Effective Care Practices in Patients Receiving Prolonged Mechanical Ventilation. An Ethnographic Study

Abstract

Rationale: Patients receiving prolonged mechanical ventilation experience low survival rates and incur high healthcare costs. However, little is known about how to optimally organize and manage their care.

Objectives: To identify a set of effective care practices for patients receiving prolonged mechanical ventilation.

Methods: We performed a focused ethnographic evaluation at eight long-term acute care hospitals in the United States ranking in either the lowest or highest quartile of risk-adjusted mortality in at least four of the five years between 2007 and 2011.

Measurements and Main Results: We conducted 329 hours of direct observation, 196 interviews, and 39 episodes of job shadowing. Data were analyzed using thematic content analysis and a positive–negative deviance approach. We found that high- and low-performing hospitals differed substantially in their approach to care. High-performing hospitals actively promoted interdisciplinary communication and coordination using a range of organizational practices, including factors related to leadership (e.g., leaders who communicate a culture of quality improvement), staffing (e.g., lower nurse-to-patient ratios and ready availability of psychologists and spiritual care providers), care protocols (e.g., specific yet flexible respiratory therapy–driven weaning protocols), team meetings (e.g., interdisciplinary meetings that include direct care providers), and the physical plant (e.g., large workstations that allow groups to interact). These practices were believed to facilitate care that is simultaneously goal directed and responsive to individual patient needs, leading to more successful liberation from mechanical ventilation and improved survival.

Conclusions: High-performing long-term acute care hospitals employ several organizational practices that may be helpful in improving care for patients receiving prolonged mechanical ventilation.

At a Glance Commentary

Scientific Knowledge on the Subject

Patients receiving prolonged mechanical ventilation experience poor long-term outcomes and incur high healthcare costs. Little is known about how to organize and manage care for this population.

What This Study Adds to the Field

In an ethnographic evaluation of long-term acute care hospitals, specialized facilities that are designed for the care of prolonged mechanical ventilation and other types of chronic critical illness, we found that care was most effective when it was simultaneously goal directed and responsive to individual patient needs. This type of care was promoted by interdisciplinary collaboration, which in turn was promoted by a range of organizational practices related to leadership, staffing, care protocols, and team meetings. Optimizing these practices may lead to faster liberation from mechanical ventilation and improved clinical outcomes.

An estimated 5–10% of patients receiving invasive mechanical ventilation in an ICU develop persistent respiratory failure, necessitating prolonged mechanical ventilation (1). These patients experience poor long-term outcomes, with up to 50% of patients dead by 1 year (2–4). Healthcare spending on prolonged mechanical ventilation and other types of chronic critical illness is in excess of $25 billion per year in the United States (5), with resource use far out of proportion to the size of the population (6, 7). Moreover, epidemiological data suggest that the incidence of prolonged mechanical ventilation and chronic critical illness is on the rise (8). This rise is likely in part due to the aging of the population, which puts more patients at risk, and in part due to therapeutic advances in the ICU, which have decreased ICU mortality but increased the number of patients dealing with the consequences of ICU survivorship (9, 10).

Despite the pressing public health consequences of prolonged mechanical ventilation, there have been relatively few studies focused on identifying effective care practices for this population (11, 12). These patients likely constitute a distinct subtype of critical illness with unique physiology (13–15) and unique barriers to patient-centered care (16–18). In this context, organizational practices derived from the ICU, where the focus is on acute resuscitation rather than on chronic rehabilitation, are unlikely to extend to prolonged mechanical ventilation (19). As a result, healthcare providers lack practical guidance on how to improve care in this high-cost and growing patient population (20, 21).

To address this knowledge gap, we performed a focused ethnographic study of U.S. hospitals specializing in the care of patients receiving prolonged mechanical ventilation, known as “long-term acute care hospitals” (22). We used a positive–negative deviance approach, a study design in which care practices common to high-performing providers are contrasted with care practices common to low-performing providers to identify a set of potentially effective care practices (23). Our goal was to identify effective clinical practices for patients with prolonged mechanical ventilation and, in doing so, to develop a framework for optimal care delivery in chronic critical illness in general.

Methods

Study Design and Setting

The study was reviewed and approved by the University of Pittsburgh Human Research Protection Office. A complete study protocol with detailed methodological description is available in the online supplement, and our methods and results are reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (24). Briefly, we performed an ethnographic study of U.S. long-term acute care hospitals. We focused on these hospitals because they are substantially more experienced in the care of patients receiving prolonged mechanical ventilation than other sites of care and thus are more likely to be sources of innovation and effective practices (25). We chose an ethnographic approach because qualitative methods are best suited to identifying nascent care strategies and novel clinical approaches for topics about which little is known (26).

We employed a positive–negative deviance study design to exploit differences between high-performing and low-performing hospitals to identify beneficial care practices (23). Under a positive–negative deviance framework, care practices common at high-performing hospitals but infrequent or absent at low-performing hospitals are hypothesized to be effective. These methods enable researchers to identify not only specific care practices that may be beneficial but also the organizational contexts in which these practices are encouraged and supported.

To identify high-performing and low-performing hospitals, we used a validated risk-adjusted mortality model for patients ventilated in an acute care ICU and then transferred to a long-term care hospital for ventilator weaning for continued care (27). We applied this model to national Medicare data derived from 375 U.S. long-term acute care hospitals (27). Hospitals were eligible for participation if they were in either the lowest or highest quartile of risk-adjusted mortality for at least four of the five years between 2007 and 2011, a strategy that helped ensure consistency of performance. We used mortality as our outcome of interest for site selection because it is an outcome of direct importance to patients and because a validated risk adjustment model was available (28). However, during the site visits, we approached qualitative data collection more broadly, considering organizational factors that potentially influenced not only mortality but also other outcomes that may act as key intermediaries, such as functional status and liberation from mechanical ventilation.

Data Collection

Among eligible hospitals, we used e-mail and phone calls to enroll a sample of high- and low-mortality hospitals. We then performed 4-day in-person site visits at participating sites between April 2016 and June 2017. During site visits, data were collected by either two or three trained qualitative researchers. Although data collectors were not blinded to hospital performance, individual hospitals were unaware of their performance. At each visit, we performed four types of data collection: direct observations, job shadowing, interviews with key informants (e.g., administrators, physicians, nurses, and respiratory therapists), and collection of documents (e.g., protocols and care pathways). Direct observations and job shadowing were recorded as field notes. Interviews were digitally recorded and transcribed verbatim. All data were uploaded into NVivo 11 software (QSR International) for analysis.

Data Analysis

During site visits, we conducted conference calls between the on-site team and the other investigators to review emerging content and identify key themes of interest. On the basis of these discussions, we created a preliminary thematic codebook, which was iteratively refined as the site visits progressed. We stopped performing site visits after achieving thematic saturation, which we defined as no additional major changes to the codebook. Three investigators independently coded the data, with disagreements resolved by consensus. We then organized the results into a comprehensive framework for the care of patients receiving prolonged mechanical ventilation. Member checking was performed by reviewing the preliminary results from each site visit with stakeholders from the hospital and by reviewing the penultimate care framework and final manuscript with an external advisory committee (see Acknowledgment). The results are reported as a summary of themes and subthemes from the care framework, together with supportive quotes and examples.

Results

Thematic saturation was reached after we visited eight hospitals, including five low-mortality hospitals (i.e., high performers) and three high-mortality hospitals (i.e., low performers). In total, we conducted 329 hours of direct observation, 196 interviews (212 total participants), and 39 episodes of job shadowing. Additional details about enrolled hospitals and participants are provided in Tables E1–E4 in the online supplement.

Key Domains for Effective Care Practices

Effective care practices related to prolonged mechanical ventilation could be grouped into four major domains: ventilator care; mobilization; nutrition; and management of pain, agitation, and delirium (Table 1). Participants believed that all of these domains influenced successful liberation from mechanical ventilation and, by extension, mortality. Participants viewed these practices as highly interdependent, not only contributing to improved outcomes by themselves but also supporting the delivery of the other care practices. For example, effective mobilization supports effective ventilator care by encouraging spontaneous breathing, and effective management of pain and agitation supports effective mobilization by ensuring patients are able to actively participate in physical therapy. Through these interactions, each care domain forms an essential link in the chain—deficiencies in one lead to deficiencies in the others. A physician at a high-performing site described it thus:

The main part of weaning this type of patient is not spinning the dials on the ventilator. It’s doing all the other things. It’s stopping the medicines that are hurting them. It’s getting them out of bed. It’s feeding them appropriately.  —Physician, high-performing site

Table 1.

Domains of Effective Care for Patients Receiving Prolonged Mechanical Ventilation

Domain	Examples and Supporting Quotes
Ventilator care	“We have a weaning protocol here that we start within 24 h of admission, placing patients on trach collar or spontaneous breathing trials as soon as possible. . . And it’s a gradual increase in time on trach collar, on weaning trials that [are] therapist driven.”—Administrator, high-performing site
	“Our vent rounds are done once a week, as a team, which is all of the PT, OT, speech. And usually it’ll be a representative from one of the three. The doctor, nursing, care management, pulmonary, our in-house pulmonologist, plus our pulmonary docs [sic] that are from a group that come here, along with the RTs. And we round on our vents.”—Respiratory therapist, high-performing site
Mobilization	“You have the patient sitting edge of bed, forcing them to work on trunk control, balance coordination, awareness, orientation. But you’re also allowing them to take that deep breath that they need.”—Administrator, high-performing site
	“If you get them up early enough and you do it consistently, every day it’s better for their lungs because they’re not laying on their backs all the time.”—Nurse, high-performing site
Nutrition	“Sometimes the patients get hypermetabolic because they’re starting to use their lungs more, having to [do]. . . the work of breathing is increased, and we want to make sure that these patients don’t waste muscle based on the work of breathing.”—Dietitian, high-performing site
	“We know that with overfeeding, we can impede or hinder that process. Same way as, to a lesser extent, if we underfeed. But making sure that we are giving them adequate calories to support everything that’s going on with [them], from weaning primarily to wounds to whatever other comorbidities they have. So, I feel my role in that is contributing to becoming free from mechanical ventilation if possible.”—Dietitian, high-performing site
Management of pain, agitation, and delirium	“You can’t leave patients on sedation for extended periods of time and expect them to be able to breathe well and do therapy.”—Advanced practice provider, high-performing site
	“If the patient receives proper pain medication, then they can participate more in therapy.”—Physical therapist, high-performing site

Definition of abbreviations: OT = occupational therapist; PT = physical therapist; RT = respiratory therapist.

What Makes Care Effective?

Specific to the goal of liberation from mechanical ventilation, effective care is defined by a trade-off between two underlying attributes: the aggressiveness of care and the responsiveness of care (Table 2). Aggressiveness is the degree to which ventilator management emphasizes physiological progress at the expense of day-to-day patient cues. For example, aggressive care could manifest in providers’ continuing an episode of spontaneous breathing according to a protocol even if the patient is asking to revert to full ventilator support. Aggressiveness leads to positive outcomes (i.e., successful liberation and survival) when it matches patient tolerance. However, aggressiveness can also inhibit effective care when it exceeds patient tolerance, resulting in avoidable setbacks.

Table 2.

Examples of Aggressiveness of Care and Responsiveness of Care in Liberation from Prolonged Mechanical Ventilation

Care Type	Examples and Supporting Quotes
Aggressive care	“If the patient subjectively wants to. . . feels distressed, but objectively looks pretty good, I think a good therapist. . . an aggressive therapist, will say, ‘No. let’s keep pushing. We’re going to wean you off the ventilator a little bit more. Let’s stay off the ventilator a little bit more’.”—Physician, high-performing site
	“And we pretty much let them wean until they don’t tolerate it anymore. We don’t just wean them 2 h and then put them back on. . . If we’re going to start the weaning process, we want to push. We want to wean them as long as the patient tolerates it. . . At that point, we would do an end. So, then we would do a [respiratory] note, patient was tolerating weaning up to this many hours today. Then, we’d probably let them rest for a few hours. Then, proceed again. . . We try to be as aggressive as we can.”—Respiratory therapist, low-performing site
	“Sometimes I think the weaning process is a little too aggressive for them. So, they may start people out guns ablaze and, ‘Okay, let’s go 8 h! Let’s go 16 h’! ​And they do great like 1 d, and then the next day, they are so worn out from what they did the day before that they can’t do anything.”—Respiratory therapist, low-performing site
Responsive care	“The anxiety and depression play a big part in barriers to weaning, especially anxiety. The fear. They’ve been sick for so long. They’ve been dependent on this machine. And to have to breathe on their own really scares them. They’re afraid to be left alone. . . And so, when we’re starting weaning trials, respiratory will stay with the patient just to alleviate that.”—Advanced practice provider, high-performing site
	“I had a guy last week. He was on high-pressure support. And I said, the second I came in, ‘We got to wean him down. He’s never going to get anywhere’. He was pulling in huge tidal volumes. It didn’t make sense. So, I slowly throughout the day weaned him down. I explained everything I did with him. I sat in the room. He asked me a thousand questions. I didn’t care. That’s fine. He’s now, today, doing 24 h off the vent.”—Respiratory therapist, high-performing site
	“It’s like, ‘Look, I don’t think the patient is going to go long; maybe 4 h. Try 6 [h]. But if not, 4 h is.…’ And [respiratory therapists] go and do their assessment. And they see the ultrasound, heartbeat, labored breathing. Patient himself, or herself, complains of being short of breath.”—Physician, low-performing site

Responsiveness is the degree to which ventilator management emphasizes day-to-day patient cues at the expense of physiological progress. For example, responsive care could manifest in early termination from a spontaneous breathing trial when a patient is tiring. Responsiveness leads to successful liberation when it encourages troubleshooting and prevents overexertion during the care processes. However, responsiveness can also inhibit successful liberation when it leads to an underestimation of patient tolerance, leading to slower progress.

In this way, aggressiveness and responsiveness are viewed as a trade-off in which more of one means less of another. Optimally, care providers strike a balance between the two, achieving a situation in which aggressiveness and responsiveness are “right sized” for each patient on each day.

If it looks like somebody’s having to work a little bit, the family member may start insisting that they go back on the ventilator and you’ve got to kind of point out—if we want to make some progress, we may have to push through some of this. But a lot of patients are very weak. Respiratory muscles are like any other muscle. You’ve got to try to build strength back up to make progress.  —Physician, high-performing site

How Do High-Performing Hospitals Achieve This Balance?

A successful balance of aggressiveness and responsiveness is achieved when care teams effectively share patient-specific knowledge in a way that is goal oriented, timely, and relevant to clinical decision making. This concept was most analogous to the sociological concept of “relational coordination,” which is defined as the process of communicating and relating for the purposes of task integration (29). Whereas typically there is a trade-off between aggressiveness and responsiveness, relational coordination allows care teams to “shift the frontier,” making care simultaneously more aggressive and more responsive. For example, at one high-performing hospital, physical therapists and nurses would coordinate mobility sessions around analgesia dosing to ensure success.

If the patient receives proper pain medication, then they can participate more in therapy. And we do have that where we try to schedule our therapy during the time when their pain medication peaks.  —Physical therapist, high-performing site

At another high-performing hospital, an administrator described relational coordination occurring in both routine and ad hoc patient care conferences:

A lot of times we’ll get the physician together, nurse practitioner, case manager, physical therapy, occupational therapy, speech. We’ll have every respiratory therapist. We’ll have everyone in the room and discuss: Hey, this is where we’re at. This is what we’ve tried to do. Now, where do we go from here?  —Administrator, high-performing site

In the following example, a psychologist at a high-performing hospital describes their role as an axis of collaboration between different types of care providers, ensuring that important knowledge about the patient’s progress is communicated from one group to another:

It’s sometimes really helpful to get kind of a snapshot of what is most affecting that patient in the given moment. . . I’m working with the dietary and stuff like that because I might, too, have information that I picked up from the patient that I then want to relay back to nurses or to dietary staff or respiratory staff and so on. And so it’s a give and take. It’s a two-way communication process.  —Psychologist, high-performing site

At low-performing hospitals, providers tended to work in parallel rather than together. For example, respiratory therapists would disconnect patients from the ventilator without first talking to the nurses; nurses would not know when physical therapists would be coming to work with their patients; and physical therapists would perform therapy sessions independently from ventilator care and medication dosing.

The nurse says they do not usually do things with respiratory together. Nurses do their stuff, and respiratory does their stuff.  —Observations, low-performing site

What Are the Roles of Organizational and Team Factors?

Relational coordination, and in turn the balance of aggressiveness and responsiveness, is determined by several identifiable organizational factors within the long-term acute care hospital setting. These are the ways in which hospital administrators and clinical leaders can design care delivery to optimize patient outcomes. These factors highlight differences between high-performing hospitals and low-performing hospitals (Table 3). In contrast to low-performing hospitals, high-performing hospitals tended to have engaged leadership teams, consistent physician staffing patterns, active efforts to manage nurse turnover through training and education, generous ancillary care staffing, conscious efforts to pair staff with the same patients across shifts, and detailed yet flexible care protocols that enabled autonomy by bedside providers. These differences are manifestations of marked variation in institutional culture: cultures of patient care, work environment, and quality improvement.

Table 3.

Organizational and Team-Level Determinants of Effective Care for Patients Receiving Prolonged Mechanical Ventilation

Domain	Attributes of High-Performing Hospitals	Attributes of Low-Performing Hospitals
Leadership	Leadership teams communicate a clear message of quality improvement that filters to every level of the organization; provide staff with supervisory support that allows profession-specific continuing education and expert knowledge; and promote a sense of collaboration and support	Leadership teams implement inconsistent, occasionally punitive quality improvement; exhibit oversight creep; and promote a work environment with clear demarcation between management and staff
	Leaders are present in care areas, routinely engaging frontline care providers	Leaders are absent from care areas and unrecognizable by staff
Physician staffing	Physician or advanced practice provider is available 24 h/d, 7 d/wk. Physician care provided by a single physician group, facilitating a consistent “style”	No nighttime physician care. Physician care provided by multiple groups with inconsistent communication practices and care styles
	Physicians are dedicated to the hospital with no other care responsibilities on that day	Physicians consult patients in an ad hoc manner, communicating via notes rather than in-person communication
Nurse staffing	Lower nurse-to-patient ratios (e.g., 1:4)	Higher nurse-to-patient ratios (e.g., 1:6)
	Turnover is present but actively managed through recruitment and retention programs. In some cases, this took the form of “nurse residency” programs to allow nurses to acclimate to patients with prolonged mechanical ventilation	Turnover is present but not actively managed. Training is for the most part “on the job,” with minimal attention to mentorship and retention
Respiratory, physical, and occupational therapy staffing	Relatively large staff enabling patients to be seen every day and for long periods of time, with the flexibility to focus care on the patients with greatest need	Relatively small therapy staff such that only a subset of patients are seen and with less consistency
	Overall staffing levels are sufficient to allow continuity of care (i.e., the same care providers across multiple days), enabling consistent delivery of complex care plans. Staff assignments are made with attention to continuity and designed to reinforce established relationships	Goals of care are established by a physical or occupational therapist while daily therapy is provided by therapy assistants
Ancillary staffing	Dietitians, wound care, pharmacist, and other staff members are fully integrated into the care teams	Other staff are disconnected from the care team, working in parallel
	Resources are readily available to support emotional needs, such as psychologists and spiritual care	More reliance on medication to treat emotional needs, with less readily available psychologists and/or spiritual care
Protocols and care pathways	Profession-driven weaning protocols, which provide autonomy and empowerment among care providers	Weaning protocols were vague, with most direction provided by physicians, limiting empowerment
	Protocols explicitly linked different provider types to encourage collaboration	Protocols were unique to individual provider types, obviating the need for collaboration to enforce the protocol
	Care pathways enable nonphysician providers to initiate care, preventing delays and ensuring the highest-priority needs are met	Care pathways rely on physician orders, creating delays and preventing optimal prioritization of care
	Goals are dynamic and adaptable to patient needs or progress. Protocols are specific, but patients occasionally go “off protocol” after discussion by the care team	Patient-specific goals are either nonexistent or discretionary, making it challenging for other members of the care team to stay up-to-date with daily plans. Protocols, if they exist, are general to the point that they function more as guidelines than as specific decision-making tools
Team meetings	Weekly interdisciplinary team meetings included direct care providers and were used to troubleshoot and problem solve rather than just to exchange information. Active involvement of physicians and/or pulmonologists in team discussions	Weekly team meetings rarely include direct care providers. Meeting content is based on rote reports with limited time for troubleshooting and problem solving. Physicians and/or pulmonologists mostly listen and sign documents
	Frequent, informal interprofessional meetings (i.e., “morning huddles”), either daily or sporadically throughout the week	Additional interprofessional meetings outside standard meetings are rare
Physical plant	Workspaces separate from but geographically proximal to clinical areas, allowing professionals to informally interact	No dedicated workspace or workspaces near patient care areas
	Patient care areas contain large workstations, allowing groups to interact	Workstations are small, forcing providers to disburse, inhibiting communication
	Patient rooms can comfortably accommodate families	Patient rooms are small, making family accommodation difficult

Although all hospitals had weekly interprofessional team meetings, hospitals differed in how they were used: High-performing hospitals used these to engender discussion among care providers and troubleshoot problems, whereas low-performing hospitals used these merely for informational exchange without active discussion. High-performing hospitals also consistently brought in frontline clinicians for interdisciplinary team meetings rather than limiting the meetings to management only. In this example, team meeting participants discuss a patient who is not improving, with active contributions from all participants regardless of role:

The physician says that everything is worse for the patient. The nurse states that the patient points at the vent and asks, “Can you pull that?” The physician states the patient is depressed. Physician: “What worries me is if he is going to be able to get off the vent.” Speech therapy: “It’s heart wrenching.” The physician says she asked point blank about end of life as she doesn’t feel the patient is cognitively the same as before. The physician says that she knows the patient well from his last visit. The chaplain says the patient cried a lot yesterday during our visit. The nurse asks about using the trach collar to give a little encouragement. Speech therapy says the patient had a little positivity about an expensive chair that is coming for them.  —Observations, high-performing site

Although hospitals discussed patient anxiety and motivation as important factors contributing to patient progress, high-performing hospitals tended to have lower patient-to-staff ratios, allowing teams to spend more time with anxious or discouraged patients. In addition, higher-performing hospitals had more robust psychology and spiritual care staffing to attend to patient and family psychological and emotional needs.

What Are the Roles of Patients and Families?

Patients and families play a key moderating role. Specifically, supportive families and engaged patients enhance relational coordination, leading to care that is more aggressive and more responsive. For example, at high-performing hospitals, family members were frequently used as coaches during episodes of spontaneous breathing, reassuring patients and reducing anxiety. In such instances, patients and families are considered part of the care team, and their input was used to refine and improve the care plan over the course of a hospitalization.

We let family members be an active part of their care as far as their self-care, rolling them, positioning them in bed, educating them on splints, and educating them on range of motion exercises. And educating them on getting them to engage in their self-care very early on in their stages of being here.  —Administrator, high-performing site

So, it took me about half an hour to explain to them what the cough assist can do to help the patient. They were scared! But I said, “Trust me. Let me try. If you don’t like it, no problem. I will take it out.” So, she just turned to the husband, blinked her eyes, and had tears. The husband said, “No problem. Let us try.” The daughter approved and said, “Go for it!” And then we did the cough assist machine. I use it one, two, and better. By the time that I was leaving, I was the hero.  —Respiratory therapist, high-performing site

In contrast, relational coordination is hindered when patients and families are considered separate from the care team. For example, at low-performing hospitals, family members frequently stood by as care team members cycled through the room, each doing their own thing. Also, at low-performing hospitals, family input was frequently either dismissed as unimportant or taken out of context as all-important—rarely were families actively engaged so that their input could be used to inform the long-term care plan.

It’s happened where a family member will be in the room while I’m doing therapy, and they’ll say [to the patient], “I wish you did this better, and I wish you did that.” And the patient will get upset. It’s hard to motivate a patient when there’s conflicting ideas.  —Occupational therapist, low-performing site

Importantly, the relationship between families and effective care practices was dynamic, creating a feedback loop. When the patient was not making progress, families tended to become disconnected or even disruptive of coordination. However, when the patient was making progress, families tended to become more engaged, engendering more successful coordination.

Again, it’s harder for them, that you’ll get families who get a little aggressive, saying, “How come? We came to you to get them off the vent, but how come you can’t get them off?” It’s not always us. We try to be as aggressive as we can with their pulmonary hygiene, or nursing care, but if their body can’t let them get off of it, then you can’t do that. But how do you explain that to someone who thinks that you’re coming here for this miracle of getting them off? Not everything can be done. —Nurse, high-performing site

Discussion

Our results suggest a comprehensive care model of effective care delivery for patients receiving prolonged mechanical ventilation (Figure 1). This model holds that effective care practices are supported by care that is balanced between aggressiveness and responsiveness, which in turn is facilitated by relational coordination between care providers. The interplay between aggressiveness, responsiveness, and relational coordination is supported by specific organizational practices common at high-performing hospitals as well as engaged patients and family members.

Figure 1.

Conceptual framework for the care of patients receiving prolonged mechanical ventilation. This framework, derived from an ethnographic evaluation at eight long-term acute care hospitals, holds that patient and family outcomes are optimized when care achieves a balance of aggressiveness and responsiveness. Although typically this balance requires a trade-off between aggressiveness and responsiveness, care can be made both more aggressive and more responsive through relational coordination (i.e., task-oriented collaboration between care providers). Patient and family factors can influence, and be influenced by, these relationships. Relational coordination is also influenced by discrete organizational and team-level factors that are common at high-performing hospitals.

These results can be used to guide critical care organization and management for patients with prolonged mechanical ventilation. On the basis of our data, hospitals caring for large volumes of patients receiving prolonged mechanical ventilation can be encouraged to implement the practices defined in Table 3. Although some of these practices are generic across all health settings, others are specific to the care of prolonged mechanical ventilation and are likely not in widespread use. Chief among these are the importance of continuity and the role of multiple hierarchical communication structures (i.e., daily huddles within weekly interdisciplinary team meetings) that enable team cross-communication and knowledge sharing, particularly related to the intersection between mobility and weaning (30).

Our results can also be used to guide health policy for the care of patients receiving prolonged mechanical ventilation. In the United States, these patients receive care in a range of health settings, including acute care hospital ICUs, long-term acute care hospitals, and skilled-nursing facilities (2). Many other countries have similar facilities (22). Despite multiple comparative effectiveness studies, it remains unclear which of these sites leads to the best outcomes (25). Our findings support the value of dedicated weaning centers that are able to build experience caring for this population and can flexibly implement the processes that may improve outcomes. In this context, health policies that encourage care at “centers of excellence,” such as bundled payments, may succeed at driving the policy discussion away from where to deliver this care toward how to help hospitals deliver this care in the most effective way.

Although we focused on prolonged mechanical ventilation, our results may extend to the broader population of patients with chronic critical illness, such as those with persistent or recurrent organ failures other than respiratory failure. These patients likely require the intense levels of care coordination and continuity among care teams that appear to benefit patients with prolonged mechanical ventilation. Although we focused on long-term acute care hospitals, which are a specific type of hospital within the United States, our findings likely can be transferred to other care settings. Indeed, dedicated weaning centers are present in a number of different countries, and prolonged mechanical ventilation is an international problem (6, 22).

Our study has several limitations. As a qualitative study subject to the cultural views of the research team, our results require validation to be fully actionable. However, we took several steps to ensure the trustworthiness and transferability of our results, including triangulation (both by method and by researcher) and member checking (31). In addition, we visited only long-term acute care hospitals. We cannot exclude the possibility that some acute care ICUs or other types of facilities caring for patients receiving long-term ventilation have developed novel strategies that would have enriched our results. A further limitation was the short duration of the site visits, which may not have allowed data collectors to develop optimal rapport with participants, and it is possible that we were not able to capture all perspectives at a given site. We also acknowledge that potential inaccuracies in our performance assessment model and the long time lag between performance assessment and the site visits may have led to bias, although the use of a validated performance model and our comprehensive ethnographic approach mitigates this possibility.

Despite these limitations, our study provides new insight into how to optimally care for patients with prolonged mechanical ventilation at both the individual and organizational levels. As the incidence of prolonged mechanical ventilation rises, the critical care landscape must evolve to care for these patients. Our results form a starting point for developing new models capable of caring for this high-risk, high-cost population.