The process of discharge from critical care to less intensive levels of care, and in particular to general ward areas, is as important as the process for admission to critical care.
Patients should be discharged
- by consultant decision
- when clinically ready and appropriate
- at an appropriate time of day
- to an appropriate choice of clinical area and receiving/supervising medical team
- with full handover of clinical information.
Late-night discharge from critical care to general wards (after 10pm and before 8am) may be disorienting and stressful for the patient, detrimental to handover and continuity compared to working-hours transfer, and associated with poorer clinical outcome.
Avoidance of discharges after 10pm and before 8am, and unplanned re-admission to ICU (effectively, failed discharge) are two of the 14 Network critical care quality measures.
Within daylight hours, there should be minimal delay (ideally < 4 hours) from the time of decision that they are clinically fit for discharge, to the time that they are able to be settled at the destination ward. Patients whose discharge from critical care is significantly delayed once clinically ready, are at unnecessarily continued risk of cross-infection; may suffer stress from a critical care environment which they no longer need; occupy clinical facilities that may cause delay to incoming patients if the unit is otherwise full; and similarly are themselves at avoidable risk from late-night discharge if their bed becomes needed at short notice for a more seriously-ill patient.
Discharge from critical care represents a step-change in nursing ratio, facilities, and monitoring, and may be a time of anxiety for patients or families. This can be minimised by preparation, counselling, appropriately-timed discharge, and patient information, whether local or generic (e.g. ICU STEPS).
The period immediately before discharge from critical care, is a recommended opportunity to re-assess the patient's critical care rehabilitation needs and goals (NICE CG83).
Patients should be reviewed after discharge from critical care, by ICU teams or Critical Care Outreach.