Delayed Hospital Discharges of Older Patients: A Systematic Review on Prevalence and Costs

Decoding the persistence of delayed hospital discharge: An in-depth scoping review and insights from two decades

OBJECTIVE

This article addresses the persistent challenge of Delayed Hospital Discharge (DHD) and aims to provide a comprehensive overview, synthesis, and actionable, sustainable plan based on the synthesis of the systematic review articles spanning the past 24 years. Our research aims to comprehensively examine DHD, identifying its primary causes and emphasizing the significance of effective communication and management in healthcare settings.

METHODS

We conducted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) method for synthesizing findings from 23 review papers published over the last two decades, encompassing over 700 studies. In addition, we employed a practical and comprehensive framework to tackle DHD. Rooted in Linderman's model, our approach focused on continuous process improvement (CPI), which highlights senior management commitment, technical/administrative support, and social/transitional care. Our proposed CPI method comprised several stages: planning, implementation, data analysis, and adaptation, all contributing to continuous improvement in healthcare delivery. This method provided valuable insights and recommendations for addressing DHD challenges.

FINDINGS

Our DHD analysis revealed crucial insights across multiple dimensions. Firstly, examining causes and interventions uncovered issues such as limited discharge destinations, signaling unsustainable solutions, and inefficient care coordination. The second aspect explored the patient and caregiver experience, emphasizing challenges linked to staff uncertainty and negative physical environments, with notable attention to the underexplored area of caregiver experience. The third theme explored organizational and individual factors, including cognitive impairment and socioeconomic influences. The findings emphasized the importance of incorporating patients' data, recognizing its complexity and current avoidance. Finally, the role of transitional and social care and financial strategies was scrutinized, emphasizing the need for multicomponent, context-specific interventions to address DHD effectively.

CONCLUSION

This study addresses gaps in the literature, challenges prevailing solutions, and offers practical pathways for reducing DHD, contributing significantly to healthcare quality and patient outcomes. The synthesis introduces the vital CPI stage, enhancing Linderman's work and providing a pragmatic framework to eradicate delayed discharge. Future efforts will address practitioner consultations to enhance perspectives and further enrich the study.

PATIENT OR PUBLIC CONTRIBUTION

Our scoping review synthesizes and analyzes existing systematic review articles and emphasizes offering practical, actionable solutions. While our approach does not directly engage patients, it strategically focuses on extracting insights from the literature to create a CPI framework. This unique aspect is intentionally designed to yield tangible benefits for patients, service users, caregivers, and the public. Our actionable recommendations aim to improve hospital discharge processes for better healthcare outcomes and experiences. This detailed analysis goes beyond theoretical considerations and provides a practical guide to improve healthcare practices and policies.

Early supported discharge for older adults admitted to hospital after orthopaedic surgery: a systematic review and meta-analysis

BACKGROUND

Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home, continuing to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. Existing literature demonstrates the concept having a reduced length of stay in stroke inpatients and medical older adults. This systematic review aims to explore the totality of evidence for the use of ESD in older adults hospitalised with orthopaedic complaints.

METHODS

A literature search of Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL), EMBASE, CINAHL and MEDLINE in EBSCO was carried out on January 10th, 2024. Randomised controlled trials or quasi-randomised controlled trials were the study designs included. For quality assessment, The Cochrane Risk of Bias Tool 2.0 was used and GRADE was applied to evaluate the certainty of evidence. Acute hospital length of stay was the primary outcome. Secondary outcomes included the numbers of fallers and function. A pooled meta-analysis was conducted using RevMan software 5.4.1.

RESULTS

Seven studies with a population of older adults post orthopaedic surgery met inclusion criteria, with five studies included in the meta-analysis. Study quality was predominantly of a high risk of bias. Statistically significant effects favouring ESD interventions were only seen in terms of length of stay (FEM, MD = -5.57, 95% CI -7.07 to -4.08, I2 = 0%). No statistically significant effects favouring ESD interventions were established in secondary outcomes.

CONCLUSION

In the older adult population with orthopaedic complaints, ESD can have a statistically significant impact in reducing hospital length of stay. This review identifies an insufficient existing evidence base to establish the key benefits of ESD for this population group. There is a need for further higher quality research in the area, with standardised interventions and outcome measures used.

Burden of delayed discharge on acute hospital medical wards: A retrospective ecological study in Rome, Italy

INTRODUCTION

Delayed discharge represents the difficulty in proceeding with discharge of patients who do not have any further benefit from prolonged stay. A quota of this problem is related to organizational issues. In the Lazio region in Italy, a macro service re-organization in on the way, with a network of hospital and territorial centers engaged in structuring in- and out- of hospital patient pathways, with a special focus on intermediate care structures. Purpose of this study is to quantify the burden of delayed discharge on a single hospital structure, in order to estimate costs and occurrence of potential resource misplacement.

MATERIAL AND METHODS

Observational Retrospective study conducted at the Santo Spirito Hospital in Rome, Italy. Observation period ranged from 1/09/2022, when the local database was instituted, to 1/03/2023 (6 months). Data from admissions records was anonymously collected. Data linkage with administrative local hospital database was performed in order to identify the date a discharge request was fired for each admission. Surgical discharges and Intensive Care Unit (ICU) discharges were excluded from this study. A Poisson hierarchical regression model was employed to investigate for the role of ward, Severity of Disease (SoD) and Risk of Mortality (RoM) on elongation of discharge time.

RESULTS

1222 medical ward admissions were recorded in the timeframe. 16% of them were considered as subject to potentially elongated stay, and a mean Delay in discharge of 6.3 days (SD 7.9) was observed.

DISCUSSION AND CONCLUSIONS

Delayed discharge may cause a "bottleneck" in admissions and result in overcrowded Emergency Department, overall poor performance, and increase in overall costs. A consisted proportion of available beds can get inappropriately occupied, and this inflates both direct and indirect costs. Clinical conditions on admission are not a good predictor of delay in discharge, and the root causes of this phenomenon likely lie in organizational issues (on structure\system level) and social issues (on patient's level).

Short-term mortality and palliative care use after delayed hospital discharge: a population-based retrospective cohort study

OBJECTIVES

In Canada, patients whose acute medical issues have been resolved but are awaiting discharge from hospital are designated as alternate level of care (ALC). We investigated short-term mortality and palliative care use following ALC designation in Ontario, Canada.

METHODS

We conducted a population-based retrospective cohort study of adult, acute care hospital admissions in Ontario with an ALC designation between January and December 2021. Our follow-up window was until 90 days post-ALC designation or death. Setting of discharge and death was determined using admission and discharge dates from multiple databases. We measured palliative care using physician billings, inpatient palliative care records and palliative home care records. We compared the characteristics of ALC patients by 90-day survival status and compared palliative care use across settings of discharge and death.

RESULTS

We included 54 839 ALC patients with a median age of 80 years. Nearly one-fifth (18.4%) of patients died within 90 days. Patients who died were older, had more comorbid conditions and were more likely to be male. Among those who died, 35.1% were never discharged from hospital and 20.3% were discharged but ultimately died in the hospital. The majority of people who died received palliative care following their ALC designation (68.1%).

CONCLUSIONS

A significant proportion of patients experiencing delayed discharge die within 3 months, with the majority dying in hospitals despite being identified as ready to be discharged. Future research should examine the adequacy of palliative care provision for this population.

Proactive and integrated consultation-liaison psychiatry for older medical inpatients: A mixed methods description of training, care provided and clinician experience in the HOME study

OBJECTIVES

To describe the practical experience of delivering a proactive and integrated consultation-liaison (C-L) psychiatry service model (PICLP). PICLP is designed for older medical inpatients and is explicitly biopsychosocial and discharge-focused. In this paper we report: (a) observations on the training of 15 clinicians (seven senior C-L psychiatrists and eight assisting clinicians) to deliver PICLP; (b) the care they provided to 1359 patients; (c) their experiences of working in this new way.

METHOD

A mixed methods observational study using quantitative and qualitative data, collected prospectively over two years as part of The HOME Study (a randomized trial comparing PICLP with usual care).

RESULTS

The clinicians were successfully trained to deliver PICLP according to the service manual. They proactively assessed all patients and found that most had multiple biopsychosocial problems impeding their timely discharge from hospital. They integrated with ward teams to provide a range of interventions aimed at addressing these problems. Delivering PICLP took a modest amount of clinical time, and the clinicians experienced it as both clinically valuable and professionally rewarding.

CONCLUSION

The experience of delivering PICLP highlights the special role that C-L psychiatry clinicians, working in a proactive and integrated way, can play in medical care.

Evaluation of Delayed Effective Discharge for Non-Medical Reasons in Patients Admitted to Acute Care Hospitals in Spain: A Scoping Review

Delayed discharge for non-clinical reasons is defined as a period of stay that continues after a patient has been deemed medically fit to leave the hospital but is unable to do so for non-medical reasons. This circumstance overburdens the healthcare system and constitutes a major problem for healthcare systems and the patients themselves in this situation. The aim of this study was to evaluate the delay in effective discharge for non-medical reasons for patients admitted to acute care hospitals in Spain. A scoping review followed the Joanna Briggs Institute methodology guidelines to search for and synthesize studies published between 2019 and 2022. To identify potentially relevant documents, the following bibliographic databases were searched: EMBASE, CINAHL and MEDLINE. For the search, we used free terms («delayed discharges», «discharge delays», «bed-blocking», «timely discharge», «unnecessary days» and «inappropriate stays»). Quantitative or qualitative studies published in scientific journals on delayed effective discharge for non-medical reasons for patients admitted to a hospital for any health issue of medical or surgical origin were selected. Information collection of the documents was performed using a structured datasheet specifically developed by the authors. The initial search strategy identified a total of 124 references, which were successively screened to a final selection of 13 studies. To conclude, delayed discharge from a hospital for non-clinical reasons is a multifactorial problem. This may be due to factors internal or external to the hospital, as well as personal factors. The main causes of the delay were similar among the studies found, as were the clinical characteristics of the patients, most of whom were elderly, frail and more dependent due to declining functional capacities. Further studies addressing the socio-familial characteristics of the patients and the perspective of the patient and families would be necessary.

Delayed discharges at a tertiary rehabilitation centre in Saudi Arabia: contributing factors and cost impact

There are various challenges in discharging hospitalized patients with disabilities. Discharge process for individuals with disabilities is multifactorial and can vary from one health system to another. The current study is aimed to explore the factors contributing to delayed discharges and to determine the number of exceeded bed days and subsequent cost impact at a government rehabilitation facility in Saudi Arabia. This retrospective cohort study was conducted at the Rehabilitation Hospital of King Fahad Medical City, Riyadh. All the 2285 discharges from inpatient rehabilitation from August 2011 to March 2017 were included in the study. Patients with delayed discharge were identified. Information about the diagnosis and reasons for delayed discharge was obtained from the rehabilitation hospital bed utilization data. The cost impact was calculated based on the number of days patients stayed beyond the estimated length of stay for each diagnosis. Of the 2285 discharges, 531 (23.3%) were delayed. The most common clinical conditions of patients with delayed discharge included spinal cord injury (n = 168, 31.6%) and traumatic brain injury (n = 145, 27.3%). The factors that led to delayed discharges were medical complications (n = 352, 66.7%), organizational factors (n = 83, 15.7%), family factors (n = 46, 8.7%), and external factors (n = 46, 8.7%). A total of 21 817 hospital bed days were exceeded, with an approximate estimated cost of 80 million Saudi Arabian Riyals. Early rehabilitation and enhancement of the discharge process may significantly decrease delayed discharge rates. Strategies need to be adapted to identify patients at risk of delayed discharge based on the factors highlighted in this study. Development of long-term care capacity, community services, and optimizing family and social support can promote timely discharge.

Discharge to Assess: an evaluation of three case studies in the southeast of England to inform service improvement

BACKGROUND

Discharge to Assess (D2A) emerged as a critical process during the COVID-19 pandemic facilitating patient flow within hospitals, however research on the post-discharge community services of this pathway remains limited. We conducted an evaluation to examine the impacts, capacity, processes and barriers associated with D2A and to identify best practice across three sites in the southeast of England.

METHODS

We interviewed 29 commissioners, providers and staff members involved in the delivery of D2A pathways within three Health and Care Partnerships. Framework analysis of the collected data revealed three prominent themes: the commissioning of services encompassing funding, structure, culture, and expected outcomes; multidisciplinary collaboration including staff skills, team connections, and coordination; and information and knowledge exchange such as assessment methods, record management, and availability of operational insights.

RESULTS

62 specific enablers and blockers to effective D2A practice emerged.

DISCUSSION

These findings supported the development of a comprehensive service improvement toolkit.

CONCLUSION

Five recommendations are proposed: 1. Examination of pathways against the 62 enablers and blockers to identify and resolve pathway obstacles; 2. Establish a local operational policy accessible to all providers; 3. Enhance coordination and communication among service providers, patients and carers; 4. Strengthen oversight of service user flow; 5. Develop a consistent Patient Reported Outcomes Measure to facilitate feedback and service enhancements for individuals discharged from urgent care pathways.

Patient and family perceptions of a discharge bedside board

Objective

To explore patient and family perspectives of a discharge bedside board for supporting engagement in patient care and discharge planning to inform tool revision.

Methods

This qualitative descriptive study included 45 semi-structured interviews with a purposeful sample of English-speaking patients (n = 44; mean age 58.5 years) and their family members (n = 5) across seven adult inpatient units at a tertiary acute care hospital in mid-western Canada. Thematic (interviews), content (board, organization procedure document), and framework-guided integrated (all data) analyses were performed.

Results

Four themes were generated from interview data: understanding the board, included essential information to guide care, balancing information on the board, and maintaining a sense of connection. Despite application inconsistencies, documented standard procedures aligned with recommended board (re)orientation, timely patient-friendly content, attention to privacy, and patient-provider engagement strategies.

Conclusion

Findings indicate the tool supported consultation and some involvement level engagement in patient care and discharge. Board information was usually valued, however, perceived procedural gaps in tool education, privacy, and the quality of tool-related communication offer opportunities to strengthen patients' and families' tool experience.

Innovation

Novel application of a continuum engagement framework in the exploration of multiple data sources generated significant insights to guide tool revision.

Trauma in the elderly: a bilateral rectus sheath haematoma

Life expectancy has more than doubled in the last century, and a new cohort of elderly and increasingly frail patients is presenting to emergency departments with new clinical challenges. When this patient cohort presents after injury, all aspects of clinical practice have to be recalibrated to provide safe and appropriate care. The prevalence of chronic disease, levels of organ failure, multiple comorbidities, greater use of anticoagulation and incidence of recurrent low- and high-impact trauma may delay and obscure diagnosis and, ultimately, increase mortality.Older age is a risk factor for rectus sheath haematoma (RSH), which is haemorrhage into the potential space surrounding the rectus abdominis muscle/s. It is a rare presentation following trauma but can provide diagnostic challenges and be fatal. Even more rare is bilateral RSH with only 12 reported in the literature since 1981.This case report describes bilateral RSH presenting in an elderly woman following a fall and the consequences of seemingly minor trauma in the elderly.

Short-Term, Community-Based, Slow-Stream Rehabilitation Program for Older Adults Transitioning from Hospital to Home: A Mixed Methods Program Evaluation

Introduction

Shortened hospital stays have shifted the burden of care for older adults to community, informal (ie, family, caregiver) and formal post-acute care and services, highlighting the need for effective post-hospital stay services and programs. As there is a dearth of information related to community-based, slow-stream rehabilitation program models for older adults transitioning from hospital to home in the Canadian context, the paper describes a mixed methods evaluation of such a program.

Materials and Methods

A mixed methods program evaluation, with process- and outcome-related elements, included 1) review and analysis of program documents; 2) observations to examine fidelity. Observation data were coded and summarized using descriptive statistics. Coded information and data were compared to document review data; 3) quantitative assessment of pre-post changes in physical, social, and psychological outcome measure and instrument scores using descriptive statistics, paired t-tests and confidence intervals (p = 0.05); and 4) exploration of acceptability through interviews and focus groups with 41 of the older adult participants and 17 family caregivers. Thematic analysis was used to examine focus group and interview transcripts.

Results

Observational data indicated alignment with the program document information overall. Statistically and clinically significant positive trends in improvement for physical outcome measure scores were observed (6-minute Walk Test, Life Space Assessment, Short Physical Performance Battery, Rapid Assessment of Physical Activity). Participants and family caregivers identified several positives and benefits of the program, ie, improvement in physical, social and mental well-being, decreased caregiver burden; and areas for improvement ie, need for more information about the program prior to enrollment and individualization, several of which aligned with the observation and quantitative data.

Discussion/Conclusion

This mixed methods program evaluation provided a detailed description of a community-based, slow-stream rehabilitation program for older adults who are transitioning to home post-hospital stay and its participants. Evidence of program fidelity, acceptability, and positive trends in improvement in physical outcome measure scores were found. Information about program strengths and areas for improvement can be used by stakeholders to inform program refinement and enhancement.

Medically ready for discharge: A multisite "point-in-time" assessment of hospitalized patients

BACKGROUND

Time spent awaiting discharge after the acute need for hospitalization has resolved is an important potential contributor to hospital length of stay (LOS).

OBJECTIVE

To measure the prevalence, impact, and context of patients who remain hospitalized for prolonged periods after completion of acute care needs.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a cross-sectional "point-in-time" survey at each of 15 academic US hospitals using a structured data collection tool with on-service acute care medicine attending physicians in fall 2022.

MAIN OUTCOMES AND MEASURES

Primary outcomes were number and percentage of patients considered "medically ready for discharge" with emphasis on those who had experienced a "major barrier to discharge" (medically ready for discharge for ≥1 week). Estimated LOS attributable to major discharge barriers, contributory discharge needs, and associated hospital characteristics were measured.

RESULTS

Of 1928 patients sampled, 35.0% (n = 674) were medically ready for discharge including 9.8% (n = 189) with major discharge barriers. Many patients with major discharge barriers (44.4%; 84/189) had spent a month or longer medically ready for discharge and commonly (84.1%; 159/189) required some form of skilled therapy or daily living support services for discharge. Higher proportions of patients experiencing major discharge barriers were found in public versus private, nonprofit hospitals (12.0% vs. 7.2%; p = .001) and county versus noncounty hospitals (14.5% vs. 8.8%; p = .002).

CONCLUSIONS

Patients experience major discharge barriers in many US hospitals and spend prolonged time awaiting discharge, often for support needs that may be outside of clinician control.

Older Adults' Experiences Living With and Having Spine Surgery for Degenerative Spine Disease

BACKGROUND AND OBJECTIVES

Globally, older adults are undergoing spine surgery for degenerative spine disease at exponential rates. However, little is known about their experiences of living with and having surgery for this debilitating condition. This study investigated older adults' understanding and experiences of living with and having surgery for degenerative spine disease.

RESEARCH DESIGN AND METHODS

Qualitative methods, grounded theory, guided the study. Fourteen older adults (≥65 years) were recruited for in-depth interviews at 2 time-points: T1 during hospitalization and T2, 1-3-months postdischarge. A total of 28 interviews were conducted. Consistent with grounded theory, purposive, and theoretical sampling were used. Data analysis included open, axial, and selective coding.

RESULTS

A conceptual model was developed illustrating the process older adults with degenerative spine disease experience, trying to get their life back. Three key categories were identified (1) Losing Me, (2) Fixing Me, and (3) Recovering Me. Losing Me was described as a prolonged process of losing functional independence and the ability to socialize. Fixing Me consisted of preparing for surgery and recovery. Recovering Me involved monitoring progression and reclaiming their personhood. Conditions, including setbacks and delays, slowed their trajectory. Throughout, participants continually adjusted expectations.

DISCUSSION AND IMPLICATIONS

The conceptual model, based on real patient experiences, details how older adults living with and having surgery for degenerative spine disease engage in recovering who they were prior to the onset of symptoms. Our findings provide a framework for understanding a complex, protracted trajectory that involves transitions from health to illness working toward health again.

Leaving the hospital on time: hospital bed utilization and reasons for discharge delay in the Netherlands

Inappropriate bed occupancy due to delayed hospital discharge affects both physical and psychological well-being in patients and can disrupt patient flow. The Dutch healthcare system is facing ongoing pressure, especially during the current coronavirus disease pandemic, intensifying the need for optimal use of hospital beds. The aim of this study was to quantify inappropriate patient stays and describe the underlying reasons for the delays in discharge. The Day of Care Survey (DoCS) is a validated tool used to gain information about appropriate and inappropriate bed occupancy in hospitals. Between February 2019 and January 2021, the DoCS was performed five times in three different hospitals within the region of Amsterdam, the Netherlands. All inpatients were screened, using standardized criteria, for their need for in-hospital care at the time of survey and reasons for discharge delay. A total of 782 inpatients were surveyed. Of these patients, 94 (12%) were planned for definite discharge that day. Of all other patients, 145 (21%, ranging from 14% to 35%) were without the need for acute in-hospital care. In 74% (107/145) of patients, the reason for discharge delay was due to issues outside the hospital; most frequently due to a shortage of available places in care homes (26%, 37/145). The most frequent reason for discharge delay inside the hospital was patients awaiting a decision or review by the treating physician (14%, 20/145). Patients who did not meet the criteria for hospital stay were, in general, older [median 75, interquartile range (IQR) 65-84 years, and 67, IQR 55-75 years, respectively, P < .001] and had spent more days in hospital (7, IQR 5-14 days, and 3, IQR 1-8 days respectively, P < .001). Approximately one in five admitted patients occupying hospital beds did not meet the criteria for acute in-hospital stay or care at the time of the survey. Most delays were related to issues outside the immediate control of the hospital. Improvement programmes working with stakeholders focusing on the transfer from hospital to outside areas of care need to be further developed and may offer potential for the greatest gain. The DoCS can be a tool to periodically monitor changes and improvements in patient flow.

Transitional care decision-making through the eyes of older people and informal caregivers: An in-depth interview-based study

BACKGROUND

Older people with multifaceted care needs often require treatment and complex care across different settings. However, transitional care is often inadequately managed, and older people and their informal caregivers are not always sufficiently heard and/or supported in transitional care decision-making.

OBJECTIVE

To explore older people's and informal caregivers' experiences with, views on, and needs concerning empowerment in transitional care decision-making.

METHODS

A qualitative descriptive study was conducted in the TRANS-SENIOR consortium's collaborative research using semistructured in-depth interviews between October 2020 and June 2021 in Flanders, Belgium. A total of 29 people were interviewed, including 14 older people and 15 informal caregivers who faced a transition from home to another care setting or vice versa. Data were analysed according to the Qualitative Analysis Guide of Leuven.

FINDINGS

Five themes were identified in relation to the participant's experiences, views and needs: involvement in the decision-making process; informal caregivers' burden of responsibility; the importance of information and support; reflections on the decision and influencing factors.

CONCLUSIONS

Overall, older people and informal caregivers wished to be more seen, recognised, informed and proactively supported in transitional care decision-making. However, their preferences for greater involvement in decision-making vary and are affected by several factors that are both intrinsic and extrinsic. Therefore, healthcare systems might seek out age-tuned and person-centred empowerment approaches focusing on older people's and informal caregivers' empowerment. For future studies, we recommend developing specific strategies for such empowerment.

PATIENT OR PUBLIC CONTRIBUTION

Older persons' representatives were involved in designing the TRANS-SENIOR programme of research, including the current study. Healthcare professionals and nursing care directors were involved in the study design and the selection and recruitment of participants.

Discharge optimization tool to decrease length of stay and improve satisfaction related to advanced practice provider communication

BACKGROUND

Prolonged length of stay (LOS) due to delayed hospital discharge is associated with increased patient morbidity and mortality and other poor outcomes. The length of stay (LOS) in patients undergoing elective, isolated coronary artery bypass grafting (CABG) at an urban, level 1 trauma center is 8.73 days, compared to the 7.0-day benchmark reported by the Society of Thoracic Surgeons (STS). Improving and reducing length of stay (LOS) can improve clinical, financial, and operational outcomes and decrease the costs of care for patients and the healthcare system.

OBJECTIVE

The purpose of this quality improvement project was to implement an evidence-based discharge optimization tool (DOT) within the Electronic Health Record to reduce LOS in patients undergoing isolated CABG and enhance communication satisfaction in cardiothoracic surgery advanced practice providers (APP).

METHODS

We used a DOT to communicate anticipated time to discharge in CABG patients to the multidisciplinary team. Outcomes included postoperative LOS and APP communication satisfaction. Data was obtained via chart review and statistically analyzed using a one sample T-test.

RESULTS

177 patients (mean age 64 years, 72% male, 66% Caucasian) were studied. The mean postoperative LOS decreased by 16% from 8.73 days to 7.31 days (p = 0.007; Standard deviation of 3.20). Cardiothoracic surgery APP communication satisfaction improved by 33%.

CONCLUSIONS

Utilization of a discharge optimization tool to communicate anticipated time to discharge can significantly decrease LOS and improve APP communication satisfaction.

Cost of stay and characteristics of patients with stroke and delayed discharge for non-clinical reasons

Delayed discharge for non-clinical reasons (bed-blocking) is characteristic of pathologies associated with ageing, loss of functional capacity and dependence such as stroke. The aims of this study were to describe the costs and characteristics of cases of patients with stroke and delayed discharge for non-clinical reasons (bed-blocking) compared with cases of bed-blocking (BB) for other reasons and to assess the relationship between the length of total stay (LOS) with patient characteristics and the context of care. A descriptive cross-sectional study was conducted at a high complexity public hospital in Northern Spain (2007–2015). 443 stroke patients presented with BB. Delayed discharge increased LOS by approximately one week. The median age was 79.7 years, significantly higher than in cases of BB for other reasons. Patients with stroke and BB are usually older patients, however, when younger patients are affected, their length of stay is longer in relation to the sudden onset of the problem and the lack of adequate functional recovery resources or residential facilities for intermediate care.

Patient Outcomes Related to In-Hospital Delays in Appendicectomy for Appendicitis: A Retrospective Study

Background and objective

In many hospitals, the availability of operating theatres and access to senior surgical and anaesthetic support diminish during night hours. Therefore, urgent surgery is sometimes postponed until the following morning rather than performed overnight, if it is judged to be safe. In this study, we aimed to determine if a delay in laparoscopic appendicectomy in cases of acute appendicitis of over 12 hours, analogous to an overnight delay, correlated with worse patient outcomes. Our primary outcome was delayed discharge from the hospital. Our secondary outcomes were appendicitis severity, conversions, and postoperative complications.

Methods

We undertook a retrospective review of the medical records of patients who underwent laparoscopic appendicectomy for appendicitis at a UK district general hospital between 01/01/2018 and 30/08/2019. For each patient, clinical and demographic information, and time of hospital admission, surgery, and discharge were collected. Delayed discharge was defined as "time to discharge" >24 hours after surgery.

Results

A total of 446 patients were included in the study. In 137 patients (30.7%), "time to surgery" was under 12 hours; in 309 patients (69.3%) "time to surgery" was over 12 hours. Of note, 319 patients (71.5%) had a delayed discharge; 303 patients (67.9%) had complicated appendicitis, and 143 patients had severe appendicitis (32.1%). No statistically significant association between "time to surgery" and delayed discharge, appendicitis severity, conversion, or 30-day re-presentations was observed.

Conclusion

Time from admission to the start of appendicectomy did not affect patient outcomes. Short in-hospital delays in appendicectomy, such as an overnight delay, may be safe in certain patients and should be determined based on clinical judgement.

Discharge planning from hospital

BACKGROUND

Discharge planning is a routine feature of health systems in many countries that aims to reduce delayed discharge from hospital, and improve the co-ordination of services following discharge from hospital and reduce the risk of hospital readmission. This is the fifth update of the original review.

OBJECTIVES

To assess the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two trials registers on 20 April 2021. We searched two other databases up to 31 March 2020. We also conducted reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomised trials that compared an individualised discharge plan with routine discharge that was not tailored to individual participants. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies by older people with a medical condition, people recovering from surgery, and studies that recruited participants with a mix of conditions. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data it was not possible because of differences in the reporting of outcomes, we summarised the reported results for each trial in the text.

MAIN RESULTS

We included 33 trials (12,242 participants), four new trials included in this update. The majority of trials (N = 30) recruited participants with a medical diagnosis, average age range 60 to 84 years; four of these trials also recruited participants who were in hospital for a surgical procedure. Participants allocated to discharge planning and who were in hospital for a medical condition had a small reduction in the initial hospital length of stay (MD - 0.73, 95% confidence interval (CI) - 1.33 to - 0.12; 11 trials, 2113 participants; moderate-certainty evidence), and a relative reduction in readmission to hospital over an average of three months follow-up (RR 0.89, 95% CI 0.81 to 0.97; 17 trials, 5126 participants; moderate-certainty evidence). There was little or no difference in participant's health status (mortality at three- to nine-month follow-up: RR 1.05, 95% CI 0.85 to 1.29; 8 trials, 2721 participants; moderate certainty) functional status and psychological health measured by a range of measures, 12 studies, 2927 participants;  low certainty evidence). There was some evidence that satisfaction might be increased for patients (7 trials), caregivers (1 trial) or healthcare professionals (2 trials) (very low certainty evidence). The cost of a structured discharge plan compared with routine discharge is uncertain (7 trials recruiting 7873 participants with a medical condition; very low certainty evidence).

AUTHORS' CONCLUSIONS

A structured discharge plan that is tailored to the individual patient probably brings about a small reduction in the initial hospital length of stay and readmissions to hospital for older people with a medical condition, may slightly increase patient satisfaction with healthcare received. The impact on patient health status and healthcare resource use or cost to the health service is uncertain.

The influence of home care supply on delayed discharges from hospital in England

BACKGROUND

Delayed transfers of care (DTOC) of patients from hospital to alternative care settings are a longstanding problem in England and elsewhere, having negative implications for patient outcomes and costs to health and social care systems. In England, a large proportion of DTOC are attributed to a delay in receiving suitable home care. We estimated the relationship between home care supply and delayed discharges in England from 2011 to 2016.

METHODS

Reduced form fixed effects OLS models of annual DTOC attributed to social care at local authority (LA)-level from 2011 to 2016 were estimated, using both number of days and patients as the dependent variable. A count of home care providers at LA-level was utilised as the measure of home care supply. Demand (e.g. population, health, income) and alternative supply (e.g. care home places, local unemployment) measures were included as controls. Instrumental Variable (IV) methods were used to control for any simultaneity in the relationship between DTOC and home care supply. Models for DTOC attributed to NHS and awaiting a home care package were used to assess the adequacy of the main model.

RESULTS

We found that home care supply significantly reduced DTOC. Each extra provider per 10 sq. km. in the average local authority decreased DTOC by 14.9% (equivalent to 449 days per year), with a per provider estimate of 1.6% (48 days per year). We estimated cost savings to the public sector over the period of analysis from reduced DTOC due to increased home care provision between £73 m and £274 m (95% CI: £0.24 m to £545.3 m), with a per provider estimate of savings per year of £12,600 (95% CI: £900 to £24,500).

CONCLUSION

DTOC are reduced in LAs with better supply of home care, and this reduces costs to the NHS. Further savings could be achieved through improved outcomes of people no longer delayed. Appropriate levels of social care supply are required to ensure efficiency in spending for the public sector overall.

The Effectiveness of a Multidisciplinary Electronic Discharge Readiness Tool: Prospective, Single-Center, Pre-Post Study

Background

In the face of hospital capacity strain, hospitals have developed multifaceted plans to try to improve patient flow. Many of these initiatives have focused on the timing of discharges and on lowering lengths of stay, and they have met with variable success. We deployed a novel tool in the electronic health record to enhance discharge communication.

Objective

The aim of this study is to evaluate the effectiveness of a discharge communication tool.

Methods

This was a prospective, single-center, pre-post study. Hospitalist physicians and advanced practice providers (APPs) used the Discharge Today Tool to update patient discharge readiness every morning and at any time the patient status changed throughout the day. Primary outcomes were tool use, time of day the clinician entered the discharge order, time of day the patient left the hospital, and hospital length of stay. We used linear mixed modeling and generalized linear mixed modeling, with team and discharging provider included in all the models to account for patients cared for by the same team and the same provider.

Results

During the pilot implementation period from March 5, 2019, to July 31, 2019, a total of 4707 patients were discharged (compared with 4558 patients discharged during the preimplementation period). A total of 352 clinical staff had used the tool, and 84.85% (3994/4707) of the patients during the pilot period had a discharge status assigned at least once. In a survey, most respondents reported that the tool was helpful (32/34, 94% of clinical staff) and either saved time or did not add additional time to their workflow (21/24, 88% of providers, and 34/34, 100% of clinical staff). Although improvements were not observed in either unadjusted or adjusted analyses, after including starting morning census per team as an effect modifier, there was a reduction in the time of day the discharge order was entered into the electronic health record by the discharging physician and in the time of day the patient left the hospital (decrease of 2.9 minutes per additional patient, P=.07, and 3 minutes per additional patient, P=.07, respectively). As an effect modifier, for teams that included an APP, there was a significant reduction in the time of day the patient left the hospital beyond the reduction seen for teams without an APP (decrease of 19.1 minutes per patient, P=.04). Finally, in the adjusted analysis, hospital length of stay decreased by an average of 3.7% (P=.06).

Conclusions

The Discharge Today tool allows for real time documentation and sharing of discharge status. Our results suggest an overall positive response by care team members and that the tool may be useful for improving discharge time and length of stay if a team is staffed with an APP or in higher-census situations.

Differential characteristics of cases of patients diagnosed with pneumonia and delayed discharge for non-clinical reasons in Northern Spain

BACKGROUND

Delayed discharge for non-clinical reasons is related to a failure to plan for discharge and a lack of availability of intermediate care resources as an alternative to acute hospitalisation. The literature concerning the relationship with pneumonia is scarce. At present, the coronavirus pandemic is a new cause of complicated pneumonias that can further affect the functionality of the most fragile patients.

OBJECTIVE

The aim of this study was to understand what characteristics are typical of patients affected by pneumonia, compared with other cases of delayed discharge.

METHODS

A cross-sectional study was conducted. All cases of delayed discharge were studied at the hospitalisation units of a general university hospital in Northern Spain from 2007 to 2015. In order to compare the differential characteristics of the groups of patients with pneumonia with the total Student's T-test and Pearson's chi-square test (χ²) were used.

RESULTS

170 patients were identified with a diagnosis of pneumonia and delayed discharge for non-clinical reasons during the study period. These cases accumulated a total of 4790 days of total stay, of which 1294 days corresponded to the prolonged stay. The mean age of the patients was 80.23 years. The mean DRG weight was 2.28 [SD 0.579], and 14.12% of patients with pneumonia and delayed discharge died. So, patients with pneumonia were older (P = .001), less complex (P = .001) and suffered greater deaths compared with the remaining patients (P = .001).

CONCLUSIONS

The sum of these factors has to do with comorbidities and complications associated with ageing and the characteristics of conditions such as aspiration pneumonia.

Examining the predictability and prognostication of multimorbidity among older Delayed-Discharge Patients: A Machine learning analytics

BACKGROUND

Patient complexity among older delayed-discharge patients complicates discharge planning, resulting in a higher rate of adverse outcomes, such as readmission and mortality. Early prediction of multimorbidity, as a common indicator of patient complexity, can support proactive discharge planning by prioritizing complex patients and reducing healthcare inefficiencies.

OBJECTIVE

We set out to accomplish the following two objectives: 1) to examine the predictability of three common multimorbidity indices, including Charlson-Deyo Comorbidity Index (CDCI), the Elixhauser Comorbidity Index (ECI), and the Functional Comorbidity Index (FCI) using machine learning (ML), and 2) to assess the prognostic power of these indices in predicting 30-day readmission and mortality.

MATERIALS AND METHODS

We used data including 163,983 observations of patients aged 65 and older who experienced discharge delay in Ontario, Canada, during 2004 - 2017. First, we utilized various classification ML algorithms, including classification and regression trees, random forests, bagging trees, extreme gradient boosting, and logistic regression, to predict the multimorbidity status based on CDCI, ECI, and FCI. Second, we used adjusted multinomial logistic regression to assess the association between multimorbidity indices and the patient-important outcomes, including 30-day mortality and readmission.

RESULTS

For all ML algorithms and regardless of the predictive performance criteria, better predictions were established for the CDCI compared with the ECI and FCI. Remarkably, the most predictable multimorbidity index (i.e., CDCI with Area Under the Receiver Operating Characteristic Curve = 0.80, 95% CI = 0.79 - 0.81) also offered the highest prognostications regarding adverse events (RRR_mortality = 3.44, 95% CI = 3.21 - 3.68 and RRR_readmission = 1.36, 95% CI = 1.31 - 1.40).

CONCLUSIONS

Our findings highlight the feasibility and utility of predicting multimorbidity status using ML algorithms, resulting in the early detection of patients at risk of mortality and readmission. This can support proactive triage and decision-making about staffing and resource allocation, with the goal of optimizing patient outcomes and facilitating an upstream and informed discharge process through prioritizing complex patients for discharge and providing patient-centered care.

The increasing impact of length of stay "outliers" on length of stay at an urban academic hospital

BACKGROUND

As healthcare systems strive for efficiency, hospital "length of stay outliers" have the potential to significantly impact a hospital's overall utilization. There is a tendency to exclude such "outlier" stays in local quality improvement and data reporting due to their assumed rare occurrence and disproportionate ability to skew mean and other summary data. This study sought to assess the influence of length of stay (LOS) outliers on inpatient length of stay and hospital capacity over a 5-year period at a large urban academic medical center.

METHODS

From January 2014 through December 2019, 169,645 consecutive inpatient cases were analyzed and assigned an expected LOS based on national academic center benchmarks. Cases in the top 1% of national sample LOS by diagnosis were flagged as length of stay outliers.

RESULTS

From 2014 to 2019, mean outlier LOS increased (40.98 to 45.11 days), as did inpatient LOS with outliers excluded (5.63 to 6.19 days). Outlier cases increased both in number (from 297 to 412) and as a percent of total discharges (0.98 to 1.56%), and outlier patient days increased from 6.7 to 9.8% of total inpatient plus observation days over the study period.

CONCLUSIONS

Outlier cases utilize a disproportionate and increasing share of hospital resources and available beds. The current tendency to exclude such outlier stays in data reporting due to assumed rare occurrence may need to be revisited. Outlier stays require distinct and targeted interventions to appropriately reduce length of stay to both improve patient care and maintain hospital capacity.

Delayed Discharge for Non-Clinical Reasons in Hip Procedures: Differential Characteristics and Opportunity Cost

Delayed discharge for non-clinical reasons shares common characteristics with hip procedures. We sought to quantify the length of stay and related costs of hip procedures and compare these with other cases of delayed discharge. A cross-sectional study was conducted at a public hospital in Spain (2007–2015) including 306 patients with 6945 days of total stay and 2178 days of prolonged stay. The mean appropriate stay was 15.58 days, and the mean prolonged stay was 7.12 days. The cost of a prolonged stay was €641,002.09. The opportunity cost according to the value of the hospital complexity unit was €922,997.82. The mean diagnostic-related groups’ weight was 3.40. Up to 85.29% of patients resided in an urban area near the hospital (p = 0.001), and 83.33% were referred to a long-stay facility for functional recovery (p = 0.001). The proportion of patients with hip procedures and delayed discharge was lower than previous reports; however, their length of stay was longer. The cost of prolonged stay could account for 21.17% of the total. Compared with the remaining cases of delayed discharge, the appropriate stay was shorter in hip procedures, with a profile of older women living in an urban area close to the hospital and referred to a long-stay center for functional recovery.

Development and Implementation of a Multidisciplinary Electronic Discharge Readiness Tool: User-Centered Design Approach

BACKGROUND

Typical solutions for improving discharge planning often rely on one-way communication mechanisms, static data entry into the electronic health record (EHR), or in-person meetings. Lack of timely and effective communication can adversely affect patients and their care teams.

OBJECTIVE

Applying robust user-centered design strategies, we aimed to design an innovative EHR-based discharge readiness communication tool (the Discharge Today tool) to enable care teams to communicate any barriers to discharge, the status of patient discharge readiness, and patient discharge needs in real time across hospital settings.

METHODS

We employed multiple user-centered design strategies, including exploration of the current state for documenting discharge readiness and directing discharge planning, iterative low-fidelity prototypes, multidisciplinary stakeholder meetings, a brainwriting premortem exercise, and preproduction user testing. We iteratively collected feedback from users via meetings and surveys.

RESULTS

We conducted 28 meetings with 20 different stakeholder groups. From these stakeholder meetings, we developed 14 low-fidelity prototypes prior to deploying the Discharge Today tool for our pilot study. During the pilot study, stakeholders requested 46 modifications, of which 25 (54%) were successfully executed. We found that most providers who responded to the survey reported that the tool either saved time or did not change the amount of time required to complete their discharge workflow (21/24, 88%). Responses to open-ended questions offered both positive feedback and opportunities for improvement in the domains of efficiency, integration into workflow, avoidance of redundancies, expedited communication, and patient-centeredness.

CONCLUSIONS

Survey data suggest that this electronic discharge readiness tool has been successfully adopted by providers and clinical staff. Frequent stakeholder engagement and iterative user-centered design were critical to the successful implementation of this tool.

Understanding transitional care programs for older adults who experience delayed discharge: a scoping review

Background

Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs?

Methods

The six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian’s structure-process-outcome model.

Results

TCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges.

Conclusion

TCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02099-9.

Do premorbid characteristics of home care clients predict delayed discharges in acute care hospitals: a retrospective cohort study in Ontario and British Columbia, Canada

BACKGROUND

Improved identification of patients with complex needs early during hospitalisation may help target individuals at risk of delayed discharge with interventions to prevent iatrogenic complications, reduce length of stay and increase the likelihood of a successful discharge home.

METHODS

In this retrospective cohort study, we linked home care assessment records based on the Resident Assessment Instrument for Home Care (RAI-HC) of 210 931 hospitalised patients with their Discharge Abstract Database records. We then undertook multivariable logistic regression analyses to identify preadmission predictive factors for delayed discharge from hospital.

RESULTS

Characteristics that predicted delayed discharge included advanced age (OR: 2.72, 95% CI 2.55 to 2.90), social vulnerability (OR: 1.27, 95% CI 1.08 to 1.49), Parkinsonism (OR: 1.34, 95% CI 1.28 to 1.41) Alzheimer's disease and related dementias (OR: 1.27, 95% CI 1.23 to 1.31), need for long-term care facility services (OR: 2.08, 95% CI 1.96 to 2.21), difficulty in performing activities of daily living and instrumental activities of daily living, falls (OR: 1.16, 95% CI 1.12 to 1.19) and problematic behaviours such as wandering (OR: 1.29, 95% CI 1.22 to 1.38).

CONCLUSION

Predicting delayed discharge prior to or on admission is possible. Characteristics associated with delayed discharge and inability to return home are easily identified using existing interRAI home care assessments, which can then facilitate the targeting of pre-emptive interventions immediately on hospital admission.

Getting Unstuck: Challenges and Opportunities in Caring for Patients Experiencing Prolonged Hospitalization While Stable for Discharge

Many physicians care for patients who remain in the hospital for prolonged periods despite being "medically ready" or stable for discharge. However, this phenomenon is not well-defined, and optimal strategies to address the problem are not known. A prolonged hospitalization past the point of medical necessity can harm patients, frustrate care teams, and is costly for the health care system. In this perspective, we describe opportunities to improve value of care for these patients through the lens of the Quadruple Aim, a common framework used to guide health care transformation efforts. We then offer recommendations, including some employed by our hospitals, for clinicians, researchers, and health care systems to improve the care for patients who are "stuck" in the hospital.

Reallocating Cancer Surgery Payments for Alternate Level of Care in Ontario: What Are the Options?

This article examines how alternate-level-of-care (ALC) days are funded through the cancer surgery funding model in Ontario and evaluates policy options to better address ALC days. The contribution of ALC days to hospital funding and the impact of removing or reallocating this funding from cancer surgery is measured. Though costs associated with ALC days in cancer surgery are low, this article highlights the need for policy options that would realign funding across the healthcare system in Ontario to better meet the needs of patients waiting for ALC, reduce pressure on inpatient bed capacity and improve value for money.

Impact of transfer status on real-world outcomes in nonelective cardiac surgery

OBJECTIVE

Transfer from hospital to hospital for cardiac surgery represents a large portion of some clinical practices. Previous literature in other surgical fields has shown worse outcomes for transferred patients. We hypothesized that transferred patients would be higher risk and demonstrate worse outcomes than those admitted through the emergency department.

METHODS

All patients undergoing cardiac operations with a Society of Thoracic Surgeons Predicted Risk of Mortality were evaluated from a multicenter, statewide Society of Thoracic Surgeons database. Only patients requiring admission before surgery were included. Patients were stratified by admission through the emergency department or in transfer. Transfers were further stratified by the cardiothoracic surgery capabilities at the referring center.

RESULTS

A total of 13,094 patients met the inclusion criteria of admission before surgery. This included 7582 (57.9%) transfers, of which 502 (6.6%) were referred from cardiac centers. Compared with emergency department admissions, transfers had increased hospital costs despite lower operative risk (Predicted Risk of Mortality 1.5% vs 1.6%, P < .01) and equivalent postoperative morbidity (15.6% vs 15.3% P = .63). In risk-adjusted analysis, transfer status was not independently associated with worse outcomes. Patients transferred from centers that perform cardiac surgery are higher risk than general transfers (Predicted Risk of Mortality 2.5% vs 1.5, P < .01), but specialized care results in excellent risk-adjusted outcomes (observed/expected: mortality 0.81; morbidity or mortality 0.90).

CONCLUSIONS

Transfer patients have similar rates of postoperative complications but increased resource use compared with patients admitted through the emergency department. Patients transferred from centers that perform cardiac surgery represent a particularly high-risk subgroup.

Understanding transitional care programmes for older adults who experience delayed discharge: a scoping review protocol

INTRODUCTION

Many hospitalised older adults experience delayed discharges due to increased postacute health and social support needs. Transitional care programmes (TCPs) provide short-term care to these patients to prepare them for transfer to nursing homes or back to the community with supports. There are knowledge gaps related to the development, implementation and evaluation of TCPs. The aims of this scoping review (ScR) are to identify the characteristics of older patients served by TCPs; criteria for transfer, components and services provided by TCPs; and outcomes used to evaluate TCPs.

METHODS AND ANALYSIS

The study involves six-step ScR and is informed by a collaborative/participatory approach whereby stakeholders engage in the development of the research questions, identification of literature, data abstraction and synthesis; and participation in consultation workshop. The search for scientific literature will be done in the Medline, PsychINFO, Emcare and CINAHL databases; as well, policies and reports that examined models of transitional care and the outcomes used to evaluate them will be reviewed. Records will be selected if they involve community dwelling older adults aged 65 years or older, or indigenous persons 45 years or older; and presented in English, French, Dutch and German languages. Records will be screened, reviewed and abstracted by two independent reviewers. Extracted data will be analysed using descriptive statistics and a narrative analysis, and organised according to Donabedian's model of structure (characteristics of older adults experiencing delayed discharge and served by TCPs), process (TCP components and services) and outcome.

ETHICS AND DISSEMINATION

This ScR does not require ethics approval. Dissemination activities include integrated knowledge translation (KT) (consultation with stakeholders throughout the study) and end-of-grant KT strategies (presentations at national and international conferences; and publication in peer-reviewed interdisciplinary journal).

Ensuring smooth transition of frail elderly patients from hospital to community

Emeritus Professor Alan Glasper, from the University of Southampton, discusses issues associated with the delayed discharge of elderly patients from hospital with reference to pertinent policies and procedures

Factors Associated with Bed-Blocking at a University Hospital (Cantabria, Spain) between 2007 and 2015: A Retrospective Observational Study

Current studies on bed-blocking or delayed discharge for non-medical reasons report important variations depending on the country or setting under study. Research on this subject is clearly important as the current system reveals major inefficiencies. Although there is some agreement on the patient-related factors that contribute to the phenomenon, such as older age or a lack of functional ability, there is greater variability regarding environmental or organizational factors. This study sought to quantify the number of cases and days inappropriately spent in hospital and identify patient characteristics and healthcare service use associated with the total length of stay. All cases of delayed discharge were studied at the hospitalization units of a general university hospital in Northern Spain between 2007 and 2015. According to regression estimates, the following characteristics were related to a longer stay: higher complexity through (Diagnosis-Related Group) DRG weight, a diagnosis that implied a lack of functional ability, surgical treatment, having to wait for a destination upon final discharge or return home. After an initial increase, a reduction in delayed discharge was observed, which was maintained for the duration of the study period. Multi-component interventions related with discharge planning can favor a reduced inefficiency with fewer unnecessary stays.

Understanding variation in unplanned admissions of people aged 85 and over: a systems-based approach

AIM

To examine system characteristics associated with variations in unplanned admission rates in those aged 85+.

DESIGN

Mixed methods.

SETTING

Primary care trusts in England were ranked according to changes in admission rates for people aged 85+ between 2007 and 2009, and study sites selected from each end of the distribution: three 'improving' sites where rates had declined by more than 4% and three 'deteriorating' sites where rates had increased by more than 20%. Each site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services and adult social care.

PARTICIPANTS

A total of 142 representatives from these organisations were interviewed to understand how policies had been developed and implemented. McKinsey's 7S framework was used as a structure for investigation and analysis.

RESULTS

In general, improving sites provided more evidence of comprehensive system focused strategies backed by strong leadership, enabling the development and implementation of policies and procedures to avoid unnecessary admissions of older people. In these sites, primary and intermediate care services appeared more comprehensive and better integrated with other parts of the system, and policies in emergency departments were more focused on providing alternatives to admission.

CONCLUSIONS

Health and social care communities which have attenuated admissions of people aged 85+ prioritised developing a shared vision and strategy, with sustained implementation of a suite of interventions.

Hospitalized After Medical Readiness for Discharge: A Multidisciplinary Quality Improvement Initiative to Identify Discharge Barriers in General Medicine Patients

Reducing the length of hospitalization is a shared priority for patients, clinicians, and other health care stakeholders. However, patients can remain hospitalized after being "medically ready" for discharge, accumulating delayed discharge bed days (DDBDs). As part of a quality improvement initiative, the authors developed a method to measure DDBD and define discrete barriers to discharge identified by inpatient clinicians. Patients with delayed discharge had a higher rate of in-hospital complications compared to those who were discharged routinely. To identify modifiable barriers among patients with delayed discharges, 2 patient subgroups were defined: prolonged hospitalization (>19 DDBDs, top quintile accumulated) and extended hospitalization (≤19 DDBDs). Patients with prolonged hospitalization were more likely than those with extended hospitalization to have financial (P < .001) or behavioral (P < .001) barriers, homelessness (P < .05), and impairment of decision-making capacity (P < .01). Understanding the characteristics and discharge barriers of patients who are hospitalized despite medical readiness may increase appropriateness of inpatient resources.