Background: While hospitals are primarily designed to provide acute care, a subset of patients have prolonged lengths of stay beyond medical necessity for months on general medicine wards[1]. These cases often occur in vulnerable patient populations, including those with mental health and substance use disorders[2], impaired decision-making capacity[3, 4], and housing insecurity[3]. However, few studies have examined in detail the “nonmedical” factors resulting in prolonged stays and their associated impact on patients and healthcare systems. This study aims to further examine the patient characteristics, barriers to discharge, and cost of these outlier lengths of stays.
Methods: We conducted a retrospective chart review of discharges from nine medicine floors of an urban academic teaching hospital in January 1, 2018 to August 12, 2021. We examined the proportion of admissions with lengths of stay ≥ 60 days. This threshold was chosen based on previous work showing stays at this time point to be primarily beyond medical necessity[5]. In order to further characterize this sample, we then extracted demographic, administrative, and outcomes data for those admitted in 2019. Barriers to discharge at 60-day intervals were noted through review of care coordination notes and categorized as “nonmedical” when patients were medically ready for discharge but remained inpatient. Delays were further described based on previous taxonomy[6, 7]. ICD-10 codes were used to categorize patient diagnoses. Descriptive analyses were performed.
Results: From 2018-2021, a total of 39,776 discharges occurred from the nine medicine floors with an average inpatient length of stay of 7.3 days. Of these, 354 or 0.9% of stays were greater than or equal to 60 days with an average length of stay 110.3 days in this sample. We examined 109 outlier stays of patients admitted in 2019 (average length of stay: 97.4 days). Demographic data is shown in Table 1. The most common primary diagnosis was sepsis, seen in 22 (20.2%) admissions. The majority (71.6%) of patients had a history of mental health disorder, and a large proportion (29.4%) had a history of substance use disorder. Less than half of all patients were conserved or required guardianship application. A minority faced homelessness (5.5%) or abuse and neglect (3.7%) complicating discharge planning. Barriers to discharge are shown in Table 2. At 60 days, 55% of patients were medically ready for discharge. At 120 days, 22 (20.2%) patients remained inpatient, with 17 (77.3%) facing non-medical delays. The most common non-medical barrier to discharge was lack of facility acceptances at 60 days and 120 days. The average total charge of these stays was $836,062 USD (range: $279,675-$4,161,827). The majority of patients (61.5%) were discharged to a skilled nursing facility. In-hospital mortality of this sample was 5.5%.
Conclusions: Our findings suggest that patients with prolonged lengths of stay represent a vulnerable population with a high prevalence of mental/substance use disorder and lack of capacity. At 60 days inpatient, the majority of patients faced nonmedical barriers to discharge, most commonly difficulty obtaining facility placement. In addition to its associations with increased complications for patients[8], long stays beyond medical necessity increase cost for healthcare systems. Greater attention needs to be paid to the biopsychosocial factors impacting transitions of care for this vulnerable subset of patients and the impact of long stays on individuals and systems.
