Duration of stay in hospitals, days weeks months?

talaxandra · Oct 30, 2009

I don't know about the really sick (ie ICU level) patients because I haven't seen any - by the time they're well enough for the wards they're no longer infectious. That said, as we have five other medical units in addition to Infectious Diseases you'd think we'd get at least some dialysis-dependant, diabetic or neurological patients from ICU, but not so far, at least not to my knowledge.

Of the several dozen confirmed H1N1 patients we've had on my ward the only sick ones have been those with preexisting illnesses, predominantly cancer. They've been isolated with us for five days then transferred to oncology. The non-oncology patients have generally been discharged on day five.

indigo girl · Oct 30, 2009

It would seem that only those that are unlucky enough to be the severe cases in ICU, end up with an extended stay. Many of them will then need rehab care as well after leaving the hospital.

I have been seeing information about the cost of those stays which burdens these families. There are many pleas for donations, and many communities are holding fund raisers to help pay the extraordinary cost of critical care. Sadly, the bill still has to be payed even though the patients have died...

Here is an example of what we have been seeing regarding costs, and this patient died quickly. In my facility, we had a young mom after an emergency C-section go on ECMO for a few weeks at least before she died.

http://www.kenburbary.com/2009/10/please-help-us-help-the-loveless-family/#more-920

A brief look thru these threads gives you an idea of the length of stay, and the tremendous financial costs of caring for these patients. Consider that with the use

of ECMO, I believe it is two nurses to one patient 24/7. Think about why the

patient is on ECMO to begin with. ECMO is used to give the lungs a chance to heal. I don't know how long this process takes but it is not likely to be that rapid that the patient could come off in a few days. Perhaps one of the ECMO nurses could answer about the length of stay.

https://allnurses.com/pandemic-flu-forum/ecmo-will-we-410682.html

https://allnurses.com/pandemic-flu-forum/no-prior-existing-400466.html

https://allnurses.com/pandemic-flu-forum/whats-happening-now-422611.html

https://allnurses.com/pandemic-flu-forum/evidence-swine-flu-399332.html

talaxandra · Oct 30, 2009

What a financial nightmare for patients and families who've already been through so much! I'm so glad that's one less thing for ours to worry about.

I'm back at work tomorrow and will ask the nursing coordinator about those H1N1 patients who've needed ICU - I know that some nurses developed nasal pressure areas from wearing N95 masks for 12 hours straight, day after day.

Pediatric Critical Care Columnist · Oct 30, 2009

While I can't speak specifically to H1N1 and ECMO treatment LOS since we haven't had one yet, I can tell you about a few of our respiratory ECMO patients from past years.

It's correct that each ECMO patient has 2 nurses or a nurse/RT or a nurse/perfusionist 24/7. The bedside nurse does all the nursing care, which can be considerable in a heavily-sedated, intubated, ventilated patient with garden hoses sprouting from their neck or groin. The ECLS specialist monitors the pump and circuit, anticoagulation, blood gases, and a number of other parameters, as well as runs CRRT if needed. Remember that there will be litres of blood circulating under high pressure through the circuit outside the patient's body every minute. Air leaks, blood leaks, fibrin deposits, clots, intrathoracic pressure changes, all these and more are the ECLS specialist's gig. If something goes wrong with the circuit, such as massive air entrainment or burst tubing, power failure or pump failure, the ECLS specialist repairs the system while the bedside nurse (and usually half of the staff on the unit as well) care for the patient. Repairing the circuit usually means taking the patient off ECMO so we try to make sure the actual stop time is as brief as possible. And with any long run, there will be the inevitable complete circuit change.

Cardiac ECMO is often only a few days' duration while the heart recovers from whatever caused it to fail or until a transplant occurs. (We are currently supporting an infant with a very complex constellation of cardiac defects who has been on for more than 6 weeks, but that's the exception for us.) Pulmonary ECMO is generally a lot longer process because the lungs recover much more slowly.

One of our respiratory kiddos had both adenovirus and RSV and was on ECMO for 8 weeks before we discontinued treatment and she died. That's 8 weeks in the ICU with two staff at the bedside 24/7 for 56 days. Another similar patient ran 5 1/2 weeks before her coagulopathy caused a massive bleed into her head and we discontinued treatment and she died. Other kids, one with severe asthma (who has been on ECMO twice now), have required upwards of two weeks, and our longest run with an intact survival was 12 weeks. WEEKS. And that's just the run time. After they're successfully decannulated, they may need ICU for several days to weeks in ICU for the other systems to recover enough to allow a ward transfer. LOS may run to months. One of our cardiac kiddies who went on to transplant was admitted to the ICU in November, went on ECMO after Christmas, was on 12 days, was transplanted in January, went to the ward in March and home in April. 5 months.

Do these examples make it a little clearer?

northwest2go · Oct 30, 2009

Thank you all for your responses. It appears that the ECMO patients can be weeks or months. What about the H1N1 patients that are admitted maybe to various types of units vs just ICU's? Are are you finding their length of stay in the days or weeks timeframe?

Pediatric Critical Care Columnist · Oct 31, 2009

The H1N1 patients we've had on our unit (PICU) but not on ECMO have been there for at least a week, generally two or more. Our first one was 23 days, the second 17 days and the most recent 2 are still there after well over a week. I can't offer any insight into their ward stays though. There was an adult death at our hospital yesterday.

indigo girl · Nov 11, 2009

Two links from a study in Ireland:

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19389

From 28 April 2009 to 3 October 2009, 205 cases of confirmed pandemic H1N1 influenza were hospitalised in Ireland. Detailed case-based epidemiological information was gathered on all hospitalised cases. Age-specific hospitalisation rates were highest in the age group of 15 to 19 year-olds and lowest in those aged 65 years and over. Nineteen hospitalised cases (9%) were admitted to intensive care units (ICU) where the median length of stay was 24 days. Four hospitalised cases (2%) died. Fifty-one percent of hospitalised cases and 42% of ICU cases were not in a recognised risk group. Asthma was the most common risk factor among cases; however, people with haemoglobinopathies and immunosuppression were the most over-represented groups.

http://www.irishexaminer.com/ireland/asthma-medication-is-most-common-swine-flu-risk-factor-105203.html

The data, which relates from April 28 to October 3, found less than 10% of hospitalised cases (19) were admitted to ICU where the average length of stay was 24 days.
The data, published in online scientific journal Eurosurveillance, shows during the initial five months of the pandemic, four people died, one of whom did not have an underlying medical condition.
The median length of stay in hospital was two days for cases under the age of 24 years but increasing to seven days in adults over 65 years. Asthma was associated with a mean length of stay of six days.

(much thanks to Avian Flu Diary for this information)

talaxandra · Nov 11, 2009

I just read an article about this is the Australian Nursing Journal - will post a link if I can (or extract if not available online) as soon as I can.