Discharge home from critical care: safety assessment in a resource constrained system.

BACKGROUND: High bed occupancy rates have delayed patient discharges from UK critical care units, especially in acute medical hospitals. As a result, more patients are discharged home directly from critical care (DH). METHODS: In this observational, retrospective study, we quantify the trends in DH from 2013 to 2018, and assess readmission rates and outcome in this group when compared to patients discharged from a ward, from 2014 to 2016. RESULTS: DH rates, as a proportion of critical care admissions, increased every year (2.47% in 2013 to 19.36% in 2018). In 2014-16, the most common admission diagnoses in DH patients were diabetic ketoacidosis (DKA; 35%), drug overdose (12%), seizures (8%) and respiratory failure (8%). DH patients were younger and had shorter critical care stay. Readmission rates in DH patients were comparable to the rest of the hospital. Patients with DKA and seizures were more likely to be readmitted. CONCLUSIONS: Our data suggest that direct home discharge from critical care is increasingly common but safe in selected patient groups.

Persistent neuromuscular and neurophysiologic abnormalities in long-term survivors of prolonged critical illness.

OBJECTIVE: To establish the prevalence, clinical characteristics, and electrophysiologic features of residual neuromuscular dysfunction after prolonged critical illness. DESIGN: Prospective follow-up study of survivors of prolonged critical illness. SETTING: A university hospital and two district general hospitals in the UK. PATIENTS: The study occurred for a period of 5 yrs. All patients during that time who were in the intensive care unit for >28 days were entered in the study. MEASUREMENTS AND MAIN RESULTS: At follow-up, length of intensive care unit and hospital stay, duration of mechanical ventilation and admission Acute Physiology and Chronic Health Evaluation II score were recorded from the case notes. A clinical history was obtained, a Barthel Index disability score was calculated, and a full neurologic examination was performed. Nerve conduction studies, needle electromyography, single-fiber electromyography and thermal thresholds were performed. A total of 195 patients were identified. There were 86 survivors, of whom 47 could be contacted and 22 consented to be studied. The median time from intensive care unit discharge to follow-up was 43 months (range, 12-57 months). All gave a clear history of severe weakness and functional impairment after hospital discharge and, in all, recovery was prolonged. Motor or sensory deficits were present on clinical examination in 59% of the patients studied. Common peroneal nerve palsy was present in two patients. A total of 21 of 22 (95%) patients had electromyographic evidence of chronic partial denervation at follow-up, findings indicative of a preceding axonal neuropathy. The single-fiber electromyographic studies were also consistent with a preceding motor neuropathy. CONCLUSION: Severe weakness requiring prolonged rehabilitation and abnormal clinical neurologic findings are extremely common in survivors of protracted critical illness. Neurophysiologic evidence of chronic partial denervation of muscle consistent with previous critical illness polyneuropathy is almost invariable and can be found up to 5 yrs after intensive care unit discharge in >90% of these long-stay patients. Evidence of myopathy is unusual. These findings have important implications for the management and rehabilitation of intensive care survivors.