Background: Fewer hospitalized patients are discharged per day on weekends as compared to weekdays.1 Hospital medicine groups have implemented quality improvement (QI) initiatives to increase weekend discharges, however, the factors contributing to lower rates of weekend discharges are not well-described.2 To better understand contributors to missed opportunities for weekend discharge, we analyzed patients discharged on Mondays to identify and categorize common reasons for delayed discharge.

Methods: A retrospective chart review was performed of adult patients discharged on a Monday between February 1 2021 and April 30 2021 from the Hospital Medicine service at an 1100 bed urban, academic, tertiary care hospital. Each chart was independently assessed by two reviewers to determine if a delay over the preceding weekend prevented timely discharge. They looked for EMR documentation that patient was medically stable for discharge prior to the discharge date and the reason the patient could not be discharged earlier. Specific causes for delays and patient disposition were categorized, and one primary delay was assigned to each patient. Discrepancies among reviewers were resolved with further chart review and discussion with the QI team to reach consensus.

Results: A total of 246 patients on the Hospital Medicine Service were discharged on a Monday during the study period; 44 were excluded due to leaving against medical advice, admission within 24 hours of discharge, or death. Of the remaining 202 patients, 81 (40%) had documentation indicating medical stability for earlier discharge. Of these, 40 (49%) were discharged home as compared to a facility. On average, these patients could have left 3.0 days earlier. Reasons for discharge delay included awaiting facility placement (33%, average 4.1 days delayed), initiation or reinstatement of home services and equipment (25%, average 2.3 days delayed), patient or caregiver disagreement about medical readiness (15%, average 3.7 days delayed), consultation (6%, average 1 day delayed), and imaging or procedures (6%, average 1.8 days delayed). Delayed discharge was more common among patients cared for by a different weekend attending compared to continuity with the preceding weekday attending (48% vs 27%, p-value .014). There was no difference in likelihood of patients with delayed discharge being on a resident teaching team versus a non-teaching team (41% vs 40%, p-value .92).

Conclusions: Over a third of patients discharged on Monday from the Hospital Medicine Service were medically ready for discharge over the prior weekend. The most frequent contributors to delayed discharge included awaiting facility placement or insurance authorization, establishing home care services and equipment, and patient or family disagreement with discharge. In addition, transitions of attending care from the weekday to the weekend were more likely to result in delayed discharge. Elucidating discharge barriers can focus QI efforts to improve length of stay and hospital throughput. Potential areas for innovation include partnership with social work for earlier facility or home care referrals, improving communication with patients and family members regarding medical readiness for discharge, and changing attending staffing models or weekday to weekend handoffs to improve throughput.

IMAGE 1: Reasons for Discharge Delay

IMAGE 2: Discharge Delay by Category