Mechanical Ventilation: Beyond the ICU Quick Reference Guide

Table 3 lists criteria for medical and respiratory stability that should be met prior to discharge of a VAI from the ICU to an intermediate facility.

**Table 3**—**Discharge Criteria for VAIs from ICUs to Intermediate Care Facilities (Where Weaning is Possible)**
Medical stability Nonrespiratory organ dysfunction stabilized Sepsis treated and controlled Hemodynamically stable and no need for invasive hemodynamic monitoring No uncontrolled arrhythmias or heart failure No uncontrolled hemorrhage Renal function and acid-base balance stable or receiving chronic dialysis No coma, or if comatose, prognosis for improvement Treatment plan for all medical conditions is in place, will not require frequent changes, and can be implemented at alternate care site Adequate nutrition program in place; preferably using enteral route
Respiratory stability Safe and secure airway; either tracheostomy with a sufficient mature stoma to allow tube changes, or stabilized on regimen of NIV with minimal risk for aspiration Able to clear secretions, either spontaneously or with assistance No episodes of severe dyspnea; no sustained moderate or severe dyspnea Stable airway resistance and lung compliance with variations in Ppeak of no more than ± 5 cm H₂O (except during coughing) Adequate oxygenation (SaO₂ > 90%) on stable FIo₂ (< 60%) and low PEEP requirements (< 10 cm H₂O) Oxygenation stable including during suctioning, repositionin Stable ventilator settings and no need for sophisticated ventilator modes (eg, inverse ratio ventilation, independent lung ventilation, high frequency ventilation)

Table 4 lists criteria supplementary to Table 3, for use with VAIs who are under consideration for transfer to lower-intensity long-term care facilities, or to home. These patients should meet the stability criteria listed in Table 3 for at least 4 weeks, and their needs for skilled nursing care should be less than for patients meeting criteria for Table 3.

**Table 4—****Discharge Criteria for VAIs from ICUs to Intermediate Care Facilities to Long-term Care Facilities (With the Goal of Optimizing Quality of Life)**
Medical stability Has met medical stability criteria in Table 3 for sustained period of time (1-2 wk) Needs for skilled nursing can be met at alternate care site For transfer to rehabilitation facility, must be capable of at least 3 h of rehabilitation per day
Respiratory stability Meets criteria in Table 3, but in addition: Has stable FIO₂< 0.4 with PEEP < 5 cm H₂O (unless on higher PEEP for obstructive sleep apnea) Ideally, is capable of some ventilator-free breathing, the more the better; if no spontaneous breathing capability, adequate monitoring is available at alternate site
If discharge home is contemplated, patients should meet stability criteria for 3-4 wk and these additional criteria should be met; Psychological stability Able and willing to supervise care provided by personal care attendants (or has family member who can assume this role) Able and willing to participate in self care, or has sufficient caregiver assistance to adequately meet medical, respiratory, and personal care needs No major affective disorders that limit participation in home Stable home and family setting, or availability of 24-h attendant care Willing and able caregivers identified and trained prior to discharge to provide necessary care Home environment prepared in advance to accommodate patient's needs Adequate financial resources and mechanisms for reimbursement identified prior to discharge Comprehensive discharge plan in place

In applying discharge criteria, psychosocial factors are as important as medical factors in assuring success of home ventilation. Patient and family should be professionally evaluated to determine their level of motivation, any family or individual psychosocial health problems, ability to make decisions, and financial stresses.

Consensus Statements

Mechanical Ventilation: Beyond the ICU
Quick Reference Guide

Criteria for Discharge to Non-ICU Facilities