Background: Prolonged hospital stays can decrease bed availability for new patients, place patients at risk for adverse events, and increase costs for the individual and system. There are few published studies that cover data of patients throughout an entire hospital; most only cover data from a specific service line. Our study aims to review patient discharge data throughout an entire safety-net hospital to assess common barriers leading to these prolonged stays.
Methods: This study took place at a 400-bed, county hospital and level 1 trauma center in the Pacific Northwest. In our institution, the Care Management department meets on a weekly basis to review patients who meet the criteria of having “avoidable days”, meaning they remain hospitalized past the point of medical necessity. Each patient case is discussed to identify barriers to discharge as well as proactive problem-solving to advance towards discharge; key information from these meetings is collected in a shared database. We retrospectively reviewed the database and extracted common discharge barriers, which we then organized into overarching categories. All adult patients discharged from August 2019 to February 2020 from any service of the hospital who had any “avoidable days” were eligible for inclusion in our study. In addition, in order to focus on long length of stay patients, we restricted to those with 21 or more total hospital days. Encounters with missing or incomplete data were excluded. This study received approval from our site’s Institutional Review Board.
Results: There were 180 encounters that met our criteria. The most common service lines represented were Medicine (n=67, 37%) and Surgery (n=41, 23%), while the most common discharge locations were Skilled Nursing Facility (n=82, 46%) and Home (n=43, 23%). The median for the total length of stay was 42 days (IQR 29-77.5) with a total of 11,287 patient-days, while the median for avoidable days was 17.5 days (IQR 10-38) with a total of 6,498 avoidable patient-days. We identified 21 common barriers. The most common discharge barriers identified were Funding (n=23, 24%), Long Term Care (n=34, 19%), Awaiting COPES/Home Caregiving, (n=16, 9%), Guardianship (n=14, 8%), Substance Use (n=14, 8%), Homelessness (n=14, 8%), and Care Needs too Great for Skilled Nursing Facility (n=14, 8%). We have also identified several areas of overlap between different barriers. Several individuals had multiple encounters. Of the 170 patients included, the majority were middle-aged (mean=57.7), white, non-Hispanic (n=103, 60.6%), and male (n=120, 70.6%).
Conclusions: In our hospital-wide study over a 6 month pre-COVID time period, a large number of patient-days were characterized as past the point of medical necessity and therefore potentially avoidable. These avoidable days and prolonged hospitalizations were found across inpatient services and represented a heterogeneous mix of discharge barriers. We have identified overlap in discharge barriers, suggesting that there are specific common typologies or patterns that may be helpful to understand better. Further attention is necessary in order to generate more specific solutions to meet patient needs.