Stranded: causes and effects of discharge delays involving non-acute in-patients requiring maintenance care in a tertiary hospital general medicine serviceArmi Salonga-Reyes A and Ian A. Scott A B C
A Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Ipswich Road, Brisbane, Qld 4102, Australia. Email: email@example.com
B School of Medicine, University of Queensland, Herston Road, Herston, Brisbane, Qld 4067, Australia.
C Corresponding author. Email: firstname.lastname@example.org
Australian Health Review - http://dx.doi.org/10.1071/AH15204
Submitted: 30 October 2015 Accepted: 9 February 2016 Published online: 31 March 2016
Objectives The aims of the present study were to identify causes of prolonged discharge delays among non-acute in-patients admitted to a tertiary general medicine service, quantify occupied bed days (OBDs) and propose strategies for eliminating avoidable delays.
Methods A retrospective study was performed of patients admitted between 1 January 2012 and 31 May 2015 and discharged as non-acute cases requiring maintenance care and who incurred a total non-acute length of stay (LOS) >7 days and total hospital LOS >14 days. Long-stay patients with non-acute LOS ≥28 days were subject to chart review in ascertaining serial causes of discharge delay and their attributable OBDs. Literature reviews and staff feedback identified potential strategies for minimising delays.
Results Of the 406 patients included in the present study, 131 incurred long-stays; for these 131 patients, delays were identified that accounted for 5420 of 6033 (90%) non-acute OBDs. Lack of available residential care beds was most frequent, accounting for 44% of OBDs. Waits for outcomes of guardianship applications accounted for 13%, whereas guardian appointments, Public Trustee applications and funding decisions for equipment or care packages each consumed between 4% and 5% of OBDs. Family and/or carer refusal of care accounted for 7%. Waits for aged care assessment team (ACAT) assessments, social worker reports, geriatrician or psychiatrist reviews and confirmation of enduring power of attorney each accounted for between 1% and 3% of OBDs. Of 30 proposed remedial strategies, those rated as high priority were: greater access to interim care or respite care beds or supported accommodation, especially for patients with special needs; dedicated agency officers for hospital guardianship applications and greater interagency collaboration and harmonisation of assessment and decision processes; and formal requests from hospital administrators to patients and family to accept care options and attend mediation meetings.
Conclusions Delayed discharge of non-acute maintenance care patients results principally from impaired access to residential care, administrative delays involving external agencies and patient or family refusal of care. Proposed remedial actions require concerted interjurisdictional advocacy.
What is known about this topic? Delays in discharge of non-acute patients requiring maintenance care can occur for many reasons and incur inordinately long hospital stays.
What does this paper add? The present detailed chart review of 131 long-stay non-acute patients identified causes of serial discharge delays and quantified their prevalence and attributable bed days. Waits for residential care accounted for less than half the bed days, administrative delays involving decisions by agencies external to the hospital accounted for one-quarter and patient or family refusal of care options accounted for one-tenth. Strategies are proposed that may minimise these delays.
What are the implications for practitioners? Delayed discharge of non-acute patients requiring maintenance care threatens to consume an ever-increasing proportion of acute hospital bed days. Remedial action is required from stakeholders both within and outside hospitals to reverse this trend.
References Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? Delayed hospital discharges and older people. J Health Serv Res Policy 2006; 11 52–8.
| All dressed up but nowhere to go? Delayed hospital discharges and older people.CrossRef | 16378533PubMed |
 Flintoft VF, Williams JI, Williams RC, Basinski AS, Blackstien-Hirsch P, Naylor CD. The need for acute, subacute, and nonacute care at 105 general hospital sites on Ontario. CMAJ 1998; 158 1289–96.
| 1:STN:280:DyaK1c3nslShtA%3D%3D&md5=b4385f67791222d1e9c842cba057ec25CAS | 9614821PubMed |
 New PW, Cameron PA, Olver JH, Stoelwinder JU. Inpatient subacute care in Australia: perceptions of admission and discharge barriers. Med J Aust 2011; 195 538–41.
| Inpatient subacute care in Australia: perceptions of admission and discharge barriers.CrossRef | 22060090PubMed |
 Bryan K. Policies for reducing delayed discharge from hospital. Br Med Bull 2010; 95 33–46.
| Policies for reducing delayed discharge from hospital.CrossRef | 20647227PubMed |
 Manzano-Santaella A. Disentangling the impact of multiple innovations to reduce delayed hospital discharges. J Health Serv Res Policy 2010; 15 41–6.
| Disentangling the impact of multiple innovations to reduce delayed hospital discharges.CrossRef | 20071501PubMed |
 Baumann M, Evans S, Perkins M, Curtis L, Netten A, Fernandez JL, Huxley P. Organisation and features of hospital, intermediate care and social services in English sites with low rates of delayed discharge. Health Soc Care Community 2007; 15 295–305.
| Organisation and features of hospital, intermediate care and social services in English sites with low rates of delayed discharge.CrossRef | 17578390PubMed |
 Hubbard G, Huby G, Wyke S, Themessl-Huber T. Research review on tackling delayed discharge. Edinburgh: Scottish Executive Social Research; 2004.
 Buist MD, Jaffray L, Bell E, Hanna L, Weinstein P, Kumar S, Grimmer K. Utilisation of beds on the general medical unit by ‘non-acute medical’ patients: a retrospective study of incidence and cost in two Tasmanian regional medical hospital units. Intern Med J 2014; 44 171–7.
| Utilisation of beds on the general medical unit by ‘non-acute medical’ patients: a retrospective study of incidence and cost in two Tasmanian regional medical hospital units.CrossRef | 1:STN:280:DC%2BC2c3kslGksA%3D%3D&md5=25e62cba5242aaf8556fea57557a9602CAS | 24320789PubMed |
 McCloskey R, Jarrett P, Stewart C, Nicholson P. Alternate level of care patients in hospitals: what does dementia have to do with this? Can Geriatr J 2014; 17 88–94.
| Alternate level of care patients in hospitals: what does dementia have to do with this?CrossRef | 25232367PubMed |
 Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy 2006; 76 194–201.
| Delayed transfers of older people from hospital: causes and policy implications.CrossRef | 16040152PubMed |
 Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med 2012; 12 320–3.
| In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience.CrossRef | 1:STN:280:DC%2BC38bitlyitQ%3D%3D&md5=3576833c066ea6e37b5a8d6b091782cfCAS |
 Marks L, Flannery RB, Spillane M. Placement challenges: implications for long-term care of dementia sufferers. Am J Alzheimers Dis Other Demen 2001; 16 285–8.
| Placement challenges: implications for long-term care of dementia sufferers.CrossRef | 1:STN:280:DC%2BD3MrlslSnsQ%3D%3D&md5=6b6b694f6ea408f4ee51d90f81150e69CAS | 11603164PubMed |
 Poole R, Pearsall A, Ryan T. Delayed discharges in an urban in-patient mental health service in England. Psychiatr Bull 2014; 38 66–70.
| Delayed discharges in an urban in-patient mental health service in England.CrossRef |
 Devapriam J, Gangadharan S, Pither J, Critchfield M. Delayed discharge from intellectual disability in-patient units. Psychiatr Bull 2014; 38 211–15.
| Delayed discharge from intellectual disability in-patient units.CrossRef |
 Australian Bureau of Statistics (ABS). Population by age and sex, regions of Australia; hospital and health services. Catalogue No. 3235.0. Canberra: ABS; 2014.
 Jansen I. Residential long-term care: public solutions to access and quality problems. Healthc Pap 2011; 10 8–22.
| Residential long-term care: public solutions to access and quality problems.CrossRef | 21593611PubMed |
 Metro South Hospital and Health Service (MSHHS). Dementia services strategy. Brisbane: MSHHS; 2015. Available at: https://metrosouth.health.qld.gov.au/sites/default/files/dementia_services_strategy.pdf [verified 26 February 2016].
 Wilkinson TJ, Kiata LJ, Peri K, Robinson EM, Kerse NM. Quality of life for older people in residential care is related to connectedness, willingness to enter care, and co-residents. Australas J Ageing 2012; 31 52–5.
| Quality of life for older people in residential care is related to connectedness, willingness to enter care, and co-residents.CrossRef | 22417155PubMed |
 Chen JJ, Finn CT, Homa K, St Onge KP, Caller TA. Discharge delays for patients requiring in-hospital guardianship: a cohort analysis. J Healthc Qual 2015; in press.
| 26042759PubMed |
 van Bilsen PM, Hamers JP, Groot W, Spreeuwenberg C. Demand of elderly people for residential care: an exploratory study. BMC Health Serv Res 2006; 6 39
| Demand of elderly people for residential care: an exploratory study.CrossRef | 1:STN:280:DC%2BD283it1Omtg%3D%3D&md5=0ec62adb823c075a66a1f3ad45cdabc3CAS | 16566822PubMed |
 Gravolin M, Rowell K, de Groot J. Interventions to support the decision-making process for older people facing the possibility of long-term residential care. Cochrane Database Syst Rev 2007; 3 CD005213
| 17636790PubMed |
 Lagoe RJ, Johnson PE, Murphy P. Inpatient hospital complications and lengths of stay: a short report. BMC Res Notes 2011; 4 135–9.
| Inpatient hospital complications and lengths of stay: a short report.CrossRef | 21545741PubMed |
 Scott IA, Rajakaruna N, Shah D, Miller L, Reymond E, Daly M. Normalising advance care planning in a tertiary hospital general medicine service: an exploratory study. Aust Health Rev 2015;
| Normalising advance care planning in a tertiary hospital general medicine service: an exploratory study.CrossRef | 26536163PubMed |
 Gamble KH. Connecting the dots. Patient flow systems are being leveraged to increase throughput, improve communication, and provide a more complete view of care. Healthc Inform 2009; 25 27–9.
| 19226941PubMed |
 Maloney CG, Wolfe D, Gesteland PH, Hales JW, Nkoy FL. A tool for improving patient discharge process and hospital communication practices: the ‘Patient Tracker’. AMIA Annual Symposium Proceedings 2007; Oct 11: 493–7.
 Coleman C, Smith J, Frank JC, Min S-J, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. J Am Geriatr Soc 2004; 52 1817–25.
| Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention.CrossRef |
 Beland F, Bergman H, Lebel P, Clarfield AM, Tousignant P, Contandriopoulos A-P, Dallaire L. A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial. J Gerontol A Biol Sci Med Sci 2006; 61 367–73.
| A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial.CrossRef | 16611703PubMed |
 Markle-Reid M, Browne G, Gafni A. Nurse-led health promotion interventions improve quality of life in frail older home care clients: lessons learned from three randomized trials in Ontario, Canada. J Eval Clin Pract 2013; 19 118–31.
| Nurse-led health promotion interventions improve quality of life in frail older home care clients: lessons learned from three randomized trials in Ontario, Canada.CrossRef | 22029487PubMed |
 Eklund K, Wilhelmson K. Outcomes of coordinated and integrated interventions targeting frail elderly people: a systematic review of randomised controlled trials. Health Soc Care Community 2009; 17 447–58.
| Outcomes of coordinated and integrated interventions targeting frail elderly people: a systematic review of randomised controlled trials.CrossRef | 19245421PubMed |
 Andersson G, Karlberg I. Integrated care for the elderly. The background and effects of the reform of Swedish care of the elderly. Int J Integr Care 2000; 1 1–10.