Direct Discharge From ICU OK for Some Patients

Norra MacReady

August 24, 2018

Discharging patients home directly from the intensive care unit (ICU) is associated with outcomes similar to those seen in patients discharged after a follow-up stay on a hospital ward, the authors of a large, population-based study say.

The groups did not differ for hospital readmission or emergency department visits at 30 days or for 1-year mortality, Henry T. Stelfox, MD, PhD, professor of critical care medicine, medicine, and community health sciences at the Cumming School of Medicine, University of Calgary, Alberta, Canada, and colleagues write in JAMA Internal Medicine

"The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality," they conclude.

The authors explain that they conducted the study, which included more than  6000 adult patients in Alberta, in response to a growing practice of discharging ICU patients directly home because of a lack of available hospital ward beds in many healthcare systems. On the basis of their findings, they suggest that discharge planning from the ICU begin as soon as possible, with the goal of sending eligible patients home, in order to make the most efficient use of hospital resources.

In an accompanying editorial, Kyan Safavi, MD, MBA, Jeanine Wiener-Kronish, MD, and Dusan Hanidziar, MD, PhD, from Massachusetts General Hospital in Boston, say the results also suggest that some patients admitted to the ICU may actually require less intensive monitoring and support and might be candidates for alternative forms of care. In other cases, "it is possible that the ICU is appropriate for a subset of patients through their entire stay, and then they are appropriately discharged directly home as soon as they are ready for transfer out of the ICU."

However, Safavi et al warn that "we must ask ourselves why direct discharge from the ICU is becoming a common practice." The most likely answer has to do with lack of space on general care units, resulting in patients spending more time in the ICU than necessary simply because no other beds are available.

Indeed, Stelfox and colleagues write that 1 in 3 patients in the present cohort spent more than 24 hours in the ICU after being deemed ready for discharge. They describe this as a "misallocation of resources" that "may slow care progression for patients recovering from critical illnesses and limit ICU access for other patients."

Similar Outcomes

For their study, the authors identified consecutive patients 18 years of age or older admitted to nine medical-surgical ICUs between January 1, 2014, and January 1, 2016, who had been discharged home, either directly or via a medical ward. They used a retrospective, population-based, cohort design to compare characteristics of patients discharged directly from the ICU with those of patients who went home after spending time on the hospital ward.

Of 6732 eligible patients, 922 (14%) were discharged home directly from the ICU, while 5810 (86%) were discharged after a stay on the ward. Patients who went directly home were younger than those who spent time in the hospital (median age, 47 vs 57 years; P < .001) and were less likely to have comorbidities (39% vs 65%; P < .001). The patients discharged directly home also had a median Acute Physiologic and Chronic Assessment II score of 15, vs 18 among the other patients (P < .001), and were more likely to have received less than 48 hours of invasive mechanical ventilation (42%  vs 34%; P < .001).

The authors calculated propensity scores on 816 patients discharged directly home and a matching group of 816 patients discharged after a hospital stay.  In this comparison, "patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42), but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) than patients discharged home via the hospital ward," the authors write. Those patients also were significantly more likely to leave against medical advice and less likely to be prescribed community support services.

There were no significant differences between groups in the primary and secondary outcomes of the study. Specifically, the rate of hospital readmission 30 days after discharge was 10% among patients discharged home and 11% among patients discharged via the hospital ward (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.64 - 1.20). Rates of emergency department visits at 30 days also were similar between the groups at 25% and 26%, respectively (HR, 0.94; 95% CI, 0.81 - 1.09). The 1-year mortality rate was 4% for both groups (HR, 0.90; 95% CI, 0.60 - 1.35).

In addition, there were no significant difference between the groups when analyzed according to the most common ICU admission diagnoses, including overdose, seizures, withdrawal, metabolic coma, pneumonia, and other respiratory illnesses.

The authors did identify three factors associated with an increased risk for hospital readmission or emergency department visits within 30 days of discharge: leaving against medical advice, prescription of community supports, and discharge from an ICU that discharges at least one patient directly home each week. Because all of these factors are "associated with characteristics of the ICU or the discharge process," they recommend that ICU staff develop procedures to identify appropriate candidates for direct discharge and put systems and procedures in place to facilitate that process, including the training of ICU clinicians.

These findings provide "the strongest data yet reported, to our knowledge, for health care utilization and outcomes among patients discharged directly home from the ICU," they write. "The results suggest that select adult patients recovering from critical illness are being discharged directly home from the ICU and that, compared with similar patients discharged home via the hospital ward, no important differences in posthospital health care utilization or outcomes were observed."

The study was funded by a University of Calgary Clinical Research Fund Seed Grant.  Stelfox is supported by an Embedded Clinician Researcher award from the Canadian Institutes of Health Research. Coauthor Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology. The study authors and commentary authors have disclosed no relevant financial relationships.

JAMA Intern Med.  Published online August 21, 2018. Abstract, Editorial

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