Homeward Bound: A Descriptive Study of Direct Discharge Home from the Pediatric ICU

By Matt Pizzuto

Critical illness in a child is a challenging experience for all involved. Patients are generally admitted to a specialized pediatric intensive care unit (PICU) for their care. Prior to discharge patients are commonly transferred to an acute care ward where care can be coordinated and the transition to outpatient care can be initiated. However sometimes patients are discharged directly to home from the PICU (DDH – direct discharge home) and bypass the acute care ward. This can be for a variety of reasons. The practice of DDH has not been well studied in children and a recent review article on this topic called for further investigation (Ref 15).

To investigate this topic, we performed a single center retrospective study at our institution. We compared baseline characteristics of patients admitted to the PICU who were discharged via the acute care ward (ACD - acute care discharge) to those who experienced DDH between 2015 to 2020. We compared hospital readmission at 30 days after discharge as our primary outcome variable.

In this period at our institution, 19% of the n=4042 PICU admissions experienced DDH. The median age of both groups was 2 years old. DDH patients had a significantly increase incidence of home ventilator-dependence (HVD) at discharge (24% vs 1%, P < .01) compared with patients experiencing ACD. DDH patients appeared to be less sick as they had a reduced need of vasoactive infusions and less of a need of new mechanical ventilation (after removing those with HVD). DDH patients also had a shorter hospital length of stay (LOS) (2.1 vs 5.9 for ACD patients P< 0.01). The 30-day readmission rate was the same for both groups (14% vs 14%, P = .88) after excluding patients with baseline HVD.

A subgroup analysis of only the DDH patients was also performed comparing those that had a readmission within 30 days to those DDH patients that did not get readmitted. Readmission in the DDH patients was associated with younger age, Hispanic ethnicity, need for vasoactive infusions, and HVD.

We found at our institution patients experienced DDH at a significant rate, 19%. This is similar to other published data ranging from 4% to 44%. The patients were generally less sick and had a high preponderance of HVD. At our institution only a limited amount of HVD patients can be transferred to the floor prior to discharge. This leads to a significant need for direct discharge home for these patients with HVD. So, after removing HVD from the analysis we found no difference in the rate of hospital readmission at 30 days. While it is challenging to define what a truly safe discharge consists of, this data at least supports that direct discharge home from the PICU does not carry increased risk of hospital readmission. However, further research is needed to support the safety of this practice, including multi-site investigations and prospective studies.

Takeaways:

Direct discharge home from the PICU (DDH) is common (19% in this study).
DDH patients are generally less sick with shorter hospital stays and commonly have home ventilator-dependence (HVD).
30-day readmission rates for DDH patients were similar to ACD patients after removing HVD patients from analysis.
This supports that DDH is likely a safe practice, but further exploration in this topic is warranted.