1996 OPEN FORUM Abstracts
EARLY EXPERIENCE WITH THE RESPIRATORY SPECIAL CARE UNIT (ReSCU) AT THE CLEVELAND CLINIC FOUNDATION.
Richard D. Rice RRT, James K. Stoller MD. The Cleveland Clinic Foundation, Cleveland, Ohio.
BACKGROUND: The Respiratory Special Care Unit (ReSCU) was implemented in August 1993 as a 6-bed ventilator unit outside the Intensive Care Unit with two major goals:1. To wean ventilator-dependent patients where possible, and 2. When weaning was not deemed possible, to optimize patient and family instruction for patients going home with ventilatory support. Methods: Features of the ReSCU include 6 private beds arrayed on a pulmonary specialty ward staffed by nurses with special pulmonary and rehabilitation expertise, 24 hour respiratory therapy supervision, non-invasive monitoring (continuous pulse oximetry, end tidal capnometry, and ventilator alarms) with signal output at each bedside and at a central monitoring station, and a multidisciplinary approach involving dietitians, physical therapists, and speech therapists. Eligibility criteria include hemodynamic stability, absence of an arrhythmia requiring telemetry, and, in the attending physician's judgment, ability to benefit from the ReSCU. Admission priority was given to patients who were deemed weanable.
Results: Between August 22, 1993 and December 31, 1995, 109 unique patients were admitted to the ReSCU, of whom 11 were re-admitted twice (3 on separate hospitalizations), 2 were admitted three times (1 on three separate hospitalizations), 1 patient four times, and 1 patient admitted seven times (total ReSCU admissions were 149). Of the 109 unique patients, 61% (n=67) were women, and the mean age was 64 years. Eleven per cent (n=12) died during the hospitalization. Among the 97 survivors, complete ventilator independence was achieved in 73% (n=71), whereas 18% (n=17) were unweanable, 6%(n=6) required nocturnal ventilation, and 3% (n=3) required nocturnal ventilation and partial daytime support. The rate of weaning success varied slightly by year (62% in 1993, 81% in 1994, and 70% in 1995). Overall, mean length of ReSCU stay was 20 days (range 1 to 100 days) and ReSCU days accounted for 33% of total hospital length of stay. Assuming that ventilator-supported patients would have remained in an intensive care unit without the availability of the ReSCU, we assessed the impact of the ReSCU on the percentage of hospital days spent in the ICU. In 1993, patients would have spent 73% of the hospitalization in the ICU vs. 55% observed, in 1994 84% vs. 47% observed, and in 1995 89% vs 53% observed. Based on lower charges for care in the ReSCU ($560/day difference in daily room charges) and assuming no prolongation of hospitalization because of ReSCU care, this decrease in the percentage of ICU days suggests a substantial savings ($1,224,720) associated with the ReSCU. Conclusions: (1) Consistent with other series, the rate of successful weaning from mechanical ventilation of selected patients in a dedicated unit can be very high. (2) In the absence of more definitive data from a randomized controlled trial, this experience suggests that a Respiratory Special Care Unit can be a cost-effective resource.