Discharge disposition of patients on an acute stroke unit

Inpatient rehabilitation centers and concern for increasing volume of ischemic stroke patients requiring rehabilitation

OBJECTIVES

To determine whether prolonged length of stay (pLOS) in ischemic stroke is related to delays in discharge disposition arrangement.

METHODS

We designed a retrospective study to compare patients with acute ischemic stroke who experienced pLOS to those who did not experience pLOS. Patients who have had acute ischemic stroke between July 2008 and December 2010 were included unless they arrived >48 hours after time last seen normal, had an unknown last seen normal, or experienced an in-hospital stroke. pLOS was defined in our prospective stroke registry (before the generation of this research question) as hospitalization extended for ≥ 24 hours more than necessary to determine neurologic stability and next level of care/disposition for a given patient. We characterized the frequency of each cause of pLOS and further investigated the destinations that were more frequently associated with pLOS among patients with delay resulting from arranging discharge disposition.

RESULTS

Of the 274 patients included, 106 (31.9%) had pLOS. Reasons for pLOS were discharge disposition (48.1%), non-neurologic medical complications (36.8%), delays in imaging studies (20.8%), awaiting procedure (10.4%), and neurologic complications (9.4%). Among patients with pLOS caused by delayed disposition, more than half were awaiting placement in an inpatient rehabilitation facility.

CONCLUSIONS

For the majority of our patients, pLOS was caused by acquired medical complications and delayed disposition, most commonly inpatient rehabilitation. Further efforts are needed to prevent complications and further investigation is necessary to identify the factors that may contribute to delayed discharge to inpatient rehabilitation facilities, which may include delayed planning or heightened scrutiny of insurance companies regarding their beneficiaries.

Acute care inpatients with long-term delayed-discharge: evidence from a Canadian health region

Background

Acute hospital discharge delays are a pressing concern for many health care administrators. In Canada, a delayed discharge is defined by the alternate level of care (ALC) construct and has been the target of many provincial health care strategies. Little is known on the patient characteristics that influence acute ALC length of stay. This study examines which characteristics drive acute ALC length of stay for those awaiting nursing home admission.

Methods

Population-level administrative and assessment data were used to examine 17,111 acute hospital admissions designated as alternate level of care (ALC) from a large Canadian health region. Case level hospital records were linked to home care administrative and assessment records to identify and characterize those ALC patients that account for the greatest proportion of acute hospital ALC days.

Results

ALC patients waiting for nursing home admission accounted for 41.5% of acute hospital ALC bed days while only accounting for 8.8% of acute hospital ALC patients. Characteristics that were significantly associated with greater ALC lengths of stay were morbid obesity (27 day mean deviation, 99% CI = ±14.6), psychiatric diagnosis (13 day mean deviation, 99% CI = ±6.2), abusive behaviours (12 day mean deviation, 99% CI = ±10.7), and stroke (7 day mean deviation, 99% CI = ±5.0). Overall, persons with morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke accounted for 4.3% of all ALC patients and 23% of all acute hospital ALC days between April 1^st 2009 and April 1^st, 2011. ALC patients with the identified characteristics had unique clinical profiles.

Conclusions

A small number of patients with non-medical days waiting for nursing home admission contribute to a substantial proportion of total non-medical days in acute hospitals. Increases in nursing home capacity or changes to existing funding arrangements should target the sub-populations identified in this investigation to maximize effectiveness. Specifically, incentives should be introduced to encourage nursing homes to accept acute patients with the least prospect for community-based living, while acute patients with the greatest prospect for community-based living are discharged to transitional care or directly to community-based care.

Factors Influencing Costs of Inpatient Ischaemic Stroke Care in Singapore

Introduction:

Stroke is a major public issue in Singapore, accounting for almost 10,000 admissions annually and the burden of disease is set to increase with an ageing population. We therefore seek to examine the factors influencing the cost of acute stroke care in Singapore.

Methods:

This is a retrospective analysis of 2,087 discharges with a primary discharge diagnosis of stroke from a tertiary hospital in Singapore from 1 January 2007 to 31 December 2008. Data including age, gender, length of hospital stay, components of direct cost and discharge disposition were obtained. A generalised linear model with a log link function and gamma distribution was used to determine the predictors of total hospital cost.

Results:

Mean age was 67.8 ± 12.4 years and 54.5% were males. Mean length of stay was 12.3 ± 16 days and mean total overall cost was S$6,783. Ward costs accounted for 48% of total cost. Length of stay strongly correlated to total cost. Being discharged to step-down facilities, death, receiving inpatient rehabilitation and length of stay significantly incurred higher total cost in multivariate analysis. However, there was an inverse relationship between age and total cost, possibly as a result of higher costs incurred for radiological, laboratory investigations and expert care.

Conclusion:

Further research is needed to examine factors influencing the cost of treatment particularly for those being discharged to step-down facilities and receiving inpatient rehabilitation as they have been found to incur higher total cost. This would impact on the planning of the continuum of healthcare facilities for stroke management.

Length of stay in an Australian stroke rehabilitation unit: a pilot study

Aims

Length of stay (LOS) is an important consideration in rehabilitation, and it can be adversely affected by delayed discharge. The purpose of this prospective study was to document LOS, frequency of discharge delay, reasons for discharge delay and its impact on LOS.

Methods

Ninety-eight inpatients in a stroke rehabilitation unit were included in the study.

Findings

Sixty (61%) patients had a LOS that exceeded the Australasian Rehabilitation Outcomes Centre (AROC) benchmark LOS according to the Australian National Sub-acute and Non-acute Patient classification system. Twenty-five (26%) patients had delayed discharge resulting in a total delay of 886 days, with most of these related to delays in the provision of community services. When patients with discharge delay were factored out of analyses, LOS was still longer than AROC benchmark figures for 39 (57%) of the 69 patients without discharge delay.

Conclusions

The LOSs of the majority of patients included in this study were longer than the AROC benchmark figures, even when patients with discharge delay were factored out. Initiatives to address this problem include the implementation of a proactive computerized tool that will provide target LOSs and enable reasons for excessive LOS to be more closely examined.

Factors Associated with Delayed Discharges after Inpatient Stroke Rehabilitation in Singapore

Introduction: This study determines the extent of, and factors associated with, delayed discharges for stroke patients from inpatient rehabilitation. Materials and Methods: A retrospective cohort study utilising medical notes review was conducted at an inpatient rehabilitation centre in Singapore. Acute stroke patients (n = 487) admitted between March 2005 and December 2006 were studied. The primary measure was delayed discharge defi ned as an extension in inpatient stay beyond the planned duration. Factors associated with delays in discharge were categorised as individual, caregiver, medical and organisational. Results: There were a total of 172 delayed discharges (35.6%). The mean [standard deviation (SD)] length of stay was 40.5 days (SD, 19.5 days) and 25.8 days (SD, 11.4 days) for patients with delayed and prompt discharges, respectively. Mean extension of stay was 9.7 days (SD, 13.8 days). Caregiver-related reasons were cited for 79.7% of the delays whereas organisational factors (awaiting nursing home placement, investigations or specialist appointments) accounted for 17.4%. Four factors were found to be independently associated with delayed discharge: discharge to the care of foreign domestic helper, nursing home placement, lower admission Functional Independence Measure (FIM) motor score and discharge planning process. Conclusions: Our study suggests that caregiver and organisational factors were main contributors of delayed discharge. Targeted caregiver training and the provision of post-discharge support may improve the confidence of caregivers of patients with greater motor disability. The use of structured discharge planning programmes may improve the efficiency of the rehabilitation service. To reduce delays, problems with the supply of formal and informal post-discharge care must also be addressed. Key words: Caregiver, Discharge planning, Length of stay, Nursing home

Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over

BACKGROUND

The delay in discharge or transfer of care back to the community following an acute admission to the hospital in older adults has long been a recognized challenge in the UK. We examined the determinants and outcomes of delayed transfer of care in older adults.

METHODS

A prospective observational study was conducted in a district general hospital with a catchment population of 250,000 in England, UK. Those >or= 65 years admitted to two care of the elderly wards during February 2007 were identified and prospectively followed-up till their discharge. Data was presented descriptively.

RESULTS

36.7% (58/158) of patients had a delay in transfer of care. They tended to be older, had poorer pre-morbid mobility, and were more likely to be confused at the time of admission. Compared to the 2003 National Audit Report, a significantly higher percentage (29.3%vs.17%) awaited therapist assessments or (27.6%vs.9%) domiciliary care, with a lower percentage (< 1%vs.14%) awaiting further NHS care. Of 18 in-patient deaths, five occurred during the delay. Seven patients developed medical conditions during the delay making them unfit for discharge. The number of extra bed days attributable to delayed discharges in this study was 682 (mean = 4.8) days.

CONCLUSION

Awaiting therapy and domiciliary care input were significant contributing factors in delayed transfer of care. Similar local assessments could provide valuable information in identifying areas for improvement. Based on available current evidence, efficacy driven changes to the organisation and provision of support, for example rapid response delayed discharge services at the time of "fit to discharge" may help to improve the situation.