Chest
Volume 103, Issue 5, May 1993, Pages 1560-1565
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Special Reports
Obstacles to Discharge of Ventilator-Assisted Children From the Hospital to Home

https://doi.org/10.1378/chest.103.5.1560Get rights and content

Home care for ventilatory-assisted children improves psychosocial development and reduces medical costs compared with hospital care; yet, many ventilator-assisted children remain hospitalized for lengthy periods of time after they have achieved medical stability. To identify factors that contributed to a delay in hospital discharge from the time medical stability was achieved, we reveiwed the records of 54 ventilator-assisted children (age 4.6 ±5.9 [SD] years at discharge) who were discharged from the hospital on a regimen of home mechanical ventilation. The length of the hospitalization from which the ventilator-assisted children were initially discharged on the ventilator was 172 ±161 days (range, 2 to 756). The time from medical stability to discharge was 118± 144 days (range, 2 to 724), or 73 percent ±29 percent of the total hospitalization. Fifty-one ventilator-assisted children were discharged to their natural parents' homes, and three were discharged to foster care. Once ventilator-assisted children were medically stable, it took 99 ± 141 days for third-party payers to approve home care funding, and only 48 ±87 days to be discharged once funding was approved. For the 27 ventilator-assisted children with public funding, it took 184± 177 days for home care funding approval, compared with 52 ±43 days for the 27 ventilator-assisted children with private funding (p<0.001). Parent training took only 52 ±65 days. It took 369 ±334 days (range, 44 to 711 days) to find placement for the three ventilator-assisted children who were placed in medical foster care. In summary, ventilator-assisted children often remained hospitalized for prolonged periods of time, after they were medically stable, for nonmedical reasons. The greatest obstacle to hospital discharge was seeking approval for home care funding and for arranging out-of-home placement. Public funding agencies took significantly longer to approve home care funding than private insurance agencies.

Section snippets

METHODS

We reviewed the charts of 54 infants and children who were discharged to the home from Childrens Hospital Los Angeles still requiring mechanical assisted ventilation full time or part time. For all children, only the initial hospital discharge on a regimen of home mechanical ventilation was evaluated. This initial hospitalization was defined as the time interval when the diagnosis of chronic respiratory failure was made and the decision to use home mechanical ventilation was made, ventilator

RESULTS

Medical records were available for review on 54 infants and children who were initially discharged on a regimen of home mechanical ventilation between November 1977 and July 1991. Thirty-four were male and 20 were female. The mean age at the time of hospital discharge was 4.6 ± 5.9 years (range, 5 months to 21 years). Eighteen children (33 percent) required assisted ventilation 16 to 24 h/d. Twenty-three children (43 percent) required 8 to 16 h/d, and 13 (24 percent) required assisted

DISCUSSION

This study shows that ventilator-assisted children often remain hospitalized for prolonged periods of time after they were medically stable, and otherwise ready for discharge, for nonmedical reasons. The mean length of this initial hospitalization was nearly 6 months and lasted over 2 years in at least 1 patient. It took only 1 to 2 months to achieve medical stability. Thus, nearly three quarters of the length of this initial hospitalization occurred after the children were medically stable and

ACKNOWLEDGMENTS

The authors wish to thank Marie Anne Legaspi for invaluable assistance with data collection; Mukul Gupta for expert assistance with analysis; and Cheryl D. Lew, M.D., C. Michael Bowman, Ph.D., M.D., and Arnold C. G. Platzker, M.D., for graciously allowing us to study their patients.

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This research was supported, in part, by grants from the Ventilatory Control Disorders Research Fund of the Division of Neonatology and Pediatric Pulmonology, Childrens Hospital Los Angeles, e Ruth and Vernon Taylor Foundation.

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