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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

Today, I have a question from Roger and Roger says,

“Hi Patrik,

It’s Thursday today. The ICU says that my mother needs to go to LTAC next week. She will be on tracheostomy collar sometimes, and they think she will need to be on the ventilator for about another week.

She is on the tracheostomy collar, no ventilator and 70% oxygen for about 8 hours during the day on Thursday. During her sleeping, she went back on the ventilator with assistance, probably PEEP (positive end expiratory pressure) of 5, pressure support of 5 at 40% or 50% of FiO2 (fraction of inspired oxygen).

Can you please let me know what questions I should be asking the LTAC on checking their quality?”

Now, couple of comments before I go into the questions that you should be asking LTAC. 

She’s on the tracheostomy with 70% of FiO2, that is a lot. That’s telling me she’s probably not quite ready for spontaneous breathing. If she’s on the ventilator with assistance, pressure support, PEEP of 5, pressure support 5, 40% or 50% of FiO2, that’s also too high.

My advice here would be to wean the FiO2 down to 30% on the ventilator and then start the tracheostomy collar. One way to achieve that is to treat any pneumonia she might have, but also to mobilize her because that’s how you get FiO2 down. That’s assuming she’s strong enough, that’s assuming she’s hemodynamically stable. But if they want to send her to LTAC, she must be hemodynamically stable. 

So, get her out of bed every day and that, I argue, will get the FiO2 down because she can breathe properly, all parts of the lungs that are not expanded, that potentially have secretions in there so much easier to get rid of the secretions and so forth.

So, before I go to the list of questions that you should be asking the LTAC, once again, your mom should never go to LTAC in the first place. Couple of things, we have helped many clients to keep their loved ones in ICU and wean them off the ventilator there and we have some testimonials around that. That’s Number 1.

Number 2, no one can discharge your mom without her consent, but I know you are the decision maker or without your consent. So, put yourself in a position of power and exercise your rights and take responsibilities for outcomes. Most families in intensive care do not take responsibility for outcomes. That is something you need to do, and you need to start learning.

So, let’s go to the questions you should be asking the LTAC. 

First thing that I would do is look up the online reviews and I can tell you, the LTAC would probably say on their website they specialize in ventilation, and tracheostomy weaning, and rehabilitation but my experience is nothing could be further from the truth. Look up the online reviews from families and that will probably tell you everything you need to know.

So, let’s look at the questions you should be asking the LTAC.

First question is what’s the nurse-to-patient ratio? How many patients is a nurse looking after? I can tell you from experience it’s often 1:4, 1:5, sometimes 1:10 overnight. Can you imagine your mom going from ICU where she has 1:1, she’s extremely vulnerable, she’s critically, critically unwell, and now, she’s going to an LTAC where she has 1:4,1:5, or 1:10 nurse to patient ratio?

That leads me to my next question. Ask them if all nurses have ICU experience, and I can tell you straight away, they won’t. You are entering a disaster area by going to LTAC. Let me repeat that. You are entering a disaster area if you let your mom go to LTAC. Let that sink in.

I’ve had so many horror stories over the years when I ring up LTACs on behalf of a client and I talk to nurses in particular, they have absolutely no clue, no clue whatsoever. You ask them about ventilator settings, and they have no idea what I’m talking about. That should scare you and it should scare you immensely.

You also need to find out if not only do you need to find out if all of those nurses have ICU experience and when I mean ICU experience, I’m talking about a minimum of two years ICU experience, a minimum. 

Do they have RTs (respiratory therapists) on site? Do they have doctors on site, ICU doctors in particular? Who’s in charge of the weaning process? Do they have a pulmonologist on site? Do they have a doctor on site overnight? 

Do they have someone with your mom at all times? Imagine you cannot leave a ventilated client alone. You just simply can’t. If she’s going from 1:1 as the patient ratio to 1:4, 1:5, or 1:10, she won’t have someone with her all the time.

So, to a degree, you are asking the wrong questions by what questions should I be asking LTACs. You shouldn’t be asking any questions to LTAC. You should be keeping your mom out of LTAC.

That leads me to the next question, how will your mom know how to alert the nurses? Your mom is vulnerable, extremely vulnerable. How can she alert the nurses if she needs help?

Also, the next question you need to ask, often there’s a 30-day time window when patients go to LTAC. And that means if your mom isn’t getting better within 30 days, if she can’t be weaned off the ventilator, she would go to a skilled nursing facility, which is even worse.

I also should have said in the beginning, this is really for our U.S. audience because LTACs only exist in the U.S.

So, let’s continue on, and what we’ve seen often, the first two weeks is just a time for LTACs to get to know the patient. The first two weeks means no weaning has been done and then they only have another two weeks to be weaned off the ventilator and then they need to go to a skilled nursing facility.

Your time, Roger, is better spent on focusing your efforts and keeping your mom in ICU rather than ringing around and asking LTACs what you already know the answer to.

Other questions you should be asking, how will they deal with medical emergencies? How will they deal with if the tracheostomy blocks, if the tracheostomy comes out, if they need to change the tracheostomy and so forth? 

Who’s going to be in charge of the weaning? Do they have speech therapist? Do they have physical therapists? Do they have Ots (occupational therapists)? What’s the mobilization plan? We should get mobilized every day. Will they also try and wean off feeding from the PEG (Percutaneous Endoscopic Gastrostomy) tubes so she can start eating and drinking again?

What’s the backup for ICU? Where’s the nearest ICU? Can she go back to the same ICU that she came from? Do they have pathology on site? X-ray on site? Can they do arterial blood gases? Do they have CT scans on site? MRI scanner on site?

So, do not let your mom go to LTAC. It’s as simple as that.

Now, other questions you should be asking, who’s in charge of the care plan? Who will be writing the care plan? What are your visitation hours? How do you prevent pressure sores? And listen carefully by what they say, listen very carefully by what they say. If they’re going to be vague about it and they can’t describe to you in detail how they prevent pressure sores, for example, how they deal with the tracheostomy, for example, they don’t have a clue.

Also ask them, what’s their success rate to wean patients off the ventilator and the tracheostomy? 

Ask them if you can talk to other families. Ask them whether your mom will get a bed bath every day or would she have a shower every day? Don’t let them tell you that they can’t shower patients. In most ICUs that I worked at, even for ventilated tracheostomy and patients, we shower them in a shower trolley. No big deal. It all comes down to mindset. It all comes down to mindset and thinking creatively and just having a can-do attitude. 

So that’s it, Roger. Spend your time on keeping your mom where she needs to be. Don’t waste your time on asking LTACs questions you already know the answer to. Spend your time keeping your mom where she needs to be.

Now, I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over 5 years. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com.

We have helped hundreds of clients and members, and we have saved many lives since we’ve started consulting and advocating for families all around the world. You can verify that on our testimonial section at intensivecarehotline.com or you can verify it on our intensivecarehotline.com podcast where we’ve interviewed clients and members.

That’s why we’ve created a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecarehotline.com if you click on the membership link or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email and we answer all questions, intensive care related.

In the membership, you also have exclusive access to 21 e-books and 21 videos that I’ve personally written and recorded sharing all my two and a half decades worth of ICU nursing experience with you making sure that you make informed decisions, you have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment always.

I also do one-on-one consulting and advocacy over the phone, Zoom, WhatsApp, Skype, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply can’t afford to get wrong. I also talk to doctors and nurses directly. When I talk to doctors and nurses directly, I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one, critically ill in intensive care. I also represent you in family meetings with intensive care teams.

We also do medical record reviews in real time so that you can get a second opinion in real time. We also do medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

All of that, you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.