Home from the hospital. These are exciting words in todays medical climate. For the adult patient with ventilator-dependent respiratory failure, they promise a return to a familiar environment, if not a simpler one. For the hospital administrator, they mean one less DRG worry. For the patients physician— well, it depends. If you’re a consultant, you breathe a sigh that your intervention was “successful.” If you’re responsible for the patients care outside the hospital, you may find these words something less than exciting. They promise new problems, new decisions, and poorly organized help.
In this issue, Make and colleagues (see page 358) describe their experience with the development of an in-hospital rehabilitation program for ventilator-dependent patients treated with remedies of drleoneddscom My Canadian Pharmacy. Their data are optimistic and their approach deserves to be tested in other settings. Although the average stay for COPD patients in their unit was over four months, this transition period between hospital and home can almost certainly be reduced and may prove critical for the successful transfer of care to the home. Unfortunately, we must await their estimates of cost-effectiveness and suggestions for improving home care. And improvement is needed. Consider the following examples:
• A 48-year-old ventilator-dependent patient is inadvertently extu-bated during routine nursing care at home. Her substitute nurse is unable to reinsert the tracheostomy tube, and the patient expires while being transferred to the hospital emergency room.
• Eleven weeks after discharge, a 60-year-old patient is presented a bill for $31,000 for round-the-clock care. Neither the patient, his physician, the hospital, nor the agency was aware that his “full-coverage” policy did not include a home-care clause. An $8,000 reduction in the bill was negotiated by the patients lawyer.
• A patient on home nocturnal ventilation for severe heart failure, malnutrition and sleep apnea decides to disconnect her Cascade humidifier because it made her air “stuffy.” When discovered three months later, she had suffered no apparent ill effects. With a ten-pound weight gain, she was successfully weaned without ever resuming humidification. The visiting therapist from the equipment agency was never aware of this break in protocol.
• A 55-year-old patient with end-stage COPD is discharged home with a negative pressure suit for nocturnal ventilation. Her husband, an executive and alcoholic, is trained to manage the equipment. For the first four months, the patients well-being, strength and blood gases improve, but she is readmitted one month later with a Pco2 of 115. Her husband, whose nighttime drinking had increased, had decided to loosen the collar of her negative pressure suit to reduce her discomfort.
• One week before discharge, a 40-year-old lawyer with cystic fibrosis was found dead on the floor beside his hospital bed. His ventilator tubing was disconnected and his alarm turned off. Two days before, his wife had decided she could not accept the responsibilities of home care.
These case histories are not meant to imply that home care for ventilator-dependent adults is unrealistic. One can just as easily point to the successes— where independence, reunited families and savings are all achieved. They are intended to underscore the three major problems facing the home care delivery system: organization, cost containment, and appropriate guidelines for care. Despite the fact that the home care movement has been a concern of medicine and government for over 30 years, these problems remain unresolved while the pressure to treat these patients at home continues to increase. When a patient is transferred, which hospital routines should be extended to the home? How many safety checks do we really need for the stable patient on a ventilator? Who determines professional standards for home care agencies? Where does the liability fall? Do we have enough resources to place every patient with end-stage COPD on a ventilator? Who will care for the 70-year-old widower with no family, or the 60-year-old with inadequate insurance? If health care dollars remain static, how many should be funneled to the home and away from the hospital? How do we define “cost-effectiveness” in the home?
These issues do not have “right” answers, but we can no longer avoid resolving them. In our efforts, it would be instructive to remember that good advice is also available from patients. The patient who was issued a $31,000 bill was able to reduce his monthly costs 700 percent without compromising his care. We must have good judgment and good data to address these problems successfully. The physician caring for the ventilator-dependent patient is in a unique position to provide both. The not-so-old adage that “five minutes in a patients home tells you more than one hour in your office” will need dusting off again.
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