Journal of Critical Care 30 (2015) 2531

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Journal of Critical Care

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Prolonged mechanical ventilation in Canadian intensive care units:

A national survey,,,,
Louise Rose, RN, PhD a, b, c, d, e, f,, Robert A. Fowler, MD, MSc e, f, h, Eddy Fan, MD, PhD g, h, Ian Fraser, MD, FRCP b,
David Leasa, MD, FRCP i, j, Cathy Mawdsley, RN, MSc i, Cheryl Pedersen, MSc k,
Gordon Rubenfeld, MD, MSc f, h, l, On behalf of the CANuVENT group 1
a

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada M5T 1P8
Provincial Centre of Weaning Excellence/Prolonged Ventilation Weaning Centre, Toronto East General Hospital, Toronto, Ontario, Canada M4C 3E7
c
Mt. Sinai Hospital, Toronto, Ontario, Canada M5G 1X5
d
Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada M5B 1W8
e
Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada M4N 3M5
f
Sunnybrook Research Institute, Toronto, Ontario, Canada M4N 3M5
g
Toronto General Hospital and University Health Network, Toronto, Ontario, Canada M5G 2C4
h
Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada, M5G 2C4
i
Department of Critical Care, London Health Sciences Centre, London, Ontario, Canada N6G 2V4
j
University of Western Ontario
k
Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michaels Hospital, Toronto, Ontario, Canada M5B 1W8
l
Trauma, Emergency, and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada M4N 3M5
b

a r t i c l e

i n f o

Keywords:
Mechanical ventilation
Weaning
Mobilization
Rehabilitation
Intensive care
Prolonged mechanical ventilation

a b s t r a c t
Background: We sought to describe prevalence and care practices for patients experiencing prolonged
mechanical ventilation (PMV), dened as ventilation for 21 or more consecutive days and medical stability.
Methods: We provided the survey to eligible units via secure Web link to a nominated unit champion from
April to November 2012. Weekly telephone and e-mail reminders were sent for 6 weeks.
Results: Response rate was 215 (90%) of 238 units identifying 308 patients requiring PMV on the survey day
occupying 11% of all Canadian ventilator-capable beds. Most units (81%) used individualized plans for both
weaning and mobilization. Weaning and mobilization protocols were available in 48% and 38% of units,
respectively. Of those units with protocols, only 25% reported weaning guidance specic to PMV, and 11%
reported mobilization content for PMV. Only 30% of units used specialized mobility equipment. Most units
referred to speech language pathologists (88%); use of communication technology was infrequent (11%). Only
29% routinely referred to psychiatry/psychology, and 17% had formal discharge follow-up services.
Conclusions: Prolonged mechanical ventilation patients occupied 11% of Canadian acute care ventilator bed
capacity. Most units preferred an individualized approach to weaning and mobilization with considerable
variation in weaning methods, protocol availability, access to specialized rehabilitation equipment,
communication technology, psychiatry, and discharge follow-up.
2014 Elsevier Inc. All rights reserved.

Funding: The work was funded by a grant from the Partnerships for Health Systems Improvement competition of the Canadian Institutes of Health Research.
Institution: This work was conducted at the Centre for Research on Inner City HealthSurvey Research Unit at St. Michaels Hospital and the University of Toronto.
Author contributions: Conception and design of the study: L.R., R.F., E.F., I.F., D.L., C.M., and G.F. Acquisition: L.R. and C.P. Analysis and interpretation of data: all authors.
Drafting the article or revising it critically for important intellectual content: all authors. L.R. is the guarantor of the paper, taking responsibility for the integrity of the work as a whole,
from inception to published article.
Previous presentation: This study was presented at the 2013 European Society of Intensive Medicine Annual Scientic Meeting in Paris.
Competing interests: The authors have no nancial or nonnancial competing interests to declare.
Corresponding author. Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Rm 276, Toronto, Ontario, Canada, M5T IP8. Tel.: + 1 416 978 3492;
fax: + 1 416 978 8222.
E-mail addresses: louise.rose@utoronto.ca (L. Rose), rob.fowler@sunnybrook.ca (R.A. Fowler), Eddy.Fan@uhn.ca (E. Fan), ifras@tegh.on.ca (I. Fraser), David.Leasa@LHSC.ON.CA
(D. Leasa), Cathy.Mawdsley@LHSC.ON.CA (C. Mawdsley), PedersenC@smh.ca (C. Pedersen), gordon.rubenfeld@sunnybrook.ca (G. Rubenfeld).
1
Reshma Amin, The Hospital for Sick Children; Monica Avendano, West Park Healthcare Centre; Sandra Dial, Montreal Chest Institute; Eddy Fan, Mount Sinai Hospital; Ian
Fraser, Toronto East General Hospital; Robert Fowler, Sunnybrook Health Sciences Centre; Roger Goldstein, West Park Healthcare Centre; Sherri Katz, Childrens Hospital of Eastern
Ontario; Judy King, University of Ottawa; David Leasa, London Health Sciences Centre; Cathy Mawdsley, London Health Sciences Centre; Douglas McKim, Ottawa Hospital; Mika
Nonoyama, University of Toronto; Jeremy Road, Provincial Respiratory Outreach Program, Vancouver Coastal Health; Louise Rose, University of Toronto; Gordon Rubenfeld,
Sunnybrook Health Sciences Centre.
http://dx.doi.org/10.1016/j.jcrc.2014.07.023
0883-9441/ 2014 Elsevier Inc. All rights reserved.

26

L. Rose et al. / Journal of Critical Care 30 (2015) 2531

1. Introduction
Population aging, increasing morbidity, and scientic and technological advances prolonging life mean that the number of patients
requiring prolonged mechanical ventilation (PMV) continues to rise,
resulting in insufcient intensive care unit (ICU) capacity to deliver
care [1-3]. International reports indicate that PMV patients account
for a minority, ranging from 4% to 30% depending on the denition
used, of all mechanically ventilated patients but consume 40% of ICU
bed days and 50% of costs [1,4-6]. Substantial variability exists in the
denition of PMV, with ventilation duration ranging from more than 6
hours [7] to more than 29 days [8]. Another common denition is
tracheostomy placement and ventilation for 96 hours or more based
on diagnosis-related group coding [9]. Awareness of epidemiological
trends for mechanical ventilation is important as there are signicant
nancial and resource implications for health care systems and
organizations. Costs to the health care system continue after
discharge, with hospital readmission rates up to 70% reported [10].
The costs of PMV are not only nancial; long-term physical and
psychologic consequences impose substantial symptom burden and
affect patient and family quality of life [11-13]. Prolonged mechanical
ventilation signals a need to change the primary focus of care from
acute resuscitation and stabilization to rehabilitation and long-term
care planning. However, the interprofessional rehabilitative approach
needed to reduce unnecessary prolongation of ventilator dependence
and to optimize mobility, communication, nutritional status, and
psychologic well-being is not consistent across ICUs [14].
No national Canadian data dene resource requirements and care
delivery for patients experiencing PMV. Our objectives were to
describe PMV prevalence and specic care practices including
weaning, mobilization, communication, swallowing, psychologic
support, discharge barriers, and follow-up.
2. Methods
2.1. Study design and sample
We conducted an exploratory cross-sectional survey. Prolonged
mechanical ventilation was dened as ventilation for 21 or more
consecutive days and medical stability as recommended by the
National Association for Medical Direction of Respiratory Care [15].
Medical stability was dened as no ongoing need for vasopressors/
inotropes and resolution of the initial reason for ICU admission.
Eligible units comprised ICUs, high-dependency units, weaning
centers, and other acute care units with ventilator capacity providing
care to PMV patients within the preceding 12 months. In the
Canadian context, ICUs are categorized as level III, capable of
providing the highest level of care, whereas level II and I ICUs
generally provide support for patients with single organ failure or
short-term ventilation. High-dependency units serve as an intermediate level of care either as a step up from the ward or a step down
from the ICU. Weaning units either accept patients from within the
institution they are located or may service as a regional referral unit.
We excluded units with no invasive ventilation capacity, those
providing only short-term ventilation or long-term institutional
care, and neonatal ICUs. We identied eligible units using an existing
inventory of Canadian ICU capacity (Rob Fowler, 2011) and snowball
referrals. Units were screened by telephone to conrm eligibility,
seek agreement for questionnaire completion, and to identify a
survey champion.
2.2. Questionnaire development
We contracted an independent survey unit (http://www.
stmichaelshospital.com/crich/sru/) to manage questionnaire development, administration, and data collection. Informed by an elec-

tronic database search (1990-2010) of literature relevant to PMV, 10

team members representing medicine, nursing, respiratory, and
physical therapy generated questionnaire domains, items, and
response formats, which were then iteratively rened. A Web-based
questionnaire was programed using Snap Professional Software
(snapsurveys.com, London, United Kingdom) and distributed to 7
international PMV experts to pilot. Experts assessed for comprehensiveness, redundancy, clarity, face validity, time to complete, and
number of people to gather required information.
After further renement based on pilot testing, the nal questionnaire comprised 8 domains: unit characteristics, patient characteristics on day survey completed and if available in a database during the
preceding 12 months, clinical practices, equipment, funding and costs,
liaison and transitions, patient follow-up, and perceptions of care. To
facilitate recruitment in Francophone provinces, the questionnaire
was professionally translated by Access Alliance.
2.3. Questionnaire administration
We provided the online questionnaire (see online supplement) via
secure Web link to the self-nominated survey champion from April to
November 2012. Survey champions comprising unit directors, nurse
managers, physicians, senior registered nurses (RNs), or respiratory
therapists (RTs) were directed to complete a 1-time assessment of
patient prevalence before survey return and to request assistance
with questionnaire completion from relevant interprofessional team
members. Weekly telephone and e-mail reminders were sent for 6
weeks, with a nal reminder in October. Telephone contact also
enabled centers to clarify questionnaire items. The questionnaire was
administered to blocks of 40 units to enable meticulous follow-up.
2.4. Ethical considerations
Research ethics boards of the University of Toronto (no. 26199)
and St. Michaels Hospital approved the study. Participation was
voluntary and consent implied by questionnaire return.
2.5. Statistical analyses
We examined results using descriptive statistics including the
Sharpiro-Wilk test for normality. We summarized continuous
variables using means and SDs or medians and interquartile ranges
depending on the data distribution and categorical variables using
frequencies, proportions, and 95% condence intervals (CIs). Because
of missing responses, denominators vary. We compared patient
demographics and clinical practices in ICUs with non-ICUs using 2
tests. Analyses were conducted using SPSS 22 (IBM, Armonk, NY).
3. Results
We screened 450 units of which 212 were ineligible. Reasons for
ineligibility comprised 101 (48%) of 212 had no invasive ventilation
capacity, 65 (31%) of 212 had only short-term ventilation capacity, 34
(16%) of 212 were PMV capable but had no patients in past 12 months,
11 (5%) of 212 were neonatal ICUs, and 1 (0.5%) of 212 was a longterm ventilation unit. We received 215 evaluable surveys (90%
response rate) of which 203 (94%) contributed data on more than
50% of items, and an additional 12 (6%) provided unit data only.
3.1. Unit characteristics
Most units (152/215, 71%) were level III [16] adult ICUs with mixed
populations using a 1:1 nurse/patient ratio (Table 1). We identied
3317 physical beds in participating units of which 2710 (82%) were
ventilator capable, 2919 ICU beds with 2553 (87%) ventilator capable,
and 398 non-ICU beds with 157 (39%) ventilator capable (Table 2).

L. Rose et al. / Journal of Critical Care 30 (2015) 2531

We identied 308 PMV patients occupying 11% of the 2710 ventilatorcapable beds. Based on the 2011 Canadian census population [17], the
estimated prevalence of PMV is 0.92/100 000 population. Of the 206
sites providing PMV patient data on the survey day, 78 (38%) had no
patients, 87 (42%) had 1 to 2, 19 (14%) had 3 to 5, and 12 (6%) had
more than 5 PMV patients.
3.2. Patient characteristics
Characteristics of PMV patients are shown in Table 3. Sepsis or
acute lung injury as the primary reason for PMV were more common
in ICU patients, whereas neuromuscular disease and spinal cord injury
were more frequent indications in non-ICU patients. Rates of chronic
obstructive pulmonary disease, neurologic insult, and ICU-acquired
weakness were similar as was age distribution. Patients with chronic
neurologic conditions comprised 36% of the study population and
occupied 4% (95% CI, 3%-5%) of ventilator-capable ICU beds. Although
most patients (188/308, 61%) had received ventilation for 21 days or
more but less than 3 months, 55 (18%) of 308 had received ventilation
for 6 months or more. More patients had been ventilated for 6 months
or more in non-ICUs (P = 10.002). Of the 18 non-ICUs and 197 ICUs, 6
(17%) and 39 (14%) maintained a database of PMV comprising 486
patients admitted in the preceding 12 months: 419 (86%) of 486 from
ICUs and 67 (14%) of 486 from non-ICUs.
3.3. Clinical practices
3.3.1. Weaning and mobilization
Most units reported using a variety of weaning methods for PMV
patients with progressive pressure support reduction being the most
common (165/198, 83%) (Fig. 1). Physicians determined weaning
methods in most units (179/194, 92%). Respiratory therapists and RNs
were reported to inuence selection of weaning method in 146 (77%)
of 190 and 58 (36%) of 162 sites, respectively. Eleven sites (6%)
indicated that selection was dependent on patient characteristics; 4
(2%) reported that weaning in their unit was guided by a protocol, but
some physicians elected not to use it; and 2 (1%) indicated that
weaning was a team approach. Few units (75/194, 39%) transitioned
PMV patients to a different ventilator.
Most units (161/198, 81%) used individualized plans for PMV
patients for weaning and mobilization. Weaning protocols
were available in 95 (48%) of 198 units, although only 24 (25%) of
95 reported protocolized guidance specic to PMV patients.
Mobilization protocols were available in 75 (38%) of 198 units;
only 22 (11%) of 75 units reported PMV-specic content. Airway
clearance strategies such as lung volume recruitment (breath
stacking), manually assisted cough, and mechanical cough assist
devices were used in 134 (68%), 102 (52%), and 55 (28%) sites,
respectively. Despite 141 (71%) of 198 sites indicating early
mobility was a priority commenced within 3 days of admission,
only 60 (31%) of 196 units reported access to specialized mobility
equipment (Fig. 2). Availability of protocols with PMV-specic
content was similar in ICUs and non-ICUs as was access to
specialized mobility equipment, mechanical cough assist devices,
and use of lung volume recruitment. Manually assisted cough was
used more commonly in non-ICUs (P = .02). Only 18 (9%) of 191
sites indicated that they used serial objective measures of muscle
strength such as dynamometry or the Medical Research Council
scale for grading muscle strength.
3.3.2. Communication and swallowing
Most units (179/201, 90%) used traditional communication tools
such as alphabet/word/picture/writing boards and had access to
speech language pathologists (172/196, 88%); use of other communication technology such as iPads (Apple Inc, Cupertino, CA), DynaVox
communication augmentation devices (DynaVox, Pittsburgh, PA), and

27

Table 1
Site characteristics
Characteristic (n =215 ventilator-capable units)
Province
Ontario
Quebec
British Columbia
Atlantic provincesa
Alberta
Manitoba
Saskatchewan
Northwest Territories
Hospital size
b100 beds
100-199 beds
200-399 beds
400-599 beds
N600 beds
Unit type
Level III ICUb
Level II and I ICUb
Weaning unit
Step-up/step-down unit
Otherc
Unit population
Adult only
Combined adult and pediatric
Pediatric only
ICU specialtyd
MSICU
MSTICU
MSTICU + CS
MSICU + CS
CVS only
MICU
Othere
Nurse/patient ratio in ICUs for all ventilated patients
1:1
1:2
1:1 or 1:2 depending on acuity
1:2 or 1:3 depending on acuity
Otherf

n (%)
75 (35)
47 (22)
25 (12)
24 (11)
19 (9)
13 (6)
11 (5)
1 (0.5)
22 (10)
46 (21)
82 (38)
39 (18)
26 (12)
152 (71)
45 (21)
8 (4)
4 (2)
6 (3)
170 (79)
28 (13)
17 (8)
85 (43)
61 (31)
21 (10)
8 (4)
8 (4)
5 (2)
9 (4)
116 (59)
58 (29)
17 (9)
3 (2)
3 (2)

MSICU, medical/surgical ICU; MSTICU, medical/surgical/trauma ICU; CS, cardiac

surgery; CVS, cardiovascular surgery; MICU, medical ICU; STICU, surgical trauma ICU;
CCU, coronary care unit; SICU, surgical ICU.
Percentage may exceed 100 due to rounding.
a
New Brunswick, Newfoundland, Nova Scotia, and Prince Edward Island.
b
Level III ICUs are capable of providing the highest level of care; level II and I ICUs
generally provide support for patients with single organ failure or short-term ventilation.
c
Other comprises the following ventilator-capable units: adult acute medical unit
(4), pediatric acute medical unit (1), and spinal unit (1).
d
Not reported by 1 unit.
e
Other comprises STICU (3), MICU + CVS (2), neurosurgical ICU (2), CCU (4), SICU
(1), and burns ICU (1).
f
Other comprises 1:1 to 1:3 depending on acuity (1); ratio is usually 1:3, 1 intubated
and 2 nonintubated (1); not described (1).

Lightwriters (TobyChurchill, Cambridge, United Kingdom) was

infrequent (23/201, 11%). Use of tracheostomy tubes and speaking
valves enabling vocalization was relatively common: 143 (71%) of 201
units used Passy-Muir valves; 130 (65%) of 201, cufess tubes; 106
(53%) of 201, fenestrated tubes; and 53 (26%) of 201, speaking tubes.
Dieticians performed swallowing assessment in 56 (29%) of 195
units and speech language pathologists in 175 (90%) of 193.
Techniques to assess safe swallowing comprised oral reex clinical
examination (131/179, 73%), trial swallow with soft feed (130/179,
73%), videouoroscopic evaluation (modied barium swallow; 105/
179, 59%), laryngeal reex clinical examination (101/179, 56%), trial
swallow with colored liquid (96/179, 54%), and beroptic endoscopic
evaluation (27/179, 15%). Nitrogen balance was measured in 88 (51%)
of 175 units, prealbumin in 124 (67%) of 184, and zinc porphyrins in
43 (25%) of 174.

28

L. Rose et al. / Journal of Critical Care 30 (2015) 2531

Table 2
Bed numbers
n = 215 units

Responding units Total physical beds Physical beds/unita Total ventilator-capable beds Ventilator-capable beds/unita PMV beds,b n (%, 95% CI)

Overall
ICUs
Non-ICUsc
Pediatric
Province
Ontario
Quebec
British Columbia
Alberta
Manitoba
Saskatchewan
Nova Scotia
New Brunswick
Newfoundland
Prince Edward Island
Northwest Territories

215
197
18
17

3317
2919
398
307

12
12
25
16

75
47
25
19
13
11
9
7
6
2
1

1312
684
357
329
215
183
79
69
67
18
4

16 (10-23)
11 (11-18)
11 (9-20)
16 (10-22)
12 (7-26)
10 (6-36)
8 (7-11)
8 (6-12)
10 (8-15)
9 (2-)
-

a
b
c

(8-20)
(8-20)
(6-37)
(9-24)

2710
2553
157
277

10 (6-18)
10 (7-18)
4 (4-10)
15 (8-23)

308 (11,
272 (11,
36 (23,
30 (11,

10-13)
10-12)
17-30)
8-15)

1157
648
247
279
96
73
65
67
65
11
2

15 (8-20)
10 (8-16)
9 (5-15)
14 (8-21)
5 (4-10)
6 (4-10)
8 (5-10)
8 (6-12)
10 (7-15)
6 (3-)

148 (13, 11-15)

69 (11, 9-13)
20 (8, 5-12)
25 (9, 6-13)
16 (17, 11-26)
10 (14, 8-23)
4 (6, 2-15)
4 (6, 2-15)
11 (17, 10-28)
1 (9, 2-38)

Median (interquartile range) beds per unit.

Number (%) of ventilator beds occupied by PMV patients on day of survey.
Non-ICUs include weaning centers, high-dependency units, and other acute care units capable of providing ventilation to medically stable patients.

3.3.3. Assessment and management of symptoms, psychologic issues, and

psychosocial issues
Use of objective anxiety measures for PMV patients was reported by
44 (23%) of 192 units; however, 22 (50%) of 44 described delirium,

Table 3
Patient characteristics
Characteristic, n (%)
Primary reason for PMV
Sepsis/multiorgan failure
NMD
COPD
Neurologic insult
ICU-acquired weakness
Spinal cord injury
ARDS/ALI
Central hypoventilation syndrome
Postcardiac surgery
Unknown
Trauma
Otherb
Not reported
Age categories, y
0-16
17-29
30-64
65-79
80
Not reported
Duration of ventilation
21 d to b2 mo
2 to b3 mo
3 to b6 mo
6 mo to b1 y
1 y
Unknown
Not reported

Non-ICUsa
(n = 36)

Overall
(n = 308)

ICUs
(n = 272)

61 (20)
50 (16)
37 (12)
30 (10)
26 (8)
24 (8)
17 (6)
8 (3)
7 (2)
6 (2)
3 (1)
26 (8)
13 (4)

58 (21)
41 (15)
32 (12)
28 (10)
22 (8)
14 (5)
17 (6)
7 (3)
7 (3)
6 (2)
3 (1)
24 (9)
13 (5)

3 (8)
9 (25)
5 (14)
2 (6)
4 (11)
10 (28)

1 (3)

2 (6)

28 (9)
16 (5)
94 (31)
120 (39)
38 (12)
12 (4)

26 (10)
13 (5)
82 (30)
105 (39)
34 (13)
12 (4)

2 (6)
3 (8)
12 (22)
15 (42)
4 (11)

142 (46)
46 (15)
42 (14)
29 (9)
26 (8)
2 (1)
21 (7)

132 (49)
39 (14)
36 (13)
23 (8)
19 (7)
2 (1)
21 (8)

10 (28)
7 (19)
6 (17)
6 (17)
7 (19)

NMD, neuromuscular disease; COPD, chronic obstructive pulmonary disease; ARDS,

acute respiratory distress syndrome; ALI, acute lung injury.
Percentage may exceed 100 due to rounding.
a
Non-ICUs include weaning centers, high-dependency units, and other acute care
units capable of providing ventilation to medically stable patients.
b
Other: chest wall restriction (2), post-transplantation (2), cardiomyopathy
(2), pancreatitis (1), severe bronchopulmonary dysplasia (1), hypophosphatasia,
tetralogy of fallot (1), severe congestive heart failure (1), chronic bronchiectasis
(1), pneumonia (1), third degree heart block and severe delirium (1), mediastinal mass
(1), persistent chylothorax (1), failure to thrive (1), thromboendarterectomy (1), burn
(1), respiratory failure (1), necrotizing fasciitis (1), not dened (5).

sedation, or pain assessment tools. Eight units used the Faces Anxiety
Scale [18]; 1 offered patients a choice of the Faces Anxiety Scale, StateTrait Anxiety Inventory [19], or a visual analog scale for anxiety [20]; and
1 used the modied COMFORT Scale [21]. Eleven sites did not describe
the tool used. An objective measure of dyspnea was used by 11 (6%) of
193 units; 7 identied use of the modied Borg scale [22].
Psychiatric/psychologic/counseling services were available for
patients in 153 (77%) of 198 units and for families in 88 (45%) of
195 units; 44 (29%) of 153 reported routinely referred PMV patients.
Most units (146/196, 74%) held regular family meetings, although the
most commonly reported frequency was on an as needed basis (66,
45%). Weekly meetings were conducted by 42 units (29%); the
remainder conducted biweekly, monthly, or bimonthly meetings.
Access to palliative care specialists and ethicists was reported by 139
(73%) of 191 and 131 (69%) of 191, respectively.
3.3.4. Discharge and follow-up
Table 4 lists discharge options available to unit for PMV patients
requiring long-term ventilation. Most commonly perceived barriers to
transition to either weaning or long-term ventilation units were lack
of beds and prolonged waiting lists (Fig. 3). Most commonly perceived
barriers to transition to the community were lack of a transition
program and insufcient paid caregivers and caregiver hours (Fig. 4).
Formal follow-up services were reported by only 34 units (17%).
Various models of follow-up were described, with the most frequent
(12/34, 35%) conducted by a team composed of a physician, RN, and
RT and within 1 month of hospital discharge.
4. Discussion
This is the rst study to document acute care bed occupancy by
patients ventilated for 21 days or more and considered medically
stable across Canada and to explore stated clinical practices specic to
PMV patients. We found that patients who potentially could be
transferred to an alternate care location occupied 11% of ventilatorcapable acute care beds. Availability of protocols to guide weaning and
mobilization was variable, with guidance specic to management of
these complex clinical processes for PMV patients lacking. Units
reported limited access to specialized equipment for rehabilitation
including exercise, mobility, and communication devices; infrequent
use of objective measures of anxiety and dyspnea; and limited referral
to psychologic services. Lack of beds and long wait lists for alternate
care locations were frequent barriers to institutional transition; lack of

L. Rose et al. / Journal of Critical Care 30 (2015) 2531

29

Fig. 1. Weaning methods for patients experiencing PMV (n = 198 units).

transition programs and paid caregiver hours were frequent barriers

to community discharge.
Comparison of our estimate of PMV prevalence with other
countries is problematic due to few multicenter or national studies
describing prevalence dened as 21 days or more and variation in the
denominator. However, our estimate of PMV prevalence appears
lower than those previously reported in the United States or Taiwan,
both countries with reimbursement plans that trigger transfer to a
lower acuity facility [23,24]. A 2006 point-prevalence survey of 58
respiratory care managers in Massachusetts estimated PMV prevalence of 3.7/100 000 population [25]. In 2004 and 2005, a Taiwanese
national administrative database identied 30 000 PMV patients
equivalent to 0.13% of the total population [24]. Lone and Walsh [5],
again using an administrative database (2002-2006), reported that
PMV incidence in 3 Scottish hospitals was 6.3/100 ventilated patients.
We found that most units preferred an individualized approach to
weaning and mobilization but considerable variation in weaning
methods, protocol availability, and access to specialized rehabilitation
equipment. Consensus recommendations for PMV weaning [15]
include integration of nonphysician-implemented protocols and use
of daily, progressively lengthening, unassisted breathing trials.
Evidence concerning weaning protocols suggests reduced ventilation
duration [26]; however, few studies include patients ventilated for 21
days or more. Jubran et al [27] recently demonstrated a substantial
reduction in ventilation duration comparing 2 protocolized approaches: pressure support ventilation and daily tracheostomy trials.
Early mobilization of ventilated patients increases the likelihood of
regaining functional independence [28]. Although mobilization in
patients ventilated 21 days or more cannot be considered early, it is
integral to rehabilitation and frequently requires access to specialized

equipment. Limited availability of mobilization protocols and equipment found in our survey indicates an area for institutional review
and further knowledge translation. In addition, few units reported
using objective measures for anxiety and dyspnea or routine referral
to psychiatry despite anxiety, depression, and posttraumatic distress
syndrome being prevalent among PMV patients both during and after
weaning [29-31] and depressive symptoms being a risk factor for
impaired physical function [32].
Our data indicate that many units had limited discharge options
for patients requiring specialized weaning services or lower care
intensity. Unlike other health care systems, in Canada, there are no
policy initiatives or nancial incentives to transfer patients out of ICU,
and facilities such as long-term acute care hospitals in the United
States [23] and respiratory intermediate care units in Taiwan [33] and
some European countries [34] either do not exist or are extremely
limited. Such facilities have lower stafng ratios and have been shown
to reduce readmission rates and health care costs [35]. In addition, for
patients requiring long-term ventilation, only half of our sample had
access to long-term care or community placements, and those units
with access considered bed availability and prolonged wait lists as
signicant barriers. In contemporaneous surveys, we identied a further
428 patients equivalent to 1.3/100 000 population in institutions
providing long-term care [36] and 4334 individuals living at home and
requiring ventilation giving an estimated prevalence of 12.9/100 000
population [37]. These ndings provide useful information for health
policy decision making and health care resource allocation.
Study strengths are rigorous development and meticulous survey
follow-up resulting in a 90% response rate and data that are
representative of acute care units across Canada. Limitations are
those of surveys describing reported as opposed to actual clinical
practices, whereby participants may provide an inaccurate reection
of actual practice based on inadequate knowledge or social desirability bias. Although we identied PMV prevalence, we were unable to
determine incidence as few units maintained a database with
this information.

Table 4
Discharge options for PMV patients requiring ongoing ventilation

Fig. 2. Specialized mobility equipment (n = 198 units).

Care venues (n = 167)

n (%)

Long-term ventilation unit external to institution

Home ventilation training services
Specialized weaning unit external to institution
Community-assisted living placements
Floor/ward with ventilator capacity within own institution
Specialized weaning unit within own institution
High-dependency/step-down unit with ventilator capacity

90
85
52
41
39
19
17

(54)
(51)
(31)
(25)
(23)
(11)
(10)

30

L. Rose et al. / Journal of Critical Care 30 (2015) 2531

Fig. 3. Perceived barriers to transition to alternative venues for weaning/long-term placement.

Fig. 4. Perceived barriers to transition to the community.

5. Conclusions
Using a point-prevalence survey, we found that PMV patients
occupied 11% of Canadian acute care ventilator bed capacity. Despite
evidence of their efcacy, availability of weaning and mobility
protocols was variable, and guidance specic to PMV patients was
uncommon. Few centers used objective measures of anxiety and
dyspnea, routinely referred to psychologic services, or had established
follow-up services. Limited discharge options and signicant discharge barriers require consideration in health policy decision making
and health care resource allocation.

Appendix A. Supplementary data

Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.jcrc.2014.07.023.

References
[1] Carson SS. Outcomes of prolonged mechanical ventilation. Curr Opin Crit Care
2006;12:40511.
[2] Zilberberg MD, de Wit M, Shorr AF. Accuracy of previous estimates for adult
prolonged acute mechanical ventilation volume in 2020: Update using 2000-2008
data. Crit Care Med 2012;40:1820.
[3] Cox CE, Carson SS, Holmes GM, Howard A, Carey TS. Increase in tracheostomy for
prolonged mechanical ventilation in North Carolina, 1993-2002. Crit Care Med
2004;32:221926.
[4] Iregui M, Malen J, Tutleur P, Lynch J, Holtzman M, Kollef M. Determinants of
outcome for patients admitted to a long-term ventilator unit. South Med J 2002;
95:3107.

[5] Lone N, Walsh T. Prolonged mechanical ventilation in critically ill patients:

epidemiology, outcomes and modelling the potential cost consequences of
establishing a regional weaning unit. Crit Care 2011;15:R102.
[6] Clark P, Lettieri C. Clinical model for predicting prolonged mechanical ventilation.
J Crit Care 2013;28:880.e17.
[7] Faenza S, Ravaglia MS, Cimatti M, Dante A, Spedicato S, Labate AMM. Analysis of
the causal factors of prolonged mechanical ventilation after orthotopic liver
transplant. Transplant Proc 2006;38:11314.
[8] Gracey DR, Naessens HM, Krishan I, Marsh HM. Hospital and posthospital survival
in patients mechanically ventilated for more than 29 days. Chest 1992;101:2114.
[9] Cox CE, Carson SS, Govert JA, Chelluri L, Sanders GD. An economic evaluation of
prolonged mechanical ventilation. Crit Care Med 2007;35:191827.
[10] Douglas S, Daly B, Brennan P, Gordon N, Uthis P. Hospital readmission among longterm ventilator patients. Chest 2001;120:127886.
[11] Euteneuer S, Windisch W, Suchi S, Kohler D, Jones P, Schonhofer B. Health-related
quality of life in patients with chronic respiratory failure after long-term
mechanical ventilation. Respir Med 2006;100:47786.
[12] Nelson J, Meier D, Litke A, Natale D, Siegel R, Morrison R. The symptom burden of
chronic critical illness. Crit Care Med 2004;32:152734.
[13] Cox CE, Martinu T, Sathy SJ, Clay AS, Chia J, Gray AL, et al. Expectations and
outcomes of prolonged mechanical ventilation. Crit Care Med 2009;37:288894.
[14] Scheinhorn DJ, Hassenpug MS, Votto JJ, Chao DC, Epstein SK, Doig GS, et al.
Ventilator-dependent survivors of catastrophic illness transferred to 23 longterm care hospitals for weaning from prolonged mechanical ventilation. Chest
2007;131:7684.
[15] MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S.
Management of patients requiring prolonged mechanical ventilation: report of a
NAMDRC consensus conference. Chest 2005;128:393754.
[16] Hill A, Fan E, Stewart T, Sibbald W, Nauenberg E, Lawless B, Bennett J, Martin C.
Critical care services in Ontario: a survey-based assessment of current and future
resource needs. Can J Anaesth 2009;56:2917.
[17] Statistics Canada. 2011 Census prole. Accessed on 28th Feb 2014 from http://
www12.statcan.gc.ca/census-recensement/index-eng.cfm.
[18] McKinley S, Coote K, Stein-Parbury J. Development and testing of a Faces Scale for
the assessment of anxiety in critically ill patients. J Adv Nurs 2003;41:739.
[19] Marteau T, Bekker H. The development of a six-item short-form of the state
scale of the Spielberger State-Trait Anxiety Inventory (STAI). Br J Clin Psychol
1992;31:3016.

L. Rose et al. / Journal of Critical Care 30 (2015) 2531

[20] Davey H, Barratt A, Butow P, Deeks J. A one-item question with a Likert or Visual
Analog Scale adequatelly measured current anxiety. J Clin Epidemiol 2007;60:
35660.
[21] Ambuel B, Hamlett K, Marx C, Blumer J. Assessing distress in pediatric intensive
care environments: the COMFORT scale. J Pediatr Psychol 1992;17:95109.
[22] Borg G. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;
14:37781.
[23] Cox C, Carson S. Medical and economic implications of prolonged mechanical
ventilation and expedited post-acute care. Semin Respir Crit Care Med 2012;33:
35761.
[24] Lu HM, Chen L, Wang JD, Hung MC, Lin MS, Yan YH, et al. Outcomes of prolonged
mechanic ventilation: a discrimination model based on longitudinal health
insurance and death certicate data. BMC Health Serv Res 2012;12:100.
[25] Divo MJ, Murray S, Cortopassi F, Celli BR. Prolonged mechanical ventilation in
Massachusetts: the 2006 prevalence survey. Respir Care 2010;55:16938.
[26] Blackwood B, Alderdice F, Burns K, Cardwell C, Lavery G, O'Halloran P. Protocolized
versus non-protocolized weaning for reducing the duration of mechanical ventilation
in critically ill adult patients. Cochrane Database Syst Rev 2010;5:CD006904.
[27] Jubran A, Grant B, Duffner L, Collins E, Lanuza D, Hoffman L, et al. Effect of pressure
support vs unassisted breathing through a tracheostomy collar on weaning
duration in patients requiring prolonged mechanical ventilation: a randomized
trial. JAMA 2013;309:6717.
[28] Schweickert W, Pohlman M, Pohlman A, Nigos C, Pawlik A, Esbrook C, et al. Early
physical and occupational therapy in mechanically ventilated, critically ill
patients: a randomised controlled trial. Lancet 2009;373:187482.

31

[29] Jubran A, Lawm G, Kelly J, Duffner L, Duffner L, Gungor G, et al. Depressive

disorders during weaning from prolonged mechanical ventilation. Intensive Care
Med 2010;36:82835.
[30] Jubran A, Lawm G, Duffner L, Collins E, Lanuza D, Hoffman L, et al. Post-traumatic
stress disorder after weaning from prolonged mechanical ventilation. Intensive
Care Med 2010;36:20307.
[31] Tate J, Devito Dabbs A, Hoffman L, Milbrandt E, Happ MB. Anxiety and agitation in
mechanically ventilated patients. Qual Health Res 2012;22:15773.
[32] Bienvenu O, Colantuoni E, Mendez-Tellez P, Dinglas V, Shanholtz C, Husain N, et al.
Depressive symptoms and impaired physical function after acute lung injury: a 2year longitudinal study. Am J Respir Crit Care Med 2012;185:51724.
[33] Liu C, Chu C, Chen W, Cheng W, Shih C, Tsai Y, et al. Impact of Taiwan's Integrated
Prospective Payment Program on prolonged mechanical ventilation: a six-year
nationwide study. Respir Care 2013;58:67682.
[34] Corrado A, Roussos C, Ambrosino N, Confalonieri M, Cuvelier A, Elliott M, et al.
Respiratory intermediate care units: a European survey. Eur Respir J 2002;20:
134350.
[35] Kahn JM, Werner RM, David G, Ten Have TR, Benson NM, Asch DA. Effectiveness of
long-term acute care hospitalization in elderly patients with chronic critical
illness. Med Care 2013;51:410.
[36] Rose L, Leasa D, McKim D, Nonoyama M, Avendano M, Goldstein R for the CANuVENT
group. Provision of institutional care for long-term mechanical ventilation in Canada: a
national survey. Am J Respir Crit Care Med 2014;189:A5372.
[37] L. Rose, D. McKim, S. Katz, D. Leasa, M. Nonoyama, C. Pedersen, et al., Home Mechanical
Ventilation in Canada: A National Survey. Respiratory Care [under review]