Consensus conference on artificial airways in patients receiving mechanical ventilation.

I has long been known that patients with respiratory failure requiring prolonged mechanical ventilation consume considerable hospital resources. Reimbursement for these costs in the elderly by the Prospective Payment System (PPS) has been found to be severely lacking. .2 In an attempt to reduce the vast differences between hospital costs and the paucity of reimbursement for this group of patients, the Health Care Financing Administration (HCFA) added tt vo new DRGs in late 1987.. DRG 474 applied to MDC4 (Major Disease Category 4: Respiratory System) patients receiving mechanical ventilation through a tracheostomy tube, whereas DRG 475 applied to similar patients receiving mechanical ventilation through an endotracheal tube. The weighting factors for DRGs 474 and 475 were 11.8772 and 3. 1757, respectively, the former one ofthe highest weighting factors in the PPS. Even though the new DRGs represented a significant improvement, at least three major problem areas remained. The first concerned the fact that the weighting factor for DRG 474 was so high that there might be undue pressure placed on physicians to perform tracheostomies prematurely on these critically ill patients. Second, there were no guidelines available on the timing of performing tracheos-tomies on intubated patients receiving mechanical ventila-lion. Third, the majority of patients requiring prolonged mechanical ventilation did not have a principal diagnosis falling into the MDC-4 category and therefore would not be covered by the new DRGs.4 To address these and other issues, a consensus conference was organized by the National Association of Medical Directors of Respiratory Care (NAMDRC). The following consensus statements developed by those scientists attending the conference should favorably affect the quality of patient care, suggest areas for future research, and should influence the development offuture reimbursement policies concerning patients receiving mechanical ventilation through artificial airr vays. INDICATIONS FOR PLACEMENT OF NASAL AND ORAL ENDOTRACHEAL TUBES Introduction Tracheal intubation is indicated for (1) maintenance of airway patency, (2) protection of the airway from aspiration, (3) facilitation of secretion clearance, or (4) provision of mechanical respiratory support. Because these indications encompass a broad range of pulmonary and nonpulmonary diseases, it is inappropriate to list specific diagnoses for which intubation is indicated. Tracheal intubation should be performed by personnel who are sufficiently skilled to provide optimal care. Institutions should credential personnel who perform intubation in a manner appropriate for the size and complexity of the facility and the medical staff. Credentialing should include consideration oftraining, experience, and backup …