or code team activation). For instance, patients who have undergone coronary bypass grafting (CABG) surgery will require postoperative mechanical ventilation to support respiratory function while they are recovering from the effects of anesthesia and are monitored closely within the ICU. Mechanical ventilation, while a therapeutic function normally used in the ICU setting, is not restricted to use in that environment. Patients with acute ailments who are in a home care or in long-term acute care facilities may also receive mechanical ventilation. Such patients who receive mechanical ventilation therapy in these settings may be receiving ventilatory assistance via tracheostomy versus endotracheal tube (ETT) for post-operative mechanical ventilation.
Mechanical ventilation not only increases the complications and cost of treatment, but it also exposes patients to the likelihood of infection. Because the patients in this environment tend to be elderly and can have several co-morbidities, these patients are also prone to ailments that can exacerbate their reasons for being in the unit as well as their decline over time. Hospital acquired infections (HAIs) and ventilator associated pneumonia (VAP) can result in mortality and become real threats the longer the stay in intensive care is and the longer the duration of mechanical ventilation. One study on the duration and costs of patients in intensive care related to mechanical ventilation made the following finding [104]:
... compared with patients who were not mechanically ventilated ... [mean] intensive care unit cost and length of stay were $31,574 ... [or] 14.4 days ... for patients requiring mechanical ventilation and $12,931 ... [or] 8.5 days for those not requiring mechanical ventilation.
As stated above, patients remaining in intensive care longer become targets for HAIs, and particularly VAPs. VAP is “pneumonia that occurs 48-72 hours or thereafter following endotracheal intubation.” It is estimated to occur in anywhere from 9-27% of patients who are mechanically ventilated and the highest risk of contracting VAP is typically early in hospitalization. Mortality is highly variable and it has been estimated at between 33% and 50% in VAP [105].
HAIs impact both quality of life and the bottom line. One estimate, based on a population of 2,238 patients diagnosed with VAP, assessed the absolute cost between those having been diagnosed with VAP and those without at more than US$39>800 [106]. For these reasons, a considerable effort has been undertaken to reduce the onset, from improved knowledge awareness associated with compliance with clinical guidelines on hand washing, to algorithms that take information from multiple sources and process them to identify the early onset of HAIs [107].
For these reasons, a considerable effort has been undertaken to apply various to reducing the likelihood of onset, from compliance with clinical guidelines on handwashing to algorithms that can take information from multiple sources and process them to identify the early onset of HAIs [121].
Clinical surveillance and close monitoring provide the tools for early detection of events as well as assisting in determining whether interventions are required to prevent or decelerate worsening decompensation that can lead to failure to rescue. Methods that can identify worsening or advancing decompensation in patients can be among the several tools available to the clinician, which include order entry systems, electronic medical record systems, and clinical decision support systems [108]. The following section delves further into the details associated with managing one special class of mechanically ventilated patient.
