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Hassan EM, Jama AB, Sharaf A, Shaikh A, El Labban M, Surani S, Khan SA. Discharging patients home from the intensive care unit: A new trend. World J Clin Cases 2024; 12:5313-5319. [PMID: 39156093 PMCID: PMC11238692 DOI: 10.12998/wjcc.v12.i23.5313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 06/07/2024] [Accepted: 06/28/2024] [Indexed: 07/05/2024] Open
Abstract
Discharging patients directly to home from the intensive care unit (ICU) is becoming a new trend. This review examines the feasibility, benefits, challenges, and considerations of directly discharging ICU patients. By analyzing available evidence and healthcare professionals' experiences, the review explores the potential impacts on patient outcomes and healthcare systems. The practice of direct discharge from the ICU presents both opportunities and complexities. While it can potentially reduce costs, enhance patient comfort, and mitigate complications linked to extended hospitalization, it necessitates meticulous patient selection and robust post-discharge support mechanisms. Implementing this strategy successfully mandates the availability of home-based care services and a careful assessment of the patient's readiness for the transition. Through critical evaluation of existing literature, this review underscores the significance of tailored patient selection criteria and comprehensive post-discharge support systems to ensure patient safety and optimal recovery. The insights provided contribute evidence-based recommendations for refining the direct discharge approach, fostering improved patient outcomes, heightened satisfaction, and streamlined healthcare processes. Ultimately, the review seeks to balance patient-centered care and effective resource utilization within ICU discharge strategies.
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Affiliation(s)
- Esraa M Hassan
- Department of Critical Care Medicine, Mayo Clinic Health system, Mankato, MN 56001, United States
| | - Abbas B Jama
- Department of Critical Care Medicine, Mayo Clinic Health system, Mankato, MN 56001, United States
| | - Ahmed Sharaf
- Department of Internal Medicine, Baptist Hospital of Southeast Texas, Beaumont, TX 77701, United States
| | - Asim Shaikh
- Department of Medicine, Aga Khan University, Karachi 74200, Sindh, Pakistan
| | - Mohamad El Labban
- Department of Internal Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Department of Medicine and Pharmacology, Texas A&M University, College Station, TX 77843, United States
- Department of Anaesthesiology, Mayo Clinic Health System, Rochester, MN 55905, United States
| | - Syed A Khan
- Department of Critical Care Medicine, Mayo Clinic Health system, Mankato, MN 56001, United States
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Leung C, Andersen CR, Wilson K, Nortje N, George M, Flowers C, Bruera E, Hui D. The impact of a multidisciplinary goals-of-care program on unplanned readmission rates at a comprehensive cancer center. Support Care Cancer 2023; 32:66. [PMID: 38150077 PMCID: PMC11391928 DOI: 10.1007/s00520-023-08265-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/17/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE This study examined the 30-day unplanned readmission rate in the medical oncology population before and after the implementation of an institution-wide multicomponent interdisciplinary goals of care (myGOC) program. METHODS This retrospective study compared the 30-day unplanned readmission rates in consecutive medical patients during the pre-implementation period (May 1, 2019, to December 31, 2019) and the post-implementation period (May 1, 2020, to December 31, 2020). Secondary outcomes included 7-day unplanned readmission rates, inpatient do-not-resuscitate (DNR) orders, and palliative care consults. We randomly selected a hospitalization encounter for each unique patient during each study period for statistical analysis. A multivariate analysis model was used to examine the association between 30-day unplanned readmission rates and implementation of the myGOC program. RESULTS There were 7028 and 5982 unique medical patients during the pre- and post-implementation period, respectively. The overall 30-day unplanned readmission rate decreased from 24.0 to 21.3% after implementation of the myGOC program. After adjusting for covariates, the myGOC program implementation remained significantly associated with a reduction in 30-day unplanned readmission rates (OR [95% CI] 0.85 [0.77, 0.95], p = 0.003). Other factors significantly associated with a decreased likelihood of a 30-day unplanned readmission were an inpatient DNR order, advanced care planning documentation, and an emergent admission type. We also observed a significant decrease in 7-day unplanned readmission rates (OR [95% CI] 0.75 [0.64, 0.89]) after implementation of the myGOC program. CONCLUSION The 30-day and 7-day unplanned readmission rates decreased in our hospital after implementation of a system-wide multicomponent GOC intervention.
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Affiliation(s)
- Cerena Leung
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Clark R Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kaycee Wilson
- Department of Inpatient Analytics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nico Nortje
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina George
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher Flowers
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Roumeliotis N, Desforges J, French ME, Dupre-Roussel J, Fiest KM, Lau VI, Lacroix J, Carnevale FA. Patient and Family Experience With Discharge Directly Home From the Pediatric ICU. Hosp Pediatr 2023; 13:954-960. [PMID: 37667850 DOI: 10.1542/hpeds.2023-007332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
BACKGROUND Children are increasingly discharged directly from the PICU. Transitions have been recognized as a period of increased patient and caregiver stress and risk of adverse events. No study has evaluated patient and caregiver outcomes after direct discharge from the PICU. This study aimed to explore the family's experiences with discharge directly home (DDH) from the PICU. METHODS This exploratory mixed-methods study was conducted in the PICU of the Institution is Sainte-Justine Hospital from February to July 2021. We included families of children expected to be DDH within 12 hours. Semistructured interviews were conducted at discharge, followed by telephone interviews 7 and 28 days post-PICU discharge. We measured comfort on a 5-point Likert scale and screened for anxiety using the Generalized Anxiety Disorder-7 tool. RESULTS Families of 25 patients were interviewed. Thematic analysis of the interviews revealed several themes, such as feeling stress and anxiety, feeling confident, anticipating home care, and needing support. These findings complemented the quantitative findings; the median comfort score was 4 (comfortable) (interquartile range 4-5) and 8 (interquartile range 4-12) for the Generalized Anxiety Disorder-7 on the day of discharge, with 16 reporting clinically significant anxiety. In the 28-day study period, 2 patients were readmitted and 6 had visited the emergency department. CONCLUSIONS Despite feelings of anxiety, many families felt comfortable with DDH from the PICU. Increasing our understanding of the patient and family experiences of discharge from the PICU will help to better support these patients and their families during transition.
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Affiliation(s)
| | | | | | | | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Jacques Lacroix
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Franco A Carnevale
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
- Pediatric ICU, Montreal Children's Hospital, Montreal, Quebec, Canada
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Safety Outcomes of Direct Discharge Home From ICUs: An Updated Systematic Review and Meta-Analysis (Direct From ICU Sent Home Study). Crit Care Med 2023; 51:127-135. [PMID: 36519986 PMCID: PMC9750104 DOI: 10.1097/ccm.0000000000005720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE 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 propensity-matched 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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Roumeliotis N, Hassine CH, Ducruet T, Lacroix J. Discharge Directly Home From the PICU: A Retrospective Cohort Study. Pediatr Crit Care Med 2023; 24:e9-e19. [PMID: 36053070 DOI: 10.1097/pcc.0000000000003061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Healthcare constraints with decreasing bed availability cause strain in acute care units, and patients are more frequently being discharged directly home. Our objective was to describe the population, predictors, and explore PICU readmission rates of patients discharged directly home from PICU, compared with those discharge to the hospital ward, then home. DESIGN An observational cohort study. SETTING Children admitted to the PICU of CHU Sainte-Justine, between January 2014 and 2020. PATIENTS Patients less than 18 years old, who survived their PICU stay, and were discharged directly home or to an inpatient ward. Patients discharged directly home were compared with patients discharged to the ward using descriptive statistics. Logistic regression was used to identify factors associated with home discharge. Propensity scores were used to compare PICU readmission rates in patients discharged directly home to those discharged to the ward. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among the 5,531 admissions included, 594 (10.7%) were discharged directly home from the PICU. Patients who were more severe ill (odds ratio [OR], 0.93; 95% CI, 0.90-0.97), had invasive ventilation (OR, 0.70; 95% CI, 0.53-0.92), or had vasoactive agents (OR, 0.70; 95% CI, 0.53-0.92) were less likely to be discharged directly home. Diagnoses associated with discharge directly home were acute intoxication, postoperative ear-nose-throat care, and shock states. There was no difference in the rate of readmission to PICU at 2 (relative risk [RR], 0.20 [95% CI, 0.02-1.71]) and 28 days (RR, 1.20 [95% CI, 0.61-3.36]) between propensity matched patients discharged to the ward for 2 or less days, compared with those discharged directly home. CONCLUSION Discharge directly home from the PICU is increasing locally. The population includes less severely ill patients with rapidly resolving diagnoses. Rates of PICU readmission between patients discharged directly home from the PICU versus to ward are similar, but safety of the practice requires ongoing evaluation.
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Affiliation(s)
- Nadia Roumeliotis
- Division of Critical care Medicine, Department of Pediatrics CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
- CHU Sainte-Justine Research Center, Université de Montréal, Montréal, QC, Canada
| | - Chatila Hadj Hassine
- Division of Critical care Medicine, Department of Pediatrics CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Thierry Ducruet
- Unité de Recherche Clinique Appliqué (URCA), Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Jacques Lacroix
- Division of Critical care Medicine, Department of Pediatrics CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
- CHU Sainte-Justine Research Center, Université de Montréal, Montréal, QC, Canada
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Patel PM, Fiorella MA, Zheng A, McDonnell L, Yasuoka M, Yoo EJ. Characteristics and Outcomes of Patients Discharged Directly Home From a Medical Intensive Care Unit: A Retrospective Cohort Study. J Intensive Care Med 2020; 36:1431-1435. [PMID: 32954949 DOI: 10.1177/0885066620960637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the safety of directly discharging patients home from the medical intensive care unit (MICU). MATERIALS AND METHODS Single-center retrospective observational study of consecutive MICU direct discharges to home from an urban university hospital between June, 1, 2017, and June 30, 2019. RESULTS Of 1061 MICU discharges, 331 (31.2%) patients were eligible for analysis. Patients were divided into 2 groups based on duration of wait-time (< or ≥24 hours) between ward transfer order and ultimate hospital discharge. Most patients (68.2%) were discharged in <24 hours. Patients who waited for a floor bed for ≥24 hours prior to discharge had longer hospital length-of-stay (LOS, median 3.83 versus 2.00 days) and ICU LOS (median 3.51 versus 1.74 days). Overall, 44 (13.3%) direct MICU discharges were readmitted to the hospital within 30-days, but there was no difference in this outcome or in 30-day mortality when comparing the 2 wait-time groups. CONCLUSIONS The practice of directly discharging MICU patients home does not negatively influence patient outcomes. Patients who overstay in the ICU after being deemed transfer-ready are unlikely to be benefiting from critical care, but impact hospital throughput and resource utilization. Prospective investigation into this practice may provide further confirmation of its feasibility and safety.
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Affiliation(s)
- Preeyal M Patel
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michele A Fiorella
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ann Zheng
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lauren McDonnell
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mina Yasuoka
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Erika J Yoo
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Factors Affecting Discharge to Home of Medical Patients Treated in an Intensive Care Unit. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16224324. [PMID: 31698814 PMCID: PMC6887772 DOI: 10.3390/ijerph16224324] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/02/2019] [Accepted: 11/05/2019] [Indexed: 12/20/2022]
Abstract
The purpose of this study was to examine the factors affecting the discharge to home of medical patients treated in an intensive care unit, including elements of in-hospital rehabilitation and prehospital movement ability. The participants of this retrospective cohort study were medical patients treated in an intensive care unit (ICU) and who began rehabilitation in ICU. We assessed the participants in the ICU and analyzed data on patient background, hospitalization, and rehabilitation status. There were 155 ICU patients available for analysis. A multivariable logistic regression model identified the four variables of age (OR 1.06, 95% CI 1.02–1.09), APACHE II score (OR 1.12, 95% CI 1.04–1.24), independence in home life before admission (OR 7.10, 95% CI 1.65–30.44), and standing within 5 days of admission (OR 6.58, 95% CI 2.60–16.61) as factors significantly related to discharge from hospital to home. Independence of home life before admission and early start of standing were identified as factors strongly related to discharge to home. The degree of independence in living before hospital admission and progress toward early mobilization are helpful when considering an ICU patient’s discharge destination.
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Survival and Safety Outcomes of ICU Patients Discharged Directly Home-A Direct From ICU Sent Home Study. Crit Care Med 2019; 46:900-906. [PMID: 29494475 DOI: 10.1097/ccm.0000000000003074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Evaluate outcomes (mortality, morbidity, unplanned return visits) of patients who are discharged directly to home from the ICU. DESIGN Prospective cohort study. SETTING Two tertiary care medical-surgical-trauma ICUs at Canadian hospitals over 1 year (February 2016-2017). SUBJECTS All adult patients who were either discharged directly to home (Recruited and Nonrecruited cohorts) from ICU or discharged home within 24 hours after ward transfer (Ward Transfer cohort). INTERVENTIONS Direct discharge home from ICU or discharge home within 24 hours of ward transfer from ICU. MEASUREMENTS AND MAIN RESULTS One-hundred ninety-eight patients were in the study, 100 patients in the discharged directly to home Recruited arm, 37 patients in the discharged directly to home Nonrecruited arm, and 61 patients in the Ward cohort. All three patient cohorts had 0% mortality at 8 weeks post discharge. The unplanned return visit rate for the Recruited cohort was 24% (emergency department 18%, Ward 4%, ICU 1%), whereas the rate for the Nonrecruited cohort was 52% (emergency department 34%, Ward 14%, ICU 3%) and the Ward Transfer cohort was 46% (emergency department 17%, Ward 26%, ICU 3%) (p = 0.005). No home support was available for 7% of the discharged directly to home Recruited cohort. Twenty-four percent of patients had funded home care nursing, but the majority of patients (81%) relied on help from friends/family. CONCLUSIONS Recruited discharged directly to home patients experienced very good 8-week postdischarge outcomes with 0% mortality and a low rate of ICU readmission (1%) or ward readmission (4%), but not an insignificant rate of emergency department visits (18%). Recruited discharged directly to home patients had better outcomes compared with nonrecruited discharged directly to home patients and patients transferred briefly to the ward prior to discharge home. Future work should include derivation of a clinical prediction tool to identify patient characteristics that make discharged directly to home safe and a randomized control trial to compare discharged directly to home with short stay ward transfers.
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Look Homeward, Intensivist. Crit Care Med 2019; 46:1015-1016. [PMID: 29762403 DOI: 10.1097/ccm.0000000000003140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lau VI, Priestap F, Lam JNH, Basmaji J, Ball IM. Clinical Predictors for Unsafe Direct Discharge Home Patients From Intensive Care Units. J Intensive Care Med 2018; 35:1067-1073. [PMID: 30477391 DOI: 10.1177/0885066618811810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To describe factors (demographics and clinical characteristics) that predict patients who are at an increased risk of adverse events or unplanned return visits to a health-care facility following discharge direct to home (DDH) from intensive care units (ICUs). METHODS Prospective cohort study of all adult patients who survived their stay in our medical-surgical-trauma ICU between February 2016 and 2017 and were discharged directly home. Patients were followed for 8 weeks postdischarge. Univariable and multivariable logistic regression analyses were performed to identify factors associated with adverse events or unplanned return visits to a health-care facility following DDH from ICU. RESULTS A total of 129 DDH patients were enrolled and completed the 8-week follow-up. We identified 39 unplanned return visits (URVs). There was 0% mortality at 8 weeks postdischarge. Eight potential predictors of hospital URVs (P < .2) were identified in the univariable analysis: prior substance abuse (odds ratio [OR] of URV of 2.50 [95% confidence interval: 1.08-5.80], hepatitis (OR: 6.92 [1.68-28.48]), sepsis (OR: 11.03 [1.19-102.29]), admission nine equivalents of nursing manpower score (NEMS) <24 (OR: 2.28 [1.03-5.04], no fixed address (OR: 22.9 [1.2-437.3]), ICU length of stay (LOS) <2 days (OR: 2.95 [1.28-6.78]), home discharge within London, Ontario (OR: 2.44 [1.00-5.92]), and left against medical advice (AMA; OR: 6.06 [2.04-17.98]). CONCLUSIONS Our study identified 8 covariates that were potential predictors of URV: prior substance abuse, hepatitis, sepsis, admission NEMS <24, no fixed address, ICU LOS <2 days, home discharge within London, Ontario, and left AMA. The practice of direct discharges home from the ICU would benefit from adequately powered multicenter study in order to construct a clinical prediction model (that would require further testing and validation).
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Affiliation(s)
- Vincent Issac Lau
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Fran Priestap
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Joyce N H Lam
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - John Basmaji
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ian M Ball
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Stelfox HT, Soo A, Niven DJ, Fiest KM, Wunsch H, Rowan KM, Bagshaw SM. Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit: A Multicenter Population-Based Cohort Study. JAMA Intern Med 2018; 178:1390-1399. [PMID: 30128550 PMCID: PMC6584269 DOI: 10.1001/jamainternmed.2018.3675] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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 PARTICIPANTS Retrospective 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 MEASURES The 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 RELEVANCE The 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.
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Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesia and Interdisciplinary Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, England
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
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12
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Basmaji J, Lau V, Lam J, Priestap F, Ball IM. Lessons learned and new directions regarding Discharge Direct from Adult Intensive Care Units Sent Home (DISH): A narrative review. J Intensive Care Soc 2018; 20:165-170. [PMID: 31037110 DOI: 10.1177/1751143718794123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose To perform a narrative review of the literature regarding the discharge of patients directly to home (DDH) from the intensive care unit, and to identify patient characteristics and clinical outcomes associated with this practice. Methods We searched MEDLINE and EMBASE from 1946 to present. We also manually searched the references of relevant articles. A two-step review process with three independent reviewers was used to identify relevant articles based on predetermined inclusion/exclusion criteria. Results Four studies were included in the final review. Two studies were retrospective and two studies were prospective that shared data from the same patient cohort. All were single center studies. Two of the four studies outlined clinical outcomes associated with DDH. Conclusions This study highlights the relative dearth in the literature regarding the increasingly common practice of DDH, underscores the importance of further studies in this area, and identifies future important foci of research.
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Affiliation(s)
- John Basmaji
- Department of Medicine, Western University, London, ON, Canada
| | - Vincent Lau
- Department of Medicine, Western University, London, ON, Canada
| | - Joyce Lam
- Department of Medicine, Western University, London, ON, Canada
| | - Fran Priestap
- Department of Medicine, Western University, London, ON, Canada
| | - Ian M Ball
- Department of Medicine, Western University, London, ON, Canada
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Abstract
OBJECTIVES This article focuses on compassionate discharge from an ICU setting for pediatric patients. DATA SOURCES Not Applicable. STUDY SELECTION Not Applicable. DATA EXTRACTION Not Applicable. DATA SYNTHESIS The rationale for compassionate discharge is described, along with suggestions for assessing feasibility. A patient case highlights the potential benefits of and provides specific examples of steps involved in the process. A general framework for consideration of compassionate discharge, along with a checklist, is provided to highlight the importance of detailed planning and communication. CONCLUSIONS Although many children die in an ICU setting, some families desire end-of-life care in a nonhospital setting, often at home. For children dependent on technology, there are considerable logistical challenges to overcome, and it may not always be possible. However, with meticulous planning and close collaboration between intensive care staff, palliative care staff, and other community services, compassionate discharge can be done successfully and provide the child and family the opportunity for end-of-life care in the place most meaningful to them.
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Lam JNH, Lau VI, Priestap FA, Basmaji J, Ball IM. Patient, Family, and Physician Satisfaction With Planning for Direct Discharge to Home From Intensive Care Units: Direct From ICU Sent Home Study. J Intensive Care Med 2017; 35:82-90. [DOI: 10.1177/0885066617731263] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: In the new era of decreasing hospital bed availability, there is an increasing rate of direct discharge to home (DDH) from intensive care units (ICUs), despite sparse literature informing this practice. Objectives: To evaluate patient, family, and ICU attending physician satisfaction with planning for DDH from the ICU and intensivists’ current DDH practices and perceptions. Methods: Prospective cohort study, using convenience sampling, of adult patients undergoing DDH from an ICU between February 2016 and February 2017 using a modified FS-ICU 24 satisfaction survey completed by patients, family members, and attending physicians at the time of patient discharge to home from the ICU. Results: Seventy-two percent of patients, 37% of family members, and 100% of ICU physicians recruited completed the survey. A majority of patients (89%) and families (78%) were satisfied or very satisfied with DDH. Only 6% of patients and 8% of families were dissatisfied to very dissatisfied with DDH. Conversely, ICU physician satisfaction varied, with only 5% being very comfortable with DDH and the majority (50%) only somewhat comfortable. Twenty percent of staff consultants were uncomfortable to very uncomfortable with the practice of DDH. Thirty-one percent of staff physician respondents felt that patient and family discomfort would be barriers to DDH. Compared to physicians and other allied health professionals, nurses were identified as the most helpful members of the health-care team in preparation for DDH by 98% of patients and 92% of family members. The DDH rates have increased for the past 12 years in our ICUs but declined during the study period (February 2016 to February 2017). Conclusions: Patients and family members are satisfied with the practice of DDH from ICU, although ICU physician satisfaction is more variable. Physician comfort may be improved by data informing which patients may be safely DDH from the ICU.
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Affiliation(s)
- Joyce Nga Hei Lam
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Vincent I. Lau
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Fran A. Priestap
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - John Basmaji
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ian M. Ball
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study. Crit Care Med 2017; 45:e347-e356. [PMID: 27635769 DOI: 10.1097/ccm.0000000000002093] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Discrepancy in the supply-demand relationship for critical care services precipitates a strain on ICU capacity. Strain can lead to suboptimal quality of care and burnout among providers and contribute to inefficient health resource utilization. We engaged interprofessional healthcare providers to explore their perceptions of the sources, impact, and strategies to manage capacity strain. DESIGN Qualitative study using a conventional thematic analysis. SETTING Nine ICUs across Alberta, Canada. SUBJECTS Nineteen focus groups (n = 122 participants). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Participants' perspectives on strain on ICU capacity and its perceived impact on providers, families, and patient care were explored. Participants defined "capacity strain" as a discrepancy between the availability of ICU beds, providers, and ICU resources (supply) and the need to admit and provide care for critically ill patients (demand). Four interrelated themes of contributors to strain were characterized (each with subthemes): patient/family related, provider related, resource related, and health system related. Patient/family-related subthemes were "increasing patient complexity/acuity," along with patient-provider communication issues ("paucity of advance care planning and goals-of-care designation," "mismatches between patient/family and provider expectations," and "timeliness of end-of-life care planning"). Provider-related factor subthemes were nursing workforce related ("nurse attrition," "inexperienced workforce," "limited mentoring opportunities," and "high patient-to-nurse ratios") and physician related ("frequent turnover/handover" and "variations in care plan"). Resource-related subthemes were "reduced service capability after hours" and "physical bed shortages." Health system-related subthemes were "variable ICU utilization," "preferential "bed" priority for other services," and "high ward bed occupancy." Participants perceived that strain had negative implications for patients ("reduced quality and safety of care" and "disrupted opportunities for patient- and family-centered care"), providers ("increased workload," "moral distress," and "burnout"), and the health system ("unnecessary, excessive, and inefficient resource utilization"). CONCLUSIONS Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.
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Lau VI, Priestap FA, Lam JNH, Ball IM. Factors Associated With the Increasing Rates of Discharges Directly Home From Intensive Care Units-A Direct From ICU Sent Home Study. J Intensive Care Med 2016; 33:121-127. [PMID: 27655852 DOI: 10.1177/0885066616668483] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the relationship between rates of discharge directly to home (DDH) from the intensive care unit (ICU) and bed availability (ward and ICU). Also to identify patient characteristics that make them candidates for safe DDH and describe transfer delay impact on length of stay (LOS). METHODS Retrospective cohort study of all adult patients who survived their stay in our medical-surgical-trauma ICU between April 2003 and March 2015. RESULTS Median age was 49 years (interquartile range [IQR]: 33.5-60.4), and the majority of the patients were males (54.8%). Median number of preexisting comorbidities was 5 (IQR: 2-7) diagnoses. Discharge directly to home increased from 28 (3.1% of all survivors) patients in 2003 to 120 (12.5%) patients in 2014. The mean annual rate of DDH was between 11% and 12% over the last 6 years. Approximately 62% (n = 397) of patients waited longer than 4 hours for a ward bed, with a median delay of 2.0 days (IQR: 0.5-4.7) before being DDH. There was an inverse correlation between ICU occupancy and DDH rates ( rP = -.55, P < .0001, 95% confidence interval [CI] = -0.36 to -0.69, R2 = .29). There was no correlation with ward occupancy and DDH rates ( rs = -.055, P = .64, 95% CI = -0.25 to 0.21). CONCLUSIONS The DDH rates have been increasing over time at our institution and were inversely correlated with ICU bed occupancy but were not associated with ward occupancy. The DDH patients are young, have few comorbidities on admission, and few discharge diagnoses, which are usually reversible single system problems with low disease burden. Transfers to the ward are delayed in a majority of cases, leading to increased ICU LOS and likely increased overall hospital LOS as well.
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Affiliation(s)
- Vincent I Lau
- 1 Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Fran A Priestap
- 1 Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Joyce N H Lam
- 1 Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Ian M Ball
- 1 Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,2 Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Razavi SS, Fathi M, Hajiesmaeili M. Intensive Care at Home: An Opportunity or Threat. Anesth Pain Med 2016; 6:e32902. [PMID: 27247913 PMCID: PMC4885143 DOI: 10.5812/aapm.32902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/27/2015] [Accepted: 01/04/2016] [Indexed: 11/16/2022] Open
Affiliation(s)
- Seyed Sajad Razavi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Fathi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Hajiesmaeili
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding author: Mohammadreza Hajiesmaeili, Loghman Hakim Medical Center, Kamali St., South Kargar Ave., Tehran, Iran. Tel: +98-2151025343, Fax: +98-2155424040, E-mail:
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