Background: As healthcare costs continue to burgeon and grow at an unprecedented rate, cost utilization is an increasingly important field of research. In-hospital costs are one of the most expensive contributors to healthcare costs in the United States. Very little research has been done in the United States regarding length of stay outliers and their barriers to discharge.

Methods: A Quality Improvement initiative at Robert Wood Johnson University Hospital identified 412 hospital visits from the administrative database between September 2015 and August 2016 as risk-adjusted LOS outliers. A retrospective chart review was conducted on a subset of 105 patients identified as part of the general medicine service line. Physician progress notes and ancillary staff documentation for each patient were reviewed by internal medicine residents. Through this review process, medical and psycho-social barriers to timely discharge were identified. Patients were subsequently categorized by the major trends observed and a descriptive analysis was performed.

Results: As a group, outliers were medically complicated patients with an average of 5 consults on each case and an average of 7-8 comorbidities. 72.4% of all outliers had at least one hospital complication, with 32.4% of outliers developing hospital-acquired infections. 34% were also waiting for placement at an outside facility. Of note, a significant portion of outliers went to LTACH, SNF, or rehab; the length of stay in these cases was 38.9 days as opposed to 36.4 days in patients that did not go to these facilities. Insurance issues were present in 7.3% of outliers, with an average length of stay of 81 days. Two patient waiting for Medicaid applications had a 186.5 day average length of stay. 9% of all outliers primarily had issues with uncontrolled pain with an average length of stay of 41 days. Four patients requiring guardianship had a length of stay of 94 days on average.

Conclusions: We found that the majority of outliers had at least one complication, with a significant portion of these being hospital-acquired infectious complications. Outliers were very unlikely to be discharged home overall. Approximately one third of outliers were awaiting placement to an outside facility, and their length of stay was higher compared to those that were not waiting. Uncontrollable pain, insurance issues, and guardianship did not account for a large proportion of outliers; however, the length of stay within this population was also significantly higher. Our data would suggest that the above factors are all barriers to discharge. In particular, placement to long-term acute care hospital (LTACH), skilled nursing facility, or rehab facility, and medical complications while hospitalized contribute to increased length of stay for a large proportion of patients.