Healthcare-Associated Adverse Events in Alternate Level of Care Patients Awaiting Long-Term Care in Hospital

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.

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.

Avoiding Hospital Admissions and Delayed Transfers of Care by Improved Access to Intermediate Care: A Simulation Study

OBJECTIVE

The current waiting times for intermediate care in the Netherlands prohibit timely access, leading to unwanted and costly hospital admissions. We propose alternative policies for improvement of intermediate care and estimate the effects on the waiting times, hospitalization, and the number of patient replacements.

DESIGN

Simulation study.

SETTING AND PARTICIPANTS

For our case study, data were used of older adults who received intermediate care in Amsterdam, the Netherlands, in 2019. For this target group, in- and outflows and patient characteristics were identified.

METHODS

A process map of the main pathways into and out of the intermediate care was obtained and a discrete event simulation (DES) was built. We demonstrate the use of our DES for intermediate care by evaluating possible policy changes for a real-life case study in Amsterdam.

RESULTS

By means of a sensitivity analysis with the DES, we show that in Amsterdam the waiting times are not a result of a lack in bed capacity but are due to an inefficient triage and application process. Older adults have to wait a median of 1.8 days for admission, leading to hospitalization. If the application process becomes more efficient and evening and weekend admissions are allowed, we find that unwanted hospitalization can be decreased substantially.

CONCLUSION AND IMPLICATIONS

In this study, a simulation model is developed for intermediate care that can serve as a basis for policy decisions. Our case study shows that the waiting times for health care facilities are not always solved by increasing bed capacity. This underlines the necessity for a data-driven approach to identify logistic bottlenecks and find the best ways to solve them.