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Patient Needs, Required Level of Care, and Reasons Delaying Hospital Discharge for Nonacute Patients Occupying Acute Hospital Beds Marc Afilalo, Xiaoqing Xue, Nathalie Soucy, Antoinette Colacone, Emmanuelle Jourdenais, Jean-Franc¸ois Boivin Current research on emergency department (ED) crowding suggests that “boarding” of admitted patients in the ED for long periods contributes to ED crowding (Moskop, Sklar, Geiderman, Schears, & Bookman, 2009). Boarding has been shown to be due to a variety of reasons including a lack of access to in-patient hospital beds (Handel et al., 2010; Moskop et al., 2009; Powell et al., 2012). One way of improving bed access is by avoiding inappropriate hospital stay and/or decreasing prolonged hospital stays (Rabin et al., 2012). However, studies have shown that certain patients continue to occupy acute hospital beds, even when their needs (for assessment, observation, and/or intervention) can be met more effectively elsewhere (Barisonzo, Wiedermann, Unterhuber, & Wiedermann, 2013; Canadian Institute for Health Information, 2009; Hammond, Phillips, Pinnington, Pearson, & Fakis, 2009). Patients who do not require acute care and whose needs can be met in another setting are commonly referred to as nonacute patients (Flintoft et al., 1998; Higginson, 2012). Efficiently relocating these patients will ensure the availability of hospital beds for incoming patients requiring admission, decrease the risk to acquiring nosocomial conditions, and decrease hospital costs and unnecessary procedures (Mould-Quevedo et al., 2009; Roberts et al., 2010; Soria-Aledo et al., 2009). A prerequisite to relocating nonacute patients is first identifying their needs and second, determining the setting where appropriate care can be delivered. There are two generally accepted approaches to determine whether a given patient’s hospitalization is appropriate or not. The first approach is based on expert opinion (Harvey, Jenkins, & Llewellyn, 1993; Namdaran & Sherval, 1995), and has been considered the gold standard. Experts consist of clinical staff and other members of a multidisciplinary team actively responsible for
Abstract: This study aims to determine the proportion of nonacute patients occupying acute care beds and to describe their needs, the appropriate level of alternative care, and reasons preventing discharge. Data from 952 patients hospitalized in an acute care unit for 30 days were obtained from their medical charts and by consulting with the medical team at two tertiary teaching hospitals. Among them, 333 (35%) were determined nonacute on day 30 of hospitalization. According to the Appropriateness Evaluation Protocol (AEP), 55% had no medical, nursing, or patient needs. Among nonacute patients with AEP needs, 88% were related to nursing/life-support services and 12% related to patient condition factors. Regarding alternative level of care, 186 (56%) were waiting for out-of-hospital resources, of which 36% were waiting for palliative care, 33% for long-term care, 18% for rehabilitation, and 12% for home care. For the remaining 147 (44%) nonacute patients, the alternative resources remained undetermined although acute care was no longer required. Main reasons preventing discharge included unavailability of alternative resources, ongoing assessment to determine appropriate resources, ongoing process with community care, and family/patient education/counseling. Available subacute facilities and community-based care would liberate acute care beds and facilitate their appropriate use.
patient care (Glasby, 2003). The second approach is the use of a variety of standardized evaluation tools such as the Appropriateness Evaluation Protocol (AEP) (Barisonzo et al., 2013; Brabrand, Knudsen, & Hallas, 2011; d’Alch´e-Gautier, Ma¨ıza, & Chastang, 2004; Fontaine et al., 2011; S´anchez-Garcia et al., 2008). The AEP is probably the most used and studied tool for identifying patients’ needs during hospitalization, which in turn determines the appropriateness of patients’ hospital stay (McDonagh, Smith, & Goddard, 2000). Limitations of the AEP include underestimating inappropriate stays (Kalant, Berlinguet, Diodati, Dragatakis, & Marcotte, 2000) and not taking into consideration the local conditions or availability of alternative services (Brabrand et al., 2011). Nevertheless, the AEP is a valuable tool which is easily used to objectively obtain patient
Keywords acute care beds appropriateness of evaluation tool nonacute medical care
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information regarding their medical, nursing, and personal needs while hospitalized. The aim of this study was to determine the proportion of nonacute patients on day 30 of hospitalization. For patients determined nonacute, we sought to identify their needs (medical, nursing, and personal), identify the appropriate level of alternative care, explore the reasons delaying discharge, and describe post–hospital discharge destinations. This study used medical expert opinion to determine nonacute patients, whereas the AEP was applied in identifying specific patient needs.
Methods Study Design, Settings, and Participants This prospective observational study was conducted in two adult tertiary care hospitals in Montreal, Canada. Affiliated with McGill University, the Jewish General Hospital has 637 hospitals beds. Affiliated with the University of Montreal, the Notre-Dame Hospital has 403 beds. Recruitment was conducted from March 2009 to April 2010. Patients aged 18 years and over hospitalized in an acute care unit for 30 days were eligible. Patients admitted under obstetrics, psychiatry, and critical care were excluded. Also excluded were patients admitted to palliative care. However, patients who were not initially admitted to palliative care but for whom palliative care became a need during the hospitalization were included. The study received approval from both hospitals’ research ethics committees.
Data Collection To obtain information on patient status on day 30 (±3 days) of hospitalization, data were collected by conducting concurrent medical chart reviews and discussions with the medical team involved in the care. Data collection was performed by a single trained research assistant at both hospitals. Data collected included sociodemographics, living arrangements, admission information, needs on day 30, reasons for delaying hospital discharge, information regarding appropriate alternative level of care, total hospital length of stay, and post–hospital discharge destination. Patient needs were identified using the AEP tool. The AEP regroups 27 items/needs related to medical services (11 items), nursing/life-support services (7 items), and patient condition factors (9 items).
The alternative level of care (i.e., long-term care, rehabilitation/convalescence care, home care, ambulatory care, and palliative care) was determined by the medical team (i.e., doctors, nurses, other consultants and services) who were directly involved in patient care. A patient’s status was determined as “nonacute” when the medical team judged that the patient’s needs could be effectively met in an alternative care setting. Information about the medical team’s decision was retrieved from the medical charts. This information included ongoing acute treatment, date of a formal request for transfer to another facility, notes from the healthcare professional on available resources that would better meet the patient’s needs, and information on ongoing discussions with community healthcare professionals. In cases where information in the patient’s medical chart was unclear, the research assistant approached the medical team in order to confirm the type of care required. The cut-off point of day 30 was chosen for various reasons. First, this study targeted the patient population occupying an acute care bed following an acute medical episode. Selecting a shorter hospital stay could have resulted in enrolling patients with unresolved acute conditions. Second, other studies which aimed at studying long-stay patients also used 30-day hospitalization as a reference (DeCoster, Bruce, & Kozyrskyi, 2005; Hwang, Kim, Jang, & Park, 2011). In addition, the results of an expert consultation agreed that 30 days was a more practical time frame, because if patients still occupied an acute care bed at this time, actions were taken to re-examine their status and seek other management solutions or alternative care. Lastly, although the data from participating hospitals showed that this group of patients constitutes only about 10% of admissions, they contribute to more than half of the total hospital days, which corresponds to a significant number of hospital bed days unavailable for new patients.
Statistical Analysis Descriptive statistics, including means (standard deviations), medians (interquartile ranges), 95% confidence intervals, and proportions were used to describe patient characteristics, needs, the level of more appropriate alternative care, and reasons for still occupying acute care beds. All analyses were performed
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Figure 1. Flow Diagram of Study Population Eligible paƟents n = 1,970 Not selected n = 1,018 •Random selecƟon of one paƟent out of two
Recruited paƟents n = 952 (48.3%)
Acute care paƟents n = 619 (65.0%)
Non acute care paƟents n = 333 (35.0%)
WaiƟng list for specific resources n = 186 (55.9%)
using the statistical software package SAS 9.3 (SAS Institute, Cary, NC).
Results Of the 1,970 eligible patients, 952 (48.3%) were enrolled, of which 333 (35%, 95% confidence interval [32–38%]) were evaluated as nonacute on day 30 of hospitalization. Among the nonacute patients, 56% were on a waiting list for specific resources whereas for the remaining 44%, alternative resources required to address their needs were as of yet undetermined (Figure 1). Baseline characteristics and admission information. As shown in Table 1, 63% of nonacute patients were 75 years and older and 79% lived at home. The majority (90%) were admitted from the ED. The largest admitting department was medicine (56%), followed by geriatrics (22%) and surgery (20%). AEP items/patients needs on day 30 of hospitalization. Among the nonacute patients (n = 333), the AEP identified no needs in 55% of cases and one need or more in 45% of patients. Of the 249 needs identified by the AEP, 88% were related to “nursing/life-support services” and 12% were related to “patient con-
AlternaƟve resources to be determined n = 147 (44.1%)
Table 1. Patients Characteristics and Admission Information Characteristics Age (years); mean (SD) 75 years and over; n Female; n (%) Living Arrangements; n (%) Home with other adult Home alone Residency Homeless Patients Admitted from; n (%) ED Home Outpatient clinic Other acute care hospital Other facilities (i.e., long-term care; rehab) Admission Service; n (%) Medicine Geriatrics Surgery Cardiology
Nonacute Patients n = 333 77 (14) 210 (63.1) 191 (57.4) 168 (50.5) 94 (28.2) 69 (20.7) 2 (0.6) 298 (89.5) 15 (4.5) 9 (2.7) 7 (2.1) 4 (1.2)
185 (55.6) 72 (21.6) 68 (20.4) 8 (2.4)
dition factors.” No patient required “medical services” on day 30 of their hospitalization.
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Table 2. AEP Items/Needs Identified on the 30th Day of Hospitalization Among Nonacute Patients AEP Items/Needs n = 249 (%)
Type of needs Nursing/life-support services Intramuscular and/or subcutaneous injections at least twice daily Parenteral therapy—intermittent or continuous IV fluid with any supplementation (electrolytes, protein, medications) Major surgical wound and drainage care (chest tubes, T-tubes, hemovacs, Penrose drains) Respiratory care—intermittent or continuous respirator use and/or inhalation therapy (with chest PT, IPPB) at least three times daily Close medical monitoring by nurse at least three times daily, under doctor’s orders Intake and output measurement Patient Condition Factors—Within 48 hr before the review Acute confusional state, not due to alcohol withdrawal Acute hematologic disorders, significant neutropenia, anemia, thrombocytopenia, leukocytosis, erythrocytosis, or thrombocytosis yielding signs or symptoms Inability to void or move bowels (past 24 hr) not attributable to neurologic disorder* Transfusion due to blood loss Progressive acute neurologic difficulties Coma—unresponsiveness for at least 1 hr Fever at least 101 rectally (at least 100 orally), if patient was admitted for reasons other than fever
137 (55.0) 53 (21.3) 11 (4.4) 10 (4.0) 6 (2.4) 3 (1.2) 9 (3.6) 6 (2.4)
4 (1.6) 3 (1.2) 3 (1.2) 3 (1.2) 1 (0.4)
*Within 24 hr before the review for inability to void or move bowels not attributable to neurologic disorder.
Table 2 shows a detailed list of needs identified by the AEP for nonacute patients. Patients waiting for specific resources on day 30. Among the nonacute patients, 186 (56%) required out-of-hospital resources that were unavailable at that time. The majority were waiting for either palliative care (36%) or permanent placement in a long-term care facility (33%), whereas 18% were waiting for rehabilitation/convalescence care, and 12% for appropriate homecare (Table 3). Of the patients waiting for palliative care, 82% were admitted under medicine. Of those waiting for long-term care, 53% were under medicine, and 29% under geriatrics. Of patients waiting for rehabilitation care, 47% were admitted under medicine and the rest were under surgery. Not mutually exclusive reasons responsible for nonacute patients occupying an acute care bed on day 30 of hospitalization (Table 3) included unavailability of appropriate alternative resources (33%), ongoing liaison process with community care staff (23%), discussion with family and/or patient education and counsel-
ing (9%), and administrative and/or social issues (7%). Total hospital length of stay and discharge destination of patients waiting (n = 186) for alternative resources are also shown in Table 3. Among patients waiting for institutional resources, the group waiting for palliative care had the longest hospital length of stay (63 days; 42% ࣙ 90 days), followed by long-term care patients (53 days; 7% ࣙ 90 days) and by patients waiting for rehabilitation/convalescence care (46 days; 3% ࣙ 90 days). For patients waiting for home care, their hospital length of stay was on average 47 days (9% ࣙ 90 days). Of the patients waiting for placement (i.e., palliative care, long-term care, rehabilitation/convalescence), the majority of palliative care patients died while in hospital (67%). The majority waiting for long-term care (60%) and rehabilitation/convalescence (59%) were discharged home or to a semiautonomous residence. Home and semiautonomous residences were provided with additional resources depending on patients’ needs while awaiting permanent placement. Similarly, 27% of patients waiting for palliative care were sent home or
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Table 3. Patients on a Waiting List for Specific Resources: Level of Care Needed, Reasons Explaining Hospital Stay, Hospital Length of Stay, and Destination Nonacute Patients on Waiting List n = 186 Level of care/specific resources needed n (%) Palliative care Long-term care Rehabilitation/convalescence care Home care Transfer in another acute care hospital Reasons explaining the stay on an acute care unit n (%) Appropriate alternative resources not available Ongoing process to liaise with community care staff Ongoing family discussion and/or patient education/counseling Administrative/social issues
67 (36.0) 62 (33.3) 34 (18.3) 23 (12.4) 1 (0.5) 61 (32.8) 43 (23.1) 16 (8.6) 13 (7.0)
Type of resources patients waiting for (n = 186)
Total hospital LOS (days) Mean (SD) Median (25th–75th percentile) Hospital LOS ࣙ 90 days; n (%) Destination postdischarge; n (%) Home or semiautonomous residence Long-term care (permanent placement) Subacute resource (palliative care, rehabilitation center) Death
Palliative care n = 67 (36%)
Long-term care n = 62 (33%)
Rehabilitation convalescence n = 34 (18%)
Home care n = 23 (12%)
63 (33) 49 (39–75) 28 (41.8)
53 (38) 41 (36–53) 4 (6.5)
46 (16) 39 (35–54) 1 (2.9)
47 (18) 41 (35–53) 2 (8.7)
18 (26.9) 2 (3.0) 2 (3.0)
37 (59.7) 19 (30.6) 2 (3.2)
19 (59.4) 2 (6.3) 12 (37.5)
18 (78.3) 2 (8.7) – (–)
45 (67.2)
4 (6.5)
1 (2.9)
3 (13.0)
to a semiautonomous residence. For patients waiting for rehabilitation/convalescence, 38% were transferred to a subacute facility, and 31% awaiting long-term care were transferred to long-term care. Lastly, of patients waiting for home care resources, 78% were discharged home (Table 3). Patients with an undetermined alternative level of care/resources on day 30. Regarding another group of nonacute patients (n = 147), although the medical team determined that acute care was no longer required, the alternative resources necessary remained undetermined. As shown in Table 4, the most frequent reasons that accounted for occupying acute care beds on day 30 included the following: further/ongoing assessment was needed to determine alternative resources (69%), appropriate resources were either difficult to find or
nonexistent (43%), there was an ongoing liaison process with community personnel (25%), the patient was waiting for treatment (23%), and administrative or social issues (19%). Total hospital length of stay and discharge destination are also shown in Table 4. The average hospital length of stay was 54 days with 8% staying in the hospital for more than 90 days. Approximately 57% were discharged to their place of residence, 16% died while in hospital, 16% were admitted to a long-term care institution, and 10% were transferred to subacute care facilities.
Discussion Our study found that 35% of patients did not require acute care hospital resources on day 30 of their hospitalization. The proportion of inappropriate stays observed in our study is within
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Table 4. Patients with Undetermined Alternative Resources: Reasons Explaining the Stay on an Acute Care Unit, Hospital Length of Stay, and Destination Nonacute Patients with Undetermined Resources, n = 147 Reasons n (%) Ongoing assessment to determined appropriate resources Appropriate alternative resources very difficult to find Ongoing liaison process with community care staff Waiting for treatment Administrative/social issues Conservative medical practice Ongoing family discussion and/or patient education/counseling Total hospital LOS (days) Mean (±SD) Median (25th–75th percentile) Hospital LOS ࣙ 90 days; n (%) Destination postdischarge; n (%) Home or semiautonomous residence Death Long-term care (permanent placement) Subacute resource (palliative care, rehabilitation center)
the range of 12% to 45%, as reported by others (Barisonzo et al., 2013; Castaldi et al., 2010; Fontaine et al., 2011; Griffiths & Sironi, 2005; Hwang et al., 2011; Mould-Quevedo et al., 2009; S´anchez-Garcia et al., 2008; Soria-Aledo et al., 2009). Using the combination of the AEP tool and expert opinion allowed for a more thorough understanding of nonacute patients. We used the AEP tool to identify patient needs because this instrument produces quantifiable results and reduces inherent subjectivity (McDonagh et al., 2000). However, as with other standardized tools, the AEP has limitations such as not accounting for the local circumstances or the availability of alternative services (Glasby, 2003). Therefore, to determine the acute status of a patient’s stay, we consulted the medical team directly involved in the care. Expert opinion allowed for the identification of certain patients as nonacute, that would otherwise have been categorized as acute if solely based on the AEP tool. For example, patients who only required intramuscular and/or subcutaneous injections or IV fluids would have been categorized as acute according to AEP’s objective criteria. However, upon further examination of available services in long-term care and/or rehabilitation facilities, these patients could be
101 (68.7) 63 (42.9) 36 (24.5) 34 (23.1) 28 (19.1) 13 (8.8) 10 (6.8) 54 (±30) 45 (36–62) 12 (8.2) 84 (57.1) 24 (16.3) 24 (16.3) 15 (10.2)
effectively treated within such centers. This is in agreement with a previous work that concluded that the AEP underestimated the inappropriateness of hospital days (Kalant et al., 2000). In order to better understand the level of alternative care required by nonacute patients on day 30 of their hospitalization, they were broadly categorized into two groups: those for which the level of alternative care was known and those for which it was still to be determined. In the first group, our results showed that the vast majority of patients required placement in a subacute care facility that included palliative care, long-term care, or rehabilitation/convalescence. Only about 12% were capable of being discharged home with assistance/services. For patients awaiting placement, the major barrier to hospital discharge was due to the lack of available alternative resources. This finding is consistent with previous work (Barisonzo et al., 2013; d’Alch´e-Gautier et al., 2004; Fontaine et al., 2011) who identified the two main reasons responsible for delays in placement: the unavailability of appropriate alternative resources and an ongoing liaison process with the community. For patients whose level of alternative care was still undetermined, the two main reasons were ongoing assessment to determine the appropriate resources
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and unavailability of the type of alternative resources specifically tailored to the patient’s needs. In certain cases, the complexity of the patients’ needs and conditions made it difficult to transfer these patients due to the facilities’ resistance in accepting such cases. Examples of this included permanent long-term care placement for patients with a language barrier or elderly patients with psychiatric issues, palliative care for an undetermined period and rehabilitation or convalescence for patients with special needs. Other contributing reasons delaying determining the alternative resources for a given patient included the following: waiting for specific in-hospital treatments (e.g., physiotherapy, radiotherapy, chemotherapy, occupational therapy), administrative social issues, a conservative medical practice, and an ongoing discussion with the family and/or patient education/counseling. In terms of identifying appropriate subacute resources similar to other research, our study also identified long-term care institutions, rehabilitation, convalescence centers, and home care as optimal subacute healthcare resources (Bruce, DeCoster, Trumbel-Waddell, & Burchill, 2002; Sheppard et al., 2002). However, unlike other studies, we also identified palliative care as an appropriate alternative subacute level of care and classified patients who required palliative care as nonacute. These patients were not hospitalized under palliative care on admission. However, during their hospital stay their medical status worsened and they were subsequently evaluated to require palliative services. Among these patients, those with a known life expectancy of less than 2 months were waitlisted to be transferred to a palliative care facility, whereas patients with a life expectancy greater than 2 months continued to occupy an acute care bed because they did not meet the 2-month life expectancy criterion for palliative care, as regulated by the provincial government. Patients who were evaluated as palliative care but did not meet the above criterion included those in a vegetative state or with end-stage degenerative diseases. In certain cases, less severe patients requiring palliative care could potentially be transferred to nursing homes or to the patient’s own home, provided that the appropriate resources and support are present (Klinger et al., 2013; Thomas & Lobo, 2011).
In our study, 14% of nonacute patients stayed for more than 90 days on an acute care unit, compared to previous research which found that only 4–5% stayed for more than 100 days (Canadian Institute for Health Information, 2009; Hammond et al., 2009). The larger proportion in our study is explained by the fact that the previous work included all hospitalized patients, while we targeted patients that were hospitalized for approximately 30 days. Most patients were discharged home or to a semiautonomous residence, except for patients waiting for palliative care, where the majority (67%) died while still in hospital. In addition, a fair proportion (16%) of patients whose needs were still undetermined on day 30 also died while in hospital.
Limitations Limitations of this study include, but are not limited to the following: First, we did not collect information on institutional factors such as hospital bed occupancy or practice protocols that may also contribute to prolonged inappropriate patient stays (Hwang, 2007; Soria-Aledo et al., 2009). A more detailed list of potential factors contributing to inappropriate stays may have provided a more thorough understanding of the issue. Furthermore, this study captured patient status on day 30 of their hospitalization and therefore, prior to and subsequent changes in medical conditions were not observed. Lastly, applicability of our findings to other healthcare environments may be limited because of differences in how healthcare systems are organized and funded outside Canada.
Conclusion Nonacute patients occupying acute care beds continue to be problematic for hospitals trying to manage precious healthcare resources. The major reasons preventing discharge are the lack of available appropriate alternative subacute resources of care, as well as the difficulty in determining the needs of a very heterogeneous group of patients with specific requirements. Because occupying acute care beds is not the best option for patients, nor the healthcare system, future research should focus on developing strategies to address the disparities between patients’ needs and available healthcare resources.
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Acknowledgments The authors thank the clinical staff of the Jewish General Hospital and Notre-Dame hospital for their valuable contributions toward this project. This project was funded by the Fonds de Recherche en Sant´e du Qu´ebec (FRSQ 13795). A poster was presented at the Canadian Association of Emergency Physicians Conference, June 4–8, 2011. The authors declare no other potential conflicts of interest with respect to the project, authorship, and/or publication of this manuscript.
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Authors’ Biographies Marc Afilalo, MD, MCFP(EM), CSPQ, FACEP, FRCP, is the director and clinical researcher at the Emergency Department of Jewish General Hospital, McGill University, Montreal, Canada.
ish General Hospital, McGill University, Montreal, Canada. Antoinette Colacone, BSc-CCRA, is the research coordinator at the Research Division of Emergency Department of Jewish General Hospital, McGill University, Montreal, Canada. Emmanuelle Jourdenais, MD, is the director and researcher at the Emergency Department of Centre hospitalier de l’Universit´e de Montr´eal, Montreal, Canada.
Xiaoqing Xue, MSc, is a biostatistician at the Research Division of Emergency Department of Jewish General Hospital, McGill University, Montreal, Canada.
Jean-Franc¸ois Boivin, MD, PhD, is a professor at the department of Epidemiology and Biostatistics at McGill University and a clinical researcher at the Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada.
Nathalie Soucy, PhD, is a research associate at the Research Division of Emergency Department of Jew-
For more information on this article, contact Antoinette Colacone at [email protected].
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Patient Needs, Required Level of Care, and Reasons Delaying Hospital Discharge for Nonacute Patients Occupying Acute Hospital Beds Marc Afilalo, Xiaoqing Xue, Nathalie Soucy, Antoinette Colacone, Emmanuelle Jourdenais, Jean-Franc¸ois Boivin Current research on emergency department (ED) crowding suggests that “boarding” of admitted patients in the ED for long periods contributes to ED crowding (Moskop, Sklar, Geiderman, Schears, & Bookman, 2009). Boarding has been shown to be due to a variety of reasons including a lack of access to in-patient hospital beds (Handel et al., 2010; Moskop et al., 2009; Powell et al., 2012). One way of improving bed access is by avoiding inappropriate hospital stay and/or decreasing prolonged hospital stays (Rabin et al., 2012). However, studies have shown that certain patients continue to occupy acute hospital beds, even when their needs (for assessment, observation, and/or intervention) can be met more effectively elsewhere (Barisonzo, Wiedermann, Unterhuber, & Wiedermann, 2013; Canadian Institute for Health Information, 2009; Hammond, Phillips, Pinnington, Pearson, & Fakis, 2009). Patients who do not require acute care and whose needs can be met in another setting are commonly referred to as nonacute patients (Flintoft et al., 1998; Higginson, 2012). Efficiently relocating these patients will ensure the availability of hospital beds for incoming patients requiring admission, decrease the risk to acquiring nosocomial conditions, and decrease hospital costs and unnecessary procedures (Mould-Quevedo et al., 2009; Roberts et al., 2010; Soria-Aledo et al., 2009). A prerequisite to relocating nonacute patients is first identifying their needs and second, determining the setting where appropriate care can be delivered. There are two generally accepted approaches to determine whether a given patient’s hospitalization is appropriate or not. The first approach is based on expert opinion (Harvey, Jenkins, & Llewellyn, 1993; Namdaran & Sherval, 1995), and has been considered the gold standard. Experts consist of clinical staff and other members of a multidisciplinary team actively responsible for
Abstract: This study aims to determine the proportion of nonacute patients occupying acute care beds and to describe their needs, the appropriate level of alternative care, and reasons preventing discharge. Data from 952 patients hospitalized in an acute care unit for 30 days were obtained from their medical charts and by consulting with the medical team at two tertiary teaching hospitals. Among them, 333 (35%) were determined nonacute on day 30 of hospitalization. According to the Appropriateness Evaluation Protocol (AEP), 55% had no medical, nursing, or patient needs. Among nonacute patients with AEP needs, 88% were related to nursing/life-support services and 12% related to patient condition factors. Regarding alternative level of care, 186 (56%) were waiting for out-of-hospital resources, of which 36% were waiting for palliative care, 33% for long-term care, 18% for rehabilitation, and 12% for home care. For the remaining 147 (44%) nonacute patients, the alternative resources remained undetermined although acute care was no longer required. Main reasons preventing discharge included unavailability of alternative resources, ongoing assessment to determine appropriate resources, ongoing process with community care, and family/patient education/counseling. Available subacute facilities and community-based care would liberate acute care beds and facilitate their appropriate use.
patient care (Glasby, 2003). The second approach is the use of a variety of standardized evaluation tools such as the Appropriateness Evaluation Protocol (AEP) (Barisonzo et al., 2013; Brabrand, Knudsen, & Hallas, 2011; d’Alch´e-Gautier, Ma¨ıza, & Chastang, 2004; Fontaine et al., 2011; S´anchez-Garcia et al., 2008). The AEP is probably the most used and studied tool for identifying patients’ needs during hospitalization, which in turn determines the appropriateness of patients’ hospital stay (McDonagh, Smith, & Goddard, 2000). Limitations of the AEP include underestimating inappropriate stays (Kalant, Berlinguet, Diodati, Dragatakis, & Marcotte, 2000) and not taking into consideration the local conditions or availability of alternative services (Brabrand et al., 2011). Nevertheless, the AEP is a valuable tool which is easily used to objectively obtain patient
Keywords acute care beds appropriateness of evaluation tool nonacute medical care
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information regarding their medical, nursing, and personal needs while hospitalized. The aim of this study was to determine the proportion of nonacute patients on day 30 of hospitalization. For patients determined nonacute, we sought to identify their needs (medical, nursing, and personal), identify the appropriate level of alternative care, explore the reasons delaying discharge, and describe post–hospital discharge destinations. This study used medical expert opinion to determine nonacute patients, whereas the AEP was applied in identifying specific patient needs.
Methods Study Design, Settings, and Participants This prospective observational study was conducted in two adult tertiary care hospitals in Montreal, Canada. Affiliated with McGill University, the Jewish General Hospital has 637 hospitals beds. Affiliated with the University of Montreal, the Notre-Dame Hospital has 403 beds. Recruitment was conducted from March 2009 to April 2010. Patients aged 18 years and over hospitalized in an acute care unit for 30 days were eligible. Patients admitted under obstetrics, psychiatry, and critical care were excluded. Also excluded were patients admitted to palliative care. However, patients who were not initially admitted to palliative care but for whom palliative care became a need during the hospitalization were included. The study received approval from both hospitals’ research ethics committees.
Data Collection To obtain information on patient status on day 30 (±3 days) of hospitalization, data were collected by conducting concurrent medical chart reviews and discussions with the medical team involved in the care. Data collection was performed by a single trained research assistant at both hospitals. Data collected included sociodemographics, living arrangements, admission information, needs on day 30, reasons for delaying hospital discharge, information regarding appropriate alternative level of care, total hospital length of stay, and post–hospital discharge destination. Patient needs were identified using the AEP tool. The AEP regroups 27 items/needs related to medical services (11 items), nursing/life-support services (7 items), and patient condition factors (9 items).
The alternative level of care (i.e., long-term care, rehabilitation/convalescence care, home care, ambulatory care, and palliative care) was determined by the medical team (i.e., doctors, nurses, other consultants and services) who were directly involved in patient care. A patient’s status was determined as “nonacute” when the medical team judged that the patient’s needs could be effectively met in an alternative care setting. Information about the medical team’s decision was retrieved from the medical charts. This information included ongoing acute treatment, date of a formal request for transfer to another facility, notes from the healthcare professional on available resources that would better meet the patient’s needs, and information on ongoing discussions with community healthcare professionals. In cases where information in the patient’s medical chart was unclear, the research assistant approached the medical team in order to confirm the type of care required. The cut-off point of day 30 was chosen for various reasons. First, this study targeted the patient population occupying an acute care bed following an acute medical episode. Selecting a shorter hospital stay could have resulted in enrolling patients with unresolved acute conditions. Second, other studies which aimed at studying long-stay patients also used 30-day hospitalization as a reference (DeCoster, Bruce, & Kozyrskyi, 2005; Hwang, Kim, Jang, & Park, 2011). In addition, the results of an expert consultation agreed that 30 days was a more practical time frame, because if patients still occupied an acute care bed at this time, actions were taken to re-examine their status and seek other management solutions or alternative care. Lastly, although the data from participating hospitals showed that this group of patients constitutes only about 10% of admissions, they contribute to more than half of the total hospital days, which corresponds to a significant number of hospital bed days unavailable for new patients.
Statistical Analysis Descriptive statistics, including means (standard deviations), medians (interquartile ranges), 95% confidence intervals, and proportions were used to describe patient characteristics, needs, the level of more appropriate alternative care, and reasons for still occupying acute care beds. All analyses were performed
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Figure 1. Flow Diagram of Study Population Eligible paƟents n = 1,970 Not selected n = 1,018 •Random selecƟon of one paƟent out of two
Recruited paƟents n = 952 (48.3%)
Acute care paƟents n = 619 (65.0%)
Non acute care paƟents n = 333 (35.0%)
WaiƟng list for specific resources n = 186 (55.9%)
using the statistical software package SAS 9.3 (SAS Institute, Cary, NC).
Results Of the 1,970 eligible patients, 952 (48.3%) were enrolled, of which 333 (35%, 95% confidence interval [32–38%]) were evaluated as nonacute on day 30 of hospitalization. Among the nonacute patients, 56% were on a waiting list for specific resources whereas for the remaining 44%, alternative resources required to address their needs were as of yet undetermined (Figure 1). Baseline characteristics and admission information. As shown in Table 1, 63% of nonacute patients were 75 years and older and 79% lived at home. The majority (90%) were admitted from the ED. The largest admitting department was medicine (56%), followed by geriatrics (22%) and surgery (20%). AEP items/patients needs on day 30 of hospitalization. Among the nonacute patients (n = 333), the AEP identified no needs in 55% of cases and one need or more in 45% of patients. Of the 249 needs identified by the AEP, 88% were related to “nursing/life-support services” and 12% were related to “patient con-
AlternaƟve resources to be determined n = 147 (44.1%)
Table 1. Patients Characteristics and Admission Information Characteristics Age (years); mean (SD) 75 years and over; n Female; n (%) Living Arrangements; n (%) Home with other adult Home alone Residency Homeless Patients Admitted from; n (%) ED Home Outpatient clinic Other acute care hospital Other facilities (i.e., long-term care; rehab) Admission Service; n (%) Medicine Geriatrics Surgery Cardiology
Nonacute Patients n = 333 77 (14) 210 (63.1) 191 (57.4) 168 (50.5) 94 (28.2) 69 (20.7) 2 (0.6) 298 (89.5) 15 (4.5) 9 (2.7) 7 (2.1) 4 (1.2)
185 (55.6) 72 (21.6) 68 (20.4) 8 (2.4)
dition factors.” No patient required “medical services” on day 30 of their hospitalization.
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Table 2. AEP Items/Needs Identified on the 30th Day of Hospitalization Among Nonacute Patients AEP Items/Needs n = 249 (%)
Type of needs Nursing/life-support services Intramuscular and/or subcutaneous injections at least twice daily Parenteral therapy—intermittent or continuous IV fluid with any supplementation (electrolytes, protein, medications) Major surgical wound and drainage care (chest tubes, T-tubes, hemovacs, Penrose drains) Respiratory care—intermittent or continuous respirator use and/or inhalation therapy (with chest PT, IPPB) at least three times daily Close medical monitoring by nurse at least three times daily, under doctor’s orders Intake and output measurement Patient Condition Factors—Within 48 hr before the review Acute confusional state, not due to alcohol withdrawal Acute hematologic disorders, significant neutropenia, anemia, thrombocytopenia, leukocytosis, erythrocytosis, or thrombocytosis yielding signs or symptoms Inability to void or move bowels (past 24 hr) not attributable to neurologic disorder* Transfusion due to blood loss Progressive acute neurologic difficulties Coma—unresponsiveness for at least 1 hr Fever at least 101 rectally (at least 100 orally), if patient was admitted for reasons other than fever
137 (55.0) 53 (21.3) 11 (4.4) 10 (4.0) 6 (2.4) 3 (1.2) 9 (3.6) 6 (2.4)
4 (1.6) 3 (1.2) 3 (1.2) 3 (1.2) 1 (0.4)
*Within 24 hr before the review for inability to void or move bowels not attributable to neurologic disorder.
Table 2 shows a detailed list of needs identified by the AEP for nonacute patients. Patients waiting for specific resources on day 30. Among the nonacute patients, 186 (56%) required out-of-hospital resources that were unavailable at that time. The majority were waiting for either palliative care (36%) or permanent placement in a long-term care facility (33%), whereas 18% were waiting for rehabilitation/convalescence care, and 12% for appropriate homecare (Table 3). Of the patients waiting for palliative care, 82% were admitted under medicine. Of those waiting for long-term care, 53% were under medicine, and 29% under geriatrics. Of patients waiting for rehabilitation care, 47% were admitted under medicine and the rest were under surgery. Not mutually exclusive reasons responsible for nonacute patients occupying an acute care bed on day 30 of hospitalization (Table 3) included unavailability of appropriate alternative resources (33%), ongoing liaison process with community care staff (23%), discussion with family and/or patient education and counsel-
ing (9%), and administrative and/or social issues (7%). Total hospital length of stay and discharge destination of patients waiting (n = 186) for alternative resources are also shown in Table 3. Among patients waiting for institutional resources, the group waiting for palliative care had the longest hospital length of stay (63 days; 42% ࣙ 90 days), followed by long-term care patients (53 days; 7% ࣙ 90 days) and by patients waiting for rehabilitation/convalescence care (46 days; 3% ࣙ 90 days). For patients waiting for home care, their hospital length of stay was on average 47 days (9% ࣙ 90 days). Of the patients waiting for placement (i.e., palliative care, long-term care, rehabilitation/convalescence), the majority of palliative care patients died while in hospital (67%). The majority waiting for long-term care (60%) and rehabilitation/convalescence (59%) were discharged home or to a semiautonomous residence. Home and semiautonomous residences were provided with additional resources depending on patients’ needs while awaiting permanent placement. Similarly, 27% of patients waiting for palliative care were sent home or
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Table 3. Patients on a Waiting List for Specific Resources: Level of Care Needed, Reasons Explaining Hospital Stay, Hospital Length of Stay, and Destination Nonacute Patients on Waiting List n = 186 Level of care/specific resources needed n (%) Palliative care Long-term care Rehabilitation/convalescence care Home care Transfer in another acute care hospital Reasons explaining the stay on an acute care unit n (%) Appropriate alternative resources not available Ongoing process to liaise with community care staff Ongoing family discussion and/or patient education/counseling Administrative/social issues
67 (36.0) 62 (33.3) 34 (18.3) 23 (12.4) 1 (0.5) 61 (32.8) 43 (23.1) 16 (8.6) 13 (7.0)
Type of resources patients waiting for (n = 186)
Total hospital LOS (days) Mean (SD) Median (25th–75th percentile) Hospital LOS ࣙ 90 days; n (%) Destination postdischarge; n (%) Home or semiautonomous residence Long-term care (permanent placement) Subacute resource (palliative care, rehabilitation center) Death
Palliative care n = 67 (36%)
Long-term care n = 62 (33%)
Rehabilitation convalescence n = 34 (18%)
Home care n = 23 (12%)
63 (33) 49 (39–75) 28 (41.8)
53 (38) 41 (36–53) 4 (6.5)
46 (16) 39 (35–54) 1 (2.9)
47 (18) 41 (35–53) 2 (8.7)
18 (26.9) 2 (3.0) 2 (3.0)
37 (59.7) 19 (30.6) 2 (3.2)
19 (59.4) 2 (6.3) 12 (37.5)
18 (78.3) 2 (8.7) – (–)
45 (67.2)
4 (6.5)
1 (2.9)
3 (13.0)
to a semiautonomous residence. For patients waiting for rehabilitation/convalescence, 38% were transferred to a subacute facility, and 31% awaiting long-term care were transferred to long-term care. Lastly, of patients waiting for home care resources, 78% were discharged home (Table 3). Patients with an undetermined alternative level of care/resources on day 30. Regarding another group of nonacute patients (n = 147), although the medical team determined that acute care was no longer required, the alternative resources necessary remained undetermined. As shown in Table 4, the most frequent reasons that accounted for occupying acute care beds on day 30 included the following: further/ongoing assessment was needed to determine alternative resources (69%), appropriate resources were either difficult to find or
nonexistent (43%), there was an ongoing liaison process with community personnel (25%), the patient was waiting for treatment (23%), and administrative or social issues (19%). Total hospital length of stay and discharge destination are also shown in Table 4. The average hospital length of stay was 54 days with 8% staying in the hospital for more than 90 days. Approximately 57% were discharged to their place of residence, 16% died while in hospital, 16% were admitted to a long-term care institution, and 10% were transferred to subacute care facilities.
Discussion Our study found that 35% of patients did not require acute care hospital resources on day 30 of their hospitalization. The proportion of inappropriate stays observed in our study is within
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Table 4. Patients with Undetermined Alternative Resources: Reasons Explaining the Stay on an Acute Care Unit, Hospital Length of Stay, and Destination Nonacute Patients with Undetermined Resources, n = 147 Reasons n (%) Ongoing assessment to determined appropriate resources Appropriate alternative resources very difficult to find Ongoing liaison process with community care staff Waiting for treatment Administrative/social issues Conservative medical practice Ongoing family discussion and/or patient education/counseling Total hospital LOS (days) Mean (±SD) Median (25th–75th percentile) Hospital LOS ࣙ 90 days; n (%) Destination postdischarge; n (%) Home or semiautonomous residence Death Long-term care (permanent placement) Subacute resource (palliative care, rehabilitation center)
the range of 12% to 45%, as reported by others (Barisonzo et al., 2013; Castaldi et al., 2010; Fontaine et al., 2011; Griffiths & Sironi, 2005; Hwang et al., 2011; Mould-Quevedo et al., 2009; S´anchez-Garcia et al., 2008; Soria-Aledo et al., 2009). Using the combination of the AEP tool and expert opinion allowed for a more thorough understanding of nonacute patients. We used the AEP tool to identify patient needs because this instrument produces quantifiable results and reduces inherent subjectivity (McDonagh et al., 2000). However, as with other standardized tools, the AEP has limitations such as not accounting for the local circumstances or the availability of alternative services (Glasby, 2003). Therefore, to determine the acute status of a patient’s stay, we consulted the medical team directly involved in the care. Expert opinion allowed for the identification of certain patients as nonacute, that would otherwise have been categorized as acute if solely based on the AEP tool. For example, patients who only required intramuscular and/or subcutaneous injections or IV fluids would have been categorized as acute according to AEP’s objective criteria. However, upon further examination of available services in long-term care and/or rehabilitation facilities, these patients could be
101 (68.7) 63 (42.9) 36 (24.5) 34 (23.1) 28 (19.1) 13 (8.8) 10 (6.8) 54 (±30) 45 (36–62) 12 (8.2) 84 (57.1) 24 (16.3) 24 (16.3) 15 (10.2)
effectively treated within such centers. This is in agreement with a previous work that concluded that the AEP underestimated the inappropriateness of hospital days (Kalant et al., 2000). In order to better understand the level of alternative care required by nonacute patients on day 30 of their hospitalization, they were broadly categorized into two groups: those for which the level of alternative care was known and those for which it was still to be determined. In the first group, our results showed that the vast majority of patients required placement in a subacute care facility that included palliative care, long-term care, or rehabilitation/convalescence. Only about 12% were capable of being discharged home with assistance/services. For patients awaiting placement, the major barrier to hospital discharge was due to the lack of available alternative resources. This finding is consistent with previous work (Barisonzo et al., 2013; d’Alch´e-Gautier et al., 2004; Fontaine et al., 2011) who identified the two main reasons responsible for delays in placement: the unavailability of appropriate alternative resources and an ongoing liaison process with the community. For patients whose level of alternative care was still undetermined, the two main reasons were ongoing assessment to determine the appropriate resources
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and unavailability of the type of alternative resources specifically tailored to the patient’s needs. In certain cases, the complexity of the patients’ needs and conditions made it difficult to transfer these patients due to the facilities’ resistance in accepting such cases. Examples of this included permanent long-term care placement for patients with a language barrier or elderly patients with psychiatric issues, palliative care for an undetermined period and rehabilitation or convalescence for patients with special needs. Other contributing reasons delaying determining the alternative resources for a given patient included the following: waiting for specific in-hospital treatments (e.g., physiotherapy, radiotherapy, chemotherapy, occupational therapy), administrative social issues, a conservative medical practice, and an ongoing discussion with the family and/or patient education/counseling. In terms of identifying appropriate subacute resources similar to other research, our study also identified long-term care institutions, rehabilitation, convalescence centers, and home care as optimal subacute healthcare resources (Bruce, DeCoster, Trumbel-Waddell, & Burchill, 2002; Sheppard et al., 2002). However, unlike other studies, we also identified palliative care as an appropriate alternative subacute level of care and classified patients who required palliative care as nonacute. These patients were not hospitalized under palliative care on admission. However, during their hospital stay their medical status worsened and they were subsequently evaluated to require palliative services. Among these patients, those with a known life expectancy of less than 2 months were waitlisted to be transferred to a palliative care facility, whereas patients with a life expectancy greater than 2 months continued to occupy an acute care bed because they did not meet the 2-month life expectancy criterion for palliative care, as regulated by the provincial government. Patients who were evaluated as palliative care but did not meet the above criterion included those in a vegetative state or with end-stage degenerative diseases. In certain cases, less severe patients requiring palliative care could potentially be transferred to nursing homes or to the patient’s own home, provided that the appropriate resources and support are present (Klinger et al., 2013; Thomas & Lobo, 2011).
In our study, 14% of nonacute patients stayed for more than 90 days on an acute care unit, compared to previous research which found that only 4–5% stayed for more than 100 days (Canadian Institute for Health Information, 2009; Hammond et al., 2009). The larger proportion in our study is explained by the fact that the previous work included all hospitalized patients, while we targeted patients that were hospitalized for approximately 30 days. Most patients were discharged home or to a semiautonomous residence, except for patients waiting for palliative care, where the majority (67%) died while still in hospital. In addition, a fair proportion (16%) of patients whose needs were still undetermined on day 30 also died while in hospital.
Limitations Limitations of this study include, but are not limited to the following: First, we did not collect information on institutional factors such as hospital bed occupancy or practice protocols that may also contribute to prolonged inappropriate patient stays (Hwang, 2007; Soria-Aledo et al., 2009). A more detailed list of potential factors contributing to inappropriate stays may have provided a more thorough understanding of the issue. Furthermore, this study captured patient status on day 30 of their hospitalization and therefore, prior to and subsequent changes in medical conditions were not observed. Lastly, applicability of our findings to other healthcare environments may be limited because of differences in how healthcare systems are organized and funded outside Canada.
Conclusion Nonacute patients occupying acute care beds continue to be problematic for hospitals trying to manage precious healthcare resources. The major reasons preventing discharge are the lack of available appropriate alternative subacute resources of care, as well as the difficulty in determining the needs of a very heterogeneous group of patients with specific requirements. Because occupying acute care beds is not the best option for patients, nor the healthcare system, future research should focus on developing strategies to address the disparities between patients’ needs and available healthcare resources.
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Acknowledgments The authors thank the clinical staff of the Jewish General Hospital and Notre-Dame hospital for their valuable contributions toward this project. This project was funded by the Fonds de Recherche en Sant´e du Qu´ebec (FRSQ 13795). A poster was presented at the Canadian Association of Emergency Physicians Conference, June 4–8, 2011. The authors declare no other potential conflicts of interest with respect to the project, authorship, and/or publication of this manuscript.
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Authors’ Biographies Marc Afilalo, MD, MCFP(EM), CSPQ, FACEP, FRCP, is the director and clinical researcher at the Emergency Department of Jewish General Hospital, McGill University, Montreal, Canada.
ish General Hospital, McGill University, Montreal, Canada. Antoinette Colacone, BSc-CCRA, is the research coordinator at the Research Division of Emergency Department of Jewish General Hospital, McGill University, Montreal, Canada. Emmanuelle Jourdenais, MD, is the director and researcher at the Emergency Department of Centre hospitalier de l’Universit´e de Montr´eal, Montreal, Canada.
Xiaoqing Xue, MSc, is a biostatistician at the Research Division of Emergency Department of Jewish General Hospital, McGill University, Montreal, Canada.
Jean-Franc¸ois Boivin, MD, PhD, is a professor at the department of Epidemiology and Biostatistics at McGill University and a clinical researcher at the Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada.
Nathalie Soucy, PhD, is a research associate at the Research Division of Emergency Department of Jew-
For more information on this article, contact Antoinette Colacone at [email protected].
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