Question 6

Angoff score

4.82

Highest mark

7.75

a. Discuss the considerations involved in the decision to discharge patients directly home from the ICU (6 marks)

b. Outline the reasons why two different ICUs might have different rates of direct home discharge from ICU (4 marks)

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Discussion

Syllabus topic/section: 2.1.1 Structure and Process; 2.1.2 Decision Making; 2.2.1 Communication and collaboration in Intensive Care; 2.1.16 Populations requiring special considerations in Intensive Care

Candidates who scored better in this question exhibited a broad and high-level grasp of the more global issues and not simply the mechanics of moving the patient out of the ICU. For instance, answers that addressed issues such as identifying those groups of patients who may be suitable for discharge home tended to gain more marks.

Candidates are again reminded to take note of the Glossary terms, especially the subheadings of what a ‘discuss’ answer should include. Those candidates who incorporated this structure into their answer were rewarded for their attention to the glossary of terms instructions with higher scores.

Interpretation

A "discuss" answer should ideally include some pros, cons, controversies, etc. A definition or introductory statement is always helpful in such SAQs, as it tends to gently ease the examiners into a docile state of receptive grade generosity, where even vague and poorly handwritten answer statements are scored more highly because the candidate has given the appearance of understanding the problem. For example, for a), "Considerations involved in the decision to discharge patients directly home from the ICU":

"Discharge directly home from the ICU represents a convenient answer to bed pressure, potentially at the cost of less effective discharge communication and planning.

The role of planned discharge home, and the consequences of resorting to it because of bed pressure, remain to be fully established."

A block of advantages and disadvantages should then follow, and of these, a massive number could potentially be brought up. Here's a list of just the ones the author could come up with:

Advantages	Disadvantages
Shorter hospital stay: avoids a pointless ward admission for a patient who is already fit to leave hospital, which was one of the main findings in Stelfox et al (2018).	Premature discharge risk: bypassing the safety buffer of ward admission does not allow enough time for the team to identify patients who are unready for home discharge for reasons that are harder to observe in ICU (eg. mobility/falls risk)
Better patient flow: allows the ICU to free a bed and avoids using ICU capacity for patients waiting for low-acuity ward care	Institution-centred bias: a decision based on bed availability is contaminated by the nonclinical pressure, i.e. it has nothing to do with the patient's interests.
Fewer care transitions: avoids another handover to a ward team which may add little value for a patient needing only prescriptions, follow-up, and discharge information.	Less mature infrastructure: ICU teams may have zero idea of what a discharge is supposed to look like, and could omit vital prescriptions or appointments.
Avoids hospital complications: less ward time may reduce exposure to delirium-provoking environments, hospital-acquired infection, falls, VTE, sleep disruption, deconditioning, MROs, etc.	Misses hospital complications: a period of hospital stay could be needed to detect complications of critical illness (DVTs, psedoaneurysms etc) which may go unrecognised in the community.
Patient and family satisfaction: the patients and their families want to go home, so naturally they are satisfied by this outcome (eg. in Lam et al, 2020)	Physician disssatisfaction with the risk: in the same study, a large percentage of physicians were uncomfortable with the idea of direct home discharge. Hilariously, most were uncomfortable because they thought the families would complain.
Potentially faster functional recovery: home may be a better environment for sleep, mobility, nutrition, family help, and return to normal roles in a genuinely recovered low-acuity patient.	Potentially slower functional recovery: Sure, you will recover faster at home if you have housing, transport, health literacy, social supports, carers, phone access, money to see a physiotherapist. Or you have none of those things, and continue to deteriorate.
Resource stewardship: may reduce unnecessary hospital days, which have a nontrivial social and personal cost; to say nothing of the opportunity cost for patients who need the ICU bed.	Resource burden export: all of the ongoing care and surveillance work is transferred to the community health providers, who have a lot less resources than hospitals, but a lot more patients and certainly a lot less critical care experience to troubleshoot post-ICU problems.

Controversies:

The effect on patient safety is not well defined by the literature
In some health services the rate is significant (~20% in Martin et al, 2020 - a Canadian study), without significant increases in readmission rate or morbidity, i.e. it appears to be safe in well-developed health systems and for carefully selected patients
Methodology of case selection is not well established through prospective data (but in retrospective data where success was observed, the patients were young, low acuity, and with single organ problems).
Whether this should be v

An ICU may differ in their rate of direct-to-home discharge if it has:

Younger/more elective case mix (eg. mostly elective surgical hospital, a trauma bypass ED, etc)
Local discharge criteria and ward capabilities vs. community capabilities
Local community health support network
Low, or high, socioeconomic status of the serviced population, which has has different implications. For example rich people are more healthy in general and require shorter ICU stay for mostly non-emergency problems and can be discharged earlier into better-resourced communities, but also it may be more lucrative to keep them in for longer to maximise the extraction of cash from their health insurance. Conversely, poor people may need to stay for longer because their access to post-ICU care will be limited and they need to be very "tidy" before they can be safely sent home, but at the same time they tend to turn up to understaffed public hospitals which are under greater bed pressure and more tempted to turf them out faster.
Cultural factors, eg. whether the family structures locally are more, or less, likely to have extended families with more in-home care and support
Definitions and denominators may differ, eg. jurisdictions may differ in whether they regard a transfer to a rehab facility nursing home or palliative care suite as "discharge home".
System-level problems, eg. the availability of beds and the pressure on the ICU bed capacity can inform these decisions (though some might argue that it should never)

References

Kennedy, Tessa K., and Andrew Numa. Factors associated with discharge delay and direct discharge home from paediatric intensive care. Journal of Paediatrics and Child Health 56.7 (2020): 1101-1107.

Chawla, Sujata, et al. Homeward bound: An analysis of patients discharged home from an oncologic intensive care unit. Journal of Critical Care 27.6 (2012): 681-687.

Lau, Vincent I., et al. Factors Associated With the Increasing Rates of Discharges Directly Home From Intensive Care Units-A Direct From ICU Sent Home Study. Journal of Intensive Care Medicine 33.2 (2018): 121-127.

Lam, Joyce N. H., et al. Patient, Family, and Physician Satisfaction With Planning for Direct Discharge to Home From Intensive Care Units: Direct From ICU Sent Home Study. Journal of Intensive Care Medicine 35.1 (2020): 82-90.

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