Delayed discharge after major surgical procedures in Ontario, Canada: a population-based cohort study

Abstract

Background: Addressing nonmedical reasons for delays in hospital discharge is important for improving the flow of patients through acute care hospital beds. Because this problem is understudied among adult surgical patients, we examined the incidence of and identified factors associated with delayed hospital discharge after major elective and emergency surgical procedures in acute care institutions.

Methods: Using health administrative data, we retrospectively compared adults with and without delayed discharge after 18 major elective and emergency surgical procedures between 2006 and 2016 in Ontario hospitals. We identified delayed discharge using the alternate level of care code, applied to patients who are medically fit for discharge but remain in an acute care hospital bed. We used hierarchical logistic regression modelling to determine factors associated with delayed discharge.

Results: Our cohort included 595 782 patients who underwent elective procedures and 180 478 who underwent emergency procedures. Delayed discharge accounted for 635 607 hospital days, of which 81.7% were related to admissions for emergency surgery. Delayed discharge affected 3.1% of patients who underwent elective surgery and 19.6% of those who underwent emergency procedures. Days attributed to delayed discharge formed about one-third of patients' total hospital stay for both surgical groups. The rate of delayed discharge across surgical specialties showed high variability (from 0.9% for lung resection or nephrectomy to 9.3% for peripheral arterial disease procedures in the elective surgery group, and from 3.8% for cardiac procedures to 33.8% for peripheral arterial disease procedures in the emergency surgery group). Risk factors for delayed discharge were older age, female sex, chronic disease burden and increasing hospital size.

Interpretation: Delayed discharge for nonmedical reasons was more common after emergency surgery than after elective surgery, and rates varied across surgery type. Optimizing early discharge planning, evaluating the variation in delayed discharge at the hospital level and improving local access to community care services could be next steps to addressing this problem.

Figure 1:

Proportion of patients affected by delayed discharge between 2006 and 2016 in Ontario, according to type of surgery performed. Patients with delayed discharge were defined as those with code for alternate level of care. Note: AAA = abdominal aortic aneurysm.

Figure 2:

Annual (A) and seasonal (B) trends in proportion of patients affected by delayed discharge, defined as those with code for alternate level of care. Seasonal trends are based on combined data from all years.

Figure 3:

Proportion of hospital stay (measured in days) attributed to delayed discharge, by type of surgery. The horizontal white line within each bar indicates the median value, and the solid bars below and above this line represent the lower and upper quartiles. Note: AAA = abdominal aortic aneurysm.

Figure 4:

Forest plots of selected covariables associated with the outcome of delayed discharge (binary outcome) for elective and emergency surgery. (A) The upper figures show patient characteristics, including comorbidities. For age, the OR is per year. (B) The lower figures show types of surgery and hospital characteristics. The range of the x axis is different for each figure. Note: AAA = abdominal aortic aneurysm, ALC = alternate level of care, CAD = coronary artery disease, CI = confidence interval, COPD = chronic obstructive pulmonary disease, CKD = chronic kidney disease, CLD = chronic liver disease, OR = odds ratio, PAD = peripheral arterial disease.