"We can never thank you for all the work you have done for our mother! We just want to thank you for your never-ending service, for always being there, even when we were being difficult. Keep up the excellent work."
- Estelle's Family

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A Letter From Our Chief Medical Officer

As Chief Medical Officer for Fox Subacute, I would like to take the time to tell you about our facilities and our philosophy. We pride ourselves on the total care of a patient, and respecting them as people.  At Fox Subacute, we adhere to a holistic and personalized method of weaning, incorporating not only ventilator care, but physical, occupational and speech therapy, recreational therapy, and other ways to make the transition back to a normal quality of life as quickly as possible.

However, there are some things that I should point out so that we are all on the same page as to how this process works, as it does take some time:

Fact: According to data from 2001, patients on a ventilator more than 21 days account for 37 % of all hospital costs.

Studies as far back as 1994 show that patients transferred to a specialized weaning facility from an ICU earlier after intubation are sicker at the initial admission, but that there is no change in mortality, more than half of the patients are able to be successfully weaned, and survival after weaning is improved. (Scheinhorn  DJ, Chao D, et al. Post-ICU Weaning from Mechanical Ventilation.  Chest 1997; 111:1654-59)

Fact: Up to 20 % of patients on a ventilator in an ICU will fail to wean in the acute setting.

It has been documented that 34-60% of patients that are discharged from an ICU on a ventilator and are labeled as “non-weanable” can be successfully weaned in a dedicated weaning facility. It has also been shown that success is likely to fall within a three-month window, although there is still a chance for weaning after that time period. 

At Fox Subacute, we specialize in the care of the short, intermediate, and long term ventilator patient.  Our goal is to wean the patient from the ventilator, however when this is not possible, we are able to care for them long term as well.  We stress a total recovery, not just weaning someone from the ventilator.

A 1997 article in the journal CHEST, (the official publication of the American College of Chest Physicians) describes the development of a regional center designed to liberate people from mechanical ventilation (MV). They felt, as we do, that the best way to optimize a patient’s chances of becoming free from MV is to optimize functional ability rather than just simply working to wean from the ventilator alone.

They describe 4 major attributes of a regional weaning center. 

  1. It will liberate patients from MV when possible.  When complete independence from MV is not possible, achieving partial ventilator independence will generally result in higher functional levels and may allow speech.
  2. It will apply a rehabilitation model of care to ventilator-dependent patients with the intent to reach maximal functional independence through traditional rehabilitation therapies.  This may be beneficial even if total ventilator independence remains.
  3. It will prepare patients and families for home MV, either through a tracheostomy or with noninvasive modalities.
  4. It will serve as a lower-cost venue for ongoing MV in the setting of other medical problems that prevent ongoing care at home or in an extended care facility, even though formal weaning or rehabilitation is not appropriate at this time.

(Bagley, P.H, Cooney, E. A Community-Based Regional Ventilator Unit: Development and Outcomes. Chest 1997; 111:1024-1029)

We believe that our facilities provide a much better environment for weaning rather than an acute care setting.  At Fox, we are intimately involved in our patients’ lives, not just their medical conditions.  We get to know their families, we incorporate their interests into their rehabilitation program and we organize community outings and get them involved in daily activities. 

Our Medically complex patients meet McKesson Interqual Criteria for subacute rehabilitation in multiple areas, including neuromuscular disease, severity of illness, and intensity or service. We are able to care for medical services such as management of central venous catheters, TPN (total parenteral nutrition), wound VAC, chest tubes to water seal, intravenous antibiotics and medications (excluding vasopressors). 

Patients who are actively weaning are placed on a protocol driven weaning program, are followed by physician visits at least twice a week, and are all seen by a pulmonologist in consultation and follow up. We have multiple specialty services available, including, but not limited to: Otolaryngology for airway management and routine tracheostomy changes, wound care nurse practitioners, and Nephrologists for our in-house hemodialysis centers, which are available at all of our buildings.  We also provide physical, occupational, speech, and nutritional therapy, as well as podiatry, psychology, and psychiatry.

At one of our Fox facilities, over the time period of June 2009 to November 2009, our census had an average of 13 people per month who were in the weaning process.  Over that time period we also discharged 10 patients either home or to a lesser level facility, who were successfully weaned from the ventilator.

 In this patient population there is no reason to transfer someone from an acute ICU to an LTACH simply to try to wean.  It is a waste of money. Our weaning and rehabilitation program is superb, and for the difficult to wean ventilator patient that is hemodynamically stable and does not require cardiac monitoring.

We follow the simple rule of holding ourselves accountable to three qualities: Respect, Excellence, and Accountability.

We respect our patients as people.  To us they are individuals each with individual needs, concerns and fears.  We work together with them and their families to address each of these barriers and work towards returning them to their highest level of function.
We strive to provide Excellence in our care, our facilities, and ourselves.  We welcome comments and concerns and will work to make any changes that will help us improve.

We hold ourselves Accountable to continue to provide the highest standard of care and total approach to the patient.  We can rest easy at night knowing we have done our best and provided the best possible care that day.

Drs. Latriano, McCauley, Astiz, Greenbaum, and Rackow said “The [prolonged mechanical ventilation] patient population is elderly with a slight female predominance, and they carry with them such a broad spectrum of acute and chronic medical and post-surgical problems that they require very specialized and individualized treatment plans and resources.  This should drive a transfer decision that not only includes continued weaning but also the availability of specific physician-directed support modalities, such as hemodialysis, wound care, physical therapy, occupational therapy, psychological counseling, and nutritional repletion, to name only a few.” (Post-ICU Weaning from Mechanical Ventilation : CHEST 2001; 120:482S-484S)

We couldn’t agree more.

 

 

Erik I. Soiferman, DO, FACOI
Chief Medical Officer, Fox Subacute Management, Inc.
Medical Director, Fox Subacute at Clara Burke
Diplomate, American Osteopathic Board of Internal Medicine

Associate Professor, Department of Medicine, Philadelphia College of Osteopathic Medicine