In the current challenging economic climate, likely reduced NHS growth, productivity and efficiency are paramount. Considering average costs for a patient to stay in an NHS ward is up to £400 per day, the financial benefits of reducing length of stay (LOS) are huge. Reducing hospital admissions and caring for people more appropriately outside of hospital is the key to success. Average LOS in hospital for all causes in the UK was 7.0 days in 2013.1

In an attempt to improve turnover of patients in hospital and thus reducing LOS, several studies have been conducted to determine the causes of delay in discharge once a patient becomes medically fit. Some patients completely recover from acute medical illness to their previous functional level and discharged without a delay. Some patient may not recover completely to their previous state of health but may not require acute medical or nursing care. These patients may require some sort of physical therapy before they are fully fit for discharge. While awaiting discharge or further therapy, these patients may attract some nosocomial infection and thus require acute medical care, further increasing their LOS.

According to literature, there are several factors including comorbidities and functional limitations which influence patient’s discharge from hospital, thus affecting over all hospital LOS.

Comorbidities identified to prolong LOS are: advancing age and frailty,2-3 unstable or complex medical condition,4 tendency to fall,6 malnutrition,7 and moderate to severe dementia,8 and dysphagia.9

Functional limitations which prolong LOS are: use of walking aids and dependency,6 assisted living residents with a particularly high risk of nursing home admission following hospitalisation7 and poor premorbid mobility.10

Prolonged LOS is also associated with lacking family or social support.4-6 Patients’ relatives were also identified as a delaying factor in one study.5 Other causes of delays in discharge were delays in the provision of social and therapy requirements10 and awaiting downstream bed (care home or rehabilitation centre).11

We also identified from literature that certain tools like appropriateness evaluation protocol (AEP) and day of care survey (DoCS) have been developed to indentify unnecessary day of hospital care and to help identify sources of delays respectively.12, 13

The aims of our study were to determine the hospital LOS of our elderly patients and to identify factors causing delay including comorbidities, functional dependency, lack of family support, prolonged medical illness and complications occurring in ward and lack of social services resources and community beds.

Method

In St Peters Hospital, Chertsey, a district general hospital, nearly all admissions came through accident and emergency department. These were then transferred to acute medical assessment unit and then to elderly care or to medical short stay unit. The male and female elderly care unit beds are shared with acute stroke unit.

Over 12 months from November 2013 to October 2014, all patients transferred to two care of elderly (COE) wards under one COE consultant were included in this retrospective study.

With the help of hospital IT records and electronic discharge summaries, information about the patients including age, sex, presenting symptoms, admission diagnosis, list of comorbidities, ability to perform activities of daily living (ADL) and to mobilise, presence of dementia, availability of family and neighbour support, patient’s usual place of residence (own home or care home), discharge destination (usual place of residence or care home) and LOS in the COE ward were collected.

Reasons for staying beyond two weeks were also identified from the hospital notes, discharge summaries and checked with the hospital records.

Median and mean values are provided. Percentages are quoted to one decimal.

Results

The complete dataset included information from 743 patients. The mean age was 84 years (range 21 to 103). There were 42.3% (n=314/743) males and 57.7% (n=429/743) were females. 65.5% (n=487/743) patients were in the age group 80 to 94. The mean length LOS was longest in age group 80 to 84 years and 95 to 99 years. (Table 1)

Patient outcome:

Some 11.4% (n=85/743) of patients died while in hospital. 424 patients out of 743 were discharged back to their usual place of residence (own home or own care home). 40.9% (n=304/743) patients went to their own home and 16.2% (n=120/424) patients were discharged back to the care homes from where they were admitted. 13.7% (n=102/743) needed to be placed in new care homes. The mean LOS was longer for those who were awaiting placement into a new care home or respite care. (Table 2)

Discharge destination and mean length of stay (LOS):

Out of 304 patients discharged home, 52.3% (n=159/304) went home in a week and 84.5% (n=258/304) went home in two weeks. Out of 120 patients who went back to their usual care homes, 52.5% (n=63/120) were discharged in a week and 73.3% (n=88/120) in two weeks. Only 7.5% (n=9/102) who went to a new care home were discharged in a week and only 25.4% (n=23/102) were discharged in two weeks. (Table 3)

The delay in discharging patients to a new care home was mostly due to lack of beds in the care homes. In some instances, the delay was due to lack of social services. We also identified that if the patient is out of our area, then we had to deal with social services from other boroughs that caused subsequent delay in patient discharge. Private funders were able to find a care home sooner.

Functional and cognitive status and length of stay (LOS):

Mean LOS was longer for those who needed assistance with ADL, had dementia and presented with falls. (Table 4)

Reasons for length of stay longer than two weeks:

28.7% patients (n=213/743) stayed in hospital for over two weeks. The majority at 40.4% (n=86/213) later went to a nursing home. 33.8% (n=72/213) of patients who stayed beyond two weeks was due to medical reasons. This mainly was due to hospital acquired problems—infections like hospital-acquired pneumonia, Clostridium difficile diarrhoea and some unrelated complications like falls, cholecystitis, bowel obstruction, gastrointestinal bleed and per vaginal bleed.

We also noticed that there were patients with medical conditions that were slow to respond. For example cardiac failure, Lewy body dementia, Parkinson’s disease, oropharyngeal dysphagia, Limbic encephalitis, chronic venous ulcers, and difficult to control epilepsy. There were some patients who awaited procedures like peripherally inserted central catheter (PICC) line, percutaneous endoscopic gastrostomy (PEG) insertion and debridement of wound.

In 8.0% (n=17/213) patients the delay in discharge was due to the family problem. For example, family changing their minds as to where the patient would be discharged, family disputes as where the patient should be discharged, delaying signing the documents or on holiday etc.

Discussion

Patient’s length of hospital stay greatly varies between NHS trusts. By reviewing and improving admission and discharge processes, trusts can improve the patient experience by reducing the number of days spent in hospital. In return, trusts can save bed days thus increasing capacity and saving money.

Reducing length of stay will reduce the cost per patient episode, the risk of patients being exposed to hospital acquired infections, A&E waits, cancelled elective procedures and waiting times for treatment therefore improving clinical outcomes.

The studies conducted to determine the causes for inappropriate discharge delays either looked at delays from the time they were “medically fit for discharge” or stay in hospital beyond a certain period of time. Staying beyond a certain time period does not tell us the reasons for a longer hospital stay. It also does not tell us whether the patient actually needed the acute medical and nursing care or not.

There are practical issues in deciding who is fit to be discharged among frail elderly patients. This is because their medical, functional level and care needs fluctuate. Even when they are medically fit and do not need the acute medical or nursing care, they may not have physically reached their baseline to be discharged. Some frail elderly patients may not get back to their previous functional level and we may have to deal with a new baseline. Hence, establishing the date when a patient is medically and physically fit to be discharged is not easy in most cases.

In order to identify those who are likely to have prolonged LOS, we decided to study the mean LOS in hospital in relation to various comorbidities, functional levels and community resource capacity.

Care of the elderly department (COE) accepts patients over the age of 85 years, but when younger patients come into a care of elderly ward, then the COE consultant in charge of the ward looks after the patients till they are either discharged or transferred out of the ward. In our study population, n=377/743 patients were aged 84 years or below. This gave us an opportunity to study the effect of age on the patient’s LOS. The mean LOS was longer (12 days) in the age group 80 to 84 years when compared to age group 70 to 74 years (seven days).

LOS was longer in patients who had functional and cognitive impairment, patients who had a tendency to fall thus requiring a package of care or needed placement into a care home. This in turn required home visits and subsequent equipment. All these procedures were time consuming, requiring resources thus causing delay in discharge.

Furthermore, our elderly patients are susceptible to hospital-acquired infections. They are also prone to get multiple other illnesses and this too delays discharges and prolongs LOS. Lack of community beds in care homes, rehabilitation centres, hospices and respite homes have been highlighted as causing delays in discharge, thus prolonging LOS.

Conclusion

There are multiple factors that affect hospital LOS in elderly patients. Some are a consequence of ageing and frailty, which in turn make these elderly patients more susceptible to a hospital-acquired infections falls and the slow response to treatment.

Hospital length of stay could be reduced by quick identification and assessment on admission of our frail elderly patients with multiple comorbidities, functional and cognitive impairment. As could prompt management of acute medical and functional problems with early discharge planning involving the family. This approach may also help improve patients’ care with a shorter hospital stay that may be cost effective, but we need more robust evidence in the form of further clinical trials.

However, because of the complex needs of our geriatric patients, along with limited social resources available, it might not always be possible to achieve prompt and effective discharge planning thus reducing LOS in every individual case.

 

Conflict of Interest: none declared

References

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Dr R Mahmood

Specialist Registrar Geriatric Medicine, Ashford & St Peters HNS Foundation Trust.

Dr R Jeyarajah

Consultant Physician, Ashford & St Peters HNS Foundation Trust

rashid.mahmood3@nhs.net