We are excited to present the first edition of the PCCM Global Critical Care Article of the Month! Every 2 months, a team of pediatric intensive care experts from WFPICCS selects one outstanding paper from Pediatric Critical Care Medicine, the Official Journal of WFPICCS, to spotlight key advances, emerging evidence, and perspectives shaping our field.
This initiative aims to foster continuous learning and reflection, encouraging our global community to engage with the latest research that informs and improves the care of critically ill children worldwide.
The selected Article for December 2025 is Return-to-Care After Discharge Directly Home From the PICU: A Propensity-Matched Cohort Study
Expert commentary by Dr. Lokesh Tiwari
Why This Question Matters?
Discharge from the pediatric intensive care unit (PICU) represents a critical juncture in a child’s illness trajectory. While survival from critical illness has steadily improved, the period immediately following PICU discharge is increasingly recognized as a time of vulnerability for children and families alike. It carries risks of communication failures, unplanned healthcare needs and caregiver anxiety. Traditionally, most children are transferred from the PICU to an acute care or step-down ward before being discharged home. Over the past decade, many PICUs have adopted the practice of discharging selected patients directly home from the PICU, reducing hospital stays.
This shift has been driven by multiple forces, including PICU bed pressure and system-wide efforts aimed at efficiency. Some acute illnesses have shorter lengths of stay requiring no step-down care, while some medically complex children need family involvement and training rather than ward-level care. Discharge is a known high-risk transition, and concerns persist that bypassing the ward could increase readmissions, emergency department (ED) visits, or caregiver distress. Prior pediatric evidence has largely been limited to small, single-centre studies, leaving uncertainty about safety and system-level impact at scale. Against this backdrop, the multicenter study by Dervan et al., published in Pediatric Critical Care Medicine December issue provides the most comprehensive evaluation of outcomes after discharge directly home from the PICU [1].
What Did This Study Add?
In this multicenter propensity-matched cohort study of 560,815 pediatric intensive care unit (PICU) discharges from 45 U.S. children’s hospitals (2016–2023), 150,126 children (26.8%) were discharged directly home from the PICU, with substantial inter-hospital variation (9.8%–55.6%). Using propensity score matching, 94,048 children discharged directly home were compared with 153,887 matched peers transferred to an acute care ward prior to discharge. Within 14 days of hospital discharge, rates of return-to-ED care were similar between groups (2.9% vs 3.0%; OR 0.94, 95% CI 0.89–0.99), as were hospital readmissions (4.8% vs 4.9%; OR 0.97, 95% CI 0.94–1.01). However, among those readmitted, children discharged directly home were more likely to require PICU readmission (2.4% vs 1.6%; OR 1.58, 95% CI 1.49–1.67). The most striking and globally relevant contribution of this study lies in its economic findings. Median 14-day inpatient costs were approximately $15,023 (IQR, $7,614–$34,295) for children discharged directly home, compared with $30,750 (IQR, $14,558–$68,831) for ward-transferred peers (p ≤ 0.001), reflecting nearly a 50% reduction, primarily due to a shorter length of hospital stay. These results are consistent with earlier single-centre pediatric studies and adult ICU literature suggesting that direct ICU discharge, when applied selectively, does not increase short-term adverse outcomes [2–5].
The Cost Story: Why This Matters Globally
In high-income settings, these findings support the value-based care approach and more efficient use of ICUs. In LMICs, where PICU beds are limited, safely shortening hospital stays could expand access and improve equity. Similar benefits have been reported in adult critical care, where direct ICU discharge preserves safety while reducing resource use. [6–8].
Interpreting the ICU Readmission Signal
Among children who were readmitted, those discharged directly home were more likely to return to the PICU than to a ward. Importantly, these children did not have higher illness severity or greater subsequent costs, suggesting this may reflect clinician risk perception rather than worse outcomes. Emergency clinicians may have a lower threshold for ICU admission in children recently discharged from the PICU, a pattern also described in adult critical care. [7,8].
Variation Across Centers: Culture, Not Risk Alone
The wide variation in direct-to-home discharge rates across hospitals, without a corresponding increase in readmissions, suggests that institutional culture, discharge processes, and confidence, rather than patient risk alone, strongly shape practice. Similar variability has been reported in pediatric and adult ICUs internationally [3,6,9]. This heterogeneity represents opportunity: if some centres can safely discharge a high proportion of patients directly home, others may be able to do so with appropriate system supports.
Counterpoints and What This Study Does Not Tell Us
Despite its strengths, several cautions merit attention. First, like most studies, the evidence remains observational, and systematic reviews of direct ICU discharge have graded the overall certainty of evidence as low to moderate [6]. Administrative datasets may underestimate the true post-discharge burden, as they often miss urgent outpatient visits, caregiver phone calls, or functional decline. Caregiver experience is central in pediatrics. Qualitative and mixed-methods studies indicate that families discharged directly home from the PICU often feel anxious and desire clearer communication, anticipatory guidance, and early follow-up [10,11]. Saving hospital resources should not mean families go home feeling unsure or unprepared. Evidence suggests that children discharged directly home were more likely to come from socially advantaged backgrounds or to have prior experience with complex home care [1,3]. Equity deserves explicit consideration. This practice will only be fair if all families have equal access to follow-up care and community support. It is worth exploring the role of Telemedicine follow-up in this context.
What Should Change in Practice?
This study demonstrates that, within current practice, discharging children directly home from the PICU can be safe, efficient, and cost-saving for selected patients, while highlighting the need for thoughtful implementation. Findings do not support routine direct discharge home for all PICU patients. Rather, they suggest a deliberate, criteria-based approach that includes physiologic stability, caregiver readiness, clear discharge communication, and reliable follow-up. Targeted post-discharge interventions, such as early follow-up calls or ICU liaison services, may mitigate risk and anxiety, although benefits are variable. Direct PICU discharge should not be automatic, but it should no longer be exceptional.
References
- Dervan LA, Heneghan JA, Hall M, Choi DH, Dziorny AC, Goodman DM, et al. Return-to-Care After Discharge Directly Home From the PICU: A Propensity-Matched Cohort Study. Pediatr Crit Care Med. 2025 Dec 1;26(12):e1467-e1475.
- Roumeliotis N, Hassine CH, Ducruet T, Lacroix J. Discharge Directly Home From the PICU: A Retrospective Cohort Study. Pediatr Crit Care Med. 2023 Jan 1;24(1):e9-e19.
- Pizzuto MF, Sutton AG, Schroeder KS, Bravo MA, Li L, Kihlstrom MJ. Characteristics and Outcomes of Patients Discharged Directly Home From the Pediatric Intensive Care Unit. J Intensive Care Med. 2023 Aug;38(8):737-742.
- Dervan LA, Garros D, Howard W, Roumeliotis N. Prevalence and Predictors of Home Discharge from the PICU. Crit Care Explor. 2025 May 16;7(5):e1266.
- Daoust D, Dodin P, Sy E, Lau V, Roumeliotis N. Prevalence and Readmission Rates of Discharge Directly Home From the PICU: A Systematic Review. Pediatr Crit Care Med. 2023 Jan 1;24(1):62-71.
- Stelfox HT, Soo A, Niven DJ, Fiest KM, Wunsch H, Rowan KM et al.. Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit: A Multicenter Population-Based Cohort Study. JAMA Intern Med. 2018 Oct 1;178(10):1390-1399.
- Martin CM, Lam M, Le B, Pinto R, Lau V, Ball IM, et al. Outcomes After Direct Discharge Home From Critical Care Units: A Population-Based Cohort Analysis. Crit Care Med. 2022 Aug 1;50(8):1256-1264.
- Lau VI, Donnelly R, Parvez S, Gill J, Bagshaw SM, Ball IM, et al. Safety Outcomes of Direct Discharge Home From ICUs: An Updated Systematic Review and Meta-Analysis (Direct From ICU Sent Home Study). Crit Care Med. 2023 Jan 1;51(1):127-135.
- Kennedy TK, Numa A. Factors associated with discharge delay and direct discharge home from paediatric intensive care. J Paediatr Child Health. 2020 Jul;56(7):1101-1107.
- Roumeliotis N, Desforges J, French ME, et al. Patient and family experience with discharge directly home from the pediatric ICU. Hosp Pediatr. 2023;13:954-960.
- Choi J, Lingler JH, Donahoe MP, et al. Home discharge following critical illness: a qualitative analysis of caregiver experience. Heart Lung. 2018;47:401-407.
You can read the full Article here: https://journals.lww.com/pccmjournal/abstract/2025/12000/return_to_care_after_discharge_directly_home_from.7.aspx
