A long wait: barriers to discharge for long length of stay patients

Temporal trends in neurosurgical volume and length of stay in a public healthcare system: A decade in review with a focus on the COVID-19 pandemic

Background

Over the past decade, neurosurgical interventions have experienced changes in operative frequency and postoperative length of stay (LOS), with the recent COVID-19 pandemic significantly impacting these metrics. Evaluating these trends in a tertiary National Health Service center provides insights into the impact of surgical practices and health policy on LOS and is essential for optimizing healthcare management decisions.

Methods

This was a single tertiary center retrospective case series analysis of neurosurgical procedures from 2012 to 2022. Factors including procedure type, admission urgency, and LOS were extracted from a prospectively maintained database. Six subspecialties were analyzed: Spine, Neuro-oncology, Skull base (SB), Functional, Cerebrospinal fluid (CSF), and Peripheral nerve (PN). Mann-Kendall temporal trend test and exploratory data analysis were performed.

Results

19,237 elective and day case operations were analyzed. Of the 6 sub-specialties, spine, neuro-oncology, SB, and CSF procedures all showed a significant trend toward decreasing frequency. A shift toward day case over elective procedures was evident, especially in spine (P < 0.001), SB (tau = 0.733, P = 0.0042), functional (tau = 0.156, P = 0.0016), and PN surgeries (P < 0.005). Over the last decade, decreasing LOS was observed for neuro-oncology (tau = -0.648, P = 0.0077), SB (tau = -0.382, P = 0.012), and functional operations, a trend which remained consistent during the COVID-19 pandemic (P = 0.01). Spine remained constant across the decade while PN demonstrated a trend toward increasing LOS.

Conclusion

Most subspecialties demonstrate a decreasing LOS coupled with a shift toward day case procedures, potentially attributable to improvements in surgical techniques, less invasive approaches, and increased pressure on beds. Setting up extra dedicated day case theaters could help deal with the backlog of procedures, particularly with regard to the impact of COVID-19.

A phase 2 trial of defibrotide for the prevention of chimeric antigen receptor T-cell-associated neurotoxicity syndrome

Chimeric antigen receptor T-cell (CAR-T) therapy represents a major advance in cancer immunotherapy; however, it can be associated with life-threatening neurotoxicity linked to blood-brain barrier disruption and endothelial activation. Defibrotide was shown to reduce endothelial cell activation in vitro and is approved in the United States for treatment of veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) in patients with renal or pulmonary dysfunction after hematopoietic cell transplantation (HCT), and in the European Union for severe VOD/SOS after HCT in patients aged >1 month. Defibrotide may stabilize the endothelium during CAR-T therapy and reduce the rate of CAR-T-associated neurotoxicity. This phase 2 study evaluated the safety and efficacy of defibrotide for prevention of CAR-T-associated neurotoxicity in patients with relapsed/refractory large B-cell lymphoma receiving axicabtagene ciloleucel. Part 1 established the recommended phase 2 dose (RP2D; 6.25 mg/kg); 20 patients (from parts 1 and 2) receiving the RP2D were evaluable for efficacy. Rate of CAR-T-associated neurotoxicity by day 30 (primary end point) was ∼50%, lower than reported in the ZUMA-1 trial (64%). Median event duration of grade ≥3 neurotoxicity was 7 days. No unexpected defibrotide-related safety findings and defibrotide-related treatment-emergent adverse events or deaths were reported. Results showed modest reduction in rate of CAR-T-associated neurotoxicity and high-grade neurotoxicity event duration relative to historical data; however, reduction was unlikely to meet the primary end point, so the study was terminated early. Nevertheless, results contribute valuable data for potential therapeutic insight on the management of CAR-T-associated neurotoxicity. This trial was registered at www.clinicaltrials.gov as #NCT03954106.

Creation and Expansion of a Mixed Patient Intermediate Care Unit to Improve ICU Capacity

OBJECTIVES

ICU capacity strain is associated with worsened outcomes. Intermediate care units (IMCs) comprise one potential option to offload ICUs while providing appropriate care for intermediate acuity patients, but their impact on ICU capacity has not been thoroughly characterized. The aims of this study are to describe the creation of a medical-surgical IMC and assess how the IMC affected ICU capacity.

DESIGN

Descriptive report with retrospective cohort review.

SETTING

Six hundred seventy-three-bed tertiary care academic medical center with 77 ICU beds.

PATIENTS

Adult inpatients who were admitted to the IMC.

INTERVENTIONS

An interdisciplinary working group created an IMC which was located on a general ward. The IMC was staffed by hospitalists and surgeons and supported by critical care consultants. The initial maximum census was three, but this number increased to six in response to heightened critical care demand. IMC admission criteria also expanded to include advanced noninvasive respiratory support defined as patients requiring high-flow nasal cannula, noninvasive positive pressure ventilation, or mechanical ventilation in patients with tracheostomies.

MEASUREMENTS AND MAIN RESULTS

The primary outcome entailed the number of ICU bed-days saved. Adverse outcomes, including ICU transfer, intubation, and death, were also recorded. From August 2021 to July 2022, 230 patients were admitted to the IMC. The most frequent IMC indications were respiratory support for medical patients and post-operative care for surgical patients. A total of 1023 ICU bed-days were made available. Most patients were discharged from the IMC to a general ward, while 8% of all patients required transfer to an ICU within 48 hours of admission. Intubation (2%) and death (1%) occurred infrequently within 48 hours of admission. Respiratory support was the indication associated with the most ICU transfers.

CONCLUSIONS

Despite a modest daily census, an IMC generated substantial ICU bed capacity during a time of peak critical care demand.

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.

Level of Care Appropriateness in VA Inpatient Surgery Cases

PURPOSE OF STUDY

Within the Veterans Health Administration, utilization management (UM) focuses on reducing unnecessary or inappropriate hospitalizations by applying evidence-based criteria to evaluate whether the patient is placed in the right level of care. This study examined inpatient surgery cases to classify reasons for not meeting criteria and to identify the appropriate level of care for admissions and subsequent bed days of care.

PRIMARY PRACTICE SETTINGS

There were 129 VA Medical Centers in which inpatient UM reviews were performed during that time, of which 109 facilities had UM reviews conducted in Surgery Service.

METHODOLOGY AND SAMPLE

All admissions to surgery service during fiscal year 2019 (October 1, 2018 to September 30, 2019) that had a UM review entered in the national database were extracted, including current level of care, recommended level of care, and reasons for not meeting criteria. The following demographic and diagnostic fields were supplemented from a national data warehouse: age, gender, marital status, race, ethnicity, and service connection status. Data were analyzed with descriptive statistics. Characteristics of patient demographics were compared using the χ2 test for categorical variables and the Student's t test.

RESULTS

A total of 363,963 reviews met conditions to be included in the study: 87,755 surgical admission reviews and 276,208 continued stay reviews. There were 71,274 admission reviews (81.22%) and 198,521 (71.87%) continued stay reviews that met the InterQual criteria. The primary reason for not meeting admission criteria was clinical variance (27.70%), followed by inappropriate level of care (26.85%). The leading reason for not meeting continued stay criteria was inappropriate level of care (27.81%), followed by clinical instability (25.67%). Of the admission reviews not meeting admission criteria, 64.89% were in the wrong level of care and 64.05% of continued stay reviews were also in the wrong level of care. Half of the admission reviews not meeting criteria had a recommended level of care as home/outpatient (43.51%), whereas nearly one-third (28.81%) continued stay reviews showed a recommended level of care of custodial care or skilled nursing.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

This study identified system inefficiencies through admission and continued stay reviews of surgical inpatients. Patients admitted for ambulatory surgery or for preoperative testing prior to day of surgery resulted in avoidable bed days of care that may have contributed to patient flow issues and limited the available hospital beds for other patients. Through early collaboration with case management and care coordination professionals, alternatives can be explored that safely address the patient needs, such as temporary lodging options. There may be conditions or complications that can be anticipated on the basis of patient history. Proactive efforts to address these conditions may help avoid unnecessary bed days and extended lengths of stay.

Analysing Monday discharges to identify lost opportunities for weekend discharge

Lower rates of hospital discharge occur on weekends compared with weekdays. The authors performed a retrospective chart review of Monday discharges from the Hospital Medicine service at an academic hospital over a 3-month period to identify reasons for delayed discharge despite medical stability. Of 202 eligible patients, 81 (40%) had documentation indicating stability for earlier discharge. Common causes included bed availability or insurance authorisation at a skilled nursing facility, home care services and patient/family disagreement with discharge.

Discharge to post-acute care and other predictors of prolonged length of stay during the initial COVID-19 surge: a single site analysis

BACKGROUND

During the initial surge of coronavirus disease 2019 (COVID-19), health-care utilization fluctuated dramatically, straining acute hospital capacity across the USA and potentially contributing to excess mortality.

METHODS

This was an observational retrospective study of patients with COVID-19 admitted to a large US urban academic medical center during a 12-week COVID-19 surge in the Spring of 2020. We describe patterns in length of stay (LOS) over time. Our outcome of interest was prolonged LOS (PLOS), which we defined as 7 or more days. We performed univariate analyses of patient characteristics, clinical outcomes and discharge disposition to evaluate the association of each variable with PLOS and developed a final multivariate model via backward elimination, wherein all variables with a P-value above 0.05 were eliminated in a stepwise fashion.

RESULTS

The cohort included 1366 patients, of whom 13% died and 29% were readmitted within 30 days. The LOS (mean: 12.6) fell over time (P < 0.0001). Predictors of PLOS included discharge to a post-acute care (PAC) facility (odds ratio [OR]: 11.9, 95% confidence interval [CI] 2.6-54.0), uninsured status (OR 3.2, CI 1.1-9.1) and requiring intensive care and intubation (OR 18.4, CI 11.5-29.6). Patients had a higher readmission rate if discharged to PAC facilities (40%) or home with home health agency (HHA) services (38%) as compared to patients discharged home without HHA services (26%) (P < 0.0001).

CONCLUSION

Patients hospitalized with COVID-19 during a US COVID-19 surge had a PLOS and high readmission rate. Lack of insurance, an intensive care unit stay and a decision to discharge to a PAC facility were associated with a PLOS. Efforts to decrease LOS and optimize hospital capacity during COVID-19 surges may benefit from focusing on increasing PAC and HHA capacity and resources.

Focusing on the Medically Ready for Discharge Patient Using a Reliable Design Strategy: A Quality Improvement Project to Improve Length of Stay on a Medicine Service

BACKGROUND AND OBJECTIVES

Length of stay is a common measure of efficiency of care. We aimed to reduce length of stay on a general medicine service through a structured quality improvement project.

METHODS

A reliable design strategy was implemented in successive stages at a 238-bed academically-affiliated VA hospital. Over a 2-year period, continuous improvement efforts were directed at discrete cohorts of patients deemed medically appropriate for discharge but who remained hospitalized because of discharge barriers. We compared the mean length of stay and medically-ready bed days of care for a hospital in statistical control charts. Pre- and post-intervention comparisons were made using t -tests.

RESULTS

In total, 5321 discharges were included in this improvement project, accounting for 35 852 bed days of care. Overall, average length of stay was reduced by 15.7%, from 7.62 to 6.40 days ( P < .05). There was a significant reduction in the mean number of medically-ready bed days of care from 2.3 to 1.72. Statistical process control charts demonstrated special cause variation across patient cohorts.

CONCLUSION

A quality improvement project using reliable design principles was associated with shorter length of stay.

When patients get stuck: A systematic literature review on throughput barriers in hospital-wide patient processes

Hospital productivity is of great importance to policymakers, and previous research demonstrates that improved hospital productivity can be achieved by directing more focus towards patient throughput at healthcare organizations. There is also a growing body of literature on patient throughput barriers hampering the flow of patients. These projects rarely, however, encompass complete hospitals. Therefore, this paper provides a systematic literature review on hospital-wide patient process throughput barriers by consolidating the substantial body of studies from single settings into a hospital-wide perspective. Our review yielded a total of 2207 articles, of which 92 were finally selected for analysis. The results reveal long lead times, inefficient capacity coordination and inefficient patient process transfer as the main barriers at hospitals. These are caused by inadequate staffing, lack of standards and routines, insufficient operational planning and a lack in IT functions. As such, this review provides new perspectives on whether the root causes of inefficient hospital patient throughput are related to resource insufficiency or inefficient work methods. Finally, this study develops a new hospital-wide framework to be used by policymakers and healthcare managers when deciding what improvement strategies to follow to increase patient throughput at hospitals.

The Association of the Day of the Week with Outcomes of Infrainguinal Lower Extremity Bypass

BACKGROUND

The day of the week (DOW) for performing procedures and operations has been shown to affect clinical and resource utilization outcomes. Limited published data are available on vascular surgery operations. Our primary objective was to assess outcomes by DOW for infrainguinal lower extremity bypass (LEB) performed for claudication or rest pain. The secondary objective was to assess outcomes by DOW for LEBs performed for tissue loss.

METHODS

The Vascular Quality Initiative was queried from 2003 to 2018 for all elective index infrainguinal LEBs performed for claudication or rest pain. Cases performed for acute limb ischemia as well as concomitant peripheral vascular intervention, nonelective LEBs, sequential grafts, and weekend cases were excluded. LEBs were grouped by DOW: Monday-Tuesday (early weekdays) versus Wednesday-Friday (later weekdays). Baseline data, operative details, and outcomes were collected. Univariate and multivariable analyses were performed. LEBs performed for claudication/rest pain were analyzed together while tissue loss was assessed separately.

RESULTS

There were 12,084 LEBs identified-44.5% performed on Monday-Tuesday and 55.5% on Wednesday-Friday. Overall, the mean age was 65.6 years, 68.6% were male, and 82.8% were Caucasian. LEBs were performed for claudication in 57.4% of cases. An autogenous great saphenous vein was used in 58.8% of cases, whereas a prosthetic graft was used in 35.1% of cases. The most common bypass origin was the femoral artery (94.1%), and target was the popliteal artery (70.1%). Significant differences between Monday-Tuesday versus Wednesday-Friday, respectively, were mean body mass index (27.8 kg/m² vs. 28 kg/m²), preoperative aspirin use (74.2% vs. 72.5%), continuous vein harvest technique (41.9% vs. 44%), and mean operative time (mins) (216.2 vs. 222.6) (all P < 0.05). Univariate postoperative outcomes were significantly different between Monday-Tuesday versus Wednesday-Friday, respectively, for mean length of stay (LOS) (days) (3.9 vs. 4.3), cardiac complications (myocardial infarction/dysrhythmia/congestive heart failure) (3.5% vs. 4.9%), stroke (0.3% vs. 0.6%), and respiratory complications (0.8% vs. 1.3%) (all P < 0.05). Multivariable analysis demonstrated that LEBs performed on Wednesday-Friday versus Monday-Tuesday for claudication/rest pain were independently associated with cardiac complications and prolonged LOS. There were also 8,491 LEBs performed for tissue loss which overall had similar findings to LEBs performed for claudication/rest pain such as increased LOS for LEBs performed for tissue loss on Wednesday-Friday (P < 0.001) and similar likeliness for respiratory complication, wound complication, return to the operating room, and mortality (all P > 0.05). However, LEBs performed for tissue loss on Wednesday-Friday versus Monday-Tuesday had similar cardiac complications (P > 0.05).

CONCLUSIONS

Elective LEBs performed on later weekdays for claudication/rest pain were associated with cardiac complications and prolonged LOS, whereas tissue loss confirmed association with prolonged LOS. Further investigations are needed to identify whether increased resources or allocation of resources should be focused on later weekdays to optimize patient outcomes.

Shorter length of hospital stay for hip fracture in those with dementia and without a known diagnosis of osteoporosis in the USA

Background

About 50% of all hospitalized fragility fracture cases in older Americans are hip fractures. Approximately 3/4 of fracture-related costs in the USA are attributable to hip fractures, and these are mostly covered by Medicare. Hip fracture patients with dementia, including Alzheimer’s disease, have worse health outcomes including longer hospital length of stay (LOS) and charges. LOS and hospital charges for dementia patients are usually higher than for those without dementia. Research describing LOS and acute care charges for hip fractures has mostly focused on these outcomes in trauma patients without a known pre-admission diagnosis of osteoporosis (OP). Lack of documented diagnosis put patients at risk of not having an appropriate treatment plan for OP. Whether having a diagnosis of OP would have an effect on hospital outcomes in dementia patients has not been explored. We aim to investigate whether having a diagnosis of OP, dementia, or both has an effect on LOS and hospital charges. In addition, we also report prevalence of common comorbidities in the study population and their effects on hospital outcomes.

Methods

We conducted a cross-sectional analysis of claims data (2012–2013) for 2175 Medicare beneficiaries (≥65 years) in the USA.

Results

Compared to those without OP or dementia, patients with demenia only had a shorter LOS (by 5%; P = .04). Median LOS was 6 days (interquartile range [IQR]: 5–7), and the median hospital charges were $45,100 (IQR: 31,500 − 65,600). In general, White patients had a shorter LOS (by 7%), and those with CHF and ischemic heart disease (IHD) had longer LOS (by 7 and 4%, respectively). Hospital charges were 6% lower for women, and 16% lower for White patients.

Conclusion

This is the first study evaluating LOS in dementia in the context of hip fracture which also disagrees with previous reporting about longer LOS in dementia patients. Patients with CHF and IHD remains at high risk for longer LOS regardless of their diagnosis of dementia or OP.

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.

Organizational determinants of hospital stay: establishing the basis of a widespread action on more efficient pathways in medical units

Given the high hospital costs, the increasing clinical complexity and the overcrowding of emergency departments, it is crucial to improve the efficiency of medical admissions. We aimed at isolating organizational drivers potentially targetable through a widespread improvement action. We studied all medical admissions in a large tertiary referral hospital from January 1st to December 31st, 2018. Data were retrieved from the administrative database. Available information included age, sex, type (urgent or elective) and Unit of admission, number of internal transfers, main ICD-9 diagnosis, presence of cancer among diagnoses, surgical or medical code, type of discharge, month, day and hour of admission and discharge. National Ministry of Health database was used for comparisons. 8099 admissions were analyzed. Urgent admissions (80.5% of the total) were responsible for longer stays and were the object of the multivariate analysis. The variables most influencing length-of-stay (LOS) were internal transfers and assisted discharge: they contributed, respectively, to 62% and 40% prolongation of LOS. Also, the daily and weekly kinetics of admission accounted for a significant amount of variation in LOS. Long admissions (≥ 30 days) accounted for the 15.5% of total bed availability. Type of discharge and internal transfers were again among the major determinants. A few factors involved in LOS strictly depend on the organizational environment and are potentially modifiable. Re-engineering should be focused on making more efficient internal and external transitions and at ensuring continuity of the clinical process throughout the day and the week.

Predicting Patients at Risk for Prolonged Hospital Stays

BACKGROUND

Patients with prolonged hospitalizations account for 14% of all hospital days in US hospitals. Predicting which medical patients are at risk for prolonged hospitalizations would allow early proactive management to reduce their length of stay.

METHODS

Using the National Inpatient Sample, we examined risk factors for prolonged hospitalizations among adults hospitalized on the medicine service in 2014. We defined prolonged hospitalizations as those lasting 21 days or longer. We divided the sample into derivation and validation sets, and used logistic regression to identify significant risk factors in the derivation set, which were validated in the validation set. We used the estimates from the model to derive a risk score for prolonged hospitalizations.

RESULTS

Our sample included 2,997,249 hospitalizations (median age of 66 y, 53.5% female). 1.2% of hospitalizations were 21 days or longer. Patients with prolonged hospitalizations were younger, and had a greater number of chronic diseases. A prolonged hospitalization risk score, derived from the many significant predictors in our model, performed well in discriminating between prolonged and nonprolonged hospitalizations, with c-statistics of 0.80 in both the derivation and validation sets.

CONCLUSIONS

Our predictive model using readily available administrative data was able to discriminate between prolonged and nonprolonged hospitalizations in a national sample of medical patients, and performed well on internal validation. If prospectively validated, such a tool could be of use to hospitals and researchers interested in targeting development, testing, and/or deployment of programs to reduce length of stay.