Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit

Abstract

IMPORTANCE The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown.OBJECTIVE To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward. DESIGN, SETTING, AND PARTICIPANTSRetrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics.EXPOSURES Patient disposition on discharge from the ICU: directly home vs home via the hospital ward. MAIN OUTCOMES AND MEASURESThe primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year. RESULTS Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), 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) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35). CONCLUSIONS AND RELEVANCEThe 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.

Subarachnoid Hemorrhage “Fast Track”: A Health Economics and Health Care Redesign Approach for Early Selected Hospital Discharge

“…We realize that not all patients with SAH are eligible for the fast-track strategy; however, even using our conservative estimate of 18.0% of 30,000 SAH cases nationally, and applying similar ICU LOS cost savings ($3000/ d), 8 days saved would equate to a $158,400,000 cost savings for the SAH patients in the US health care system. Recently, Stelfox et al 18 reported similar ICU discharge to home safety and feasibility among a large cohort of 6732 ICU patients in a multicenter Canadian ICU system. They reported discharge from the ICU to home in 922 patients (13.7%) that was feasible and relatively safe for general medical conditions, with similar readmission rates.…”

“…They reported discharge from the ICU to home in 922 patients (13.7%) that was feasible and relatively safe for general medical conditions, with similar readmission rates. 18 Our center is currently exploring a multicenter comparative effectiveness study to scale this model to other hospitals using similar inclusion and safety monitoring criteria to validate our preliminary data. In the future, we are also considering creation of an "UltraeFast-Track" SAH model with a potential discharge time of less than 7 days by using the same care process but focused on individualizing or using precision medicine for those patients with low mFS (1-2), who are at even lower risk for DCI and vasospasm and have no cerebrospinal fluid diversion requirements.…”

Association between delirium in the intensive care unit and subsequent neuropsychiatric disorders

“…We used clinical and administrative databases from Alberta Health Services and Alberta Health (Discharge Abstracts Database [DAD], National Ambulatory Care Reporting System [NACRS], Physician Claims, Vital Statistics, and eCritical Tracer Database), previously successfully used in research studies [24,25]. eCritical Tracer is a bedside electronic medical record that prospectively captures demographic, clinical, and patient outcomes for all patients admitted to an Alberta ICU [26]…”

Association between Afterhours Discharge from the Intensive Care Unit and Hospital Mortality: A Multi-Centre Retrospective Cohort Study

“…16 For patients with multiple ICU admissions, only the rst admission was analyzed. The included ICUs were nine mixed medical/surgical units with a median [IQR] of 24 [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] beds. Two units were classi ed as academic/quaternary, two were academic/tertiary units, and ve were community/metropolitan units ( Table 1).…”

“…The eCritical Alberta system provides high-quality data due to rigorous data quality assurance and auditing processes and has been used by our team previously in health services research. 4,[18][19][20][21] There were no missing data elements for our primary exposure and outcome (afterhours discharge and hospital mortality, respectively). Missing data for individual variables were <3% and were not replaced or imputed.…”