Encouraging direct discharges home from Critical Care

This is one of a pair of articles looking a direct discharges from critical care. For an opposing view, see Watts. ¹

Pressure on acute NHS trusts has been intense in recent years, with many hospitals resorting to “corridor care” at times when there are insufficient inpatient beds to accommodate emergency admissions. ² One of the many consequences of this pressure is that patients may become “stuck” in critical care units; no longer requiring critical care but with no ward bed to go to. As delays persist, critical care staff are increasingly faced with patients who have improved to the point of being able to go home but who are still in critical care.

This leaves intensivists competing with emergency and acute teams for scarce beds for their patients. We do both our own patients and those waiting in corridors in the emergency department a disservice if we lengthen hospital stay unnecessarily due to a lack of familiarity with local processes.

To safely execute a discharge home from hospital, a number of assessments and processes are required, often things that historically critical care staff have been unfamiliar with. Direct communication with primary care teams is somewhat of a rarity for many intensivists. The processes to start or restart various community support services can seem labyrinthine to negotiate. Then there are practicalities to attend to. Does the patient need advice on returning to driving or other activities? How does one issue a sick note? What is a discharge lounge and when does it close? How on earth do you “do a TTO” (For international readers, “TTO” is a term in widespread use in the UK NHS, referring to a combination of a hospital discharge prescription and summary of an inpatient stay to be sent to the patient’s general practitioner. It was probably originally an acronym for “to take out.”) these days?

One probably false assumption here is that an optimally functioning system would provide a ward bed as soon as a critical care patient no longer requires advanced organ support. Delays in leaving critical care are probably a good thing; Gilligan pointed out nearly 10 years ago in the pages of this journal that the optimum time to got to a ward from critical care is about 24 h after your intensivist thinks you are ready to go. ³ This is something that has been replicated in international data. ⁴ The patient on a rapidly improving trajectory may well become ready to go home without ever going through the stage of being suitable for a ward.

The most obvious group of patients who would be best served by discharge home from critical care is the group with a sudden, easily reversible physiological crisis on the background of a known chronic disease process, for example

• Diabetic ketoacidosis in a patient with a known diagnosis of diabetes. Such individuals are normally already engaged with outpatient and community services and maintaining good glycaemic control in the face of inpatient hospital catering remains an unsolved problem. ⁵

• The patient receiving long term dialysis who is caught short with pulmonary oedema, perhaps having missed a scheduled dialysis session or two. They are presumably at their physiological peak immediately after acute renal replacement therapy.

• The patient who has taken a drug overdose, who certainly does need psychosocial assessment and care by a mental health professional. ⁶ Continued inpatient stay in a general hospital may be to the convenience of psychiatric services but generally to the detriment of the patient.

• The uncomplicated seizure in a patient with an established epilepsy diagnosis.

Two other groups should be being discharged direct from the critical care unit. The first is the “chronically critically ill” patient, for example the home tracheostomy ventilated patient, whose normal levels of support in the community are impossible to meet in hospital in anything other than a critical care setting. The second is the palliative discharge; the individual admitted to critical care in the hope of curative treatment but whose goals of care have changed and who wishes to die at home. Both of these types of discharges are substantially more complex than the first group but are also much rarer. Critical care units need the first group to maintain their discharge skills, awareness of community processes and services, and so forth.

One objection occasionally raised to directly discharging patients home from critical care is that it is not “safe.” This objection is not supported by data. In a recent meta analysis, ⁷ there was no difference in subsequent emergency department attendences, hospital readmission or mortality in individuals discharged directly home from an ICU compared with those who were transferred to a ward prior to discharge home. Another concern raised by intensivists is that they will be blamed in some way for readmissions or “failed” discharges. People who have been unwell enough to require critical care are likely to have a higher need for, and more contact with, healthcare services longer term. ⁸ It is hard to see how briefly passing through a general ward would modify this, nor why a clinician acting thoughtfully and in good faith should be criticised for it. Indeed, there is an old adage, if you don’t get any complications, you are not doing enough procedures. Similarly, if all discharges “succeed,” then patients are being kept in hospital unnecessarily.

Critical care medicine in the UK has, to varying degrees, inherited somewhat of a “technician” mindset from anaesthesia; the idea that we are merely running the machines on behalf of some “parent” team; a surgeon or physician perhaps. This isn’t what happens on a modern critical care unit, of course. Patient care is directed and overseen by a consultant intensivist who is responsible for that patient’s care. You are responsible for the test you requested on your patient. ⁹ The reluctance of some intensivists to discharge patients directly home may be linked apprehension around being held responsible for results coming back once the patient is no longer in front of them. Rather than ignoring a slightly low selenium level yourself, if the patient has gone home, then it becomes necessary to ask the patient’s general practitioner to ignore it for you. Capturing outstanding clinical results and having robust ways of communicating with external agencies do require proactive thought by critical care units. Do clinicians have time available for this? Is there secretarial support to manage correspondence to and from patients, primary care and other services? I would argue that such systems are vital for critical care units, regardless of how their patients escape their doors. Modern intensive care medicine relies to an ever increasing degree on advanced imaging and thus produces victims of modern imaging technology ¹⁰ at an increasing rate. Whether your unit is organising it’s own interval scans on lung nodules, adrenal incidentalomas, etc, or referring on to someone else to do so, this is best done explicitly rather than hoping that someone else outside the ICU notices and takes on the work.

A final objection is that community discharge planning did not previously feature in critical care curricula and thus older intensivists are not “trained” to do this. Critical care medicine continually advances and new approaches won’t, by definition, have been included in earlier education programmes. The training requirements for discharging patients home are pretty minimal. There certainly isn’t the need for the complex competency frameworks^11,12 and national accreditation ¹³ required by other innovations enthusiastically adopted by the critical care community. A working knowledge of common local community support services and their referral pathways would cover most of it. Perhaps more important is the confidence that comes from knowing one’s organisation has systems in place to actively support such discharges.

Direct discharges home from critical care units are likely to continue to be a feature of our healthcare system going forward. Properly managed this is something that will be of overall benefit to appropriately selected patients. Perhaps for some conditions (diabetic ketoacidosis, uncomplicated overdose), direct discharge home from critical care should be the norm, not the exception. Rather than clinging to outdated notions of “parent teams” and that direct discharges home are not feasible, we should embrace this as an opportunity and proactively support these groups of patients as they re enter the community.