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Stiell IG, Odorizzi S, Perry JJ, Eagles DA, Yadav K. Decreased patient discharges on weekends part 1: what do the data tell us? CAN J EMERG MED 2024:10.1007/s43678-024-00726-z. [PMID: 38935239 DOI: 10.1007/s43678-024-00726-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/27/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND We believe that hospital and emergency department (ED) crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. In part 1 of 3 concurrent studies, we documented the number of weekend discharges and the extent of hospital and ED crowding on the days following weekends. METHODS We conducted a data analysis study at The Ottawa Hospital, a major academic health sciences center with two EDs. We created reports of the 18-month period (January 1, 2022-June 30, 2023) regarding the status of in-patients at the two campuses. We compared the total admissions, discharges, and hospital occupancy on weekends (or long weekends), the Monday following weekends (or Tuesday following long weekends), or Tuesdays-Fridays. For these three time periods, we also compared the proportion of ED beds occupied by admitted patients to all ED beds, as well as the proportion of days with > 70% admitted patients housed in the ED at 8:00am. RESULTS Our data for 55,692 patients demonstrated that on weekends compared to weekdays, there were almost 50% fewer discharges with the ratio of admissions to discharges averaging 1.16 (95% CI 1.10-1.22). This was accompanied by a 2.4% absolute increase (P < 0.001) in hospital occupancy on Mondays or Tuesdays, often exceeding 100%. Both EDs are particularly crowded on these Mondays and Tuesdays with the proportion of admitted patients to regular ED beds averaging 68%. We observed serious crowding with > 70% occupancy with admitted patients on almost 50% of Mondays. INTERPRETATION We have demonstrated that there are much fewer discharges on weekends, and this is associated with significant hospital and ED crowding on Mondays. This blocks safe and timely access to beds for newly arriving patients in the ED. These results should spur Canadian hospitals to evaluate their own data and seek solutions to this important problem.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| | - Scott Odorizzi
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Debra A Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Stiell IG, Cheung WJ, Eagles DA, Yadav K, Perry JJ. Decreased patient discharges on weekends: part 2-what do the ward nurses tell us? CAN J EMERG MED 2024:10.1007/s43678-024-00697-1. [PMID: 38829484 DOI: 10.1007/s43678-024-00697-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/28/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Hospital and emergency department (ED) crowding is exacerbated on Mondays because fewer in-patients are discharged during the weekend. We evaluated the experiences and attitudes of in-patient ward nurses to better understand the challenges they face when considering the weekend discharge of their patients. METHODS We conducted a qualitative study of in-patient ward nurses, using the theoretical domains framework (TDF), at two campuses of a major academic health sciences centre. The interview guides consisted of, first, a series of questions to explore the typical processes involved for safe patient discharges and, second, exploration of the influence of the 14 TDF domains. All interviews were audio-recorded, transcribed verbatim, and anonymized and then imported into NVivo qualitative software for data management and analysis. Analysis was conducted in three stages (coding, generation of specific beliefs, identification of relevant and nonrelevant domains). RESULTS The 28 interviewed nurses represented a variety of medical, surgical and other wards, and reported being acutely aware of the pressures to discharge patients on weekends (knowledge). They believed that increasing weekend discharges would improve hospital flow and aid in decanting the ED (beliefs about consequences). However, they also acknowledged that the weekend discharge pressures might result in patients being discharged prematurely and bouncing back to the hospital (beliefs about consequences). Overall, the nurses reported that as a hospital culture, discharging patients was not much of a priority (goals; environmental context and resources). CONCLUSION We know there are much fewer discharges on weekends, and this is associated with significant hospital and ED crowding on Mondays. This study has illuminated the many challenges faced by in-patient ward nurses when considering the discharge of admitted patients on weekends. In order to decrease ED and hospital crowding related to decreased weekend discharges, hospitals will need to effect a culture change amongst all staff.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | - Warren J Cheung
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Debra A Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Stiell IG, Madore S, Knoll G, Ludwig C, Wooller K, Eagles D, Yadav K, Perry JJ, Cheung WJ. Decreased patient discharges on weekends part 3: what do the leaders tell us? CAN J EMERG MED 2024:10.1007/s43678-024-00703-6. [PMID: 38703268 DOI: 10.1007/s43678-024-00703-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/04/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Emergency department (ED) crowding is a significant challenge to providing safe and quality care to patients. We know that hospital and ED crowding is exacerbated on Mondays because fewer in-patients are discharged on the weekend. We evaluated barriers and potential solutions to improve in-patient flow and diminished weekend discharges, in hopes of decreasing the severe ED crowding observed on Mondays. METHODS In this observational study, we conducted interviews of (a) leaders at The Ottawa Hospital, a major academic health sciences centre (nursing, allied health, physicians), and (b) leaders of community facilities (long-term care and chronic hospital) that receive patients from the hospital, and (c) home care. Each interview was conducted individually and addressed perceived barriers to the discharge of hospital in-patients on weekends as well as potential solutions. An inductive thematic analysis was conducted whereby themes were organized into a summary table of barriers and solutions. RESULTS We interviewed 40 leaders including 30 nursing, physician, and allied health leaders from the hospital as well as 10 senior personnel from community facilities and home care. Many barriers to weekend discharges were identified, highlighting that this problem is complex with many interdependent internal and external factors. Fortunately, many specific potential solutions were suggested, in immediate, short-term and long-term time horizons. While many solutions require additional resources, others require a culture change whereby hospital and community stakeholders recognize that services must be provided consistently, seven days a week. INTERPRETATION We have identified the complex and interdependent barriers to weekend discharges of in-patients. There are numerous specific opportunities for hospital staff and services, physicians, and community facilities to provide the same patient care on weekends as on weekdays. This will lead to improved patient flow and safety, and to decreased ED crowding on Mondays.
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Affiliation(s)
- Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
| | | | - Greg Knoll
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Krista Wooller
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Warren J Cheung
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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Rogers MP, Kuo PC. Decreasing excess lengths of hospital stay in the Veterans Affairs population: An example of the influence of care delivery macroenvironment factors. Surgery 2021; 171:411-412. [PMID: 34809969 DOI: 10.1016/j.surg.2021.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Michael P Rogers
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Paul C Kuo
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL.
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