438 • CID 2009:49 (1 August) • HEALTHCARE EPIDEMIOLOGY
H E A LT H C A R E E P I D E M I O L O G YI N V I T E D A R T I C L E
Robert A. Weinstein, Section Editor
Long-Term Acute Care Hospitals
L. Silvia Munoz-Pricea
Medical Specialists, Munster, Indiana
Long-term acute care hospitals (LTACHs) are health care facilities that admit complex patients with acute care needs (eg,
mechanical ventilator weaning, administration of intravenous antibiotics, and complex wound care) for a mean duration of
stay of 25 days. LTACHs are different than nursing homes and were initially created in the 1990s in an effort to decrease
Medicare costs by facilitating prompt discharge from intensive care units of patients with difficulty weaning mechanical
ventilation; however, current admission diagnoses are quite broad. Patients admitted to these facilities have multiple co-
morbidities and are at risk for colonization with multidrug-resistant organisms. LTACH patients have been shown to have
high rates of hospital-acquired infections, including central vascular catheter–associated bloodstreaminfectionandventilator-
associated pneumonia. In addition, LTACHs have been implicated in various regional outbreaks of multidrug-resistant
organisms. This review summarizes the limited amount of scientific literature on LTACHs while highlighting their infection
control problems, as well as the role LTACHs play on regional outbreaks.
Most US patients treated by physicians are seen either during
outpatient visits or short-term hospitalization; however, there
is a large group of patients who, because of their high medical
needs, cannot return to their homes or nursing homes after
acute care hospitalization. Institutions that accommodate these
patients are known as postacute care providers . Postacute
care providers include long-term acute care hospitals, skilled
nursing homes, inpatient rehabilitation facilities, and home
health care services . This review deals with long-term acute
care hospitals, their infection control problems, and their im-
pact on regional outbreaks.
Definitions and history.
During the 1980s, long-termacute
care hospitals (LTACHs), which are also called long-term care
hospitals by Medicare , were created to facilitate prompt
discharge of medically complex patients from acute hospitali-
zations, in an effort to decrease Medicare spending. LTACHs
are not nursing homes; nevertheless, the terms are used inter-
changeably by physicians. Nursing homes, also known as long-
Received 3 February 2009; accepted 5 April 2009; electronically published 23 June 2009.
aPresent affiliation: Division of Infectious Diseases, University of Miami and Jackson
Memorial Hospital, Miami, Florida.
Reprints or correspondence: Dr. L. Silvia Munoz-Price, 1611 NW 12th Ave., Miami, FL 33136
Clinical Infectious Diseases2009;49:438–43
? 2009 by the Infectious Diseases Society of America. All rights reserved.
term care facilities (LTCFs), take care of more stable patients
for longer periods of time than do LTACHs, sometimes serving
as patients’ lifetimeresidences.ConfusionbetweenLTACHsand
LTCFs originates on the basis of similarities and misusage of
their nonstandardized names and acronyms, as well as thepost-
acute care nature of both. Nevertheless, LTACHs need to com-
ply with all the accreditations of acute care hospitals; in ad-
dition, LTACH patients are required to have “medically
complex” situations, with a mean length of stay of ?25 days.
In 1982, the Tax Equity and Fiscal Responsibility Act allowed
Medicare to reimburse LTACHs on the basis of expenses in-
curred during each hospitalization, regardless of the initial di-
agnosis. The Medicare Payment Advisory Commission—an in-
dependent Congressional agency established by the Balanced
Budget Act of 1997 to advise the US Congress on Medicare
issues—believes that Tax Equity and Fiscal Responsibility Act
constituted a strong incentive for the creation of additional
LTACHs . The result was that, from 1990 to 2004thenumber
of LTACHs quadrupled, causing Medicare’s spending on these
institutions to increase as well .
In 2002, on the basis of the increase of Medicare costs for
LTACHs, the payment-per-service fee was institutedinaneffort
to decrease Medicare fees . Under the current payment-per-
service system, at the time of admission to an LTACH, patients
are assigned admission diagnosis codes; Medicare payments are
then calculated on the basis of these codes rather than on the
basis of actual expenditures during hospitalization. Despite the
institution of payment-per-service fees, the number of LTACHs
HEALTHCARE EPIDEMIOLOGY • CID 2009:49 (1 August) • 439
across the United States, 1990–2004. Adapted from Medicare Payment
Advisory Commission analysis of provider of service files for Centers for
Medicare Services . PPS, prospective payment system; TEFRA, Tax
Equity and Fiscal Responsibility Act of 1982.
Change in the number of long-term acute care hospitals
continued to multiply, approaching 400 in 2007 (figure 1) .
Moreover, Medicare expenses swelled exponentially, constitut-
ing 73% of the LTACH’s reimbursements. As a consequence,
Medicare implemented a 3-year moratorium on all expansions
and creations of new LTACHs. A new “25% rule” is also in
effect, which limits the number of patients transferred to an
LTACH from any single acute care hospital down to 25% in
any given quarter .
According to a 2008 Medicare Payment Advisory Commis-
sion’s Report to the Congress, 58% of LTACHs are for-profit
organizations, two-thirds of which are owned by eitherKindred
Healthcare or Select Medical . LTACHs are unevenly dis-
tributed across the United States, concentrating primarily in
the midwestern and eastern side of the country (figure 2) .
This explains why so many American doctors may not beaware
of the role of or even existence of these facilities. There are 2
types of LTACHs: hospital-within-the-hospital and free-stand-
ing LTACHs. The former comprises 47% of all facilities and
consists of LTACHs that lease a portion of preexisting acute
care hospitals but that function as complete separate entities,
retaining their own administrations and ancillaryservices.Free-
standing LTACHs, as the name implies, are entities geograph-
ically independent from acute care hospitals [3, 5].
Regarding patient safety at LTACHs, the Medicare Payment
Advisory Commission compiled Medicare discharge data from
2004–2006 on 4 different patient safety indicators, revealing an
increase in the rate of complications in all but one (table 1)
. LTACHs are licensed both by the state and Medicare; how-
ever, LTACHs can electively undergo additional certification by
the Joint Commission, just as can any acute carehospital.Nurs-
ing staffing at LTACHs, with either registered nurses or licensed
practical nurses, is regulated by state authorities. Ratios of
nurses to patients also follow state regulations and vary de-
pending on the acuity mix of patients; the ratio can be as low
as 1:1 in select cases. Interestingly, full-time or part-time in-
fection preventionists are not required for licensure purposes
by all states.
Originally, LTACHs were intended
for patients in need of prolonged weaning of mechanical ven-
tilator use [6, 7]; however, present admission diagnoses en-
compass a wide range of diseases (table 2) . Patients who
are admitted to LTACHs have complex situations, multiple co-
morbidities, and acute medical needs; comorbidities include
respiratory failure that requires weaning of mechanical venti-
lator, recent surgeries, presence of gastrostomy tubes, diabetes,
receipt of total parenteral nutrition, presence of bladder cath-
eters or central vascular catheters, decubital ulcers, and mal-
nutrition . It is important to note that a large number of
LTACH patients have had long-length stays at their acute care
hospitals of origin, including stays at intensive care units
(ICUs). All of these characteristics place patients who are trans-
ferred to LTACHs at high risk of colonization with multidrug-
resistant bacteria. A couple of studies have examined the col-
onization rates for patients at the time of admission and during
LTACH stay. Gould et al  compiled active surveillance data
at the time of LTACH admission and foundthat 64%ofpatients
were colonized or infected with methicillin-resistant Staphy-
lococcus aureus, vancomycin-resistant enterococci, or both. A
recent study developed a cumulative database that included 4
years of results of surveillance admission cultures at a mid-
western LTACH; the study revealed that, of 1905 patients
screened, 55% were infected or colonized with multidrug-re-
sistant organisms at any site; vancomycin-resistant enterococci
and extended-spectrum b-lactamase–producing gram-negative
organisms were found in 33% and 9% of rectal cultures, re-
spectively. Of 1708 wound cultures, 16% yielded vancomycin-
resistant enterococci, and 6% yielded imipenem-resistant Aci-
netobacter species .
Antibiotic use, devices, and colonization rates.
al  also evaluated the antibiograms and antibioticpurchasing
data from 45 LTACHs during the period 2002–2003. They
found that the rate of carbapenem and vancomycin use at
LTACHs was higher than the 50th percentile of ICU use re-
ported by the National Nosocomial Infections Surveillance sys-
tem; fluoroquinolone use at those LTACHs was comparable to
the 90th percentile for use at ICUs. A composite antibiogram
for all facilities revealed that 84% of S. aureus isolates were
methicillin resistant and that 60% of Pseudomonas aeruginosa
isolates were fluoroquinolone resistant. In addition, central
lines were found to be present for one-half of the duration of
stay for all patients, and mechanical ventilators were required
during 20% of patient-days. High rates of device use were also
440 • CID 2009:49 (1 August) • HEALTHCARE EPIDEMIOLOGY
analysis of provider of service files for Centers for Medicare Services .
Geographical distribution of long-term acute care hospitals across the United States. Adapted from Medicare PaymentAdvisoryCommission
Table 1.Safety Indicators at Long-term Acute Care Hospitals
Patient safety indicator
Risk-adjusted rates per
1000 eligible discharges
in 200620042005 2006
Infection associated with medical care
Postoperative PE or DVT
with a previous acute hospital stay. Because of a change in methodology, this chart cannot be compared withits counterparts
in previous Medicare Payment Advisory Commission data books. Adapted from Medicare Payment Advisory Commission
analysis of Medicare Provider Analysis and Review data from the Centers for Medicare Services . DVT, deep vein throm-
bosis; PE, pulmonary embolism.
To control for patient condition on admission to the long-term care hospital, eligible discharges include only those
documented by a group from Emory University who found
that 74% of patients at 2 LTACHs in Atlanta, Georgia, had
central vascular catheters in place . To date, to my knowl-
edge, there have been no studies of compliance with hand-
washing and isolation precautions at LTACHs.
With regard to colonization rates with multidrug-resistant
organisms during LTACH stays, Furuno et al  performed
a point-prevalence surveillance study at a 180-bed, university-
affiliated LTACH in Maryland. Of 147 patients screened, 30%
and 28% were found to carry methicillin-resistant S. aureus or
Acinetobacter baumannii, respectively, at any site; however,
none of the recovered Acinetobacter isolates were imipenem
resistant. This finding contrasts with findings from 2 recent
outbreaks of A. baumannii infection in Ohio and Michigan, in
which multidrug-resistant A. baumannii infections occurred
both in acute care hospitals and in associated LTACHs; most
isolates were respiratory in origin [13, 14]. In both studies,
patients were “shared” amongacutecarehospitalsandLTACHs,
with identical isolates among facilities. A similar outbreak was
experienced in 2005 in the greater Chicago, Illinois, area; the
outbreak involved OXA-40 carbapanemase–producing A. bau-
mannii, which spread among various university hospitals,
LTACHs, and nursing homes in the region .Klebsiellapneu-
monia carbapenemase (KPC) K. pneumoniae infection was re-
cently reported among 7 patients at a Florida LTACH . At
the time that I was writing this article, a multiple-facility out-
HEALTHCARE EPIDEMIOLOGY • CID 2009:49 (1 August) • 441
Table 2.Most Common Admission Diagnoses to Long-term Acute Care Hospitals in 2006.
Admission diagnosis (LTC-DRG)a
Respiratory system diagnosis with ventilator support (475)
Skin ulcers (271)
Septicemia in persons aged 117 years (416)
Pulmonary edema and respiratory failure (87)
Respiratory infections and inflammation in persons aged 117 years with CC (79)
Aftercare, without history of malignancy (466)
Simple pneumonia and pleurisy in persons aged 117 years with CC (89)
Aftercare, musculoskeletal system and connective tissue (249)
Chronic obstructive pulmonary disease (88)
Degenerative nervous system disorders (12)
Skin graft and/or debridement for skin ulcer in persons with CC (263)
Heart failure and shock (127)
Postoperative and posttraumatic infections (418)
Renal failure (316)
Top 15 LTC-DRGs
from the Centers for Medicare Services . Columns may not sum because of rounding. CC, complication or comorbidity;
LTC-DRG, long-term care diagnosis related group.
aLTC-DRGs are the case-mix system for these facilities.
Adapted from Medicare Payment Advisory Commission analysis of Medicare Provider Analysis and Review data
of infection with multidrug-resistant organisms have been found to follow
the flow of colonized patients across institutions.
Patient flow among regional health care facilities. Outbreaks
break of KPC-producing K. pneumoniae was occurring in the
greater Chicago area and in neighboring northwest Indiana at
tertiary care and community hospitals, LTACHs, and nursing
homes ; the spread among hospitals appeared to follow the
flow of colonized patients (figure 3) and was similar to what
occurred during the 2005 outbreak of A. baumannii infection
in Chicago . As has been described elsewhere for nursing
homes , it appears that colonization at the time of admis-
sion or during stay at an LTACH varies across the United States
and may depend on regional flora [10, 12].
Studies of hospital-acquired infections at LTACHs are scarce.
Wolfenden et al  found a rate of central vascular catheter
(CVC)–associated bloodstream infection (BSI) of 16.44 cases
per 1000 CVC-days. This rate is twice than the 90th percentile
for ICU rates, according to the National Nosocomial Infections
Surveillance system. Enterococci and staphylococci were the
most common pathogens isolated. A similar study at a greater
Chicago area LTACH found a median CVC-associated BSI rate
of 7.2 cases per 1000 CVC-days (monthly range, 1.9–16.5 cases
per 1000 CVC-days). Of 136 episodes, 37% were polymicrobial.
The most common organisms isolated were coagulase-negative
staphylococci, enterococci, and Acinetobacter species [19, 20].
A different study from a 70-bed LTACH found a rate of ven-
tilator-associated pneumonia (VAP) of 6.16 cases per 1000 ven-
tilator-days. Gram-negative organisms—in particular, carbape-
nem-resistant Acinetobacter species—were the predominant
organisms isolated . Similarly, a recent publication thatchar-
acterized VAP cases at LTACHs identified gram-negative rods as
the causative organisms in 85% of all recovered sputum isolates
. Studies of device-associated urinary tract infections and
Clostridium difficile infection are currently lacking.
Despite the high rate of device-associated infections, infection
control interventions have been shown to positively affect in-
fection rates at LTACHs. Universal chlorhexidine baths suc-
cessfully decreased CVC-BSI rates by 99% at the end of the
intervention period (9.5 vs. 3.8 CVC-associated BSIs per 1000
CVC-days) at a greater Chicago area LTACH . In addi-
tion, a VAP bundle (elevation of the head of the bed, oral
care every 4 h, and administration of proton pump inhibitors)
442 • CID 2009:49 (1 August) • HEALTHCARE EPIDEMIOLOGY
at an LTACH reduced VAP rates from 6.16 to 0.52 cases per
1000 ventilator-days . Similarly, after the institution of a
VAP bundle at a 207-bed LTACH, VAP rates decreased from
3.8 to 1.67 cases per 1000 ventilator-days . In addition, a
recent report showed a 43% reduction in antibiotic use at an
LTACH after implementation of an antibiotic stewardship pro-
Managing outbreaks of infection at an LTACH setting can
be particularly challenging, given that outbreaks tend to be
regional rather than “single-institution”; therefore, despite
control measures, constant influx of patients colonized with
multidrug-resistant organisms has been documented .
Control of additional horizontal spread within the institution
has been accomplished by using bundles that include contact
precautions (gowns and gloves), chlorhexidine baths, staff ed-
ucation, environmental cleaning, and cohorting [13, 24].
LTACHs have been called the “perfect storm” , which seems
like an appropriate description of these facilities, given that
who have multiple comorbidities for long periods of time (?3
weeks); in addition, LTACHs admit patients who are already
colonized with multidrug-resistant organisms and who have
high rates of both antibiotic use and device use. Given all these
factors, it should only be expected for these facilities to have
high rates of infection with multidrug-resistant organisms.
LTACHs, like other non–acute care facilities, appear to play a
crucial role in regional outbreaks of infection with multidrug-
resistant organisms by magnifying the colonization rates of a
population [17, 24]; therefore, cooperation of LTACHs during
regional outbreaks should be granted by their corporations
rather than pleaded by localresearchers.Therearevariousques-
tions pertaining to LTACHs that remain unanswered, such as
questions about catheter-associated urinary tractinfectionsand
C. difficile colitis, as well as a need for more in-depth research
on the importance of these institutions on the regional epi-
demiology of multidrug-resistant bacteria.
Potential conflicts of interest.
L.S.M.-P.: no conflicts.
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