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Direct Discharge to Home From the Pediatric Cardiovascular ICU
Dana B Gal1,2, David M Kwiatkowski1,2, Camila Cribb Fabersunne3
1Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA.
Insights
Direct discharge to home from the cardiovascular ICU (CICU) appears safe for select pediatric patients, with no increase in readmissions. However, frontline providers face challenges with logistics and time constraints for this discharge pathway.
Area of Science:
- Pediatric Cardiology
- Critical Care Medicine
- Health Services Research
Background:
- Direct discharge to home from the cardiovascular ICU (CICU) is an evolving practice.
- Understanding its safety and provider perspectives is crucial for optimizing patient care transitions.
Purpose of the Study:
- To describe the characteristics of direct discharge to home from a pediatric CICU.
- To evaluate the safety of this discharge pathway by comparing readmission rates.
- To assess frontline provider confidence in managing direct discharge to home.
Main Methods:
- A mixed-methods approach was used, combining retrospective data from the Pediatric Cardiac Critical Care Consortium and Pediatric Acute Care Cardiology Collaborative.
- Patient data for direct discharge to home encounters were compared with internal and national benchmarks.
- A survey assessed frontline cardiovascular ICU providers' comfort and skills related to direct discharge to home.
Main Results:
- 364 direct discharge to home encounters were analyzed, with 84% associated with surgery or procedure.
- The 7-day unplanned readmission rate for direct discharge to home was 1.9%, lower than the 4.6% for internal acute care discharges (p=0.04).
- Frontline providers reported mixed confidence in technical skills and low confidence in logistical aspects of direct discharge to home.
Conclusions:
- Direct discharge to home from the CICU may be safe for select pediatric patients, without an increase in unplanned readmissions.
- Time constraints and logistical challenges hinder frontline providers' ability to implement direct discharge to home effectively.
- Further research is needed to identify patient criteria for safe direct discharge to home and develop supportive systems.
Objectives:
To describe direct discharge to home from the cardiovascular ICU.
Design:
Mixed-methods including retrospective Pediatric Cardiac Critical Care Consortium and Pediatric Acute Care Cardiology Collaborative data and survey.
Setting:
Tertiary pediatric heart center.
Patients:
Patients less than 25 years old, with a cardiovascular ICU stay of greater than 24 hours and direct discharge to home from January 1, 2016, to December 8, 2020, were included. Select data describing patients discharged from acute care internally and nationally from Pediatric Acute Care Cardiology Collaborative sites were compared with the direct discharge to home cohort.
Interventions:
None.
Measurements And Main Results:
Encounter- and patient-specific characteristics. Seven-day and 30-day readmission and 30-day mortality served as surrogate safety markers. A survey of cardiovascular ICU frontline providers assessed comfort and skills related to direct discharge to home.There were 364 direct discharge to home encounters that met inclusion criteria. The majority of direct discharge to home encounters were associated with a surgery or procedure (305; 84%). There were 27 encounters (7.4%) for medical technology-dependent patients requiring direct discharge to home. Unplanned 7-day readmissions among direct discharge to home patients was 1.9% compared with 4.6% (p = 0.04) of patients discharged from acute care internally. Readmission among those discharged from acute care internally did not differ from those at Pediatric Acute Care Cardiology Collaborative sites nationally. Frontline cardiovascular ICU providers had mixed levels of confidence in technical aspects and low levels of confidence in logistics of direct discharge to home.
Conclusions:
Cardiovascular ICU direct discharge to home was not associated with increased unplanned readmissions compared with patients discharged from acute care and may be safe in select patients. Frontline cardiovascular ICU providers feel time constraints challenge direct discharge to home. Further research is needed to identify patient characteristics associated with safe direct discharge to home and systems needed to support this practice.Summary statistics are described using proportions or medians with interquartile ranges (IQRs) and were performed using Microsoft Excel (Microsoft, Redmond, WA). Two-sample tests of proportions were used to compare readmission frequency of the DDH cohort compared with internal and national PAC3 data using STATA Version 15 (StataCorp, College Station, TX).
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