Characteristics and Outcomes of Patients Discharged Directly Home From a Medical Intensive Care Unit: A Retrospective Cohort Study

Patel, Preeyal M.; Fiorella, Michele; Zheng, Ann; McDonnell, Lauren; Yasuoka, Mina; Yoo, Erika J.

doi:10.1177/0885066620960637

Cited by 4 publications

(5 citation statements)

References 12 publications

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“…DDH occurred for 19% of PICU admissions during the study period, which is consistent with published reports of 4% to 44% of patients undergoing DDH. 18,19 This represents a significant percentage and indicates that this is an important practice to investigate and better understand. The population of patients that experience DDH is demographically similar to patients who are transferred to the ward before discharge.…”

Section: Discussionmentioning

confidence: 99%

“…Though this approach is utilized in other studies safety would be better determined with long-term morbidity and mortality data that we did not have access to for this study. 13,18,19 Determination of severity of illness is also limited in this retrospective cohort study. Use of vasoactive infusion and new mechanical ventilation were used as surrogate markers of severity of illness but data on different acuity scoring systems (such as PRISM III or PIM3) were not available.…”

Section: Discussionmentioning

confidence: 99%

“…This outcome variable is similar to other studies previously reported on in the pediatric and adult literature. 11,13,18,19 To assess outcomes based on individual patients as opposed to individual admissions, we additionally performed this analysis only utilizing the first admission to the PICU per patient in the study period. We also repeated the analysis after removing patients discharged home with a ventilator, as these patients can have technology dependence best suited for care in an ICU.…”

Section: Methodsmentioning

confidence: 99%

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Characteristics and Outcomes of Patients Discharged Directly Home From the Pediatric Intensive Care Unit

Pizzuto

Sutton

et al. 2023

J Intensive Care Med

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Introduction: Patients admitted to the pediatric intensive care unit (PICU) typically transfer to an acute care floor prior to discharge (ACD). Various circumstances, including rapid clinical improvement, technology dependence, or capacity constraints, may lead to discharge directly to home from a PICU (DDH). This practice has been studied in adult intensive care units, but research is lacking for PICU patients. Methods: We aimed to describe characteristics and outcomes of patients requiring PICU admission who experienced DDH versus ACD. We conducted a retrospective cohort study of patients ≤18 years old admitted to our academic, tertiary care PICU between 1/1/15 and 12/31/20. Patients who died or were transferred to another facility were excluded. Baseline characteristics (including home ventilator dependence) and markers of illness severity, specifically the need for vasoactive infusion or new mechanical ventilation, were compared between groups. Admission diagnoses were categorized using the Pediatric Clinical Classification System (PECCS). Our primary outcome was hospital readmission within 30 days. Results: Of 4042 PICU admissions during the study period, 768 (19%) were DDH. Baseline demographic characteristics were similar, although DDH patients were more likely to have a tracheostomy (30% vs 5%, P < .01) and require a home ventilator at discharge (24% vs 1%, P < .01). DDH was associated with being less likely to have required a vasoactive infusion (7% vs 11%, P < .01), shorter median length of stay (LOS) (2.1 days vs 5.9 days, P < .01) and increased rate of readmission within 30 days of discharge (17% vs 14%, P < .05). However, repeat analysis after removing ventilator-dependent patients at discharge (n = 202) showed no difference in rates of readmission (14% vs 14%, P = .88). Conclusions: Direct discharge home from the PICU is a common practice. DDH and ACD groups had similar 30-day readmission rate when patient admissions with home ventilator dependence were excluded.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Characteristics and Outcomes of Patients Discharged Directly Home From the Pediatric Intensive Care Unit

Pizzuto

Sutton

et al. 2023

J Intensive Care Med

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“…However, what is still unclear is which patients are best suited for safe DDH from ICU (1–6) and which patients need further outpatient interventions from the healthcare system prior to discharge (1–3). Although different from typical ICU admissions (e.g., sepsis and respiratory failure), overdose, seizures, and diabetic ketoacidosis are the most common reasons of ICU admission in DDH patients (1–5), which is evidenced in other jurisdictions outside of Canada as well (e.g., United Kingdom [17] and United States [29]). These patients still have ICU-level care needs, as evidence by nursing man power scores (1).…”

Section: Discussionmentioning

confidence: 99%

Safety Outcomes of Direct Discharge Home From ICUs: An Updated Systematic Review and Meta-Analysis (Direct From ICU Sent Home Study)*

Lau

Donnelly

Parvez

et al. 2022

Critical Care Medicine

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To evaluate the impact of direct discharge home (DDH) from ICUs compared with ward transfer on safety outcomes of readmissions, emergency department (ED) visits, and mortality. DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature from inception until March 28, 2022. STUDY SELECTION: Randomized and nonrandomized studies of DDH patients compared with ward transfer were eligible. DATA EXTRACTION:We screened and extracted studies independently and in duplicate. We assessed risk of bias using the Newcastle-Ottawa Scale for observational studies. A random-effects meta-analysis model and heterogeneity assessment was performed using pooled data (inverse variance) for propensity-matched and unadjusted cohorts. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach.DATA SYNTHESIS: Of 10,228 citations identified, we included six studies. Of these, three high-quality studies, which enrolled 49,376 patients in propensitymatched cohorts, could be pooled using meta-analysis. For DDH from ICU, compared with ward transfers, there was no difference in the risk of ED visits at 30-day (22.4% vs 22.7%; relative risk [RR], 0.99; 95% CI, 0.95-1.02; p = 0.39; low certainty); hospital readmissions at 30-day (9.8% vs 9.6%; RR, 1.02; 95% CI, 0.91-1.15; p = 0.71; very low-to-low certainty); or 90-day mortality (2.8% vs 2.6%; RR, 1.06; 95% CI, 0.95-1.18; p = 0.29; very low-to-low certainty). There were no important differences in the unmatched cohorts or across subgroup analyses. CONCLUSIONS:Very low-to-low certainty evidence from observational studies suggests that DDH from ICU may have no difference in safety outcomes compared with ward transfer of selected ICU patients. In the future, this research question could be further examined by randomized control trials to provide higher certainty data.

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“…11 In prior studies of large integrated healthcare systems, the practice of directly discharging patients home from the ICU appears to be safe, without an associated increase in emergency department (ED) visits, hospital readmissions, and deaths within 30 days. 1,3,6,12 However, only one prior study had evaluated longer-term outcomes (ie, 90-day and 365-day outcomes). 1 Compared to other Canadian provinces, Saskatchewan has a large (>35%) rural population.…”

Section: Introductionmentioning

confidence: 99%

Long-term Safety of Directly Discharging Patients Home from the ICU Compared to Ward Transfer

Gupta

Shahab

et al. 2022

J Intensive Care Med

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Purpose: To evaluate the long-term safety of directly discharging intensive care unit (ICU) survivors to their home. Methods: A retrospective observational cohort of 341 ICU survivors who were directly discharged home from the ICU (“direct discharge”) or discharged home ≤72 hours after ICU transfer to the ward (“ward transfer”) was conducted in Regina, Saskatchewan ICUs between September 1, 2016 and September 30, 2018. The primary outcome was 90-day hospital readmission. Secondary outcomes included 30-day, 90-day, and 365-day emergency department (ED) visits, 30-day and 365-day hospital readmissions, and 365-day mortality. All outcomes were evaluated by multivariable Cox regression after adjustment for demographic and clinical characteristics. Results: Of 341 survivors (25.5% of total ICU visits), 148 (43.4%) patients were direct discharges and 193 (56.6%) were ward transfers. The median age was 46 years (interquartile range, 34-62), 38.4% were female, and 61.8% resided in Regina. Compared to the ward transfer cohort, more patients in the direct discharge cohort had at least one 90-day hospital readmission (30.4% versus 17.1% of patients, adjusted hazard ratio 2.09, 95% confidence interval 1.28-3.40, P = .003), after adjustment. Additionally, there were more 90-day ED visits ( P = .045), and 30-day ( P = .049) and 365-day hospital readmissions ( P = .03), after adjustment. Conclusions: In Saskatchewan, direct discharge compared to ward transfer was associated with an increase in 90-day hospital readmissions, and potentially other clinical outcomes. Further study is necessary.

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Characteristics and Outcomes of Patients Discharged Directly Home From a Medical Intensive Care Unit: A Retrospective Cohort Study

Cited by 4 publications

References 12 publications

Characteristics and Outcomes of Patients Discharged Directly Home From the Pediatric Intensive Care Unit

Characteristics and Outcomes of Patients Discharged Directly Home From the Pediatric Intensive Care Unit

Safety Outcomes of Direct Discharge Home From ICUs: An Updated Systematic Review and Meta-Analysis (Direct From ICU Sent Home Study)*

Long-term Safety of Directly Discharging Patients Home from the ICU Compared to Ward Transfer

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