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Quick Tip for Families in Intensive Care: Mom Has Gone Back to ICU From LTAC (Long-Term Acute Care) for Low Hemoglobin & Blood Transfusion. How Can I Keep Her in ICU?

If you want to know why your critically ill loved one in intensive care with the tracheostomy and the ventilator should not go to LTAC, stay tuned. I have another example for you today.

My name is Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

So earlier in the year, we worked with a client who had their mother, as a matter of fact, in LTAC, due to long-term ventilation and tracheostomy. Now, we advise that patients from intensive care with long-term ventilation and tracheostomy should not go to LTAC because it’s dangerous and LTACs are not equipped to look after long-term ventilation and tracheostomy. That is specific for our U.S. viewers and U.S. audience because LTACs only exist in the U.S.

LTAC stands for long-term acute care hospital and what happens in the U.S.? Many patients in ICU does not end up on a ventilator with a tracheostomy. ICUs want to send them out to an LTAC as soon as possible to free up their ICU bed. But LTACs, from our experience, are not even the better version of a nursing home. One of the reasons we advise against it is that patients often bounce back into ICU within a few days only because they’re simply not ready. Pushing patients from ICU to LTAC is often a result of saving money. It’s not based on clinical need because the clinical need for someone on a ventilator with a tracheostomy is an intensive care need.

Now, let’s read out an email from one of our previous clients who says,

“Hi Patrik,

My mom was at the LTAC from January 21st until yesterday February 8th, 18 days. She has 14 more days authorized unless there was a decline or plateau. Today, she transferred to the local hospital ER and to ICU because the LTAC was very concerned that she should get a blood transfusion as her blood hemoglobin number was low. ICU says that it was 6.6 now. They’ll give her a transfusion tonight. They will monitor for any sign of internal bleeding as a possible source of blood loss.

She also needs tests to see what is going on. My sister was with her today and I checked her in to the ER and then to ICU. I will leave to visit her around 9 a.m. Would it be possible to give me your thoughts about her condition and any recommendations within the next six hours? If not, I understand and I would instead just look for your reply after that while I’m at the hospital visiting. I hope to see what you think and then meet with the doctor, nurse practitioner, or physician assistant to discuss.

The past three days at the LTAC, there was no weaning due to high white cell count, swelling, lethargy, shaking, worsening fluids, and wheezing in the lungs. They had her on full ventilation support from 45% FiO2 and pressure support of 10/5, up to 65% FiO2, pressure support of 10 and PEEP (positive end expiratory pressure) of 5.

Four days before that, she had solid weaning and got up to 18 hours in one of the days on the ventilator – CPAP (continuous positive airway pressure), 40% FiO2, pressure support of 10, PEEP of 5.  Before that, she also had up to 10 hours on the T-piece or tracheostomy mask and speaking valve at about 28 to 30% regular oxygen.

She unfortunately vomited last night or this morning. I think that could be because at 5:30 p.m. last night, when I was leaving, I noticed the speed of her order feeding to the PEG (Percutaneous Endoscopic Gastrostomy) was at 85 mls an hour, and usually it’s at 45 mls or 50 mls an hour at the most. Also, maybe vomiting due to the antibiotics, cefepime and vancomycin.

Last Tuesday and Wednesday until 5 p.m., she was shaking all over, lots of sleeping, not alert, and rarely opened her eyes.

Wednesday morning, around 11 a.m., when my sister visited, still no shaking, good vitals. The cefepime course was ending or had just ended. The vancomycin had high troughs was still enough in a system to do good things, but they had recently stopped it. The white cell count I think is around 30,000, so maybe they will have to continue the cefepime.

She had swelling in her extremities for many weeks, not providing much physical therapy, getting some occupational therapy. She was diagnosed during one of her hospital stays, December or January, with congestive heart failure and her ejection fraction was around 30%. The X-ray also showed slightly enlarged heart. In the LTAC, she was seen by a nephrologist today and started her own Nepro, kidney nutrition.”

Also, with just as a side note, with the enlarged heart, that is also probably one of the reasons why your mom is so swollen.

“LTAC doesn’t have an electronic record system and only gave me records printouts for the first three days after admission and then said giving those was a mistake and wouldn’t let me have any more. Since transferring to the UCHealth Medical Center this afternoon, we have electronic access again. It’s the same company as before the LTAC, just another ICU in another hospital which is one hour and five minutes north of our home.

I believe she can still recover and still wants to come home. I’m glad she’s back in the ICU now because the care in LTAC was just so poor.”

Now, here is why we advise against LTAC and sorry, the email continues actually.

“Her blood pressure is 125/50. It was low in ED, it was 105/50, and then they gave her some fluids and that’s when it came up. I wish my mom could stay in the ICU for several weeks and either wean off the ventilator completely in ICU or at least during the day, be off the ventilator and on regular oxygen with nasal cannula and then go back on the ventilator overnight if need be. Thank you so much for your help.”

Now, here is the reality. You can hear from the email that the client wants his mom to stay in ICU and that’s why we say never go to LTAC in the first place because as quickly as things go pear shaped, LTAC doesn’t really know what to do because they simply don’t have the skills and the expertise to deal with any complications that come their way when it comes to long-term ventilation, tracheostomy or ventilator weaning.

Now, whilst she did make some progress there, it certainly wasn’t enough, and generally speaking, what we know is that if clients stay in ICU for longer, ICU knows what to do to wean a patient off the ventilator. It’s a skill. It’s a skill ICUs have. It’s not a skill many LTACs have, if any.

The other issue with LTACs is that most of the time they want to send patients away, far away from their families. It really comes down to bed availability in LTAC, it’s not really based on family presence. It’s not a good idea to send someone who’s extremely vulnerable to an LTAC that’s hours away from their family. The patients need the moral support from their families.

The other thing is here, why did LTAC not pick up on hemoglobin dropping? That should have been picked up early on. But the problem here is LTACs are not equipped to deal with anything that is complex. They can’t give a blood transfusion, for example, and I’m not surprised. They don’t employ intensive care nurses, don’t employ intensive care doctors who need to deal with that, which is why she bounced back into ICU.

Like I said over and over again, LTACs are not equipped to deal with long-term intensive care patients, intensive care units are, or if all of that fails, then you can look at services like Intensive Care at Home. Also, you’re mentioning that she’s vomited last night, and you think that’s because her feeds were turned up to 85 instead of 50 mls an hour.

Now, again, who was doing that and why? Also, when someone is on PEG feeds, the residuals need to be checked every four hours. So, what needs to happen every four hours, the feeds need to be stopped for a couple of minutes, then the critical care nurse should be checking the residuals in the stomach i.e. aspirate. And if the residuals are too high, that’s a risk for vomiting and aspiration. Therefore, it looks like it wasn’t checked. Then you need to remove some fluids and feeds from the PEG tube so that you can actually avoid aspiration and vomiting because that can really set patients back which is what’s happening here. Was there an order to increase the feed rate to 85 mls an hour? But I’m also glad to hear that your mom is back in the ICU now because that’s where she should be until she’s weaned off the ventilator.

Also, you’re mentioning that her ejection fraction was 30%, that also means she needs to be seen by a cardiologist and her medication for the ejection fraction and for a heart failure needs to be optimized. Again, that is not happening in LTAC because there is, generally speaking, no specialist input. So, I’m glad to hear that she’s back in the right place, that’s where she should stay.

Like I’ve been saying it over and over again, there’s never been an issue with our clients going from ICU to LTAC, just with the right advice, just with not agreeing to what they want. It’s really up to you and your family, what you want. Don’t let them dissuade you otherwise because how many horror stories have we read out here on this blog where patients in LTAC had just such a horrible experience? It’s one story after another, also a couple of days ago, I made a video about that. There’s a Wikipedia page about LTACs and it’s pretty much confirmed what I’ve been saying here for over 10 years that LTAC has such a bad rap and that they are designed to save money. They are not designed for appropriate clinical care and appropriate clinical need for a long-term intensive care patients.

So, I have worked in critical care for nearly 25 years in three different countries where I also worked as a nurse manager for over 5 years. I’ve been consulting and advocating here at intensivecarehotline.com since 2013. I can very confidently say that we have saved many lives with our consulting and advocacy. You can verify that on our testimonial section at intensivecarehotline.com and you can also verify it on our podcast section at intensivecarehotline.com where we’ve done some client interviews.

That’s one of the main reasons we’ve also created a membership for families of critically ill patients in intensive care and 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 eBooks and 21 videos that I have personally written and recorded sharing with you freely all my over two decades worth of intensive care nursing experience, making sure you can look behind the curtains, but more importantly, making sure you make informed decisions, have peace of mind, control, power, and influence.

I also offer one-on-one consulting over the phone, Zoom, WhatsApp, Skype, whichever medium works best for you. I talk to you and your families directly. I talk to doctors and nurses directly. I really handhold you through this once in a lifetime experience that you can’t afford to get wrong. The families think they can do this alone. They unfortunately are in for a big surprise when they realize they can’t do it alone, but they then often realize it when it’s too late. You can’t leave things to chance when you have a loved one in intensive care. You can work with me and my team here, one-on-one. We know what to look for. We know what questions to ask. We know how to set it up so that your loved one gets best care and treatment.

I also represent you in family meetings with intensive care teams.

We also do medical record reviews for families in intensive care in real time so that you can get a second opinion in real time. We also offer 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 the intensivecarehotline.com. Call us on one of the numbers on the top of our website or send us an email to support@intensivecarehotline.com 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.