Burden of delayed discharge on acute hospital medical wards: A retrospective ecological study in Rome, Italy

Abstract

Introduction: Delayed discharge represents the difficulty in proceeding with discharge of patients who do not have any further benefit from prolonged stay. A quota of this problem is related to organizational issues. In the Lazio region in Italy, a macro service re-organization in on the way, with a network of hospital and territorial centers engaged in structuring in- and out- of hospital patient pathways, with a special focus on intermediate care structures. Purpose of this study is to quantify the burden of delayed discharge on a single hospital structure, in order to estimate costs and occurrence of potential resource misplacement.

Material and methods: Observational Retrospective study conducted at the Santo Spirito Hospital in Rome, Italy. Observation period ranged from 1/09/2022, when the local database was instituted, to 1/03/2023 (6 months). Data from admissions records was anonymously collected. Data linkage with administrative local hospital database was performed in order to identify the date a discharge request was fired for each admission. Surgical discharges and Intensive Care Unit (ICU) discharges were excluded from this study. A Poisson hierarchical regression model was employed to investigate for the role of ward, Severity of Disease (SoD) and Risk of Mortality (RoM) on elongation of discharge time.

Results: 1222 medical ward admissions were recorded in the timeframe. 16% of them were considered as subject to potentially elongated stay, and a mean Delay in discharge of 6.3 days (SD 7.9) was observed.

Discussion and conclusions: Delayed discharge may cause a "bottleneck" in admissions and result in overcrowded Emergency Department, overall poor performance, and increase in overall costs. A consisted proportion of available beds can get inappropriately occupied, and this inflates both direct and indirect costs. Clinical conditions on admission are not a good predictor of delay in discharge, and the root causes of this phenomenon likely lie in organizational issues (on structure\system level) and social issues (on patient's level).

Fig 1. Organization of intermediate care services in the Italian National Health Service (NHS).

Adapted from Onen-Dumlu et Al. with permission from the Authors [38].

Fig 2. Roma 1 operation centers model for discharge management.

COT-A: Authority Center of Operation; COT-H: Hospital Center of Operation; COT-D: District Center of Operation; GP: General Practitioner.

Fig 3. Study patients flow.

COT-H: Hospital Center of Operation; COT-D: District Center of Operation.

Fig 4. Barber nomogram for the wards included in the study in the selected period.

Dashed green lines represent Bed Turn-Over percentage (BTO). Solid Blue lines represent Bed Occupancy percentage (BO). Solid Green Area represent the desirable area for medical divisions.