Yesterday The New York Times ran a lengthy expose` on patient safety concerns at long term acute care hospitals (LTAC's), specifically Select Medical Corporation, a for profit, publically traded company that operates 89 long term hospitals across the U.S. Many of these hospitals are known as "hospitals within a hospital," as typically entities like Select lease a floor of an existing hospital and set up their own separate hospital for patients' long term care needs.
The article is a must read for anybody considering a transfer of their loved ones to an LTAC facility. Interestingly, this article comes on the heels of a case we recently litigated against a long term acute care hospital arising out of the death of a ventilator dependent patient. As a result of that case, we prepared an article for consumers,reproduced in full below, entitled: LONG TERM ACUTE CARE HOPSITALS AND ARTIFICIAL AIRWAYS: WHAT PATIENTS AND THEIR FAMILIES NEED TO KNOW. Hopefully both articles will provide real guidance to families considering these facilities beyond their fancy brochures and websites touting their excellence...
LONG TERM ACUTE CARE HOSPITALS & ARTIFICIAL AIRWAYS:
WHAT PATIENTS AND THEIR FAMILIES NEED TO KNOW
Long term acute care facilities ( LTAC’s) in many ways are like hospitals: they care for critically ill patients who sustain strokes, brain injuries, and other serious conditions.
Frequently these patients are transferred to LTAC’s with artificial airways in place, such as an endotracheal (ETT) or, more commonly, a tracheostomy tubes. Because these patients are ventilator dependent, artificial airways are their “lifeline” for supplying oxygen to their vital organs. If artificial airways are dislodged or compromised for any reason, brain damage or death can occur within a matter of minutes.
LTAC’s must have clear guidelines in place as to how staff will respond to airway emergencies. However, in our experience, some LTAC’s give little thought to preventing airways from being dislodged, while others are unprepared to provide safe emergency airway management when airways become dislodged.
PREVENTING DISLODGED AIRWAYS
Airways can become dislodged during patient turning or repositioning when staff causes excessive tension on the airway tube or the ventilator tubing (which connects the airway tube to the ventilator). Surprisingly, some LTAC’s allow nurses’ aides to turn artificial airway patients without supervision of a nurse or respiratory therapist (RT). Whether the LTAC has a written policy mandating the presence of a nurse or an RT during patient turns is a crucially important question for patients’ families to ask LTAC staff. If there is no such policy, it is a red flag that the LTAC has not adopted a “prevention first” mentality to patient airway safety.
Equally important is whether the LTAC has policies to alert staff that a patient’s tracheostomy is “fresh” or new, commonly defined as one that is 7-10 days old. If a fresh trach becomes dislodged, it is a medical emergency requiring immediate action to restore an open airway and provide life sustaining oxygen. Some LTAC’s have written policies requiring “fresh trach” signage to be placed above the patient’s bed as an additional warning to staff. Lack of mandatory signage is another red flag that the LTAC does not fully appreciate the hazards associated with these vulnerable airways.
RESPONDING TO AIRWAY EMERGENCIES
“Airway management” is the process of ensuring that a patient has a patent or open airway for life sustaining oxygen. When an airway becomes dislodged, staff must act immediately to restore the airway. Obvious questions to ask staff are: Who are the first responders to an airway emergency? Does the LTAC have an in house physician to respond to an emergency at all times, or is troubleshooting this emergency delegated to in house RT’s?
If RT’s are the designated first responders, are they trained and competent to intubate patients – one of the most fundamental aspects of airway management? Intubation is the process of inserting a breathing tube into a patient’s mouth or nose and into their upper airway in order to provide oxygen to the lungs. Surprisingly, some LTAC’s do not train their RT’s to intubate, even when there is no physician-responder available on site.
An LTAC’s emergency response protocols are even more critical when a fresh trach becomes dislodged. The surgical hole or “stoma” in the trachea created by the original tracheostomy surgery will close rapidly if the tube is dislodged, because the hole has not matured. A serious risk of re-inserting any trach tube is misplacing it into the tissues surrounding the patient’s trachea, known as “false passage” placement. This results in forcing oxygen into the patient’s face, neck, and chest instead of the lungs, and is a serious and life threatening complication.
Because of this risk, some facilities have clear policies prohibiting RT’s from attempting to place any trach tube into a fresh trachea hole. Instead, many facilities require that RT’s call a “Code Blue” and provide oxygen through a bedside oxygen “AMBU” bag rather than attempt a risky emergency trach tube change.
Amazingly, some LTAC’s permit RT’s to attempt the dangerous practice of inserting a new trach tube into a fresh tracheostomy hole.
To summarize, any LTAC accepting patients with artificial airways should be prepared to answer the following questions:
1. Do you allow nurses aides to turn patients with airways with no nurse or RT supervision?
2. Do you require special signage above patients’ beds warning staff of a fresh or new trach?
3. Do you have a physician on hand at all times to respond to airway emergencies?
4. Are your RT’s competent to intubate patients who’ve lost their airway for whatever reason?
5. Do you prohibit your RT’s from re-inserting or replacing a dislodged fresh trach?
The more “No” answers you receive, the more likely the LTAC has not implemented practices that promote a culture of safety when it comes to protecting patients' artificial airways. Given that the maximum foreseeable harm of a dislodged airway is brain damage or death, there is no excuse for an LTAC’s systemic lack of preparedness when it comes to patient airway safety. Their lack of foresight should not expose your loved one to increased risks while recuperating from a serious illness.