Discharging people home editorial: Article against—Should patients be discharged directly home (DDH) from critical care?

Introduction

A reduction in the total number of hospital beds in England by half between 1987 and 2019 (particularly in intermediate care beds), an increase in the number of patients treated, and increasing illness complexity ¹ have caused pressure on NHS hospital beds by prolonging stays and stranding patients with lower medical and non-medical needs in acute wards disrupting the flow of patients around and out of the hospital. It is estimated that to meaningfully improve the demand for hospital beds by 2030 an additional 21,000–37,000 would need to be created, resourced and staffed. ² It is estimated that nearly 14% of acute hospital in-patient beds are occupied by patients who medically could be discharged, a 57% increase since 2020. ³ Delays in hospital discharge after the patient is determined to be medically fit average at 1.3 days nationally, but vary around England. Only 40% of these delays are related to community services, the majority of being related to inefficient hospital discharge processes.^3–8 The resulting adverse effects on treatment pathways, A&E care, and elective admission cancellations have increased pressures on the NHS as a whole and result in knock-on delays for patients who are well enough to be discharged from critical care units (CCU) to the ward as there is no ward bed to go to. There are now some patients who complete the entirety of their medical episode on CCU and it is argued that they should then be discharged directly home (DDH) rather than wait for a ward bed to go to. But is it safe to do so? And, on a related issue, is it fair or ethical to expect critical care services to adopt the responsibility for addressing a global hospital and health economy issue which they did not create?

The benefits of such an approach would be to free up hospital resource and improve flow, maximising access and reducing unnecessary cost. The key consideration should however be whether it is safe to DDH patients from CCU. Concerns include the ability to safety net patients and ensure that appropriate follow up, communication and community resources are in place.

Delay in CCU discharge may not result in direct harm to the patients themselves ⁹ —although it might be associated with increased infection risk, chronic mobility and independence issues and psychological sequalae. ¹⁰ Irrespective of issues relating directly to patients ‘stuck’ on CCU, there are also opportunity costs for the rest of the unwell population who may benefit from timely and appropriate CCU admission as well as possible negative effects on staff wellbeing.^11–14

Information from my own unit has confirmed that an average of 2.2 surgical and 1.6 medical patients/week are being discharged directly home (Smith M, personal communication, 2025). In 2019, 5% of discharges from CCU in a 4-month period were directly home; in 2024 over the same 4-month period it was 15% (Costly E, personal communication, 2024).

This is a practise that has always occurred to some degree but tended to be confined to a limited group of patients, for example, those discharged within an end of life or continuing community care framework or to an appropriate community rehabilitation facility. ¹⁵ Very little work has been done on the safety of patients directly home from CCU who have fully completed their recovery.

The intrinsic assumption underlying this concept is that CCU patients are a homogeneous group, who fall under the remit of a fully defined admission-to-discharge care pathway which seamlessly covers their community and follow up arrangements. There is also an assumption that those admitted with an acute decompensation of a chronic disease (e.g. diabetic ketoacidosis, or of acute dialysis need in an established renal failure patient, etc.), not only have pre-existing engagement with a fully functioning community/hospital follow up/monitoring pathway that takes pro-active action when needed but that they will also continue to do so when discharged; that community support services are in place or actually exist; that there are no ‘gaps’ between different parts of services supplied by different providers; and that there is an overall co-ordinator of their care who has full accountability for ensuring it is implemented.

Generally, patients admitted to CCU following elective and emergency surgery do remain associated with an admitting surgeon or surgical service which has continuing accountability in their care after discharge home within a well-defined governance framework. Unfortunately, those admitted to CCU with medical problems directly from A&E or Acute Medicine often remain ‘orphaned’ without an accountable non-CCU consultant until discharged to an in-patient ward, particularly if their care has been shared with physicians outside of the admitting Trust (e.g. neurology, oncology, mental health, etc.). This means that CCU staff responsible for DDH of such patients may find themselves in some ethical, legal and bureaucratic difficulties in their role as the designated discharging consultant (DDC).

Is discharge directly home from the CCU harmful to patients?

There is a small amount of research in this area which suggests that it is not harmful for patients to be discharged directly home from CCU in appropriate circumstances. These are relatively small, localised trials where appropriate pathways and governance arrangements were firmly in place proactively before the trial began.^16,17 Such patients were generally younger, had been admitted with a single defined diagnosis without other complicating factors, and had low disease burden on discharge.^18,19 Medical factors that were associated with a high risk associated with DDH included prior substance abuse, hepatitis and sepsis. Social factors that were associated with high risk included self-discharge against medical advice, a shorter length of stay (<2 days) and having no fixed abode. Although Lau et al. found a 0% mortality risk in 129 patients who were DDH, the unplanned readmission to hospital (i.e. failed discharge) rate for these low risk, well supported patients was still up to 30% within 30 days. ²⁰ One of the major contributors to failed discharge home is known to be a lack of appropriate robust follow up arrangements. ²¹

Should CCU consultants be the designated discharging consultant?

The discharging consultant is the individual who is responsible for ensuring all appropriate follow up arrangements (including errant or delayed blood, radiology and histology tests) are accounted for, seen and acted upon; that information is correctly communicated in a timely fashion to the patient and their GP; that other relevant referrals have been made to community, primary care and hospital specialists; and may be responsible for answering subsequent GP queries about continuity of care, medication doses and future care planning.^22–24 It is not just a matter of dropping a letter to the GP and ensuring the discharge medications are in order.

Such multi-factorial issues become even more complex when cross-border factors are involved. For example, patients in my own Trust’s catchment area may access services from across five counties (Lancashire, West Yorkshire, Greater Manchester, Cumbria and Merseyside), multiple councils, several Integrated Care Boards; and at least 10 different NHS Hospital Trusts and about 20 hospitals if we just consider only a 40-mile radius and if we exclude Mental Health and other such services. Responsibilities of the discharging consultant may also spread wider than just the patient themselves and can include a duty of care to unpaid carers, particularly if they are under 18 years old. ²⁵ Even if a team from another relevant specialty can be persuaded to review the patient on CCU for discharge planning, the responsibilities of the discharging consultant may remain with the current CCU consultant.

The CCU training curriculum states only that a Critical Care specialist should:

. . .[communicate] the continuing care requirements of patients at discharge from both ICU and hospital to healthcare professionals, patients and relatives. This will include the patient’s plan for ongoing care, medical follow up and rehabilitation. (p. 66)

It does not address these other responsibilities, or the possible need to engage in longer term non CCU follow up.^26,27 Whilst GPICS recommends facilities for a CCU follow up clinic this is solely for the management of CCU related problems, not the follow up of more general medical issues. ²⁸

A recent survey confirmed that 77% of Critical Care Consultants in the UK have an anaesthetic background. Anaesthesia as a specialty does not tend to link with community care at all. Anaesthetists do not ‘own’ patients outside of administering an anaesthetic and are not responsible for discharging them. ²⁹ They can in fact have performed the majority of their post-foundation years without ever having discharged a patient home at all. Therefore, it cannot be assumed that the majority of CCU consultants in the UK at this time have been trained in the nuances of DDH or the continuing responsibilities of being the discharging consultant as this is not now, and never has been, a core skill for them.

DDH is a multidisciplinary issue which requires close liaison with primary care and community services, and clear lines of accountability. The current situation is that the CCU community does not possess the knowledge, skill, training or understanding to safely fulfil this task; and is not gifted the administrative support required to minimise the risks associated with the required communication, follow up and trouble-shooting required to support the patient. ³⁰ Neither is such support and resource likely to be provided any time soon.

GMC guidance is clear. Good medical practice paragraph two states:

2 You must recognise and work within the limits of your competence. You must only practise under the level of supervision appropriate to your role, knowledge, skills and training, and the task you’re carrying out. ³¹

The more specific guidance on the delegation of care reads:

4. You must be confident that the colleague you delegate to has the necessary knowledge, skills, and training to carry out the task, or that they will be adequately supervised to ensure safe care. ³²

It is therefore unprofessional and unethical of the NHS, individual Trusts and non CCU colleagues to place Critical Care Physicians in the position of performing a task they have never been trained to do, that is, evolving without a clear governance and accountability structure, and which cannot be guaranteed to be safe or in the wider best interests of patients, and for which they are not resourced simply on the grounds of expediency.

Conclusion

The concept of DDH patients from critical care is born of pragmatism rather than evidence. It is most likely to be beneficial to selected small groups of patients with single, resolved pathologies if they are discharged within a robust and established governance framework that establishes their continuing care pathway in the community and the accountability for their follow up. However, even well managed discharge home can fail, and whilst currently there is little evidence that prolonging CCU stay places patients at clear material risk there is surely a risk to patients who are discharged by medical staff who lack the training, skill, insight and support to fulfil the role of discharging consultant safely. A doctor untrained and unfamiliar with the complexities of DDH should not be discharging patients home from CCU unless proper investment and funding has been made in the support, resources, training, clinical pathways and governance frameworks that are clearly required.