Background: There is little data on the relative prevalence of different causes of care delays that contribute to prolonged length of stay. Unnecessary delays in the care of hospitalized patients increase the risk of hospital-related complications and drive up healthcare costs. Prior observational studies have suggested that a reduction in hospital length-of-stay is possible without causing an increase in readmission rate. In this study, we sought to systematically identify and categorize the various care delays that contribute to prolonged length of stay on a hospital medicine service.

Methods: For the fiscal year 2021, all inpatient encounters to the hospitalist service were screened (N = 6,633) for eligibility. Observation patients, patients treated for COVID-19, and patients discharged from other services were excluded (N = 2,849). After stratified random sampling, a 5% representative sample of the total eligible population of encounters (N = 3,784) was obtained (N= 191). We compared patient demographics and clinical metrics from the resulting stratified sample to the total population of encounters using t-test and Chi-squared test of distribution. Using a standardized data extraction tool, a day-by-day review of the sample encounters was performed for all care delays. These care delays were categorized into specific groups (System, Provider, Patient/Family or Consultant related) and subgroups based on predetermined criteria.

Results: The resulting 5% stratified random sample accounted for 191 encounters and 1126 patient-days. The sample was found to be comparable to the total patient population, with no statistically significant differences on key demographic and clinical metrics. Upon review, we noted that 29% of all patient-days had a care delay. 35% of these delays were attributable to factors in the hospital system, largely due to delays in obtaining procedures and imaging studies. 28% of delays were due to discharge barriers, driven overwhelmingly by a lack of available post-acute care beds. 19% of delays were attributable to the primary provider, with the remainder of delays attributable to the patients, their families, or consultants.

Conclusions: To our knowledge, this is the first study to identify the factors leading to prolonged hospital length of stay in a systematic manner. Our study shows that the majority of delays in care were caused by either wait times for procedures and imaging studies or by lack of post-acute care bed availability. These results can be used by hospitals and health systems to determine which systemic changes are likely to be the most effective at reducing length of stay.