Chest Pain A Manifestation of Migraine

Background

Chest pain is an alarming symptom; it justifies many visits to the emergency department (ED). The etiology is often unknown. Chest wall pain in the presence of migraine headache, although not a common occurrence, is intriguing when it resolves with antimigraine treatment.

Objectives

To characterize the manifestations and outcomes and investigate the relationship between chest wall pain and headache as a manifestation of migraine exacerbation.

Methods

Among patients visiting our ED, we identified those individuals whose pain originated in the chest wall in the setting of migraine exacerbation. Patients with clinical indications for specific treatments were dispositioned accordingly. Control of symptoms including chest pain and headache with antimigraine agents was considered the primary outcome. A prospective follow-up via telephone interview and medical records review was performed.

Results

We collected a convenience sample of 33 patients. All manifested migraine headache with an earlier onset than the chest pain, and all had taken medications prior to visiting the ED. Twelve patients reported a higher visual analog scale score for the headache than for the chest pain. Still, chest pain was the main complaint. The chest pain originated at the chest wall. Ten patients received sublingual nitroglycerin or opiates, or both; no pain relief was reported. However, all symptoms resolved with metoclopramide. On follow-up, 6 patients reported recurrence of chest pain with subsequent migraines.

Conclusions

Chest pain can be a complication of migraine. The treatment should be focused on migraine control. Migraine should be included in the differential diagnosis of chest pain.     

Steroids for Migraine Headaches: A Randomized Double-Blind, Two-Armed, Placebo-Controlled Trial

Background: Recurrence of migraine headache after treatment in the emergency department (ED) is common. Conflicting evidence exists regarding the utility of steroids in preventing migraine headache recurrence at 24–48 h. Objective: To determine if steroids decrease the headache recurrence in patients treated for migraine headaches in the ED. Methods: Double-blind placebo-controlled, two-tailed randomized trial. Patients aged >17 years with a moderately severe migraine headache diagnosed by treating Emergency Physician were approached for participation. Enrollees received either dexamethasone (10 mg i.v.) if intravenous access was utilized or prednisone (40 mg by mouth × 2 days) if no intravenous access was obtained. Each medication was matched with an identical-appearing placebo. Patients were contacted 24–72 h after the ED visit to assess headache recurrence. Results: A total of 181 patients were enrolled. Eight were lost to follow-up, 6 in the dexamethasone group and 2 in the prednisone arm. Participants had a mean age of 37 years (±10 years), with 86% female. Eighty-six percent met the International Headache Society Criteria for migraine headache. Of the 173 patients with completed follow-up, 20/91 (22%) (95% confidence interval [CI] 13.5–30.5) in the steroid arm and 26/82 (32%) (95% CI 21.9–42.1) in the placebo arm had recurrent headaches (p = 0.21). Conclusion: We did not find a statistically significant decrease in headache recurrence in patients treated with steroids for migraine headaches.     

Air pollution and daily ED visits for migraine and headache in Edmonton,Canada

Background

A variety of environmental factors have been identified as possible triggers for migraine and other headache syndromes.

Objective

We analyzed associations between air pollution and emergency department (ED) visits for migraine and headache.

Methods

Analysis was based on 56 241 ED visits for migraine and 48 022 ED visits for headache to Edmonton hospitals between 1992 and 2002. A Poisson model of counts hierarchically clustered by day of week, month, and year was applied using generalized linear mixed models. Temperature and relative humidity were included as covariates.

Results

Females accounted for 78.5% of migraine visits and 56.3% of headache visits. An interquartile range (IQR) increase (6.2 μg/m³) in daily average particulate matter of median aerodynamic diameter less than 2.5 μm (PM_2.5) was associated with increases in visits of 3.3% for migraine (95% confidence interval [CI]: 0.6-6.0), lagged 2 days, and 3.4% for headache (95% CI: 0.3-6.6), lagged 0 days, among females in the cold season (October-March). PM_2.5 was also associated with cold season migraine visits among females at lag 0 and 1 day (P < .1). In the warm period (April-September), a 2.3-ppb IQR increase in sulfur dioxide was associated with a 2.5% increase in migraine visits (95% CI: 0.3-4.6) among females, whereas a 12.8-ppb IQR increment in nitrogen dioxide was associated with a 6.8% increase in headache visits (95% CI: 1.5-12.5) for males.

Conclusions

Findings provide preliminary evidence of an association between air pollution and ED visits for migraine and nonspecific headache. Findings were most consistent for particulate matter.     

Prospective analysis of the use of OnabotulinumtoxinA (BOTOX) in the treatment of chronic migraine; real-life data in 254 patients from Hull,UK

Background

Chronic migraine affects 2% of the population. It results in substantial disability and reduced quality of life. Medications used for prophylaxis in episodic migraine may also work in chronic migraine. The efficacy and safety of OnabotulinumtoxinA (BOTOX) in adults with chronic migraine was confirmed in the PREEMPT programme. However, there are few real-life data of its use.

Method

254 adults with chronic migraine were injected with OnabotulinumtoxinA BOTOX as per PREEMPT Protocol between July 2010 and May 2013, their headache data were collected using the Hull headache diary and analysed to look for headache, migraine days decrements, crystal clear days increment in the month post treatment, we looked at the 50% responder rate as well.

Results

Our prospective analysis shows that OnabotulinumtoxinA, significantly, reduced the number of headache and migraine days, and increased the number of headache free days. OnabotulinumtoxinA Botox also improved patients’ quality of life. We believe that these results represent the largest post-marketing cohort of patients treated with OnabotulinumtoxinA in the real-life clinical setting.

Conclusion

OnabotulinumtoxinA is a valuable addition to current treatment options in patients with chronic migraine. Our results support findings of PREEMPT study in a large cohort of patients, we believe, is representative of the patients seen in an average tertiary headache centre. While it can be used as a first line prophylaxis its cost may restrict its use to more refractory patients who failed three oral preventive treatments.     

Prochlorperazine in children with migraine: a look at its effectiveness and rate of akathisia

Objective

The objective of this study is to evaluate the effectiveness of prochlorperazine and the rate of akathisia in children with severe migraine.

Methods

The study is a prospective cohort of a convenient sample of patients younger than 18 years old diagnosed with migraine and treated with intravenous prochlorperazine in adjunction with diphenhydramine in the emergency department. The evaluation of pain and akathisia was performed before the treatment and was repeated 60 minutes later and before discharge. A telephone follow-up was completed to assess relapse in pain and presence of akathisia. The effectiveness of prochlorperazine was determined using different outcomes: 50% reduction of pain, pain-free patients, treatment failure, and relapse of pain.

Results

Of the 79 patients included in the study for 25 months, 64 (81%) either met the International Headache Society criteria or had a diagnosis of migraine confirmed by a neurologist at follow-up. Among these patients, 47 (100%) of 47 had a 50% reduction of pain, and 24 (50%) of 48 were pain free at discharge. Only 14 (22%) of 64 patients had a treatment failure. However, 43 (68%) of 63 patients had a relapse of their headache within the first week after discharge. Overall, among the 79 patients, 4 (5%) had a definitive diagnosis of akathisia, but 27 (34%) other patients presented symptoms suggesting a possible diagnosis of akathisia.

Conclusion

Prochlorperazine seems very effective to decrease pain on a short-term basis in children. However, more than two thirds of the patients, overall, had a relapse of their migraine at home in the first week. Despite the use of diphenhydramine, akathisia remains a concern.     

Efficacy of high-flow oxygen therapy in all types of headache: a prospective,randomized, placebo-controlled trial

Objective

We aimed to assess the efficacy of oxygen inhalation therapy in emergency department (ED) patients presenting with all types of headache.

Method

We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED with a chief complaint of headache. The patients were randomized to receive either 100% oxygen via nonrebreather mask at 15 L/min or the placebo treatment of room air via nonrebreather mask for 15 minutes in total. We recorded pain scores at 0, 15, 30, and 60 minutes using the visual analog scale. At 30 minutes, the patients were assessed for the need for analgesic medication. Patient headache type was classified by the treating emergency physician using standardized diagnostic criteria.

Results

A total of 204 patients agreed to participate in the study and were randomized to the oxygen (102 patients) and placebo (102 patients) groups. Patient headache types included tension (47%), migraine (27%), undifferentiated (25%), and cluster (1%). Patients who received oxygen therapy reported significant improvement in visual analog scale scores at all points when compared with placebo: 22 mm vs 11 mm at 15 minutes (P < .001), 29 mm vs 13 mm at 30 minutes (P < .001), and 55 mm vs 45 mm at 60 minutes (P < .001). When questioned at 30 minutes, 72% of patients in the oxygen group and 86% of patients in the placebo group requested analgesic medication (P = .005).

Conclusion

In addition to its role in the treatment of cluster headache, high-flow oxygen therapy may provide an effective treatment of all types of headaches in the ED setting.     

Current Aura Without Headache

Purpose of Review

This review evaluates and explains our current understanding of a rare subtype of migraine, typical aura without headache, also known as migraine aura without headache or acephalgic migraine.

Recent Findings

Typical aura without headache is a known entity within the spectrum of migraine. Its pathophysiology is suggested to be similar to classic migraines, with cortical spreading depression leading to aura formation but without an associated headache. No clinical trials have been performed to evaluate treatment options, but case reports suggest that most patients will respond to the traditional treatments for migraine with aura. Bilateral greater occipital nerve blocks may be helpful in aborting migraine with prolonged aura. Transcranial magnetic stimulation has shown efficacy in aborting attacks of migraine with aura but has not been specifically tested in isolated aura.

Summary

Typical aura without headache occurs exclusively in 4% patients with migraine, and may take place at some point in 38% of patients with migraine with aura. Typical aura without headache commonly presents with visual aura without headache, brainstem aura without headache, and can also develop later in life, known as late-onset migraine accompaniment.

     

Frovatriptan in the practice of office-based neurologists/pain therapists: Results of postmarketing surveillance study ALADIN

Introduction

Large postmarketing surveillance (PMS) studies have demonstrated the efficacy and tolerability of frovatriptan for treatment of acute migraine in patients attending general practitioners (GPs). The aim of the ALADIN (Allegro® Anwendung durch interessierte Neurologen [Allegro® application by interested neurologists]) PMS study was to evaluate frovatriptan in patients attending neurologists or pain therapists.

Methods

Patients fulfilling International Headache Society criteria for migraine, with or without aura, were enrolled. Patients completed an attack diary, including details of the attack, time to onset of action of frovatriptan, and recurrence of headache. Physicians completed a case report form detailing prior and actual migraine treatment. Frovatriptan 2.5 mg was administered for up to three consecutive attacks.

Results

In total, 2160 patients were enrolled and data were obtained for 5831 attacks. Patients attending neurologists had more frequent attacks and longer history of migraine compared with those attending GPs. Median time to frovatriptan onset of action was 40 min and time to freedom from headache 70 min. An average of 1.2 frovatriptan tablets was required per attack, and mean additional analgesic use was 0.13. Recurrent headache occurred in 13.6%–15.5% of patients. Physicians as well as patients judged frovatriptan onset and duration of action as at least “good” in approximately 80% of attacks. A similar number judged the efficacy of frovatriptan against headache as “better” than previous treatment. The study drug was generally well tolerated. The frequency of adverse events was 0.6%.

Conclusion

Frovatriptan, with fast onset of action and low rate of headache recurrence, was efficacious and well accepted by migraineurs attending neurologists or pain therapists. Approximately 80% of patients wished to continue migraine treatment with frovatriptan.

     

Characteristics of elderly fall patients with baseline mental status: high-risk features for intracranial injury

Background

Falls are a major cause of morbidity in the elderly.

Objectives

We describe the low-acuity elderly fall population and study which historical and clinical features predict traumatic intracranial injuries (ICIs).

Methods

This is a prospective observational study of patients at least 65 years old presenting with fall to a tertiary care facility. Patients were eligible if they were at baseline mental status and were not triaged to the trauma bay. At presentation, a data form was completed by treating physicians regarding mechanism and position of fall, history of head strike, headache, loss of consciousness (LOC), and signs of head trauma. Radiographic imaging was obtained at the discretion of treating physicians. Medical records were subsequently reviewed to determine imaging results. All patients were called in follow-up at 30 days to determine outcome in those not imaged. The study was institutional review board approved.

Results

A total of 799 patients were enrolled; 79.5% of patients underwent imaging. Twenty-seven had ICIs (3.4%). Fourteen had subdural hematoma, 7 had subarachnoid hemorrhage, 3 had cerebral contusion, and 3 had a combination of injuries. Logistic regression demonstrated 2 study variables that were associated with ICIs: LOC (odds ratio, 2.8; confidence interval, 1.2-6.3) and signs of head trauma (odds ratio, 13.2; confidence interval, 2.7-64.1). History of head strike, mechanism and position, headache, and anticoagulant and antiplatelet use were not associated with ICIs.

Conclusion

Elderly fall patients who are at their baseline mental status have a low incidence of ICIs. The best predictors of ICIs are physical findings of trauma to the head and history of LOC.     

Headache,migraine and risk of brain tumors in women: prospective cohort study

Background

While headache is a common symptom among brain tumors patients, often patients with common headache have concerns of being at risk for developing brain tumors. We aimed to disprove that migraine or headache in general is associated with increased risk of developing brain tumors.

Methods

Prospective study among 39,534 middle-aged women, free of any cancer, and who provided information on headache history at baseline. We followed participants for occurrence of medical record-confirmed brain tumors. We ran multivariable-adjusted Cox proportional hazards models to evaluate associations between any headache, migraine, and non-migraine headache with incident brain tumors. We further evaluated whether migraine frequency and updated headache information during follow-up could be linked with brain tumors.

Results

A total of 13,022 (32.9%) women reported headache, of which 5,731 were classified as non-migraine headache and 7,291 as migraine. During a mean follow-up of 15.8 years, 52 brain tumors were confirmed. The multivariable-adjusted hazard ratios (95% confidence interval) for brain tumors were 1.33 (0.76-2.34) for any headache, 1.18 (0.58-2.41) for migraine and 1.53 (0.75-3.12) for non-migraine headache. The association for any headache was further attenuated in time-varying analyses (1.15; 0.58-2.24). Those who experience migraine six times/year were also not at increased risk of brain tumor (0.67; 0.13-3.32).

Conclusions

Results of this large, prospective cohort study in women do not provide evidence that headache in general or migraine in particular are associated with the occurrence of brain tumors. Our data should reassure patients with headache that brain tumor is not a long-term consequence of headache.     

Treatment with rituximab,dexamethasone, high-dose cytarabine,and oxaliplatin (R-DHAOx) produces a strong long-term antitumor effect in previously treated patients with follicular non-Hodgkin's lymphoma

Background

We explored the addition of rituximab to high-dose cytarabine (ara-C), oxaliplatin (L-OHP), and dexamethasone [R-DHAOx], in resistant and relapsed patients with CD20-positive follicular non-Hodgkin's lymphoma.

Methods

Twenty-two patients were included; they were treated previously with one to five chemotherapy regimens, including 13 patients who had also received rituximab. R-DHAOx consisted of rituximab, 375 mg/m², day 1; dexamethasone, 40 mg/d, days one to four; L-OHP, 130 mg/m², day 1; and ara-C, 2000 mg/m² every 12 h, day 2. Courses were repeated every 21 days for eight courses.

Results

Twenty-one patients (95%) achieved a complete response and one had a partial response. Responses were obtained in patients with and without resistance to prior treatment, either alone or combined with rituximab. The median follow-up time was 58.3 months (range, 8.7–92.6 months). Progression-free survival reached a plateau at 84% at 38.2 months. Only two of the 21 complete responders have relapsed. Tumor molecular markers disappeared in all 10 complete responders whose markers were found before treatment. Peripheral neuropathy related to the cumulative dose of L-OHP, and myelosuppression were the most prominent toxic effects.

Conclusions

R-DHAOx is highly active for salvage treatment of patients with follicular non-Hodgkin's lymphoma, and it produces long-term antitumor efficacy.     

Quantifying drug-seeking behavior: a case control study

Background

Drug-seeking behavior (DSB) is common in the Emergency Department (ED), yet the literature describing DSB in the ED consists predominantly of anecdotal evidence.

Study Objectives

To perform a case-control study examining the relative frequency of DSB in suspected drug-seeking patients as compared to all ED patients.

Methods

We performed a retrospective chart review of 152 drug-seeking patients and of age- and gender-matched controls, noting which of the following behaviors were exhibited during a 1-year period: reporting a non-narcotic allergy, requesting addictive medications by name, requesting a medication refill, reporting lost or stolen medication, three or more ED visits complaining of pain in different body parts, reporting 10 out of 10 pain, reporting > 10 out of 10 pain, three or more ED visits within 7 days, reporting being out of medication, requesting medications parenterally, and presenting with a chief complaint of headache, back pain, or dental pain.

Results

The odds ratios for each studied behavior being used by drug seeking patients as compared to controls were: non-narcotic allergy: 3.4, medication by name: 26.3, medication refill: 19.2, lost or stolen medication: 14.1, three or more pain related visits in different parts of the body: 29.3, 10 out of 10 pain: 13.9, three visits in 7 days: 30.8, out of medication: 26.9, headache: 10.9, back pain: 13.6, and dental pain: 6.3. Zero patients in the control group complained of greater than 10-out-of-10 pain or requested medication parenterally, resulting in a calculated odds ratio of infinity for these two behaviors.

Conclusions

Requesting parenteral medication and reporting greater than ten out of ten pain were most predictive of drug-seeking, while reporting a non-narcotic allergy was less predictive of drug-seeking than other behaviors.     

Facilitated angioplasty with combo therapy among patients with ST-segment elevation myocardial infarction: a meta-analysis of randomized trials

Introduction

Time to treatment has been shown to be a major determinant of mortality in primary angioplasty. The aim of the current study was to perform a meta-analysis of randomized trials evaluating the benefits from pharmacologic facilitation with adjunctive glycoprotein (Gp) IIb-IIIa inhibitors + reduced lytic therapy vs adjunctive Gp IIb-IIIa inhibitors among patients with ST-segment elevation myocardial infarction (MI).

Methods

We obtained results from all randomized trials comparing facilitated PCI with adjunctive Gp IIb-IIIa inhibitors and reduced lytic therapy vs adjunctive Gp IIb-IIIa inhibitors among patients with ST-segment elevation MI (STEMI). The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL) from January 1990 to December 2007. The following key words were used: randomized trial, MI, reperfusion, primary angioplasty, pharmacologic facilitation, facilitated angioplasty, combo therapy, fibrinolysis, thrombolysis, half-dose lytic therapy, duteplase, reteplase, tenecteplase, alteplase, abciximab, tirofiban, eptifibatide, and Gp IIb-IIIa inhibitors. Angiographic end points were the rate of preprocedural and postprocedural thrombolysis in MI (TIMI) 3 flow. Clinical end points assessed were mortality and reinfarction at 30-day follow-up, whereas major bleeding complications were assessed as safety end point. No language restriction was applied.

Results

We identified 6 randomized trials, including 2684 patients with STEMI. Even though combo therapy was associated with a significant improvement in preprocedural TIMI 3 flow (44.3% vs 15.2%, P < .0001, P_het < .0001), it did not improve the rate of postprocedural TIMI 3 flow (91.5% vs 91.2%, P = .12). No benefits were observed in terms of 30-day mortality (4.2% vs 4.6%, P = .66, P_het = .22) and/or 30-day reinfarction (1.3% vs 1.3%, P = .84). However, combo therapy was associated with higher risk of major bleeding complications (5.8% vs 3.9%, P = .03).

Conclusions

This meta-analysis shows that among patients with STEMI undergoing primary angioplasty, pharmacologic facilitation with combined reduced-dose thrombolytic therapy and Gp IIbIIIa inhibitors is not superior to Gp IIb-IIIa inhibitors alone and, thus, may not be routinely recommended. However, future randomized trials should investigate whether this strategy may further improve outcome when applied within the first hours from symptoms onset, especially in patients undergoing transferring for primary angioplasty.     

Findings of Chronic Sinusitis on Brain Computed Tomography Are Not Associated with Acute Headaches

Background

Headache is a common complaint in emergency department (ED) patients. Nearly 15% of ED headache patients will have brain computed tomography (CT) done. One frequent finding on these scans is “chronic sinusitis.” Assuming that “chronic sinusitis” is the cause of the patient's headache is a potential source of mis-diagnosis.

Study Objective

We hypothesized that CT findings of chronic sinusitis occur with equal frequency in patients with atraumatic headache as in control patients with minor head injury.

Methods

This is a retrospective, single-center medical record review of consecutive discharged patients who received noncontrast head CT scans in an urban ED for either minor closed head injury or atraumatic headache. Each patient's head CT radiologic report was reviewed for findings of sinusitis and classified as chronic sinusitis, indeterminate for sinusitis, air-fluid levels, or no findings of sinusitis.

Results

We enrolled 500 patients (234 in the atraumatic headache group, 266 in the minor head injury group). The two groups were similar except that more women were enrolled in the atraumatic headache group. CT findings of chronic sinusitis in the atraumatic headache group (22.2%) and the minor head injury group (17.7%; difference 4.5%; 95% confidence interval of −2.5–11.6%).

Conclusion

Prevalence of CT findings of sinusitis in ED patients with atraumatic headaches and mild head injury are similar. This strongly suggests that CT findings of chronic sinusitis in patients with atraumatic headache may be incidental, and are rarely the cause of a patient's acute headache.     

Prospective evaluation of an ED observation unit protocol for trauma activation patients

Background

The University of Utah emergency department (ED) observation unit (EDOU) cares for over 2500 patients each year, with a significant portion of these patients being trauma activation patients. We evaluated the safety and efficacy of our EDOU trauma protocol and described patient characteristics and outcomes of trauma patients managed in an EDOU.

Methods

We performed a prospective observational study of all trauma patients admitted to the EDOU over a 1-year period. Patient disposition, interventions, and adverse events during observation were recorded. Thirty-day follow-up was performed by telephone and chart review to evaluate for missed injuries, repeat hospitalizations, or repeat traumatic events.

Results

A total of 259 trauma patients were admitted to the EDOU during the study period and were contacted at least 30 days after discharge. There were no deaths, intubations, or other adverse events. At 30-day follow-up, there was 1 missed injury, which did not result in an adverse outcome. Ten patients were reevaluated in the ED or required hospitalization for events occurring after their initial EDOU stay but related to their initial trauma evaluation. The inpatient admission rate from the EDOU was 10.4%, and 3.1% of patients reported another traumatic event during the 30-day follow-up period.

Conclusions

There were no adverse outcomes in trauma patients admitted to the EDOU, and our inpatient admission rate was within the generally accepted admission rate for patients in observation status. The EDOU appears to be a safe alternative to inpatient admission for the evaluation of minimally injured trauma activation patients.     

Intravenous Magnesium As Acute Treatment for Headaches: A Pediatric Case Series

Background

Acute i.v. treatment for pediatric headache varies widely.

Objectives

Our aim was to describe our experience with i.v. magnesium for acute treatment of pediatric headache.

Methods

We reviewed the electronic medical records of all patients ages 5 to 18 years old treated with a standard dose of i.v. magnesium for headache at our institution from January 2008 to July 2010. Charts were assessed for headache diagnosis, prior medications given, side effects, tolerability, and response to treatment. Individuals were excluded if they had an underlying unstable medical condition or a secondary etiology for headache. Only first encounters were included if the patient had multiple encounters.

Results

There were 34 episodes of children who received i.v. magnesium in the emergency department (ED) or hospital. Of these, 14 were excluded because the patients had complex medical conditions (n = 6), they were repeat encounters (n = 7), or known secondary etiology for the headache (n = 1). Of the 20 included charts (range 13–18 years old), 5 had migraine, 4 had tension-type headache, and 11 had status migrainosus. Thirteen were treated in the ED and seven as an inpatient with a standard i.v. dose of magnesium. Ten of thirteen adolescents receiving i.v. magnesium in the ED were admitted for further headache treatment but not for side effects, and three were discharged home. Side effects of treatment included pain (1 of 20), redness (1 of 20), burning (1 of 20), and decreased respiratory rate without change in oxygenation (1 of 20).

Conclusions

In our case series, adolescents given i.v. magnesium as an abortive therapy for headache experienced minimal side effects and further studies should evaluate for effectiveness.     

Homeward bound: An analysis of patients discharged home from an oncologic intensive care unit

Purpose

The objectives of our study were to evaluate the characteristics and outcomes of patients discharged home directly from an oncologic intensive care unit (ICU) and their 30-day hospital readmission patterns.

Materials and Methods

We retrospectively reviewed ICU discharges over 3 years (2008-2010) and identified patients who were discharged directly home. Demographic, clinical, ICU discharge, and 30-day hospital readmission and mortality rates were analyzed.

Results

Ninety-five patients (3.6%) were discharged home directly from the ICU (average annual rate of 3.9%). ICU diagnoses primarily included respiratory insufficiency, sepsis, cardiac syndromes, and gastrointestinal bleeding. Home discharge occurred most commonly between Thursday and Saturday. Five (5.3%) patients, including 2 hospice patients, died within 30 days of ICU home discharge. Thirty (31.6%) patients were readmitted within 30 days of discharge. The unplanned 30-day readmission rate was 23.2% (22/95) with a median time to hospital readmission of 13 (8-18) days. Most (64%) of the unplanned readmissions were related to the initial ICU admission.

Conclusions

Home discharge of ICU patients at our institution is infrequent but consistent. Almost one third of these patients were readmitted to the hospital within 30 days. Enhancements to the ICU home discharge process may be required to ensure optimal post-ICU care.