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.
JAMA Intern Med. 2018 Oct 1;178(10):1390-1399. doi: 10.1001/jamainternmed.2018.3675.
The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown.
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.
Patient disposition on discharge from the ICU: directly home vs home via the hospital ward.
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.
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).
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.
从重症监护病房（ICU）直接出院回家的成年患者康复安全性尚不清楚。
比较直接从 ICU 出院回家的 ICU 患者与通过医院病房出院回家的患者的医疗保健利用和临床结局。
设计、地点和参与者：这是一项回顾性基于人群的队列研究，纳入了 2014 年 1 月 1 日至 2016 年 1 月 1 日期间入住 9 家医疗外科医院 ICU 的成年患者，出院后进行为期 1 年的随访。所有 ICU 患者均从医院活着出院回家，基于患者特征、在 ICU 接受的治疗和医院特征的倾向评分匹配队列（1:1）。
从 ICU 出院时的患者处置：直接回家与通过医院病房回家。
主要结局是出院后 30 天内再次入院。次要结局是出院后 30 天内的急诊就诊和 1 年内的死亡。
在研究纳入的 6732 名患者中，有 2826 名（42%）为女性；中位年龄为 56 岁（四分位距，41-67 岁）；922 名（14%）直接出院回家，不同医院之间存在显著差异（范围，4.4%-44.0%）。与通过医院病房出院回家的患者相比，直接出院回家的患者年龄更小（中位年龄 47 岁 vs 57 岁；P < .001），更可能因药物过量、物质戒断、癫痫发作或代谢性昏迷而入院（32%[295] vs 10%[594]；P < .001），入院时急性疾病严重程度更低（中位急性生理和慢性健康评分 II 为 15 分 vs 18 分；P < .001），接受的侵入性机械通气时间不足 48 小时（42%[389] vs 34%[1984]；P < .001）。在倾向评分匹配队列（n = 1632）中，直接出院回家的患者 ICU 住院时间相似（中位数，3.1 天 vs 3.0 天；P = .42），但医院住院时间明显更短（中位数，3.3 天 vs 9.2 天；P < .001）与通过医院病房出院回家的患者相比。直接出院回家或通过医院病房出院回家的患者在出院后 30 天内再次入院（10%[n = 81] vs 11%[n = 92]；危险比[HR]，0.88；95%CI，0.64-1.20）或急诊就诊（25%[n = 200] vs 26%[n = 212]；HR，0.94；95%CI，0.81-1.09）的差异无统计学意义。出院后 1 年内，两组各有 4%的患者死亡（n = 31 和 n = 34 分别为直接出院回家组和通过医院病房出院回家组）（HR，0.90；95%CI，0.60-1.35）。
从 ICU 直接出院回家的成年患者选择是常见的，与增加的医疗保健利用或增加的死亡率无关。
