A prospective study of reasons for prolonged hospitalizations on a general medicine teaching service

Abstract

Background: Delays in the care of hospitalized patients may lead to increased length of stay, iatrogenic complications, and costs. No study has characterized delays among general medicine inpatients in the current prospective payment era of care.

Objective: To quantify and characterize delays in care which prolong hospitalizations for general medicine inpatients.

Design: Prospective survey of senior residents.

Setting: Urban tertiary care university-affiliated teaching hospital.

Participants: Sixteen senior residents were surveyed regarding 2,831 patient-days.

Interventions: None.

Measurements and main results: Data were collected on 97.6% (2,762) of patient-days eligible for evaluation. Three hundred seventy-three patient-days (13.5% of all hospital days) were judged unnecessary for acute inpatient care, and occurred because of delays in needed services. Sixty-three percent of these unnecessary days were due to nonmedical service delays and 37% were due to medical service delays. The vast majority of nonmedical service delays (84%) were due to difficulty finding a bed in a skilled nursing facility. Medical service delays were most often due to postponement of procedures (54%) and diagnostic test performance (21%) or interpretation (10%), and were significantly more common on weekend days (relative risk [RR], 1.49; P=.02). Indeed, nearly one fourth of unnecessary patient-days (24% overall, 88 patient-days) involved an inability to access medical services on a weekend day (Saturday or Sunday).

Conclusions: At our institution, a substantial number of hospital days were judged unnecessary for acute inpatient care and were attributable to delays in medical and nonmedical services. Future work is needed to develop and investigate measures to decrease delays.

Figure 1

Survey instrument for detecting delays that unnecessarily prolonged hospitalizations by at least 1 day. The first page queries whether a delay occurred, and if so, whether it occurred at a time of possible discharge (coded A-No D/C for nonmedical causes and B-No D/C for medical causes), prior to a time of possible discharge (coded C-Delay), or not at all (coded C-No Delay). The second page was designed to categorize the factors that may have contributed to the delay. The instrument was administered separately for every patient-day (i.e., if a patient was in the hospital for 4 days, his care would have been surveyed 4 separate times).

Figure 1

Survey instrument for detecting delays that unnecessarily prolonged hospitalizations by at least 1 day. The first page queries whether a delay occurred, and if so, whether it occurred at a time of possible discharge (coded A-No D/C for nonmedical causes and B-No D/C for medical causes), prior to a time of possible discharge (coded C-Delay), or not at all (coded C-No Delay). The second page was designed to categorize the factors that may have contributed to the delay. The instrument was administered separately for every patient-day (i.e., if a patient was in the hospital for 4 days, his care would have been surveyed 4 separate times).

Figure 2

Distribution of unnecessary hospital days. Causes are divided into medical and nonmedical groupings. Each number that follows a cause refers to the number of patient-days that were judged attributable to that cause. Six of the days could not be categorized. Pt, patient; PM&R, physical medicine and rehabilitation; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococcus; C Diff, clostridium difficile; SW, social work; ABX, antibiotics.

Figure 3

Timing of unnecessary hospital days. Each bar shows the percentage of unnecessary patient-days occurring on each day of hospitalization.