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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
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