Source: Dervan LA, Heneghan JA, Hall M, et al. Return-to-care after discharge directly home from the PICU: a propensity-matched cohort study. Pediatr Crit Care Med. 2025;26 (12): e1467-e1475; doi: 10. 1097/PCC. 0000000000003830. Investigators from multiple institutions conducted a retrospective study to compare rates of hospital readmission or return emergency department (ED) visits for children discharged from the PICU directly home, or transferred from the PICU to an inpatient ward prior to discharge. For the study, the reviewed the Pediatric Health Information (PHIS) database, which includes demographic information and data on encounters, diagnostic and procedures codes, and charges for patients seen at 48 tertiary hospitals in the US. Study participants were children included in the PHIS database who were admitted to the PICU between 2016 to 2023. Data on demographics, type of admission, discharge information, and costs were collected. Patients were classified as being discharged directly to home from the PICU or transferred to the ward. The primary study outcome was readmission or return ED visit within 14 days of hospital discharge. Secondary outcomes included rate of hospital readmission or return ED visit, assessed separately, rate of PICU admission for those readmitted, and costs, including the index hospitalization and return encounters. For the main analysis, patients in the group discharged directly home that could be propensity score matched to those in group transferred to the ward were included. The propensity score was calculated using multiple demographic and clinical characteristics. Among the propensity score matched children, outcomes among children in the 2 groups were compared. A total of 560, 815 PICU admissions were included in the study. Of these PICU admissions, 150, 126 (26. 8%) patients were discharged directly home, with the rate varying between 9. 8% and 55. 6% among the participating hospitals. There were 94, 048 children in the group discharged directly home who were successfully propensity score matched to 153, 887 patients transferred to the ward. The rate of readmission or return ED visit were similar for those discharged directly home and children transferred from the PICU to the ward prior to hospital discharge (7. 3% and 7. 6%, respectively; odds ratio OR, 0. 96; 95% confidence interval CI, 0. 93, 0. 99). Rates of return ED visit were 2. 9% and 3. 0%, respectively (OR, 0. 94; 95% CI, 0. 89, 0. 99), and rates of readmission were 4. 8% and 4. 9%, respectively (OR, 0. 97; 95% CI, 0. 94, 1. 01). Patients directly discharged home who were readmitted were more likely to require a PICU admission than those who had been transferred to the ward during their index PICU stay (2. 4% vs 1. 6%; OR, 1. 58; 95% CI, 1. 49, 1. 67). The median cost for those discharged directly home was 15, 023, compared to 30, 750 for those transferred to the ward from the PICU. The authors conclude that discharge directly home from the PICU was a common practice and was associated with similar rates of hospital readmission and return ED visits than among patients transferred from the PICU to the ward prior to discharge. Drs Kononowicz and Miller-Smith has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. The growing practice of discharge directly home (DDH) from the PICU likely reflects intensifying operational pressure on hospitals but may invoke concern for patient safety from providers. 1 Safe DDH depends on clinician assessment of physiologic stability and outpatient caregiver support. Adult studies demonstrate that DDH can be done safely without increased mortality or health care utilization. 2 While some single-center pediatric studies signaled similar safety, 1 a larger, multi-institutional study was needed. In the current study of the national PHIS database, the large cohort provides the statistical power needed to evaluate readmission rates. The authors found that DDH subjects had a similar rate of hospital return compared with ward discharges. While propensity matching balanced measurable clinical characteristics, many critical domains are not available in PHIS, including caregiver readiness, discharge communication, and reliability of home-based support. 3Readmissions following DDH were predominantly routed directly to PICUs, a trend noted in earlier PICU DDH cohorts. 4 This pattern may relate to clinician familiarity influencing unit choice and greater chronic medical complexity among children needing readmission. Because PHIS captures return encounters only within the discharging hospital network, visits to other hospitals or community EDs are not measured, so early return-to-care burden likely is undercaptured. Additionally, LOS reduction most likely reflects removal of charge-generating ward observation days rather than true decreases in monitoring need. The dataset cannot determine whether reassessment or surveillance shifted to caregivers, outpatient teams, home nursing, or non-PHIS hospitals, nor whether these shifts were consistent across families. Overall, the current study findings support selective DDH work-flows but emphasize persistent gaps in caregiver readiness, external revisit capture, and long-term transition outcomes. Expansion of DDH pathways should rely on structured readiness assessment, predictable early follow-up, clear deterioration contingency planning, and intentional attention to transition equity. DDH appears safe for carefully selected children in large academic centers, and is not associated with increased likelihood of return to ED or inpatient care.
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