Clinical trajectories of critically ill patients discharged directly from a critical unit to a postacute care facility: retrospective cohort

Ramos, João Gabriel Rosa; Souza Neto, Milton José de; Rezende, Alef Santiago; Ferreira, Flavia dos Santos; Amorim, Yanne Danielly Santos; Souza, Flaviane Ribeiro de; Andrade, Lucas Freire de

doi:10.62675/2965-2774.20240015-en

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Original Article • Crit. Care Sci. 36 • 2024 • https://doi.org/10.62675/2965-2774.20240015-en copy

Clinical trajectories of critically ill patients discharged directly from a critical unit to a postacute care facility: retrospective cohort

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To describe the clinical trajectories of patients discharged directly from a critical unit to a postacute care facility.

Methods:

This was a retrospective cohort study of patients who were transferred from an intensive care unit or intermediate care unit to a postacute care facility between July 2017 and April 2023. Functional status was measured by the Functional Independence Measure score.

Results:

A total of 847 patients were included in the study, and the mean age was 71 years. A total of 692 (82%) patients were admitted for rehabilitation, while 155 (18%) were admitted for palliative care. The mean length of stay in the postacute care facility was 36 days; 389 (45.9%) patients were discharged home, 173 (20.4%) were transferred to an acute hospital, and 285 (33.6%) died during hospitalization, of whom 263 (92%) had a do-not-resuscitate order. Of the patients admitted for rehabilitation purposes, 61 (9.4%) had a worsened functional status, 179 (27.6%) had no change in functional status, and 469 (63%) had an improved functional status during hospitalization. Moreover, 234 (33.8%) patients modified their care goals to palliative care, most of whom were in the group that did not improve functional status. Patients whose functional status improved during hospitalization were younger, had fewer comorbidities, had fewer previous hospitalizations, had lower rates of enteral feeding and tracheostomy, had higher Functional Independence Measure scores at admission to the postacute care facility and were more likely to be discharged home with less complex health care assistance.

Conclusion:

Postacute care facilities may play a role in the care of patients after discharge from intensive care units, both for those receiving rehabilitation and palliative care, especially for those with more severe illnesses who may not be discharged directly home.

Keywords:
Patient discharge; Functional status; Length of stay; Hospitalization; Subacute care; Delivery of health care; Palliative care; Aged; Intensive care units

Characteristics		All patients (n = 847)	Referred for palliative care (n = 155)	Referred for rehabilitation (n = 692)	p value^* * p value for comparison between patients admitted for palliative care or rehabilitation;	Referred for rehabilitation with at least 2 FIM score measurements during PACF hospitalization (n = 649)
Characteristics		All patients (n = 847)	Referred for palliative care (n = 155)	Referred for rehabilitation (n = 692)		Worsened functional status during hospitalization (n = 61)	No change in functional status during hospitalization (n = 179)	Improved functional status during hospitalization (n = 409)	p value^† † p value for comparison between patients with worsened functional status, no change in functional status and improved functional status during hospitalization;
Male sex		441 (52.1)	76 (49)	365 (52.7)	0.403	27 (44.3)	99 (55.3)	215 (52.6)	0.329
Age		71 ± 17	80 ± 15	69 ± 17	< 0.001	77 ± 14	71 ± 18	67 ± 17	< 0.001^‡ ‡ p < 0.05 between worsened functional status during hospitalization versus no change in functional status during hospitalization; ^§ § p < 0.05 between worsened functional status during hospitalization versus improved functional status during hospitalization; ^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
Number of comorbidities		2.6 ± 1.8	2.1 ± 1.9	2.6 ± 1.8	0.006	3.2 ± 1.8	2.6 ± 1.9	2.6 ± 1.8	0.042^§ § p < 0.05 between worsened functional status during hospitalization versus improved functional status during hospitalization;
Hospitalizations in the previous year		0.86 ± 1.2	1.27 ± 1.48	0.76 ± 1.11	< 0.001	1.11 ± 1.26	0.81 ± 1.13	0.69 ± 1.05	0.017^§ § p < 0.05 between worsened functional status during hospitalization versus improved functional status during hospitalization;
Length of stay in the acute hospital (days)		35 ± 31	24 ± 23	38 ± 32	< 0.001	36 ± 33	44 ± 38	36 ± 29	0.012^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
Unit before transfer to the PACF					0.022				0.703
	ICU	543 (64.1)	87 (56.1)	456 (65.9)		38 (62.3)	122 (68.2)	273 (66.7)
	IMCU	304 (35.9)	68 (43.9)	236 (34.1)		23 (37.7)	57 (31.8)	136 (33.3)
Enteral feeding at admission to the PACF		567 (66.9)	97 (62.6)	470 (67.9)	0.202	43 (70.5)	153 (85.5)	2487 (60.4)	< 0.001^‡ ‡ p < 0.05 between worsened functional status during hospitalization versus no change in functional status during hospitalization; ^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
Tracheostomy at admission to the PACF		288 (34)	28 (18.1)	260 (37.6)	< 0.001	22 (36.1)	98 (54.7)	129 (31.5)	< 0.001^‡ ‡ p < 0.05 between worsened functional status during hospitalization versus no change in functional status during hospitalization; ^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
Mechanical ventilation at admission to the PACF		35 (4.1)	8 (5.2)	27 (3.9)	0.476	3 (4.9)	9 (5)	13 (3.2)	0.508
FIM at admission to the PACF		3 5 ± 19	27 ± 20	37 ± 19	< 0.001	35,7 ± 15,9	26,4 ± 16,6	41,4 ± 19,2	< 0.001^‡ ‡ p < 0.05 between worsened functional status during hospitalization versus no change in functional status during hospitalization; ^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
Last measured FIM at PACF hospitalization, mean (SD)		48 ± 32	27 ± 20	51 ± 32	< 0.001	26,7 ± 13,5	26,4 ± 16,6	66,6 ± 31,1	< 0.001^§ § p < 0.05 between worsened functional status during hospitalization versus improved functional status during hospitalization; ^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
FIM categories at admission					< 0.001				< 0.001^‡ ‡ p < 0.05 between worsened functional status during hospitalization versus no change in functional status during hospitalization; ^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
	Total functional dependence	191 (24.7)	59 (54.6)	132 (19.8)		0 (0)	99 (55.3)	31 (7.6)
	Severe functional dependence	501 (64.8)	42 (38.9)	459 (69.0)		55 (90.2)	73 (40.8)	319 (78.0)
	Moderate functional dependence	72 (9.3)	5 (4.6)	67 (10.1)		6 (9.8)	5 (2.8)	54 (13.2)
	Slight functional dependence/independence	9 (1.2)	2 (1.9)	7 (1.1)		0 (0)	2 (1.1)	5 (1.2)
FIM categories at last measurement during PACF hospitalization					< 0.001				< 0.001^§ § p < 0.05 between worsened functional status during hospitalization versus improved functional status during hospitalization; ^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
	Total functional dependence	187 (24.5)	61 (59.2)	126 (19.1)		25 (41.0)	99 (55.3)	0 (0)
	Severe functional dependence	335 (43.9)	33 (32.0)	302 (45.8)		34 (55.7)	73 (40.8)	190 (46.5)
	Moderate functional dependence	168 (22.0)	7 (6.8)	161 (24.4)		2 (3.3)	5 (2.8)	150 (367)
	Slight functional dependence/independence	73 (9.6)	2 (1.9)	71 (10.8)		0 (0)	2 (1.1)	69 (16.9)
Changes of goals-of-care to palliative care		234 (27.6)	NA	234 (33.8)	NA	40 (65.6)	93 (52)	83 (20.3)	< 0.001^§ § p < 0.05 between worsened functional status during hospitalization versus improved functional status during hospitalization; ^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
Length of stay in the PACF)		36 ± 34	22.6 ± 25	39.2 ± 35	< 0.001	41 ± 29	33 ± 51	44 ± 25	0.002^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
Discharge disposition					< 0.001				< 0.001^‡ ‡ p < 0.05 between worsened functional status during hospitalization versus no change in functional status during hospitalization; ^§ § p < 0.05 between worsened functional status during hospitalization versus improved functional status during hospitalization; ^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
	Death	285 (33.6)	127 (81.9)	169 (24.4)		31 (50.8)	86 (48)	27 (6.6)
	Transference to acute hospital	173 (20.4)	4 (2.6)	158 (22.8)		11 (18)	59 (33)	81 (19.8)
	Discharged home	389 (45.9)	24 (15.5)	365 (52.7)		19 (31.1)	34 (19)	301 (73.6)
Death with a do-not-resuscitate order among deceased patients		263 (92.2)	127 (100)	136 (80.4)	< 0.001	30 (96.8)	71 (82.5)	21 (77.8)	< 0.001^‡ ‡ p < 0.05 between worsened functional status during hospitalization versus no change in functional status during hospitalization; ^§ § p < 0.05 between worsened functional status during hospitalization versus improved functional status during hospitalization;
Complexity of health care assistance after discharge from the PACF					0.196				< 0.001^§ § p < 0.05 between worsened functional status during hospitalization versus improved functional status during hospitalization; ^¶ ¶ p < 0.05 between no change in functional status during hospitalization versus improved functional status during hospitalization. Results expressed as n (%) or mean ± standard deviation.
	Discharged home without home assistance	104 (12)	4 (3)	100 (14)		1 (2)	5 (3)	93 (23)
	Discharged home with home-based rehabilitation services	232 (27)	14 (9)	218 (32)		9 (15)	8 (4)	191 (47)
	Discharged home with 24-hour nursing care	54 (6)	6 (4)	48 (7)		9 (15)	21 (12)	17 (4)
Satisfaction score with hospitalization in the PACF		9.5 ± 1	9.5 ± 1	9.5 ±1	0.681	9.4 ± 0.9	9.5 ± 1.1	9.5 ± 1.1	0.718

Associação de Medicina Intensiva Brasileira - AMIB Rua Arminda, 93 - 7º andar - Vila Olímpia, CEP: 04545-100, Tel.: +55 (11) 5089-2642 - São Paulo - SP - Brazil
E-mail: ccs@amib.org.br

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[1] Corresponding author: João Gabriel Rosa Ramos Clínica Florence Rua Bela Vista do Cabral, 271 - Nazaré Zip code: 40055-000 - Salvador (BA), Brazil E-mail: jgrr25@gmail.com.