Timely discharge of older patients from hospital: improving the process

Healthcare professionals' perception of barriers and facilitators for care coordination of older adults with complex care needs being discharged from hospital: A qualitative comparative study of two Nordic capitals

BACKGROUND

The handover of older adults with complex health and social care from hospital admissions to homebased healthcare requires coordination between multiple care providers. Providing insight to the care coordination from healthcare professionals' views is crucial to show what efforts are needed to manage patient handovers from hospitals to home care, and to identify strengths and weaknesses of the care systems in which they operate.

OBJECTIVE

This is a comparative study aiming to examine healthcare professionals' perceptions on barriers and facilitators for care coordination for older patients with complex health and social care needs being discharged from hospital in two capital cities Copenhagen (DK) and Stockholm (SE).

METHOD

Semi-structured interviews were conducted with 25 nurses and 2 assistant nurses involved in the coordination of the discharge process at hospitals or in the home healthcare services (Copenhagen n = 11, Stockholm n = 16). The interview guide included questions on the participants' contributions, responsibilities, and influence on decisions during the discharge process. They were also asked about collaboration and interaction with other professionals involved in the process. The data was analysed using thematic analysis.

RESULTS

Main themes were communication ways, organisational structures, and supplementary work by staff. We found that there were differences in the organisational structure of the two care systems in relation to integration between different actors and differences in accessibility to patient information, which influenced the coordination. Municipal discharge coordinators visiting patients at the hospital before discharge and the follow-home nurse were seen as facilitators in Copenhagen. In Stockholm the shared information system with access to patient records were lifted as a facilitator for coordination. Difficulties accessing collaborators were experienced in both settings. We also found that participants in both settings to a high degree engage in work tasks outside of their responsibilities to ensure patient safety.

CONCLUSIONS

There are lessons to be learned from both care systems. The written e-communication between hospitals and home health care runs more smoothly in Stockholm, whereas it is perceived as a one-way communication in Copenhagen. In Copenhagen there are more sector-overlapping work which might secure a safer transition from hospital to home. Participants in both settings initiated own actions to weigh out imperfections of the system.

The influence of sociodemographic factors and close relatives at hospital discharge and post hospital care of older people with complex care needs: nurses’ perceptions on health inequity in three Nordic cities

Hospital discharge of older people in need of both medical and social care following their hospital stay requires extensive coordination. This study aims to examine and compare the views of nurses in three Nordic cities on the influence of sociodemographic factors and having close relatives, for the hospital discharge and post hospital care of older people with complex health and social care needs. Thirty-five semi-structured interviews (Copenhagen n = 11, Tampere n = 8, Stockholm n = 16) with nurses were conducted. The nurses were identified through the researchers’ networks, invitation and snowball sampling, and recruited from hospitals, primary care practices, home care units, home nursing units, and geriatric departments. The interviews were transcribed and analysed using thematic analysis. Interpretations were discussed and agreed within the team. Four main themes and 13 sub-themes were identified. Across the cities, informants reported that the patient’s health status, rather than their gender or ethnicity, steered the discharge date and further care. Care costs, commonly reported in Tampere but also in Copenhagen and Stockholm including costs for medications and home help, were considered barriers for disadvantaged older people. Home situation, local arrangements and differences in collaboration between healthcare professionals at different sites also influenced the hospital discharge. Generally, the patient’s health status steered the hospital discharge and post-hospital care. Close relatives were regarded important and a potential advantage. Some informants tried to compensate for the absence of close relatives, highlighting the importance of care systems that can compensate for this to minimise avoidable inequity.

Prospective Analysis of Operating Room and Discharge Delays in a Burn Center

Delays to the operating room (OR) or discharge (DC) lead to longer lengths of stay and increased costs. Surprisingly, little work has been done to quantify the number and cost of delays for inpatients to the OR, and to DC to outpatient status. They reviewed their burn admissions to determine how often a patient experiences delays in healthcare delivery. Data for all burn admissions were prospectively collected from 2014 to 2016. A quality improvement filter was created to define acceptable parameters for patient throughput. Every hospital day was labeled as 1) No delay, 2) Operation, 3) Delay to the OR, or 4) Delay to DC. They had 1633 admissions: 432 ICU admissions (26%) and 1201 floor admissions (74%). Six hundred fifteen patients (37.7%) received an operation. Patients with delays included 331 with OR delays (20.3%) and 503 with DC delays (30.8%). Average delay days included (Mean ± SD): OR delay days = 4.7 ± 6.2 and DC delay days = 4.1 ± 4.4. Total number of hospital days was 13,009, divided into 1616 OR delay days (12%) and 2096 DC delay days (16%). Significant OR delays were due to patient unstable for OR (n = 387 [24%]), OR space availability (n = 662 [41%]), indeterminate wound depth (n = 437 [27%]), and donor site availability (n = 83 [5%]). Significant DC delays were due to medical goals not reached (n = 388 [19%]), pain control and wound care (n = 694 [33%]), PT/OT clearance (n = 168 [8.0%]), and DC placement delays (n = 754 [36%]). Costs for OR and DC delays ranged between US$1,000,000 and US$5,000,000. Costs of increasing OR capacity and/or additional social work ancillary staff can be justified through millions of dollars of savings annually.

[Redesigning the hospital discharge process]

OBJECTIVE

The aim of this article is to show that the redesign and planning process of hospital discharge advances the departure time of the patient from a hospital environment.

MATERIAL AND METHOD

Quasi-experimental study conducted from January 2011 to April 2013, in a local hospital. The cases analysed were from medical and surgical nursing units. The process was redesigned to coordinate all the professionals involved in the process. The hospital discharge improvement process improvement was carried out by forming a working group, the analysis of retrospective data, identifying areas for improvement, and its redesign. The dependent variable was the time of patient administrative discharge. The sample was classified as pre-intervention, inter-intervention, and post-intervention, depending on the time point of the study.

RESULTS

The final sample included 14,788 patients after applying the inclusion and exclusion criteria. The mean discharge release time decreased significantly by 50 min between pre-intervention and post-intervention periods. The release time in patients with planned discharge was one hour and 25 min less than in patients with unplanned discharge.

CONCLUSIONS

Process redesign is a useful strategy to improve the process of hospital discharge. Besides planning the discharge, it is shown that the patient leaving the hospital before 12 midday is a key factor.

Analysis of the Influencing Factors Associated With Being Designated Alternate Level of Care

A health care organization within the Western region of Newfoundland and Labrador has been experiencing high levels of alternate level of care (ALC) cases and days within their acute care units. The majority of these individuals are older adults. The overall goal of this mixed-methods study was to identify factors for becoming designated ALC and to present recommendations for early intervention. This research found that older female adults with co-morbid conditions who access emergency medical services often are admitted to a hospital. The authors also found that once these patients are admitted to an acute care unit, they tend to experience functional decline that may also result in being designated ALC. This study outlines recommendations that may prevent patients from being designated ALC.

Predictors of prolonged hospital stay for the treatment of severe neuropsychiatric symptoms in patients with dementia: a cohort study in multiple hospitals

BACKGROUND

Long hospitalization is often needed to treat severe behavioral and psychological symptoms of dementia (BPSD), which places heavy demands on hospital resources. Consequently, patients with severe BPSD usually wait for a long time to be admitted. There is a need to identify factors related to long hospitalization to better manage resources of a psychiatric hospital.

METHODS

We surveyed 150 consecutive patients hospitalized in the neuropsychiatric units of three hospitals for treatment of BPSD from 11 May 2009 to 30 November 2010. Only patients with reliable relatives were included in the study. We evaluated data of the patients (demographics, cognitive impairment, activities of daily living, causal disease for dementia, dementia severity, and the amount of pension), their primary caregivers (demographics and care burden), and their doctors' years of experience in treating dementia. We followed up to 180 days and assessed the effect of these factors on the length of stay.

RESULTS

Of the 150 patients, 104 were discharged within 180 days and 46 were hospitalized for more than 180 days. Average length of stay for patients was 110.4 ± 58.1 days. In both univariate and multivariate Cox proportional hazard analyses, length of stay was longer for patients with smaller pensions and patients whose doctors had fewer years of experience in treating dementia. Length of stay was not found to be associated with any of the other variables.

CONCLUSIONS

Patients with smaller pensions and whose doctors had less experience in treating dementia tended to require longer hospitalization.