Discharge Directly From ICU Not Linked to Increased Health Care Use or Mortality

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Patients discharged home directly from the ICU were younger in age, less likely to have comorbidities, and less likely to have been admitted to the ICU from the operating or recovery room.
Patients discharged home directly from the ICU were younger in age, less likely to have comorbidities, and less likely to have been admitted to the ICU from the operating or recovery room.

Discharging patients directly home from an intensive care unit (ICU) compared with discharge home from a hospital ward is not associated with increased patient hospital care utilization or mortality, according to a study published in JAMA Internal Medicine.

A group of researchers conducted a population-based, retrospective cohort study to analyze the characteristics, healthcare utilization patterns, and outcomes of ICU patients recovering from critical illnesses. All patients were aged ≥18 years and admitted to medical-surgical ICUs in various hospitals across Canada. Patients discharged directly from an ICU (n= 922) were compared with patients transferred to a hospital ward after ICU followed by discharge (n=5,810).

Data were obtained from 3 Canadian databases; patient factors included demographic variables, comorbidities, ICU admission diagnosis, illness severity upon admission and discharge, interventions received in the ICU, and external support prescribed at discharge. Hospitals included in the study were identified based on teaching status, number of hospital and ICU beds, number of patients discharged directly home, ICU occupancy, and transfer delay.  

The primary outcome was defined as hospital admission within 30 days of discharge. Secondary outcomes included emergency department visits within 30 days and death at 365 days.

More patients were discharged directly home from at ICU at hospitals that were nonteaching and had fewer ICU and hospital beds. These patients were also younger (median age, 47 vs 57 years), less likely to have comorbidities (39% [n=360] vs 65% [n=3774]), less likely to have been admitted to the ICU from the operating or recovery room (11% [n=98] vs 29% [n=1,669]), and less acutely ill in the first 24 hours in the ICU (median APACHE II score 15 vs 18) compared with patients discharged home via the hospital ward. Illnesses most frequently seen in ICU patients discharged directly home included overdose (23%; n=208), pneumonia (11%; n=104), and trauma or orthopedic injuries (9%; n=79).

Patients discharged directly home were more likely to leave against medical advice (6%, [n=45] vs 4% [n=31]) and less likely to be prescribed external support services (6% [n=52] vs 16% [n=131]) compared with patients discharged via the hospital ward.

A total of 10% of patients discharged directly home (n = 81) were readmitted to the hospital after 30 days compared with 11% of patients discharged home via the hospital ward (n = 92) (hazard ratio [HR], 0.88). Approximately 25% of patients in both groups had an emergency department visit within 30 days of hospital discharge (HR, 0.94). A total of 4% [n=31] of patients sent directly home vs 4% [n=34] discharged home via hospital ward died within 1 year of discharge (HR, 0.90).

“In summary, we found that the discharge of select adult patients recovering from critical illness directly home from the ICU is common, associated with shorter hospital stays, but not associated with increased health care utilization or mortality in the year following hospital discharge,” the authors concluded.

Reference

Stelfox HT, Soo A, Niven DJ, et al. Assessment of the safety of discharging select patients directly home from the intensive care unit: a multicenter population-based cohort study [published online August 20, 2018]. JAMA Intern Med. doi:10.1001/jamainternmed.2018.3675

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