Direct Discharge to Home From the Pediatric Cardiovascular ICU

Abstract

To describe direct discharge to home from the cardiovascular ICU. DESIGN: Mixed-methods including retrospective Pediatric Cardiac Critical Care Consortium and Pediatric Acute Care Cardiology Collaborative data and survey. SETTING: Tertiary pediatric heart center.PATIENTS: Patients less than 25 years old, with a cardiovascular ICU stay of greater than 24 hours and direct discharge to home from January 1, 2016, to December 8, 2020, were included. Select data describing patients discharged from acute care internally and nationally from Pediatric Acute Care Cardiology Collaborative sites were compared with the direct discharge to home cohort. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:Encounter-and patient-specific characteristics. Seven-day and 30-day readmission and 30-day mortality served as surrogate safety markers. A survey of cardiovascular ICU frontline providers assessed comfort and skills related to direct discharge to home. There were 364 direct discharge to home encounters that met inclusion criteria. The majority of direct discharge to home encounters were associated with a surgery or procedure (305; 84%). There were 27 encounters (7.4%) for medical technology-dependent patients requiring direct discharge to home. Unplanned 7-day readmissions among direct discharge to home patients was 1.9% compared with 4.6% (p = 0.04) of patients discharged from acute care internally. Readmission among those discharged from acute care internally did not differ from those at Pediatric Acute Care Cardiology Collaborative sites nationally. Frontline cardiovascular ICU providers had mixed levels of confidence in technical aspects and low levels of confidence in logistics of direct discharge to home. CONCLUSIONS:Cardiovascular ICU direct discharge to home was not associated with increased unplanned readmissions compared with patients discharged from acute care and may be safe in select patients. Frontline cardiovascular ICU providers feel time constraints challenge direct discharge to home. Further research is needed to identify patient characteristics associated with safe direct discharge to home and systems needed to support this practice. Summary statistics are described using proportions or medians with interquartile ranges (IQRs) and were performed using Microsoft Excel (Microsoft, Redmond, WA). Two-sample tests of proportions were used to compare readmission frequency of the DDH cohort compared with internal and national PAC3 data using STATA Version 15 (StataCorp, College Station, TX). KEY WORDS: acute care cardiology unit; cardiovascular intensive care unit; direct discharge to home; discharge; readmission H istorically, patients admitted to ICUs have typically transferred to acute care prior to discharge home. However, direct discharge to home (DDH) from the ICU has been increasing, partly due to ward bed availability constraints resulting in transfer delays (1, 2). Additionally,

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

“…Our findings are generally consistent with other research in adult and pediatric cardiac critical care units. 11,13 Despite the frequency, there is a paucity of data about the risks and outcomes in pediatric patients undergoing DDH. To attempt to better define outcomes for this population, we measured hospital readmission rates.…”

“…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.…”

“…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.…”

“…A recent study of pediatric cardiac intensive care unit patients demonstrated no increased risk of unplanned readmission in this select pediatric population. 13 A 2020 investigation by Australian researchers showed that DDH is increasingly common and potentially related to 1 Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA 2 Duke University, Durham, NC, USA delays in discharge at their institution. 14 A 2023 review article on this topic highlighted the need for more research of this practice.…”

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“…An article (12) and editorial (13) on fluid overload, intravascular volume, and fluid removal in the perioperative pediatric cardiac surgery population. A mixed-methods, single-center PC4-registry dataset of outcomes in 364 patients discharged to home directly from the cardiac ICU (14).…”