To the Editor,

In Canada, there is an increasing trend of patients being directly discharged home (DDH) from intensive care units (ICUs).1,2 Approximately 14%–23% of ICU survivors are DDH in Alberta and Ontario.1,3 Previous studies have found similar safety outcomes between DDH from ICU and ward transfer, and the majority (> 70%) of patients and patient-families felt comfortable with DDH at the time of discharge.1,4,5 In a single-centre survey in Ontario, only 5% of ICU physicians felt very comfortable with DDH, with the majority feeling somewhat comfortable (4). Nevertheless, perceptions of Canadian healthcare providers (HCPs) on DDH from ICU are relatively unknown. The primary objective of this study was to evaluate Canadian HCPs (including ICU, community, and allied HCPs) perceptions of DDH, including its prevalence, perceived safety, and barriers. We also sought to identify areas for improvement.

We administered an open web-based, anonymous, voluntary survey to Canadian HCPs between 23 July 2020 and 31 December 2020 using REDCap (Vanderbilt University, Nashville, TN, USA) (see Electronic Supplementary Material [ESM] for additional methods). Using emails and e-newsletters, we distributed the survey in English and French, through 22 national, provincial, and local organizations (representing > 52,000 Canadian HCPs). There were 360/367 (98%) completed responses, of which there were 234 (65%) ICU providers and 126 (35%) non-ICU providers (see ESM for additional results). Many HCPs (28%) had > 20 years of experience, many (42%) worked in Ontario, most (78%) worked in large urban centres, and most (59%) worked at teaching hospitals.

Most providers (84%) had been involved in the care of a patient that was DDH. The majority (58%) were aware of the increasing trend of DDH (Table). Intensive care unit providers commonly identified the following reasons for DDH: lack of ward beds (82%), the patient’s clinical status (73%), and leaving against medical advice (62%). Most characterized these patients with single-system (66%) or easily reversible (65%) problems, and few comorbidities (53%).

Table Survey responses
Full size table

Healthcare providers felt comfortable (36%) or very comfortable (17%) with DDH. When comparing ICU and non-ICU providers (Table), there were differences in perception regarding the likelihood of a DDH patient having an unexpected visit. This held true whether the visits were to community care or acute care providers (both, P < 0.001). For non-ICU providers, concerns with DDH included lack of home support (48%), complex medication changes (46%), vague care plans (42%), and lack of follow-up (42%). Non-ICU providers felt that a patient should be kept in hospital instead of DDH if they had more than two complications during hospitalization (38%), needed outpatient physiotherapy or occupational therapy (29%), or needed medication changes (28%).

Our survey identified room for potential improvement in ICU-to-community provider communication. Handover from ICU providers after DDH was uncommon, with handover only provided sometimes (29%), rarely (27%), or never (17%). Additionally, most providers rated the quality of handover as either good (31%), fair (35%), or poor (14%). Non-ICU providers felt that it was moderately important (25%) or very important (27%) to include them in the decision-making process for DDH, yet 60% of ICU providers always included them. Only 54% of ICU providers used a standardized tool (i.e., handover tool, discharge template, standardized form) when performing DDH, in contrast to 62% of ICU providers for ward transfer.

In conclusion, this study shows that many HCPs were aware of the increasing trend of DDH and felt comfortable with DDH, unlike findings from a prior study.4 Nevertheless, non-ICU providers had concerns regarding DDH safety. There may be potential to improve communication and discharge documentation, involve community HCPs in the decision-making process, and ensure follow-up arrangements. Further research is warranted to improve the transitions in care of DDH patients from the ICU to the community.