Inappropriately delayed discharge from hospital: what do we know?

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.

The Association Between Age and Admission to an Inappropriate Ward: A Cross-Sectional Survey in France

Half of elderly patient hospitalizations are preceded by an emergency department (ED) visit. Hospitalization in inappropriate wards (IWs), which is more frequent in case of ED overcrowding and high hospital occupancy, leads to increased morbidity. Elderly individuals are the most exposed to these negative health care outcomes. Based on a nationwide cross-sectional survey involving all EDs in France, the aim of this study was to explore whether age was associated with admission to an IW after visiting an ED. Among the 4384 patients admitted in a medical ward, 4065 were admitted in the same hospital where the ED was located, among which 17.7% were admitted to an IW. Older age was associated with an increased likelihood of being admitted to an IW (OR = 1.39; 95% CI = 1.02-1.90 for patients aged 85 years and older and OR = 1.40; 95% CI = 1.02-1.91 for patients aged 75-84 years, compared with those under 45 years). ED visits during peak periods and cardio-pulmonary presenting complaint were also associated with an increased likelihood of admission to an IW. Despite their higher vulnerability, elderly patients are more likely to be admitted to an IW than younger patients. This result reinforces the need for special attention to be given to the hospitalization of this fragile population.

Delay in hospital discharge of trauma patients in a University Hospital in Egypt: A prospective observational study

INTRODUCTION

"Delayed discharge" is defined as patients who remain hospitalised beyond the time of being fit for discharge after a decision of discharge has been made by the managing team. There is no standardised amount of time defining delayed discharge documented in the literature, and there is a lack of evidence about this topic in Egypt. This study is a quality improvement project aiming to identify the factors associated with discharge delays at a single centre in Egypt in order to address this issue.

METHODS

A prospective observational study included all trauma patients admitted to a University Hospital in Egypt over two months. The time of the decision of discharge and actual discharge time were recorded by reviewing patients' medical records. The patients and their caregivers were asked to fill in a questionnaire about the reasons for delayed discharge. Potential reasons for the delayed discharge were classified into system-related, medical and family-related factors.

RESULTS

The study included 498 patients with a median age of 41 years (9-72). The median time from discharge decision until actual discharge was 3 h. System-related factors were documented in 48.8% of cases, followed by medical factors (36.3%), and family-related factors (28.1%). When controlling for age, gender and injury severity score using a logistic regression analysis, longer time to discharge (≥3 h) showed a stronger association with medical factors [adjusted OR (95% CI) = 5.44 (2.73-10.85)] and family-related factors [adjusted OR (95% CI) = 7.94 (3.40-18.54)] compared to system-related factors [adjusted OR (95% CI) = 2.20 (1.12-4.29)].

DISCUSSION

Although system-related factors were more prevalent, medical and family-related factors appear to be associated with longer discharge delays compared to system-related factors.

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.

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.

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

PURPOSE OF THE STUDY

To determine the prevalence of delayed discharges of elderly inpatients and associated costs.

DESIGN AND METHODS

We searched Medline, Embase, Global Health, CAB Abstracts, Econlit, Web of Knowledge, EBSCO - CINAHL, The Cochrane Library, Health Management Information Consortium, and SCIE - Social Care Online for evidence published between 1990 and 2015 on number of days or proportion of delayed discharges for elderly inpatients in acute hospitals. Descriptive and regression analyses were conducted. Data on proportions of delayed discharges were pooled using a random effects logistic model and the association of relevant factors was assessed. Mean costs of delayed discharge were calculated in USD adjusted for Purchasing Power Parity (PPP).

RESULTS

Of 64 studies included, 52 (81.3%) reported delayed discharges as proportions of total hospital stay and 9 (14.1%) estimated the respective costs for these delays. Proportions of delayed discharges varied widely, from 1.6% to 91.3% with a weighted mean of 22.8%. This variation was also seen in studies from the same country, for example, in the United Kingdom, they ranged between 1.6% and 60.0%. No factor was found to be significantly associated with delays. The mean costs of delayed discharge also varied widely (between 142 and 31,935 USD PPP adjusted), reflecting the variability in mean days of delay per patient.

IMPLICATIONS

Delayed discharges occur in most countries and the associated costs are significant. However, the variability in prevalence of delayed discharges and available data on costs limit our knowledge of the full impact of delayed discharges. A standardization of methods is necessary to allow comparisons to be made, and additional studies are required-preferably by disease area-to determine the postdischarge needs of specific patient groups and the estimated costs of delays.

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.

Long-term care provision, hospital bed blocking, and discharge destination for hip fracture and stroke patients

We examine the relationship between long-term care supply (care home beds and prices) and (i) the probability of being discharged to a care home and (ii) length of stay in hospital for patients admitted to hospital for hip fracture or stroke. Using patient level data from all English hospitals and allowing for a rich set of demographic and clinical factors, we find no association between discharge destination and long-term care beds supply or prices. We do, however, find evidence of bed blocking: hospital length of stay for hip fracture patients discharged to a care home is shorter in areas with more long-term care beds and lower prices. Length of stay is over 30% shorter in areas in the highest quintile of care home beds supply compared to those in the lowest quintile.

Reasons for discharge delays in teaching hospitals

OBJECTIVE

To analyze the causes of delay in hospital discharge of patients admitted to internal medicine wards.

METHODS

We reviewed 395 medical records of consecutive patients admitted to internal medicine wards of two public teaching hospitals: Hospital das Clínicas of the Universidade Federal de Minas Gerais and Hospital Odilon Behrens. The Appropriateness Evaluation Protocol was used to define the moment at which notes in the medical records indicated hospital stay was no longer appropriate and patients could be discharged. The interval between this estimated time and actual discharge was defined as the total number of days of delay in hospital discharge. An instrument was used to systematically categorize reasons for delay in hospital discharge and frequencies were analyzed.

RESULTS

Delays in discharge occurred in 60.0% of 207 hospital admissions in the Hospital das Clínicas and in 58.0% of 188 hospital admissions in the Hospital Odilon Behrens. Mean delay per patient was 4.5 days in the former and 4.1 days in the latter, corresponding to 23.0% and 28.0% of occupancy rates in each hospital, respectively. The main reasons for delay in the two hospitals were, respectively, waiting for complementary tests (30.6% versus 34.7%) or for results of performed tests to be released (22.4% versus 11.9%) and medical-related accountability (36.2% versus 26.1%) which comprised delays in discussing the clinical case and in clinical decision making and difficulties in providing specialized consultation (20.4% versus 9.1%).

CONCLUSIONS

Both hospitals showed a high percentage of delay in hospital discharge. The delays were mainly related to processes that could be improved by interventions by care teams and managers. The impact on mean length of stay and hospital occupancy rates was significant and troubling in a scenario of relative shortage of beds and long waiting lists for hospital admission.

An examination of factors influencing delayed discharge of older people from hospital

OBJECTIVE

This study aimed to investigate the factors associated with the delayed discharge of older people from hospital and their length of stay (LOS).

METHODS

Data were collected retrospectively from inpatient records and adult social care services on older patients referred to the latter prior to hospital discharge.

RESULTS

Data on two related measures--delayed discharge and LOS--were analysed separately within a four-stage sequential framework. Using bivariate analysis, we found that cognitive impairment and dependency were significantly associated with delay. Patients admitted to trauma and orthopaedics specialties were significantly more likely to be delayed on discharge. Respiratory illness was negatively associated with delay. Factors related to care received as an inpatient associated with delayed discharge from hospital were not being in the responsible consultant's bed for part of their stay, two or more moves between specialties and receipt of rehabilitation services. Admission to a care home and receipt of domiciliary care if returning to a private dwelling on discharge were associated with delay. In the multivariate analysis, dependence and cognitive impairment impacted differently on delay and LOS. Hospital variables were the most important predictors of LOS and social care variables in respect of delayed discharge.

CONCLUSION

Patient characteristics and especially the organisation of care in hospital and the provision of services on discharge are related to the likelihood of delayed discharge and LOS. Improved services and structures to systematically assess and treat patient needs in hospital, together with the timely provision of services providing post-discharge services tailored to individual circumstances, are required.

Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study

INTRODUCTION

Frail older people experience frequent care transitions and an integrated healthcare system could reduce barriers to transitions between different settings. The study aimed to investigate care transitions of frail older people from acute hospital wards to community healthcare or community hospital wards, within a system that had vertically integrated acute hospital and community healthcare services.

THEORY AND METHODS

The research design was a multimethod, qualitative case study of one healthcare system in England; four acute hospital wards and two community hospital wards were studied in depth. The data were collected through: interviews with key staff (n = 17); focus groups (n = 9) with ward staff (n = 36); interviews with frail older people (n = 4). The data were analysed using the framework approach.

FINDINGS

THREE THEMES ARE PRESENTED: Care transitions within a vertically integrated healthcare system, Interprofessional communication and relationships; Patient and family involvement in care transitions.

DISCUSSION AND CONCLUSIONS

A vertically integrated healthcare system supported care transitions from acute hospital wards through removal of organisational boundaries. However, boundaries between staff in different settings remained a barrier to transitions, as did capacity issues in community healthcare and social care. Staff in acute and community settings need opportunities to gain better understanding of each other's roles and build relationships and trust.

The Appropriateness Evaluation Protocol is a poor predictor of in-hospital mortality

BACKGROUND

The Appropriateness Evaluation Protocol (AEP) proposes admission criteria based only on physiological and laboratory parameters and has recently informed an Irish national bed utilisation review. Severity of illness tools can be poorly predictive of outcomes, particularly in older patients.

AIMS

To assess the clinical utility of the AEP in moribund older and younger patients.

METHODS

The study was conducted in four acute hospitals in South Munster, Ireland, and was of retrospective analytical cohort study design. The Hospital In-Patient Enquiry Scheme was used to ascertain patients who died within 10 days of hospital admission, over a 2-year period. Proximate death was used as a robust measure of validity of admission. Emergency department (ED) records were screened retrospectively to allocate the AEP criteria.

RESULTS

There were 803 eligible in-hospital deaths. Establishment of AEP criteria was available in 72.9 % (585 patients, 50.8 % female). The median length of stay until death was 4 days. Just over 30 % (179/585) of patients did not meet AEP criteria, two-fifths (72/179) of whom had been coded as severely unwell on arrival to the ED. There was no significant difference in AEP identification rates between older and younger age groups.

CONCLUSIONS

Our study illustrates that the AEP is a poor predictor of mortality in all age groups, having failed to identify approximately one-third of our cohort. Based on our findings, we feel that this tool should not be used to assess the appropriateness of admission.

In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience

Delayed patient discharge will likely exacerbate bed shortages. This study prospectively determined the frequency, causes and potential cost implications of delays for 83 consecutive patients, who were inpatients for a total of 888 days. 65% of patients experienced delay whilst awaiting a service. 48% of patients experienced delays that extended their discharge date. Discharge delays accounted for 21% of the cohort's inpatient stay, at an estimated cost of 565 sterling pounds per patient; 77% of these hold-ups resulted from delays in the provision of social and therapy requirements. Discharge delays are costly for hospitals and depressing for patients. Investment is required to enable health and social-care professionals to work more closely to improve the patient journey.

From bed-blocking to delayed discharges: precursors and interpretations of a contested concept

Delayed hospital discharges have been identified as a problem for the English National Health Service and have prompted several policy and service development responses in the last decade. However, bed-blocking is an issue surrounded by rival interpretations on how and why hospital delays occur and the way in which they are measured. To better understand this contested concept, this paper provides a brief description of the historical accounts that framed the emergence of delayed hospital discharges as a phenomenon. Three key features of the bed-blocking concept are also analysed: the reduction of patients' length of stay to improve efficiency, the intrinsic methodological difficulties of measuring hospital delays and the most common reasons for delayed discharges. A description of the characteristics of the patients frequently labelled as delayed discharge, their common traits and how these have been examined by previous research is also provided. Finally, this paper argues that the presence of hospital delays in a health system tends to be considered as an indicator of two possible system inefficiencies: a failure in the discharge planning process, which generally blames social services departments for not ensuring timely services, or a shortage of alternative forms of care for this group of patients.

An evaluation of pharmacist-written hospital discharge prescriptions on general surgical wards

Objective

To evaluate the quality of pharmacist-written hospital discharge prescriptions (DPs) in comparison to those written by doctors.

Method

The study was carried out in two, week-long phases on the general surgical wards in one UK hospital. In phase 1, doctors wrote the DPs, which were then checked by the ward pharmacist. In phase 2, ward pharmacists wrote the DPs which were then checked by the patient's junior doctor. In both phases, the clinical dispensary pharmacist made their routine check of the prescription prior to dispensing. All interventions were recorded on a pre-piloted data collection form.

Key findings

In phase 1, doctors wrote 128 DPs; in phase 2, pharmacists wrote 133 DPs. There were 755 interventions recorded during phase 1 in comparison to 76 during phase 2. In phase 1, transcription errors accounted for 118 interventions, 149 were due to ambiguity/illegibility; 488 amendments were to facilitate the dispensing process e.g. clarification of patient, medical and drug details, and dosage form discrepancies. In phase 2, transcription errors accounted for one intervention, 50 interventions were due to ambiguities or illegibility; 25 amendments were to facilitate the dispensing process. During phase 2, doctors made 10 minor alterations to pharmacist-written DPs. On 52 occasions during phase 2, the ward pharmacist had to clarify, prior to writing the DP, either the dose of a drug, or, whether a drug should be continued on discharge, and if so, for what duration.

Conclusion

Pharmacist-written DPs contained considerably fewer errors, omissions and unclear information in comparison to doctor-written DPs. Doctors recorded no significant alterations when validating pharmacist-written DPs.

Policies for reducing delayed discharge from hospital

INTRODUCTION

Delayed discharge from acute hospital has been a cause of concern for the last 10 years. Older people with complex health needs are particularly vulnerable to delayed discharge with negative consequences for their health and wellbeing.

SOURCE OF DATA

Review of the literature on the impact of the Community Care (Delayed Discharge) Act (2003) and subsequent policy initiatives on delayed discharges. Areas of agreement A number of cross-institutional complexities contribute to delayed discharges. Policy measures have contributed positively to reducing delayed discharges. Investment in intermediate care services has provided a range of services to promote maximum independence for older people after acute hospital admission. Joint working between health and social services is necessary to prevent delayed discharges.

AREAS OF CONTROVERSY

Pressure to achieve rapid hospital throughput may be contributing to older people leaving hospital too soon and to recent increases in hospital re-admission rates. Policy measures are extending to older people with mental health problems.

AREAS TIMELY FOR DEVELOPING RESEARCH

Patient and carer experiences of delayed or premature discharge. Quality and equity of access to intermediate care for older people.

Long-term care and hospital utilisation by older people: an analysis of substitution rates

Older people are intensive users of hospital and long-term care services. This paper explores the extent to which these services are substitutes. A small area analysis was used with both care home and (tariff cost-weighted) hospital utilisation for older people aggregated to electoral wards in England.Health and social-care structural equations were specified using a theoretical model. The estimation accounted for the skewed and censored nature of the data. For health utilisation, both a fixed effects instrumental variables GMM model and a generalised estimating equations (GEE) model were fitted, the later on a log dependent variable with predicted values of social care utilisation used to account for endogeneity (bootstrapping was used to derive standard errors). In addition to a GMM model, the social-care estimation used both two-part and tobit models (also with predicted health utilisation and bootstrapping).The results indicate that for each additional pound1 spent on care homes, hospital expenditure falls by pound0.35. Also, pound1 additional hospital spend corresponds to just over pound0.35 reduction on care home spend. With these cost substitution effects offsetting, a transfer of resources to care homes is efficient if the resultant outcome gain is greater than the outcome loss from reduced hospital use.

The patient experience of being a delayed discharge

AIM

To explore what life was like for frail older people, classed as 'delayed discharges'.

BACKGROUND

Delayed discharge or 'bed blocking' is when a patient is inappropriately occupying a hospital bed. Most delayed discharges are frail older people who are waiting until a care home bed is available for them to move to. This paper explores what life was like for some people who were living in such a state of transition.

METHODS

An ethnographic approach was employed, using a variety of methods. This paper discusses one of the methods used; participant observation on a ward for older people classed as delayed discharge. The researcher visited the ward for over a year, field notes and interviews were transcribed and the data analysed using thematic analysis.

RESULTS

The frail older people were anxious about their futures. Not one voiced their anxieties to staff and the findings showed they felt unsupported during this critical and final stage in their lives.

CONCLUSIONS

In order to support frail older people undergoing a major life event, staff need to be aware of the effect of the stress involved for those who know they have to move on and yet have no control over their destiny.

IMPLICATIONS FOR NURSING MANAGEMENT

Qualified and unqualified staff need to understand that patients in transition have many anxieties about their futures. The stress of moving on should be sensitively addressed in everyday care.

Characteristics of patient and healthcare service utilization associated with inappropriate hospitalization days

AIM

This paper is a report of a study to examine the number of inappropriate days of hospitalization and to identify the characteristics of patient and healthcare service utilization associated with inappropriate hospital stays.

BACKGROUND

Inappropriate hospitalization stays are recognized as an important indication of the misuse of healthcare services, but the published literature shows inconsistent findings on factors influencing this.

METHOD

A descriptive, correlational study was carried out in September 2005, with a patient survey and a review of patient records. Data were collected for 383 patients discharged from eight general nursing care units in a tertiary teaching hospital in Korea. Inappropriate hospitalization days were defined as inpatient days not requiring continuous and active medical, nursing or paramedical treatment provided by hospital services, and were judged using the Korean version of the Appropriate Evaluation Protocol. Univariate and multiple regression analyses were performed to determine factors associated with inappropriate hospitalization days.

FINDINGS

A total of 3076 hospitalization days were reviewed. The average proportion that were inappropriate was 5.1% (+/-16.0) per patient, and 14.1% of patients were determined to have had at least one inappropriate hospitalization day. The most common reason judged as appropriate was need for nursing/life support services. Statistically significant factors associated with inappropriate stay included gender, age, primary disease, length of stay and ward bed occupancy level during the patient's hospitalization.

CONCLUSION

Managers should take into account patient and clinical characteristics to promote better utilization of hospital resources.

A waiting list to go home: an analysis of delayed discharges from surgical beds

INTRODUCTION

The aim of this paper was to analyse patients who were unable to be discharged from a surgical ward despite being surgically fit to leave.

PATIENTS AND METHODS

Data were collected on all surgical in-patients on a single day. Patients who were surgically fit for discharge but whose discharge was delayed were identified. Demographic data and reasons for delay were noted.

RESULTS

Nine of 75 patients (12%) were surgical bed blockers. These patients were more likely to have been admitted as emergencies (P = 0.035) and were older (P < 0.01) than the remaining patients. They occupied 35% of the total 'bed-days' of the group as a whole with a median in-patient stay of 41 days compared with 2 days for the other patients. Trust-collected data, based on UK Government guidelines, showed only one surgical delayed discharge patient on the day studied.

CONCLUSIONS

Due to problems in defining delayed discharge Government figures probably underestimate the true numbers. Lack of intermediate care and social service provision are a major cause of bed blocking.

Delayed discharge from rehabilitation after brain injury

OBJECTIVE

To investigate the extent of, and factors contributing to, delayed discharges for younger adults in rehabilitation.

METHOD

Survey of patients discharged and awaiting discharge in a six-month period in five centres across England operated by a leading independent sector provider. Discharge was classified as delayed if a person had been waiting more than 30 days for transfer.

RESULTS

One in three beds was occupied by a delayed discharge (median delay > seven months). Common reasons were absence of a suitable placement (41%) and failure to obtain funding for postdischarge support (31%). Delays were also associated with poor indoor mobility and additional physical/mental health problems. We estimated earlier discharge would have resulted in overall cost savings of almost ł490 000.

CONCLUSION

Delayed discharge remains a significant obstacle to the development of cost-effective care pathways for younger adults. Our study suggests that health and social services are not exploiting the UK government's legislation for flexible partnership working in this area.

Delayed transfers of older people from hospital: Causes and policy implications

Health and social care agencies in the UK. have been under pressure for some time to reduce delayed transfers of older people from hospital because they absorb scarce health service resources and incur a human cost through inappropriate placement. A local study based on an analysis of records and interviews with managers showed that delays reflect the complex needs of older people, and arise from financing and organisational problems at both the planning and implementation stages of a discharge. Family resistance may also be a factor. Budgetary constraints result in delays in confirming public support for some clients. Shortages of professional staff and care assistants limit the provision of domiciliary packages. The contraction of the residential sector has reduced the availability of beds and increased the cost of care home placements. Scope exists for expediting administrative aspects of transfers by coordinating health and social services. More recent legislation that imposes fines on social service departments for delayed transfers does not address underlying causes.

Impact of physician training level on emergency readmission within internal medicine

Objectives: The research question was whether training level of admitting physicians and referrals from practitioners in primary health care (PHC) are risk factors for emergency readmission within 30 days to internal medicine.

Methods: This report is a prospective multicenter study carried out during 1 month in 1997 in seven departments of internal medicine in the County of Stockholm, Sweden. Two of the units were at university hospitals, three at county hospitals and two in district hospitals. The study area is metropolitan–suburban with 1,762,924 residents. Data were analyzed by multiple logistic regression.

Results: A total of 5,131 admissions, thereby 408 unplanned readmissions (8 percent) were registered (69.8 percent of 7,348 true inpatient episodes). The risk of emergency readmission increased with patient's age and independently 1.40 times (95 percent confidence interval [CI], 1.13–1.74) when residents decided on hospitalization. Congestive heart failure as primary or comorbid condition was the main reason for unplanned readmission. Referrals from PHC were associated with risk decrease (odds ratio, 0.53; 95 percent CI, 0.38–0.73).

Conclusion: The causes of unplanned hospital readmissions are mixed. Patient contact with primary health care appears to reduce the recurrence. In addition to the diagnoses of cardiac failure, training level of admitting physicians in emergency departments was an independent risk factor for early readmission. Our conclusion is that it is cost-effective to have all decisions on admission to hospital care confirmed by senior doctors. Inappropriate selection of patients to inpatient care contributes to poor patient outcomes and reduces cost-effectiveness and quality of care.

An audit of anticipated discharge planning for acute medical and orthopaedic admissions

The authors of this article audited an anticipated discharge survey on acute medical and orthopaedic admissions to a UK hospital over a 2-month period. An anticipated discharge form was filled in on admission by an experienced clinician and a discharge date set based on the patient's clinical condition, age and social circumstances. In total, 31 patients (51%) went home on the day planned or within one day of this date. The reasons for delays in discharge included failure of doctors to review patients, slow response to treatment and waiting for social services. Slow mobilization in eight patients accounted for the longest length of stays.

The authors found that discharge plans may break down at weekends and are exploring innovative ways of solving this problem.