Defining Delayed Discharges of Inpatients and Their Impact in Acute Hospital Care: A Scoping Review

Document Type : Review Article

Authors

1 Department of Health Services Management, Faculty of Health Sciences, University of Malta, Msida, Malta

2 Department of Computer Information Systems, Faculty of ICT, University of Malta, Msida, Malta

Abstract

Background
With the ever-increasing demand on acute healthcare, the hospital discharge process and delayed discharges are considered relevant in achieving optimal performance in clinical settings. The purpose of this paper is to review the literature to identify conceptual and operational definitions of delayed discharges, identify causes and effects of delayed discharges, and also to explore the literature for interventions aimed at decreasing the impact (in terms of reducing the number/rate of delays) of delayed discharges in acute healthcare settings.

Methods
An extensive literature search yielded a total of 26 248 records. Sixty-four research articles were included in the scoping review after considering inclusion/exclusion criteria and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) search strategy. The following databases were utilized: Cochrane, EBSCO, PubMed, PubMed Central, Medline, and Web of Science. The search was carried out between January 2017 and March 2020 and covered literature ranging from 1990 to 2019. Results were reviewed by authors for duplicates and filtered using the inclusion/exclusion criteria. Tables were created to classify the chosen articles (n = 64), allowing us to organise findings and results.

Results
Conceptual and operational definitions were analysed. In turn, causes and effects of delayed discharges were extracted and represented in diagrammatic format, together with specific interventions used in acute healthcare settings to lessen the effect of delayed discharges. Operational definitions of delayed discharges were found to be more difficult to establish, particularly in the light of the vast number of different scenarios and workplace interventions uncovered in the literature. The main causes of delayed discharges were faulty organisational management, inadequate discharge planning, transfer of care problems, and age. The main effects were bed-blocking, A&E (Accident & Emergency) overcrowding, and financial implications. The main interventions included ‘discharge before noon’ initiative, ‘discharge facilitation tools,’ ‘discharge delay tracking’ mechanisms, and the role of general practitioners and social care staff.

Conclusion
This paper fills a gap in the fragmented literature on delayed inpatient discharges by providing a research-based perspective on conceptual and operational definitions, causes and effects, as well as interventions to minimize their impact. The findings and definitions are intended as points of reference for future research.

Highlights

 

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Keywords

References

  1. Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P. WHO European review of social determinants of health and the health divide. Lancet. 2012;380(9846):1011-1029. doi:10.1016/s0140-6736(12)61228-8
  2. Bauer MW, Becker S. The unexpected winner of the crisis: the European Commission's strengthened role in economic governance. J Eur Integr. 2014;36(3):213-229. doi:10.1080/07036337.2014.885750
  3. Fowler PH, Craig J, Fredendall LD, Damali U. Perioperative workflow: barriers to efficiency, risks, and satisfaction. AORN J. 2008;87(1):187-208. doi:10.1016/j.aorn.2007.07.001
  4. Waring J, Marshall F, Bishop S, et al. An Ethnographic Study of Knowledge Sharing Across the Boundaries Between Care Processes, Services and Organisations: The Contributions to ‘Safe’ Hospital Discharge. Health Serv Deliv Res. 2014;2(29).
  5. 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 (Lond). 2012;12(4):320-323. doi:10.7861/clinmedicine.12-4-320
  6. Green MA, Dorling D, Minton J, Pickett KE. Could the rise in mortality rates since 2015 be explained by changes in the number of delayed discharges of NHS patients? J Epidemiol Community Health. 2017;71(11):1068-1071. doi:10.1136/jech-2017-209403
  7. Baumann M, Evans S, Perkins M, et al. 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(4):295-305. doi:10.1111/j.1365-2524.2007.00697.x
  8. Lenzi J, Mongardi M, Rucci P, et al. Sociodemographic, clinical and organisational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi:10.1186/1472-6963-14-128
  9. Mendoza Giraldo D, Navarro A, Sánchez-Quijano A, Villegas A, Asencio R, Lissen E. [Impact of delayed discharge for nonmedical reasons in a tertiary hospital internal medicine department]. Rev Clin Esp. 2012;212(5):229-234. doi:10.1016/j.rce.2011.12.009
  10. Tan ES, Bonnett TJ, Abdelhafiz AH. Delayed discharges due to initiation of warfarin in atrial fibrillation: a prospective audit. Am J Geriatr Pharmacother. 2007;5(3):232-235. doi:10.1016/j.amjopharm.2007.10.006
  11. El-Eid GR, Kaddoum R, Tamim H, Hitti EA. Improving hospital discharge time: a successful implementation of Six Sigma methodology. Medicine (Baltimore). 2015;94(12):e633. doi:10.1097/md.0000000000000633
  12. Peterson J, Pearce PF, Ferguson LA, Langford CA. Understanding scoping reviews: definition, purpose, and process. J Am Assoc Nurse Pract. 2017;29(1):12-16. doi:10.1002/2327-6924.12380
  13. Moher D, Stewart L, Shekelle P. All in the family: systematic reviews, rapid reviews, scoping reviews, realist reviews, and more. Syst Rev. 2015;4:183. doi:10.1186/s13643-015-0163-7
  14. Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-473. doi:10.7326/m18-0850
  15. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097
  16. da Silva SA, Valácio RA, Botelho FC, Amaral CF. Reasons for discharge delays in teaching hospitals. Rev Saude Publica. 2014;48(2):314-321. doi:10.1590/s0034-8910.2014048004971
  17. Victor CR, Healy J, Thomas A, Seargeant J. Older patients and delayed discharge from hospital. Health Soc Care Community. 2000;8(6):443-452. doi:10.1046/j.1365-2524.2000.00270.x
  18. Wong H, Wu RC, Tomlinson G, et al. How much do operational processes affect hospital inpatient discharge rates? J Public Health (Oxf). 2009;31(4):546-553. doi:10.1093/pubmed/fdp044
  19. Sant J, Abela GP, Farrugia D. Delayed discharges and unplanned admissions from the day care unit at Mater Dei hospital, Malta. Malta Med J. 2015;27(2):26-30.
  20. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi:10.1016/j.healthpol.2005.06.005
  21. Edirimanne S, Roake JA, Lewis DR. Delays in discharge of vascular surgical patients: a prospective audit. ANZ J Surg. 2010;80(6):443-446. doi:10.1111/j.1445-2197.2009.05130.x
  22. Rohatgi N, Kane M, Winget M, Haji-Sheikhi F, Ahuja N. Factors associated with delayed discharge on general medicine service at an academic medical center. J Healthc Qual. 2018;40(6):329-335. doi:10.1097/jhq.0000000000000126
  23. Mustafa F, Gilligan P, Obu D, et al. 'Delayed discharges and boarders': a 2-year study of the relationship between patients experiencing delayed discharges from an acute hospital and boarding of admitted patients in a crowded ED. Emerg Med J. 2016;33(9):636-640. doi:10.1136/emermed-2015-205039
  24. Brown L, Abello A, Thurecht L. Length of Hospital Stay by Older Australians: Bed-blocking or Not. National Centre for Social and Economic Modelling (NATSEM); 2011.
  25. Swanson J. Bed Blocking and the City: An Analysis of the Factors Explaining Variation in the Number of Days Associated with Specific Measures Relevant to Patient Discharges One Year After Implementation of the Coordination Reform Within the Municipality of Oslo [thesis]. Oslo: University of Oslo; 2013.
  26. Falcone D, Bolda E, Leak SC. Waiting for placement: an exploratory analysis of determinants of delayed discharges of elderly hospital patients. Health Serv Res. 1991;26(3):339-374.
  27. Majeed MU, Williams DT, Pollock R, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012;12:410. doi:10.1186/1472-6963-12-410
  28. Devapriam J, Gangadharan S, Pither J, Critchfield M. Delayed discharge from intellectual disability in-patient units. Psychiatr Bull (2014). 2014;38(5):211-215. doi:10.1192/pb.bp.113.044388
  29. Bai AD, Dai C, Srivastava S, Smith CA, Gill SS. Risk factors, costs and complications of delayed hospital discharge from internal medicine wards at a Canadian academic medical centre: retrospective cohort study. BMC Health Serv Res. 2019;19(1):935. doi:10.1186/s12913-019-4760-3
  30. Triggle N. NHS “Must Get a Grip on Hospital Discharge Delays.” BBC News. May 26, 2016. https://www.bbc.com/news/health-36383804.
  31. Godden S, McCoy D, Pollock A. Policy on the rebound: trends and causes of delayed discharges in the NHS. J R Soc Med. 2009;102(1):22-28. doi:10.1258/jrsm.2008.080202
  32. Fairhurst K, Blair M, Cutting J, et al. The quality of hospital discharge: a survey of discharge arrangements for the over-65s. Int J Qual Health Care. 1996;8(2):167-174. doi:10.1093/intqhc/8.2.167
  33. Grimmer K, Moss J, Falco J. Experiences of elderly patients regarding independent community living after discharge from hospital: a longitudinal study. Int J Qual Health Care. 2004;16(6):465-472. doi:10.1093/intqhc/mzh071
  34. Bryson D. Care homes shouldn't profit from delays in assessing their residents for discharge from hospital. BMJ. 2011;343:d6570. doi:10.1136/bmj.d6570
  35. Holland DE, Pacyna JE, Gillard KL, Carter LC. Tracking discharge delays: critical first step toward mitigating process breakdowns and inefficiencies. J Nurs Care Qual. 2016;31(1):17-23. doi:10.1097/ncq.0000000000000141
  36. Mathews KS, Corso P, Bacon S, Jenq GY. Using the red/yellow/green discharge tool to improve the timeliness of hospital discharges. Jt Comm J Qual Patient Saf. 2014;40(6):243-252. doi:10.1016/s1553-7250(14)40033-3
  37. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-168. doi:10.1002/gps.3983
  38. Gaughan J, Gravelle H, Siciliani L. Testing the bed-blocking hypothesis: does nursing and care home supply reduce delayed hospital discharges? Health Econ. 2015;24 Suppl 1(Suppl 1):32-44. doi:10.1002/hec.3150
  39. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-320. doi:10.1191/0269215502cr496oa
  40. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-652. doi:10.1308/003588406x149246
  41. Worthington AD, Oldham JB. Delayed discharge from rehabilitation after brain injury. Clin Rehabil. 2006;20(1):79-82. doi:10.1191/0269215506cr881oa
  42. Costa AP, Poss JW, Peirce T, Hirdes JP. Acute care inpatients with long-term delayed-discharge: evidence from a Canadian health region. BMC Health Serv Res. 2012;12:172. doi:10.1186/1472-6963-12-172
  43. Jasinarachchi KH, Ibrahim IR, Keegan BC, et al. Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over. BMC Geriatr. 2009;9:4. doi:10.1186/1471-2318-9-4
  44. Feigal J, Park B, Bramante C, Nordgaard C, Menk J, Song J. Homelessness and discharge delays from an urban safety net hospital. Public Health. 2014;128(11):1033-1035. doi:10.1016/j.puhe.2014.06.001
  45. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2016;27(2):737-745. doi:10.1007/s00198-015-3293-9
  46. Nardi R, Scanelli G, Tragnone A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-99. doi:10.1007/s11739-007-0029-7
  47. 47 Salonga-Reyes A, Scott IA. Stranded: causes and effects of discharge delays involving non-acute in-patients requiring maintenance care in a tertiary hospital general medicine service. Aust Health Rev. 2017;41(1):54-62. doi:10.1071/ah15204
  48. Philp I, Mills KA, Thanvi B, Ghosh K, Long JF. Reducing hospital bed use by frail older people: results from a systematic review of the literature. Int J Integr Care. 2013;13:e048. doi:10.5334/ijic.1148
  49. 49 Glasby J, Littlechild R, Pryce K. Show me the way to go home: a narrative review of the literature on delayed hospital discharges and older people. Br J Soc Work. 2004;34(8):1189-1197. doi:10.1093/bjsw/bch136
  50. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008;34(1):24-28. doi:10.1007/s00068-007-6184-8
  51. Coffey A, Leahy-Warren P, Savage E, et al. A Systematic Literature Review on Tackling Delayed Discharges in Acute Hospitals Inclusive of Hospital (Re) Admission Avoidance. Dublin: Department of  Health; 2015.
  52. Fox MT, Persaud M, Maimets I, Brooks D, O'Brien K, Tregunno D. Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: a systematic review and meta-analysis. BMC Geriatr. 2013;13:70. doi:10.1186/1471-2318-13-70
  53. Davidson PM, Cockburn J, Newton PJ, et al. Can a heart failure-specific cardiac rehabilitation program decrease hospitalizations and improve outcomes in high-risk patients? Eur J Cardiovasc Prev Rehabil. 2010;17(4):393-402. doi:10.1097/HJR.0b013e328334ea56
  54. Miller CD, Case LD, Little WC, et al. Stress CMR reduces revascularization, hospital readmission, and recurrent cardiac testing in intermediate-risk patients with acute chest pain. JACC Cardiovasc Imaging. 2013;6(7):785-794. doi:10.1016/j.jcmg.2012.11.022
  55. Ryan S, O'Riordan JM, Tierney S, Conlon KC, Ridgway PF. Impact of a new electronic handover system in surgery. Int J Surg. 2011;9(3):217-220. doi:10.1016/j.ijsu.2010.11.012
  56. Stall N, Nowaczynski M, Sinha SK. Systematic review of outcomes from home-based primary care programs for homebound older adults. J Am Geriatr Soc. 2014;62(12):2243-2251. doi:10.1111/jgs.13088
  57. Venkataraman R, Panousis K, Deakin AH, Sale G, Picard F. Warfarin—an expensive cause of delay in discharge of elective arthroplasty patients. Eur Orthop Traumatol. 2015;6(2):77-82. doi:10.1007/s12570-014-0285-8
  58. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013;13(3-4):201-217. doi:10.1007/s10754-013-9135-4
  59. Landeiro F, Roberts K, Gray AM, Leal J. Delayed hospital discharges of older patients: a systematic review on prevalence and costs. Gerontologist. 2019;59(2):e86-e97. doi:10.1093/geront/gnx028
  60. Rojas-García A, Turner S, Pizzo E, Hudson E, Thomas J, Raine R. Impact and experiences of delayed discharge: a mixed-studies systematic review. Health Expect. 2018;21(1):41-56. doi:10.1111/hex.12619
  61. Butcher L. How one neurology department improved on early hospital discharges. Neurology Today. 2013;13(17):34-35.
  62. McCoy D, Godden S, Pollock AM, Bianchessi C. Carrot and sticks? The Community Care Act (2003) and the effect of financial incentives on delays in discharge from hospitals in England. J Public Health (Oxf). 2007;29(3):281-287. doi:10.1093/pubmed/fdm026
  63. Levin KA, Crighton E. Measuring the impact of step down intermediate care on delayed discharge: an interrupted time series analysis. J Epidemiol Community Health. 2019;73(7):674-679. doi:10.1136/jech-2018-211628
International Journal of Health Policy and Management
Volume 11, Issue 2
February 2022
Pages 103-111

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History

  • Receive Date: 30 June 2019
  • Revise Date: 04 June 2020
  • Accept Date: 04 June 2020
  • First Publish Date: 01 February 2022

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