Traditionally, patients discharged from an intensive care unit (ICU) have been transferred to a ward of the same hospital. However, there is a growing trend toward ICU patients being discharged directly to home (DDH). DDH has grown to account for as many as one out of five ICU discharges.¹ A popular narrative holds that the rising rate of DDH stems from hospitals more frequently running near or over capacity. Interestingly, the peer-reviewed data runs counter to this narrative.^2,3 Moreover, in January, Critical Care Medicine published a large meta-analysis concluding that our best evidence shows DDH patients suffer no ill effects from being discharged directly to home.⁴     

Do ICUs Discharge Patients Directly to Home Due to Overcrowding?

The data seems to indicate this is not the case. Martin et al. found that the lower the ICU occupancy, the higher the likelihood of being discharged directly to home (DDH).² Furthermore, researchers could find no correlation between DDH and ward census. The data might suggest that, rather than being a product of necessity, the rise of DDH is a product of modern care planning.

Is DDH Equally Safe for Patients?

To provide the most authoritative answer to date, Vincent Lau, MD, Msc, FRCPC, and colleagues performed a meta-analysis combining the results of three high-quality, observational studies that enrolled a total of nearly 50,000 patients. Comparing DDH outcomes with ward transfers, researchers found no differences: 30-day emergency department use (22.4% vs 22.7%), 30-day rehospitalization (9.8% vs 9.6%), 90-day mortality (2.8% vs 2.6%).

Obviously, this data should not be interpreted to mean that all ICU patients are appropriate for DDH. On the other hand, these observational studies could fairly be interpreted to mean ICUs and hospitals in general are doing a good job of discharge planning and that increasing use of DDH stems from an intelligent pursuit of optimal outcomes rather than a reaction to challenging circumstances. Among Medicare beneficiaries, early, supported hospital discharge has the potential to increase hospital profitability, decrease costs for patients, improve availability of hospital resources, and improve patient and family quality of life. Additionally, DDH may improve care by reducing handovers. Even for short clinical encounters, research finds an association between increased handovers between care teams and worse outcomes.⁵ The data shows no reason to try to reign in DDH and provides a foundation for considering ongoing expansion of DDH.

Lau et al. cite ICU staff preparation as one obstacle to DDH. They state that ICU staff needs to be prepared to

• coordinate with community resources
• assess patient safety in a home environment
• ensure adequate outpatient follow-up

The Observation

This observation should be qualified with the understanding that high-quality Medicare-certified home health routinely facilitates these tasks. For instance, referring to home health will coordinate all other home medical services, assess the home environment, and ensure patients participate in their follow-up care. Additionally, home health can provide nursing visits up to twice daily, home care aides to help with activities of daily living, and home visiting therapists to perform rehabilitation – all with Medicare paying 100% of allowable charges for homebound patients.   

References

1. 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 Internal Medicine. 2018 Oct 1;178(10):1390-9.
2. Martin CM, Lam M, Allen B, Richard L, Lau V, Ball IM, Wunsch H, Fowler RA, Scales DC. Determinants of direct discharge home from critical care units: A population-based cohort analysis. Critical Care Medicine. 2020 Apr 1;48(4):475-83.
3. 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. Journal of the Intensive Care Society. 2019 May;20(2):165-70.
4. Lau VI, Donnelly R, Parvez S, Gill J, Bagshaw SM, Ball IM, Basmaji J, Cook DJ, Fiest KM, Fowler RA, Mailman JF. Safety Outcomes of Direct Discharge Home From ICUs: An Updated Systematic Review and Meta-Analysis (Direct From ICU Sent Home Study). Critical Care Medicine. 2023 Jan 1;51(1):127-35.
5. Jones PM, Cherry RA, Allen BN, Jenkyn KM, Shariff SZ, Flier S, Vogt KN, Wijeysundera DN. Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery. JAMA. 2018 Jan 9;319(2):143-53.