THE CHRONICALLY ILL--LONG TERM MECHANICAL VENTILATION

“慢性危重病”是一个仅在过去十年才被认为是一个独特群体的群体(Daly等人，1991；Girard&Raffin，1985)。这些患者由于其原发病的并发症或先前存在的慢性疾病的恶化而经历了长时间的危重疾病，并且由于普遍要求长时间的机械通气，也被归类为“长期呼吸机患者”。以前的研究记录了巨大的年度成本，估计在全国范围内为186亿美元(Goins等人，1991年)。尽管有这样的投资，住院死亡率仍然保持在30-50%(Daly等人，1991；Cohen&Booth，1994)。虽然我们之前已经证明，为这一人群提供“特殊护理单元”可以降低住院费用和改善临床结果(Douglas，Daly等人，1996；Rudy，Daly，Douglas等人，1995)，但直到最近，能够脱离呼吸机并出院的患者的持续护理需求一直没有受到关注。现在有充分证据表明，即使在出院后，慢性危重病患者仍然需要大量资源，但结果非常糟糕。目前的项目旨在将特别护理股在住院期间被证明在降低费用和改善结果方面有效的那些功能扩大到出院后的头两个月。这是第一项对这部分ICU人群进行门诊干预的研究。干预措施将包括由高级执业护士(APN)、肺科医生和老年医生组成的团队实施的疾病管理计划。将调查以下研究问题：(1)参加疾病管理计划的慢性危重患者与不参加疾病管理计划的慢性危重患者在出院后前2个月的相对资源利用方面是否存在差异？(2)参加疾病管理计划的慢性危重患者与不参加疾病管理计划的慢性危重患者在生活质量、死亡率、(3)参加疾病管理计划的慢性危重病患者和出院后前两个月对护理不满意的慢性危重病患者是否有差异？(4)参加疾病管理计划的慢性危重病患者的家属与不参加疾病管理计划的慢性危重病患者的家属是否有差异？

The "chronically-critically ill" are a population that has been recognized as a distinct group only for the past decade (Daly et al, 1991; Girard & Raffin, 1985). These patients experience a prolonged period of critical illness, due either to complications of their primary illness or exacerbation of pre-existing chronic diseases and have also been categorized as "long-term ventilator patients" because of the universal requirement for lengthy periods of mechanical ventilation. Previous research has documented enormous yearly costs, estimated at $18.6 billion nationally (Goins, et al, 1991). Despite this investment, in-patient mortality rates remain at 30-50% (Daly et al, 1991; Cohen & Booth, 1994). While we have previously demonstrated that the availability of a "Special Care Unit," for this population, can reduce in-patient costs and improve clinical outcomes (Douglas, Daly et al, 1996; Rudy, Daly, Douglas et al, 1995), until recently there has been no attention paid to continuing care needs of patients who are able to wean from the ventilator and be discharged from the hospital. There is now sufficient evidence that, even after discharge, chronically critically ill patients continue to require intensive resources but experience very poor outcomes The current project designed to extend those features of the Special Care Unit that were shown to be effective in reducing costs and improving outcomes during hospitalization to the first two months of the post- discharge period. It is the first study to test an out-patient intervention for this segment of the ICU population. The intervention will consist of a disease-management program, implemented by a team of Advanced Practice Nurses (APN), pulmonologist, and geriatrician. The following research questions will be investigated: (1)Are there differences between chronically critically ill patients who participate in a disease management program and those who do not in relative resource use in the first 2 months post-discharge? (2) Are there differences between chronically critically ill patients who participate in a disease management program and those who do not in quality of life, mortality, and rehospitalization in the first 2 months post-discharge? (3) Are there differences between chronically critically ill patients who participate in a disease management program and those who do not in satisfaction with care in the first two months post-discharge? (4) Are there differences between family members of chronically critically ill patients who participate in a disease management program and family members of those who do not in care-giving burden and depression?