The American Journal of Managed Care February 2011
Excess Hospitalization Days in an Academic Medical Center: Perceptions of Hospitalists and Discharge Planners
Ongoing quality improvement initiatives to reduce the number of excess hospitalization days are proposed. A simple data collection tool can help identify the most common reasons for excess hospitalization days on a real-time basis, which in turn can be used to deploy countermeasures with appropriate hospital-based specialists and staff. In our organization, we expect to further explore the intrahospital delays as characterized in Table 2. By implicating procedural services with the largest proportion of excess hospitalization days, valuable feedback can be provided to these departments to improve patient flow. Furthermore, although our data did not directly evaluate whether weekend services led to greater rates of excess hospitalization days, the literature suggests that weekend service restrictions may contribute to inappropriate delays and that weekend availability of services should continue to be monitored for perceived delays.10 This type of real-time information regarding specific hospital services may be helpful to hospital administration focusing on efficiency of clinical operations.
There are inherent limitations to our quality improvement survey. First, our data were collected from a single AMC, and the results may not be generalizable. Furthermore, given that our study population included patients admitted to the general medicine services, the results may not be applicable to other clinical services such as pediatrics and surgery. Second, we had less than 100% compliance with completion of the survey. In particular, if there was some sort of systematic lack of response in which some hospitalists may have responded to the survey at a much lower rate than other hospitalists, there may be overrepresentation or underrepresentation biases introduced within the results. Because we collected data on more than 3500 patient-days from our hospitalists and more than 2500 patient-days from our discharge planners, we believe that the data are fairly representative of our AMC during the study period. Third, we identified a difference in the perception of excess hospitalization days between the hospitalists vs the discharge planners. This could be attributed to our survey process in which discharge planners did not complete surveys on weekends, and review of the data showed that some discharge planners reported an unspecified number of multiple delay days. Given the lack of clarity, we input these data points as a single delay day, which may have underestimated some of the discharge planners’ perceptions. Fourth, weekend days may be times of reduced efficiency, with at least 1 study10 noting resultant excess hospitalization days on weekends, and there are likely other forces (such as staffing and hours of operation) that can lead to excess hospitalization days for a hospital. Fifth, given that our survey allowed for respondents to select only a single response, it is unclear how respondents may have dealt with competing reasons for a discharge delay, which in turn may have affected some of our categorization of results. Furthermore, because the primary intent of our evaluation was to determine the frequency of delay, we did not ask our discharge planners or our hospitalists to include patient-specific information, and we were unable to perform any sort of interrater comparative statistical analysis.
In conclusion, more than 10% of hospital days on the general medicine services were found to be unnecessary at our AMC. A simple-to-use data collection survey can help staff recognize excessive hospitalization days in real time and quickly identify the reasons for delay. Hospitalists could work cooperatively with discharge planners to gather data prospectively and report their findings on causes of delay. This may be relevant to hospitalist groups, who care for an increasing proportion of inpatients. Moreover, such data should be of interest to hospital administrators, as well as to payers of this nation’s increasingly costly inpatient care.
We thank all of the hospitalists and discharge planners who took the time to help us evaluate this issue in our health system by completing the daily online surveys. Their expertise and professional contribution to our ongoing efforts at improvement are much appreciated.
Author Affiliations: From the Department of Internal Medicine (CSK, ALH, RFP, LK, DAS), University of Michigan, Ann Arbor, MI; and the Department of Practice Management and Discharge Planning (AED, JLB), University of Michigan Health System, Ann Arbor, MI.
Funding Source: The authors report no external funding for this study.
Author Disclosures: The authors (CSK, ALH, RFP, LK, AED, JLB, DAS) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (CSK, ALH, AED, JLB, DAS); acquisition of data (CSK, ALH, AED, JLB); analysis and interpretation of data (CSK, ALH, RFP, LK); drafting of the manuscript (CSK, RFP, LK); critical revision of the manuscript for important intellectual content (CSK, ALH, RFP, DAS); statistical analysis (ALH, LK); administrative, technical, or logistic support (AED, JLB); and supervision (CSK, DAS).
Address correspondence to: Christopher S. Kim, MD, MBA, Department of Internal Medicine, University of Michigan, 3119 Taubman Ctr, Box 5376, Ann Arbor, MI 48109-5376. E-mail: firstname.lastname@example.org.
1. Society of Hospital Medicine. About SHM. http://www.hospitalmedicine.org/AM/Template.cfm?Section=About_SHM. Accessed 2010.
2. Sehgal NL, Shah HM, Parekh VI, Roy CL, Williams MV. Non-house staff medicine services in academic centers: models and challenges. J Hosp Med. 2008;3(3):247-255.
3. Saint S, Flanders SA. Hospitalists in teaching hospitals: opportunities but not without danger. J Gen Intern Med. 2004;19(4):392-393.
4. Fletcher KE, Underwood W III, Davis SQ, Mangrulkar RS, McMahon LF Jr, Saint S. Effects of work hour reduction on residents' lives: a systematic review. JAMA. 2005;294(9):1088-1100.
5. Selker HP, Beshansky JR, Pauker SG, Kassirer JP. The epidemiology of delays in a teaching hospital: the development and use of a tool that detects unnecessary hospital days [published correction appears in Med Care. 1989;27(8):841]. Med Care. 1989;27(2):112-129.
6. Carey MR, Sheth H, Braithwaite RS. A prospective study of reasons for prolonged hospitalizations on a general medicine teaching service. J Gen Intern Med. 2005;20(2):108-115.
7. Srivastava R, Stone BL, Patel R, et al. Delays in discharge in a tertiary care pediatric hospital. J Hosp Med. 2009;4(8):481-485.
8. Minichiello TM, Auerbach AD, Wachter RM. Caregiver perceptions of the reasons for delayed hospital discharge. Eff Clin Pract. 2001;4(6): 250-255.
9. Brasel KJ, Rasmussen J, Cauley C, Weigelt JA. Reasons for delayed discharge of trauma patients. J Surg Res. 2002;107(2):223-226.
10. Varnava AM, Sedgwick JE, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002;87(3):216-219.
11. Manning DM, Tammel KJ, Blegen RN, et al. In-room display of day and time patient is anticipated to leave hospital: a "discharge appointment". J Hosp Med. 2007;2(1):13-16.