Academic journal article Australian Health Review

Stranded: Causes and Effects of Discharge Delays Involving Non-Acute In-Patients Requiring Maintenance Care in a Tertiary Hospital General Medicine Service

Academic journal article Australian Health Review

Stranded: Causes and Effects of Discharge Delays Involving Non-Acute In-Patients Requiring Maintenance Care in a Tertiary Hospital General Medicine Service

Article excerpt

Introduction

Hospitals frequently experience delays in the discharge of older patients who, despite being medically stable, occupy beds as nonacute patients pending the availability of home support or beds in a residential aged care facility (RACF). Up to one-third of hospital bed days relate to patients receiving non-acute care.1,2 The causes of these delays are multiple, can occur at several points in the patient trajectory (see Box 1)1,3 and be associated with inordinately long hospital stays.

The rising numbers of acute presentations to emergency departments (EDs), the advent of '4-h' national emergency access targets (NEAT) mandating rapid transit of patients from the ED to vacant in-patient beds, and constant pressure for more elective surgery all bring a focus on minimising discharge delays (or exit block) for patients no longer requiring acute care in hospital beds. Knowing the types, prevalence, bed occupancy and resource utilisation pertaining to different causes of delayed discharge of non-acute patients may allow health professionals, hospital administrators and care agencies to consider targeted strategies for overcoming such delays.

The aims of the present study were to: (1) identify the causes and prevalence of prolonged discharge delay among older patients admitted to a general medicine service of a tertiary hospital who no longer required acute care; (2) quantify the occupied bed days (OBDs) and estimated bed day costs incurred; (3) define acute medical complications with onset during the non-acute stay; (4) estimate resource utilisation; and (5) elicit, from relevant literature review and surveys of health professionals, possible strategies for eliminating avoidable delays.

Methods

Design, participants and setting

The present study was a retrospective study of patients admitted via the ED to the general medicine service of Princess Alexandra Hospital in Brisbane (Qld, Australia), a tertiary hospital serving a catchment population of 600000, between 1 January 2012 and 31 May 2015, and who satisfied the following criteria: were discharged as non-acute cases; required community home support or care packages or placement in an RACF (i.e. non-acute category of maintenance care); and incurred a total non-acute length of stay (LOS) of >7 days and total hospital LOS of >14 days. Patients meeting these criteria were identified from the hospital health information management system and medical charts, either paper or electronic, retrieved for detailed analysis. For patients with multiple admissions during the study period, the admission corresponding to the first non-acute discharge was chosen as the index stay. Patients were divided into two groups: (1) long-stay patients with non-acute LOS >28 days, who were subject to detailed chart review; and (2) short-stay patients with non-acute LOS <28 days, for whom only administrative data were collected for purposes of comparison in identifying patient characteristics associated with longer non-acute LOS.

The general medicine service of the study hospital in 2014-15 admitted 3975 patients to seven general medicine units with a total mean and median LOS of 7.4 and 3.4 days, respectively. Approximately 12% were discharged as non-acute patients who incurred a mean and median non-acute LOS of 21.8 and 12.8 days, respectively, accounting for 10 765 OBDs (37% of all OBDs) in 2014-15, a 55% increase compared with 6927 OBDs (25%) in 2009-10. The proportion of these OBDs accounted for by maintenance care patients had risen from 31% (2175 OBDs) in 2009-10 to 50% (5352 OBDs) in 2014-15.

Over this 6-year period, the general medicine service averaged an acute LOS of <5 days (median 3.0 days) and, according to Health Roundtable data, ranked within the most efficient tertiary hospital general medicine units in Australia. Timely reclassification of patients to non-acute is performed on consultant ward rounds and at multidisciplinary case conferences. …

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