A Systematic Review of Criteria-Led Patient Discharge

Using Clinical-based Discharge Criteria to Discharge Patients After Endoscopy Procedures Under Drug-induced Intravenous Sedation in the Outpatient Care Unit: An Observational Study

PURPOSE

To verify the feasibility of clinical-based discharge (CBD) criteria and to find out the reasons for the delayed discharge of outpatients after endoscopy procedures under drug-induced intravenous sedation.

DESIGN

A prospectively observational study conducted at a tertiary endoscopy center.

METHODS

Medical records were collected from outpatients admitted for endoscopy procedures under drug-induced intravenous sedation from June 1, 2021 to December 30, 2021. Patients were scheduled to discharge at least 30 minutes based on the time-based discharge (TBD) method. Postanesthetic discharge scoring system in the outpatient post-anesthesia care unit (PACU) recorded the time of patients discharged home on the CBD criteria. Postoperative complications were recorded in the PACU and within 24 hours after discharge. Multivariate analysis was applied to identify the factors relating to late discharges.

FINDINGS

10,597 patients were safely and successfully discharged home, and we were informed of no serious emergency or accidental readmissions to the hospital. The mean CBD time (21.77 ± 11.35 minutes) was compared with the TBD time (30 minutes) and actual TBD discharge time (61.56 ± 4.93 minutes), which were statistically significant, without changes in the patient's vital signs (P < .01). Primarily, further univariate and multivariate analyses showed that abdominal pain and fatigue were key factors accountable for delay in PACU discharge (P < .05).

CONCLUSIONS

The study concluded that in patients undergoing ambulatory endoscopy procedures with drug-induced intravenous sedation, discharge times based on physiological scoring systems can efficiently and safely guide ambulatory patient discharge as compared to the traditional TBD method. Postoperative fatigue and pain were the main factors affecting patients discharge associated with a relatively long PACU length of stay.

Discharge criteria for inpatient paediatric asthma: a narrative systematic review

INTRODUCTION

Criteria-led discharges (CLDs) and inpatient care pathways (ICPs) aim to standardise care and improve efficiency by allowing patients to be discharged on fulfilment of discharge criteria. This narrative systematic review aims to summarise the evidence for use of CLDs and discharge criteria in ICPs for paediatric inpatients with asthma, and summarise the evidence for each discharge criterion used.

METHODS

Database search using keywords was performed using Medline, Embase and PubMed for studies published until 9 June 2022. Inclusion criteria included: paediatric patients <18 years old, admitted to hospital with asthma or wheeze and use of CLD, nurse-led discharge or ICP. Reviewers screened studies, extracted data and assessed study quality using the Quality Assessment with Diverse Studies tool. Results were tabulated. Meta-analysis was not performed due to heterogeneity of study designs and outcomes.

RESULTS

Database search identified 2478 studies. 17 studies met the inclusion criteria. Common discharge criteria include bronchodilator frequency, oxygen saturation and respiratory assessment. Discharge criteria definitions varied between studies. Most definitions were associated with improvements in length of stay (LOS) without increasing re-presentation or readmission.

CONCLUSION

CLDs and ICPs in the care of paediatric inpatients with asthma are associated with improvements in LOS without increasing re-presentations or readmissions. Discharge criteria lack consensus and evidence base. Common criteria include bronchodilator frequency, oxygen saturations and respiratory assessment. This study was limited by a paucity of high-quality studies and exclusion of studies not published in English. Further research is necessary to identify optimal definitions for each discharge criterion.

Implementing criteria-led discharge for acute admissions to facilitate the elective recovery from COVID-19: an example in acute tonsillitis

BACKGROUND

Healthcare systems face unprecedented numbers of patients waiting for elective treatments in the wake of the COVID-19 pandemic. Hospitals must urgently optimise patient pathways and build capacity to meet the populations health needs. Criteria-led discharge (CLD) is frequently used to optimise elective care pathways but may hold potential in discharging patients at the end of an acute hospital admission.

METHODS

We conducted a quality improvement project to design and introduce a novel inpatient pathway using CLD for patients with severe acute tonsillitis. Our analysis compared the standardisation of treatment, length of stay, discharge time and readmission rate between those treated on the novel pathway compared with standard treatment.

RESULTS

The study population included 137 patients admitted to a tertiary centre with acute tonsillitis. Introduction of the tonsillitis pathway using CLD resulted in a significant reduction in median length of stay from 24 hours to 18 hours. Of those treated on the tonsillitis pathway, 52.2% were discharged prior to midday compared with 29.1% who received standard treatment. No patient discharged using CLD required readmission.

CONCLUSION

CLD is safe and effective at reducing length of stay in patients requiring acute hospital admission for acute tonsillitis. CLD should be used and evaluated in further novel patient pathways across different areas of medicine to optimise care and build capacity for provision of elective healthcare services. Further research is required to investigate safe and optimal criteria which indicate patients are fit for discharge.

Postoperative Discharge Scoring Criteria After Outpatient Anesthesia: A Review of the Literature

PURPOSE

The aim of this review was to explore the existing literature on discharge criteria, tools and strategies used in the postanesthesia care unit (PACU) after ambulatory surgery and to identify the essential components of an effective and feasible scoring system based on applicable criteria for the three phases of anesthesia recovery to assess patient discharge after outpatient anaesthesia.

DESIGN

A review of the literature.

METHODS

In this study, a review of sixteen articles was conducted to analyze the affecting factors, evaluation tools, and the current research status of patients discharge after outpatient anesthesia.

FINDINGS

The main factors affecting the discharge after diagnostic or therapeutic procedures under outpatient anesthesia were hospital management, medical treatment and patients themselves. Physiological systems-based discharge assessment had several advantages over traditional time-based discharge assessment. The Aldrete scoring scale was often used for patients in the first stage of anesthesia recovery to leave the PACU, and the Chung's scoring scale was often used to evaluate patients in the second stage of recovery until they leave the hospital. These two scales were often used in combination for outpatient anesthesia. The Fast-tracking assessment tool was used in patients who directly returned to the ward or discharge of patients after ambulatory surgery. There is currently no uniform standard or tool for assessing patients discharge after diagnostic or therapeutic procedures under the outpatient anesthesia.

CONCLUSIONS

Optimal care under anesthesia should allow the patient to recover from anesthesia smoothly and quickly and leave the hospital safely. When the patients can safely leave the hospital after outpatient anesthesia is still a problem that needs to be solved in the nursing field. Various existing scoring systems have their historical advancements, but we need to formulate more in line with the current status of postoperative patients discharge standards.

Criteria-led discharge for simple appendicitis in children: A pilot study

AIM

Criteria-led discharge (CLD) protocols have been suggested to increase efficiency of discharge from hospital following surgical interventions. Our aim was to assess the feasibility, clinical outcomes and parental satisfaction following the introduction of a pilot CLD for simple appendicitis (SA) in children.

METHODS

A prospective pilot cohort study was conducted including paediatric patients with SA who were managed with CLD and a control group who were managed with standard discharge procedures. A CLD pro forma was developed, standardising care guidelines and clinical criteria indicators to be met for children to be discharged post-operatively. A post-discharge parent survey was also utilised. The primary outcome measure was post-operative length of stay (pLOS), with secondary outcomes of post-operative complication rates and parental satisfaction.

RESULTS

The control group consisted of 31 patients and CLD group 35 patients. There was no difference in the median pLOS (24 [16.7-44.6] vs. 25.3 [19.1-50.1] h, P = 0.3). Furthermore, there were no significant differences on any of the secondary outcomes. Parental confidence with time of discharge was very high in both control (85.7%) and CLD (88.2%) groups (P = 1.0).

CONCLUSION

The introduction of CLD is safe and feasible. Whilst this pilot has not demonstrated a reduction in pLOS, our data suggest that it is well accepted by the parents.

Validity and Utility Testing of a Criteria-led Discharge Checklist to Determine Post-operative Recovery after Abdominal Surgery: an International Multicentre Prospective Cohort Trial

BACKGROUND

Criteria-led discharge (CLD) has promising potential to reduce unnecessary hospital stay after abdominal surgery; however, the validity and utility of CLD is uncertain as studies are limited to small single-centre studies involving predominantly elective colorectal surgery.

METHODS

This prospective international multicentre cohort study explored the relationship between a CLD checklist, post-operative recovery, and hospital length of stay using patient-level data from four clinical trials involving 1071 adults undergoing all types of emergency and elective abdominal surgery at five hospitals across Australia and New Zealand. Patients were assessed daily for 21 post-operative days using a standardised CLD checklist. Surgeons and hospital clinicians were masked to findings. Criterion, construct, and content validity of the checklist to accurately reflect discharge decisions by surgical teams, assess physiological recovery, and encompass parameters signalling physiological readiness to discharge were tested. Potential utility of CLD to minimise unnecessary hospital stay was assessed by comparing day of readiness to discharge to actual day of discharge.

RESULTS

The CLD checklist had concordance with existing discharge planning practices and accurately measured a longer post-operative recovery in more complex clinical situations. The CLD checklist in its current format did not detect all legitimate medical and surgical reasons necessitating a continued stay in hospital. Day of readiness to discharge was 0.8 days (95% CI 0.7 to 0.9, p < 0.001) less than actual day of discharge.

CONCLUSION

A CLD checklist has excellent criterion and construct validity in measuring physiological recovery following all types of major elective and emergency abdominal surgery. Content validity could be improved. The use of CLD has the potential to reduce unnecessary hospital stay although the safety of discharging patients according to the criteria requires investigation prior to implementation.

TRIAL REGISTRATION

Trials were prospectively registered at the Australian New Zealand Clinical Trials Registry (LIPPSMAck POP 12613000664741, ICEAGE 12615000318583, PLASTIC 12619001344189, NIPPER PLUS 12617000269336).

Developing a Process for Criteria-Led Discharge: Selection of Patients for Efficient and Effective Discharge (SPEED)

BACKGROUND

Criteria-led discharge (CLD) is an approach for maximizing bed capacity by expediting patient discharge.

PROBLEM

In acute medicine settings, patients commonly have multiple medical problems, which render single care pathway and clinical protocols of limited use. CLD offers potential, but little evidence exists about how to best implement it in these contexts.

APPROACH

Retrospective case note analysis generated characteristics from patients' discharge plans to design a criterion-based framework to aid patient selection for CLD. These criteria were hypothetically tested on patient case notes (n = 50).

OUTCOMES

CLD was identified as suitable (n = 27) and unsuitable (n = 23) from 50 case notes. Interrater agreement was 86% between 3 reviewers.

CONCLUSIONS

This review has provided greater understanding of the complexity of discharge in acute medicine settings. Implementing CLD to optimize timeliness of patient discharge might offer a solution for selected patients.

Association of Discharge Disposition with Outcomes

Understanding the relationships between discharge disposition, readmissions, and cost of care is an important strategy for Accountable Care Organizations (ACOs) with aspirations to achieve shared savings. The purpose of this retrospective cohort study is to examine whether there is an association between the discharge dispositions of home with home health (HH) compared to skilled nursing facility (SNF) and the readmission rate and cost of care for Medicare ACO patients discharged from the hospital. The authors studied the variables associated with readmission rates and cost of care, including discharge disposition and risk score for 1151 patients attributed to an ACO. In multivariate logistic regression analysis, variables associated with increased risk for 30-day readmission were the Centers for Medicare & Medicaid Services Hierarchical Condition Category risk score and the discharge setting. Discharges to SNF were almost 5 times more likely to be readmitted to the hospital at 30 days compared to patients discharged to the HH setting. The cost of care is lower for the HH discharge disposition, with an $8678 per patient difference between the cost of care for patients discharged to HH and SNF levels of care. Findings from this study suggest that employing a transitional care planning approach that prioritizes discharging patients to the least restrictive next site of care, shifting patients from SNF disposition to HH as appropriate, is an effective strategy to improve readmission rates and cost of care.