Determinants of Direct Discharge Home From Critical Care Units: A Population-Based Cohort Analysis*

Abstract

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.

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

“…6 Stelfox et al noted the proportion of patients discharged directly home varied substantially across Canadian hospitals (range, 4.4%-44.0%) and was higher at non-teaching hospitals and those with fewer ICU and hospital beds. 5 Like Martin et al , 2 our results did not confirm these system-level effects; however, the relatively high proportion of MICU patients discharged directly home from our large teaching hospital further highlights that the direct discharge practice has grown to be commonplace and worthy of address as a distinct ICU process impacting resource utilization.…”

“…Several studies conducted under the Canadian universal healthcare system showed no increase in emergency room visits or rehospitalization after direct ICU discharges. 2,4,5 In 8-week follow-up, Lau et al also observed a 0% post-discharge mortality among patients discharged directly home after an ICU stay. 1 In contrast, the single U.S. study conducted in an oncologic ICU between 2008-2010 not only reported a far lower average annual rate of direct discharge at 4%, but also saw 23% of their discharges with unplanned readmission within 30 days.…”

“…The practice of discharging patients directly home from the intensive care unit (ICU) is becoming increasingly common, largely driven by decreased availability of floor beds as evidenced by transfer delays. 1 Although there has been growing interest in evaluating the characteristics and outcomes of these patients, 2 there is limited literature on the subject. 3 Recent studies from Canada have deemed this process to be safe by comparing outcomes for patients discharged directly home from the ICU to those discharged home via the hospital ward.…”

Assessment of Costs of Avoidable Delays in Intensive Care Unit Discharge

“… 9 The observed increased trend in avoidable time has translated into organizational changes that directly affect patient care, such as after-hours discharge and direct hospital discharge from the ICU. 7 , 8 , 25 , 26 In our study, 9.9% of patients were directly discharged home with an increasing trend evident during the study period, a process that was likely unplanned and often in response to lack of ward bed availability. 7 We submit that this may present opportunities to redesign and implement innovative care models, such as pathways to facilitate direct discharge to the community for carefully selected patients or to transition to temporary step-down units to enable timely discharge of suitable patients and preserve ICU capacity.…”

“… 5 , 6 Discharge delay may also be associated with unplanned after-hours discharge or direct discharge home from the ICU, a care process most ICUs are not traditionally prepared to manage. 1 , 7 , 8 …”