The DDH rates have been increasing over time at our institution and were inversely correlated with ICU bed occupancy but were not associated with ward occupancy. The DDH patients are young, have few comorbidities on admission, and few discharge diagnoses, which are usually reversible single system problems with low disease burden. Transfers to the ward are delayed in a majority of cases, leading to increased ICU LOS and likely increased overall hospital LOS as well.

In the unconscious patient, there is a diagnostic void between the neurologic physical exam, and more invasive, costly and potentially harmful investigations. Transcranial color-coded sonography and two-dimensional transcranial Doppler imaging of the brain have the potential to be a middle ground to bridge this gap for certain diagnoses. With the increasing availability of point-of-care ultrasound devices, coupled with the need for rapid diagnosis of deteriorating neurologic patients, intensivists may be trained to perform point-of-care transcranial Doppler at the bedside. The feasibility and value of this technique in the intensive care unit to help rule-in specific intra-cranial pathologies will form the focus of this article. The proposed scope for point-of-care transcranial Doppler for the intensivist will be put forth and illustrated using four representative cases: presence of midline shift, vasospasm, raised intra-cranial pressure, and progression of cerebral circulatory arrest. We will review the technical details, including methods of image acquisition and interpretation. Common pitfalls and limitations of point-of-care transcranial Doppler will also be reviewed, as they must be understood for accurate diagnoses during interpretation, as well as the drawbacks and inadequacies of the modality in general.Electronic supplementary materialThe online version of this article (doi:10.1186/s13089-017-0077-9) contains supplementary material, which is available to authorized users.

Recruited discharged directly to home patients experienced very good 8-week postdischarge outcomes with 0% mortality and a low rate of ICU readmission (1%) or ward readmission (4%), but not an insignificant rate of emergency department visits (18%). Recruited discharged directly to home patients had better outcomes compared with nonrecruited discharged directly to home patients and patients transferred briefly to the ward prior to discharge home. Future work should include derivation of a clinical prediction tool to identify patient characteristics that make discharged directly to home safe and a randomized control trial to compare discharged directly to home with short stay ward transfers.

No abstract

OBJECTIVES: To compare health service use and clinical outcomes for patients with and without direct discharge to home (DDH) from ICUs in Ontario. DESIGN: Population-based, observational, cohort study using propensity scoring to match patients who were DDH to those not DDH and a preference-based instrumental variable (IV) analysis using ICU-level DDH rate as the IV. SETTING: ICUs in Ontario. PATIENTS: Patients discharged home from a hospitalization either directly or within 48 hours of care in an ICU between April 1, 2015, and March 31, 2017. INTERVENTION: DDH from ICU. MEASUREMENTS AND MAIN RESULTS: Among 76,737 patients in our cohort, 46,859 (61%) were DDH from the ICU. In the propensity matched cohort, the odds for our primary outcome of hospital readmission or emergency department (ED) visit within 30 days were not significantly different for patients DDH (odds ratio [OR], 1.00; 95% CI, 0.96–1.04), and there was no difference in mortality at 90 days for patients DDH (OR, 1.08; 95% CI, 0.97–1.21). The effect on hospital readmission or ED visits was similar in the subgroup of patients discharged from level 2 (OR, 0.98; 95% CI, 0.92–1.04) and level 3 ICUs (OR, 1.02; 95% CI, 0.96–1.09) and in the subgroups with cardiac conditions (OR, 1.03; 95% CI, 0.96–1.12) and noncardiac conditions (OR, 0.98; 95% CI, 0.94–1.03). Similar results were obtained in the IV analysis (coefficient for hospital readmission or ED visit within 30 d = –0.03 ± 0.03 (se); p = 0.3). CONCLUSIONS: There was no difference in outcomes for patients DDH compared with ward transfer prior to discharge when two approaches were used to minimize confounding within a large health systemwide observational cohort. We did not evaluate how patients are selected for DDH. Our results suggest that with careful patient selection, this practice might be feasible for routine implementation to ensure efficient and safe use of limited healthcare resources.

Purpose: To perform a narrative review of the literature regarding the discharge of patients directly to home (DDH) from the intensive care unit, and to identify patient characteristics and clinical outcomes associated with this practice. Methods: We searched MEDLINE and EMBASE from 1946 to present. We also manually searched the references of relevant articles. A two-step review process with three independent reviewers was used to identify relevant articles based on predetermined inclusion/exclusion criteria. Results: Four studies were included in the final review. Two studies were retrospective and two studies were prospective that shared data from the same patient cohort. All were single center studies. Two of the four studies outlined clinical outcomes associated with DDH. Conclusions: This study highlights the relative dearth in the literature regarding the increasingly common practice of DDH, underscores the importance of further studies in this area, and identifies future important foci of research.

Our observational data support intensivist-performed TEE as being safe and therapeutically influential across a broad range of indications. Our program's demonstrated feasibility and impact may act as a model for TEE adoption in other North American ICUs.

Objective: To describe trends and patient and system factors associated with direct discharge from critical care to home in a large health system. Design: Population-based cohort study of direct discharge to home rates annually over 10 years. We used a multivariable, multilevel random-effects regression model to analyze current factors associated with direct discharge home in a subcohort from the most recent 2 years. Setting: One hundred seventy-four ICUs in 101 hospitals in Ontario. Patients: All patients discharged from an ICU between April 1, 2007, and March 31, 2017. Interventions: None. Measurements and Main Results: Overall, 237,200 patients (21.1%) were discharged directly home from an ICU. The rate of direct discharge to home increased from 18.6% in 2007 to 23.1% in 2017 (annual increase of 1.02; 95% CI, 1.02–1.03). There were marked variations in rates of direct discharge to home across all critical care units. For medical and surgical units, the median odds ratio was 1.76 (95% CI, 1.59–1.92). In these units, direct discharge to home was associated with younger age (odds ratio, 0.36; 95% CI, 0.34–0.39 for age 80–105 vs age 18–39), fewer comorbidities (odds ratio, 1.74; 95% CI, 1.63–1.85 for Charlson comorbidity index of 0 vs 2), diagnoses of overdose/poisoning (odds ratio, 1.35; 95% CI, 1.23–1.47) and diabetic complications (odds ratio, 1.35; 95% CI, 1.2–1.51), and admission after a same-day procedure (odds ratio, 2.82; 95% CI, 2.46–3.23 compared with emergency department). ICU occupancy was inversely associated with direct discharge to home with an odds ratio of 0.88 (95% CI, 0.87–0.88) for each 10% increase. Conclusions: High rates of direct discharge to home with evidence of significant practice variation combined with identifiable patient characteristics suggest that further evaluation of this increasingly common transition in care is warranted.