New information suggests that the ICU environment is not needed for long-term ventilator care and may even interfere with optimization of functional potential. Patients requiring long-term ventilation may reach a state of relative clinical stability and not require ICU nursing or invasive monitoring. Furthermore, most, if not all, long-term ventilator-assisted patients require significant rehabilitation, and a multidisciplinary treatment plan focusing on rehabilitation is difficult to implement in an ICU.

Decisions on the most appropriate non-ICU setting for long-term mechanical ventilation must be individualized, but regardless of the site chosen, several essential criteria for patient stability must be met to ensure that discharge to an alternative site is safe, logistically possible, and cost saving. Clinical criteria for stability of a VDP transferred to a more intensely supervised site (such as a specialized respiratory care unit in an acute care facility) are less rigid than for patients discharged to an intermediate care facility (such as a rehabilitation hospital) or to a long-term facility or home.

Patients should also meet the criteria for respiratory stability. They should have a secure airway or be stabilized on a regimen of NIV. They should not have episodic severe dyspnea or desaturations, and oxygenation needs should be met easily without requiring high supplementary oxygen concentrations or high levels of positive end-expiratory pressure. Respiratory secretions should be manageable outside of the ICU environment, and variations in airway resistance should be minimal. In addition, the patient should not be undergoing frequent ventilator setting changes, other than for weaning, and should not require sophisticated ventilator modes.

For VDPs who are being considered for transfer home, additional psychological and social stability criteria should also be met to ensure that the patient presents a successful psychological adaptation to home and will have sufficient human and financial resources to sustain that success. It is also advantageous to have a family that fully comprehends the situation, is capable and desirous of participating in the patient’s care, and has sufficient support from an experienced multidisciplinary team of health-care professionals.

All members of the health-care team should evaluate these factors as they relate to the individual requiring assisted ventilation. Should the current level of care be continued? Or is an alternate site now appropriate? The patient and the patient’s family should be asked to provide input. The physician, as the individual responsible for ordering services and care, has a key role in this process and should determine the amount of medical care, monitoring, and intervention required by listing the needs and goals of the VDP.

The discharge planning process should ensure a smooth transition and safety in addition to an optimal outcome in the new site both when planning the patient´s discharge from the hospital to home and when transferring the patient from an ICU to non-ICU acute care. The patient’s goals and a list of patient needs, including personnel requirements and specific equipment, should be clearly defined. Guidelines for the discharge planning process have been written by the American Medical Association [8], the American Association of Respiratory Care [9], and a group of health-care professionals at a university medical center [10].

Successful transition of a VDP from the ICU to an intermediate or long-term care site outside the traditional hospital setting, particularly to the home, requires the collaborative efforts of a discharge team [11]. The team identifies all patient care issues that must be resolved prior to discharge and develops a plan to facilitate the transfer. The team, which includes the patient and his or her family, should be comprised of key hospital and community-based personnel, many of whom will play an ongoing role in the patient’s care once he or she is discharged. Discharge planning team members should include the following:

The patient and their family need to learn skills about care, and on this way the role of doctors and nurses is crucial. The coordinator usually selects the specific types of home respiratory care equipment and ensures that the patient, family, and other caregivers have a detailed understanding of the equipment. When patients are discharged to long-term care sites, including the home, the home care company should be responsible for equipment maintenance and should also provide personal trained in NIV management when necessary. A social worker can also provide an evaluation of the alternate site as well as of community and home resources and support available for long-term care. In addition, beds, wheelchairs, and other general medical equipment must be provided or their acquisition facilitated (see the checklist in Table 45.2 for equipment and supplies required).