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First off, thank you for taking the time to read and respond to our article. We are in agreement that invasive mechanical ventilation and hospital readmissions are important as they pertain to both patient-centered outcomes and resource utilization.
We also agree with your statement that Emergency Department (ED) length of stay is comparatively short when compared to the time spent in the hospital. However, in time-critical conditions such as sepsis, trauma, acute ischemic stroke, and myocardial infarction, this time period is highly influential on long-term patient outcomes. Regarding the management of mechanical ventilation, our group has previously demonstrated that the initial management of ventilator settings in the ED influences outcome (i.e. ventilator-associated lung injury and exposure to hyperoxia are also time-sensitive) (1-3). As it was previously unknown if hospital readmissions are influenced by initial ED management, and readmission is a patient-centered reflection of morbidity, we felt this topic merited further evaluation.
We agree that the relationship between chronic illness and clinically significant outcomes is important (i.e. length of stay, duration of mechanical ventilation, etc.). Unfortunately, we felt that this data and subsequent analysis was beyond the scope of our paper. Our aim was simply to evaluate whether or not processes of care in the ED influenced the rate of hospital readmissions in patients requir...
We agree that the relationship between chronic illness and clinically significant outcomes is important (i.e. length of stay, duration of mechanical ventilation, etc.). Unfortunately, we felt that this data and subsequent analysis was beyond the scope of our paper. Our aim was simply to evaluate whether or not processes of care in the ED influenced the rate of hospital readmissions in patients requiring invasive mechanical ventilation.
You are also correct in stating that excluding patients that were chronic tracheostomy and ventilator-dependent patients may affect the statistical analysis, but our present study was a retrospective analysis of a previously performed prospective interventional study which excluded these patients (1). Given the nature of the primary study, this data is unavailable. In spite of this limitation, we still feel that our study provides valuable data as it pertains to the outcomes of ED patients with respiratory failure requiring mechanical ventilation. Even with these patients excluded, the study cohort represents an extremely ill subset of patients with poor long-term outcomes; this is demonstrated by the fact that 42.8% of the original study population either died during their incident hospitalization or required hospital readmission within 30 days.
Lastly, we also agree that the level of dependency following hospitalization is extremely important to the patient and healthcare system. Unfortunately, this data was is not readily available to us and js also beyond the scope of our original study aims.
Once again, we thank you for taking the time to read our work and provide a thoughtful response to our article.
David B. Page & Brian M. Fuller
1. Fuller BM, Ferguson IT, Mohr NM, et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Annals of emergency medicine. 2017;70(3):406-418.e404.
2. Fuller BM, Page D, Stephens RJ, et al. Pulmonary Mechanics and Mortality in Mechanically Ventilated Patients Without Acute Respiratory Distress Syndrome: A Cohort Study. Shock (Augusta, Ga). 2018;49(3):311-316.
3. Page D, Ablordeppey E, Wessman BT, et al. Emergency department hyperoxia is associated with increased mortality in mechanically ventilated patients: a cohort study. Critical care (London, England). 2018;22(1):9.
It is widely recognised that the management of patients with acute respiratory failure in the Emergency Department (ED) is a pivotal point that may influence outcomes at later stages in patient care pathways. In particular, the decision to submit patients to invasive mechanical ventilation (IMV) and the mode of ventilator settings utilised are of relevance in determining patient outcomes. It is also acknowledged that early hospital readmission following an episode of acute critical illness is a major problem not only for patients’ quality of life but also healthcare systems in general. Thus we read with great interest the recent retrospective study by Page DB et al., in which the authors investigated the relationship between ED pathways of care and the risk factors for unplanned 30-day readmissions. We applaud the authors on their efforts, however we also feel that there are several confounding issues that warrant further discussion.
Firstly, the length of the time for which patients were treated and mechanically ventilated in the ED was relatively short - at 5 hours and 30 mins - compared the total length of stay (LOS) in hospital. We feel that this short period is unlikely to have contributed any meaningful effect on overall patient outcomes. Moreover, it would have been of great interest to discuss any changes in ventilator parameters between ED and ICU, and if the initial choice of ventilator settings could have influenced patient outcomes, i...
Firstly, the length of the time for which patients were treated and mechanically ventilated in the ED was relatively short - at 5 hours and 30 mins - compared the total length of stay (LOS) in hospital. We feel that this short period is unlikely to have contributed any meaningful effect on overall patient outcomes. Moreover, it would have been of great interest to discuss any changes in ventilator parameters between ED and ICU, and if the initial choice of ventilator settings could have influenced patient outcomes, including LOS and complications seen.
Secondly, with respect to the past medical history of patients included in the study it would be logical to expect that patients affected by chronic diseases (such as COPD, CHF and diabetes) are at greater risk of hospital readmission, especially those suffering from chronic pulmonary disorders. It is not clear from the discussion if this was indeed the case. It would also be of great interest to the reader to see statistical analysis of the impact of disease entities on LOS and readmission rates: for instance, do patients with CHF in acute cardiac pulmonary oedema require fewer days of IMV and as a consequence have a shorter LOS, whilst conversely standing a greater risk of readmission to hospital?
Thirdly, it is possible that the decision to exclude a number of patients with relevant medical conditions – including tracheostomy and long term ventilation patients, and those transferred from other hospitals) may affect the statistical analysis. Furthermore a significant percentage of patients requiring IMV are not defined as having critical conditions or disease processes, and are catergorised under “group other”. These patients contribute 19.5% of the readmission group compared to 25.1% in the not readmitted group. It is not clear from the authors’ comments the extent to which this high incidence of patients apparently unaffected by chronic illness may influence the findings of the study.
Finally, no information is provided by the authors regarding levels of dependency and the need for domicillary home assistance following hospital discharge. Patients who survive critical illness with significant care needs represent a significant challenge to healthcare systems worldwide, and some discussion of the role that individual organisations play in this issue would be interesting and enlightening.
We commend the authors on an interesting study which addresses some of the questions surrounding the impact that care provided acutely to patients may have on their longer term outcomes. We agree with the authors that further clinical trials need to investigate the questions that arise from this study and others like it.
Authors declare no conflict of interest
Angotti LB, Richards JB, Fisher DF, Sankoff JD, Seigel TA, Al Ashry HS, Wilcox SR. Duration of Mechanical Ventilation in the Emergency Department. West J Emerg Med. 2017 Aug;18(5):972-979. doi: 10.5811/westjem.2017.5.34099. Epub 2017 Jul 11. PubMed PMID: 28874952; PubMed Central PMCID: PMC5576636.
Page DB, Drewry AM, Ablordeppey E, Mohr NM, Kollef MH, Fuller BM. Thirty-day hospital readmissions among mechanically ventilated emergency department patients. Emerg Med J. 2018 Apr;35(4):252-256. doi: 10.1136/emermed-2017-206651. Epub 2018 Jan 5. PubMed PMID: 29305381.
Rezaee ME, Ward CE, Nuanez B, Rezaee DA, Ditkoff J, Halalau A. Examining 30-day COPD readmissions through the emergency department. Int J Chron Obstruct Pulmon Dis. 2017 Dec 27;13:109-120. doi: 10.2147/COPD.S147796. eCollection 2018. PubMed PMID: 29343950; PubMed Central PMCID: PMC5749550
Conflict of Interest