Characteristics and Outcomes of Patients Discharged Directly Home from a Medical Intensive Care Unit

Introduction: Discharging patients directly home from the ICU is becoming increasingly common, largely driven by decreased ward bed availability. We evaluated readmission patterns of ICU patients discharged directly home. Methods: Retrospective review was conducted of direct discharges from the ICU to home between June 2017 and June 2019. The primary outcome of interest was 30-day hospital readmission. Patients were dichotomized by “wait-time” between transfer order and hospital discharge (\u3c24 hours or ≥24 hours). Outcomes were compared using t-test, Fisher exact, and chi-squared. Risk-adjustment was performed using the Mortality Probability Model (MPM0-III). ICU workload was estimated using the nine equivalents of nursing manpower use score (NEMS). Results: 331 patients were identified, with a mean time of 0.72 [0 - 5.84] days between ICU transfer order and discharge to home. 68.3% (226/331) of patients waited \u3c24 hours for discharge. There was no difference in severity-of-illness or admission NEMS between the groups. 10.3% (45/331) of patients presented for evaluation within 30 days of discharge. 10.3% (34/331) of patients were readmitted. There was no significant difference in 30-day readmission between patients who were discharged after waiting \u3c24 hours vs. waiting ≥24 hours (p=0.70). Discussion: Patients returning directly home from the ICU without discharge delay were not readmitted more frequently within 30 days than those discharged after a delay exceeding 24 hours. Further investigation into identifying patients eligible for safe, early discharge may reduce unnecessary critical care resource utilization

Characteristics and Outcomes of Patients Directly Discharged to Home from the Intensive Care Unit

Introduction: Given the current era of decreasing hospital bed availability, there has been a rise in the practice of direct discharge to home (DDH) from ICUs. We evaluated the demographics, clinical characteristics, outcomes and readmission patterns among DDH patients. Methods: Retrospective review of patients from 2 MICUs from June 2017 to June 2019 at Thomas Jefferson University hospital, an urban tertiary care center. Primary outcome of interest was 30-day hospital readmission. Patients were dichotomized into two groups based on time between ward transfer order and hospital discharge (\u3c24 or ≥24 hours). Risk adjustment performed with Mortality Probability Model (MPM0 -III). ICU workload at admission and discharge was estimated with nine equivalents of nursing manpower use score (NEMS). Patient characteristics compared using t-test and Fisher exact or χ2 test. Results: 331 DDH patients were analyzed, with the majority (68.3%, 226/331) waiting \u3c24 hours for discharge. Mean LOS significantly longer in patients who had waited ≥24 hours prior to discharge compared to that of patients who waited \u3c24 hours (4.63 vs 2.65 days, p\u3c0.001). 10.3% (45/331) presented to TJU for evaluation within 30 days of discharge. Of these patients, 75.6% (34/45) were readmitted. No significant difference in severity-of-illness, admission NEMS, or 30-day readmission between the 2 groups (p=0.70). Discussion: Shorter wait-times for ICU patients after being determined ready for DDH were associated with shorter hospital and ICU LOS but not with an increase in 30-day readmissions. Further examining pre-discharge and post-discharge data could better identify those at risk of readmission

Characteristics and Outcomes of Patients Discharged Directly Home from a Medical Intensive Care Unit

RATIONALE: Discharging patients directly from ICUs is an increasingly common practice, largely due to decreased availability of ward beds. The purpose of this study was to describe the population and evaluate the outcomes of patients discharged directly from the MICU. METHODS: We conducted a retrospective chart review of direct discharges to home from June 2018 to June 2019 from two MICUs. Patients were separated into two groups based on wait time (\u3c24 hours or ≥ 24 hours) between ward transfer order and actual discharge. The primary outcome was 30-day hospital readmission. Risk was adjusted using Mortality Probability Model (MPM-III); ICU workload at admission and discharge was estimated using the nine equivalents of nursing manpower use score (NEMS). Patient characteristics were compared using t-test and Fisher exact or X2. RESULTS: There was no difference in severity-of-illness or admission NEMS between the two groups. Patients who waited \u3c24 hours for discharge were more likely to be admitted from home. Patients who waited ≥24 hours prior to discharge had significantly longer mean hospital LOS compared to those who waited \u3c24 hours (4.63 days vs. 2.65 days, p\u3c0.001). There was no significant difference in 30-day readmission between patients who were discharged after waiting \u3c24 hours vs. waiting ≥24 hours (p=0.70). CONCLUSION: Patients who returned directly home from the MICU without any discharge delay were not readmitted to the hospital more frequently within 30 days than those discharged to home after a delay exceeding 24 hours. Further investigation into identifying those patients for whom early discharge planning directly to home from the ICU is viable and safe may aid in reducing unnecessary critical care resource utilization

Outcomes of Mechanical Circulatory Support for Giant Cell Myocarditis: A Systematic Review

Treatment of giant cell myocarditis (GCM) can require bridging to orthotopic heart transplantation (OHT) or recovery with mechanical circulatory support (MCS). Since the roles of MCS and immunotherapy are not well-defined in GCM, we sought to analyze outcomes of patients with GCM who required MCS. A systematic search was performed in June 2019 to identify all studies of biopsy-proven GCM requiring MCS after 2009. We identified 27 studies with 43 patients. Patient-level data were extracted for analysis. Median patient age was 45 (interquartile range (IQR): 32–57) years. 42.1% (16/38) were female. 34.9% (15/43) presented in acute heart failure. 20.9% (9/43) presented in cardiogenic shock. Biventricular (BiVAD) MCS was required in 76.7% (33/43) of cases. Of the 62.8% (27/43) of patients who received immunotherapy, 81.5% (22/27) used steroids combined with at least one other immunosuppressant. Cyclosporine was the most common non-steroidal agent, used in 40.7% (11/27) of regimens. Immunosuppression was initiated before MCS in 59.3% (16/27) of cases, after MCS in 29.6% (8/27), and not specified in 11.1% (3/27). Immunosuppression started prior to MCS was associated with significantly better survival than MCS alone (p = 0.006); 60.5% (26/43) of patients received bridge-to-transplant MCS; 39.5% (17/43) received bridge-to-recovery MCS; 58.5% (24/41) underwent OHT a median of 104 (58–255) days from diagnosis. GCM recurrence after OHT was reported in 8.3% (2/24) of transplanted cases. BiVAD predominates in mechanically supported patients with GCM. Survival and bridge to recovery appear better in patients on immunosuppression, especially if initiated before MCS

Outcomes of Mechanical Circulatory Support for Giant Cell Myocarditis: A Systematic Review

Treatment of giant cell myocarditis (GCM) can require bridging to orthotopic heart transplantation (OHT) or recovery with mechanical circulatory support (MCS). Since the roles of MCS and immunotherapy are not well-defined in GCM, we sought to analyze outcomes of patients with GCM who required MCS. A systematic search was performed in June 2019 to identify all studies of biopsy-proven GCM requiring MCS after 2009. We identified 27 studies with 43 patients. Patient-level data were extracted for analysis. Median patient age was 45 (interquartile range (IQR): 32–57) years. 42.1% (16/38) were female. 34.9% (15/43) presented in acute heart failure. 20.9% (9/43) presented in cardiogenic shock. Biventricular (BiVAD) MCS was required in 76.7% (33/43) of cases. Of the 62.8% (27/43) of patients who received immunotherapy, 81.5% (22/27) used steroids combined with at least one other immunosuppressant. Cyclosporine was the most common non-steroidal agent, used in 40.7% (11/27) of regimens. Immunosuppression was initiated before MCS in 59.3% (16/27) of cases, after MCS in 29.6% (8/27), and not specified in 11.1% (3/27). Immunosuppression started prior to MCS was associated with significantly better survival than MCS alone (p = 0.006); 60.5% (26/43) of patients received bridge-to-transplant MCS; 39.5% (17/43) received bridge-to-recovery MCS; 58.5% (24/41) underwent OHT a median of 104 (58–255) days from diagnosis. GCM recurrence after OHT was reported in 8.3% (2/24) of transplanted cases. BiVAD predominates in mechanically supported patients with GCM. Survival and bridge to recovery appear better in patients on immunosuppression, especially if initiated before MCS