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Discharging patients home from ICU poses no added risk

Direct discharge home from the ICU does not increase health care utilization or mortality, according to research published in JAMA Internal Medicine.

“The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown,” Henry T. Stelfox, MD, PhD, from University of Calgary, Alberta, and colleagues wrote.

Stelfox and colleagues performed a retrospective population-based cohort study to determine the health care utilization and clinical outcomes for patients discharged directly home from the ICU compared with those discharged home via the hospital ward.

The researchers enrolled 6,732 adult patients (median age, 56 years; 42% women) admitted to one of nine medical-surgical hospitals. Participants were followed for 1 year after hospital discharge.

Overall, 14% of participants were discharged directly home, while the rest went to the hospital ward, from which they were ultimately discharged. Direct discharges home from the ICU ranged significantly across hospitals from 4.4% to 44%.

Patients discharged directly home were more likely to be younger (median age, 47 vs. 57 years); to have been admitted to the hospital due to overdose, substance withdrawal, seizures or metabolic coma (32% vs. 10%); to have less severe acute illness on ICU admission (median APACHE II score, 15 vs. 18) and to have received less than 48 hours of invasive mechanical ventilation (42% vs. 34%) than those discharged home via hospital ward.

In the propensity score matched cohort (n = 1632), there were similar lengths of ICU stays among patients discharged directly home and those discharged home via the hospital ward (median, 3.1 days vs. 3 days); however, length of hospital stay was significantly shorter among those discharged directly home (median, 3.3 days vs. 9.2 days).

Readmission to the hospital (10% vs. 11%; HR = 0.88; 95% CI, 0.64-1.2) or ED visit (25% vs. 26%; HR = 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge did not significantly differ between the two groups. Risk factors for readmission to the hospital or ED visits included leaving against medical advice, lack of community supports and discharge from an ICU with high volumes of patients, according to the researchers.

The percentage of patients who died within 1 year of hospital discharge was the same in both groups (4%; HR = 0.9; 95% CI, 0.6-1.35).

“We recommend that ICUs develop discharge procedures that include identification of candidate patients for discharge directly home, develop protocols to facilitate the process, train ICU clinicians in these procedures, and measure outcomes,” Stelfox and colleagues concluded.

In an accompanying editorial, Kyan Safavi, MD, MBA, from Massachusetts General Hospital, and colleagues suggest that direct discharge from the ICU may help to reduce congestion both in the ICU and on the floors.

“It is important, however, that strategies are also pursued to ensure safe and timely discharge from the general care unit, and studies are needed to investigate the factors that are keeping patients on the wards beyond the time needed,” they wrote. – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.