Background:
Unintentional discharge delays account for up to 20% of total patient hospital days. Previous studies identified bed availability, scheduling logistics for studies, and poor communication as causes of delay factors. Although discharge requires a team approach, no single study has examinedperceptions of discharge delays among interprofessional team members, including residents and hospitalists, at an academic teaching hospital.
Methods:
We designed a 35-question survey to assess perceptions about themost frequent causes of discharge delays. The survey was developed by adapting items from previous studies and by pilotingquestions among 20 different providers. The final survey examined frequency of discharge delaycauses on a scale ranging from rarely, almost daily, daily, and more than once daily. Attendings, residents, nurses, case managers and social workers (discharge facilitators) at a tertiary care center were surveyed between April and July 2015. Chi-square and Fisher’s exact tests were used to identify significant differences between groups in perceptions of causes of the top seven discharge delays.
Results:
A 75% response rate was achieved (249/331) with no difference between groups. Facility placement was the most frequently reported cause of discharge delay (71%) followed by insurance approval (41%), arrangements for indigent patients (20%), caregiver input (19%), and patient clinical deterioration (17%). Providers differed in their perception of facility placement (p<0.001) [Residents (89%) vs. Attendings (75%) vs. nurses (57%) vs. discharge facilitators (50%)], insurance approval (p=0.031) [discharge facilitators (63%) vs. Residents (48%) vs. nurses (39%) vs. Attendings (28%)], or arrangements for indigent patients (p=0.040) [Residents (29%) vs. discharge facilitators (25%) vs. Attendings (18%) vs. nurses (12%)].
Discharge facilitators cited pending consultant recommendations (p=0.002) as a more frequent cause of delay [discharge facilitators (62.5%) vs. attendings (41.2%) vs. nurses (31.6%) vs. residents (19.3%)] and changes in medical status (p=0.001) [(discharge facilitators (63%) vs. attendings (25%) vs. nurses (28%) vs. residents (14%)].
Nurses cited transportation delays from the inpatient unit out of the hospital more frequently than others (p<0.001) [nurses (55%) vs. residents (17%) vs. attendings (16%) vs. discharge facilitators (6%)]. Nurses also perceived transportation from the hospital to a disposition location more frequently than other surveyed providers (p=0.010) [nurses (48%) vs. attendings (24%) vs. residents (27%) vs. discharge facilitators (19%)].
Conclusions:
In this large needs assessment, we found that perceptions of discharge delay vary by healthcare profession, indicating the need to reconcile team views on discharge delays before QI approaches. This data can inform a formal FMEA to take a systematic approach to improving discharge delays.