‘Delayed discharges and boarders’: a 2-year study of the relationship between patients experiencing delayed discharges from an acute hospital and boarding of admitted patients in a crowded ED

Mustafa, Farah; Gilligan, Peadar; Obu, Deborah; O’Kelly, Patrick; O'Hea, Eimear; Lloyd, Catherine M.; Kelada, S; Heffernan, Attracta; Houlihan, Patricia

doi:10.1136/emermed-2015-205039

Cited by 21 publications

(26 citation statements)

References 16 publications

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“…There are also issues regarding the closure of beds due to infection and the increased need for specialised isolation facilities 52. Therefore, bed management forms an important component of the wider efficient use of hospital resources, a concern encapsulated by operational capacity planning and control 53–55. In general, operational capacity management is considered to be poorly developed in most acute hospitals 53.…”

Section: Discussionmentioning

confidence: 99%

An interrupted time-series analysis of the impact of emergency department reconfiguration on regional emergency department trolley numbers in Ireland from 2005 to 2015

et al. 2019

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ObjectivesTo understand the impact of emergency department (ED) reconfiguration on the number of patients waiting for hospital beds on trolleys in the remaining EDs in four geographical regions in Ireland using time-series analysis.SettingEDs in four Irish regions; the West, North-East, South and Mid-West from 2005 to 2015.ParticipantsAll patients counted as waiting on trolleys in an ED for a hospital bed in the study hospitals from 2005 to 2015.InterventionThe system intervention was the reconfiguration of ED services, as determined by the Department of Health and Health Service Executive. The timing of these interventions varied depending on the hospital and region in question.ResultsThree of the four regions studied experienced a significant change in ED trolley numbers in the 12-month post-ED reconfiguration. The trend ratio before and after the intervention for these regions was as follows: North-East incidence rate ratio (IRR) 2.85 (95% CI 2.04 to 3.99, p<0.001), South IRR 0.68 (95% CI 0.51 to 0.89, p=0.006) and the Mid-West IRR 0.03 (95% 1.03 to 2.03, p=0.03). Two of these regions, the South and the Mid-West, displayed a convergence between the observed and expected trolley numbers in the 12-month post-reconfiguration. The North-East showed a much steeper increase, one that extended beyond the 12-month period post-ED reconfiguration.ConclusionsFindings suggest that the impacts of ED reconfiguration on regional level ED trolley trends were either non-significant or caused a short-term shock which converged on the pre-reconfiguration trend over the following 12 months. However, the North-East is identified as an exception due to increased pressures in one regional hospital, which caused a change in trend beyond the 12-month post reconfiguration.

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Section: Discussionmentioning

confidence: 99%

An interrupted time-series analysis of the impact of emergency department reconfiguration on regional emergency department trolley numbers in Ireland from 2005 to 2015

et al. 2019

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“…One such peer-reviewed study exists although it does not acknowledge the issues we have presented when analysing time series data. 13 limitations Both this study and the original analysis 2 are examples of ecological studies as measurements are grouped from individual hospital-level data but analysed together in a group. Ecological studies are commonly used to generate hypotheses, which may be worth investigating using more rigorous epidemiological methodologies, 5 but are known to have severely limited causal inference.…”

Section: What Next To Understand Patient Flow?mentioning

confidence: 99%

The impact of delayed transfers of care on emergency departments: common sense arguments, evidence and confounding

Keogh

Monks

2019

Emerg Med J

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ObjectivesThere have been claims that Delayed Transfers of Care (DTOCs) of inpatients to home or a less acute setting are related to Emergency Department (ED) crowding. In particular DTOCs were associated with breaches of the UK 4-hour waiting time target in a previously published analysis. However, the analysis has major limitations by not adjusting for the longitudinal trend of the data. The aim of this work is to investigate whether the proposition that DTOCs impact the 4-hour target requires further research.MethodEstimation of an association between two or more variables that are measured over time requires specialised statistical methods. In this study, we performed two separate analyses. First, we created two sets of artificial data with no correlation. We then added an upward trend over time and again assessed for correlation. Second, we reproduced the simple linear regression of the original study using NHS England open data of English trusts between 2010 and 2016, assessing correlation of numbers of DTOCs and ED breaches of the 4-hour target. We then reanalysed the same data using standard time series methods to remove the trend before estimating an association.ResultsAfter introducing upward trends into the uncorrelated artificial data the correlation between the two data sets increased (R2=0.00 to 0.51 respectively). We found strong evidence of longitudinal trends within the NHS data of ED breaches and DTOCs. After removal of the trends the R2 reduced from 0.50 to 0.01.ConclusionOur reanalysis found weak correlation between numbers of DTOCs and ED 4-hour target breaches. Our study does not indicate that there is no relationship between 4-hour target and DTOCs, it highlights that statistically robust evidence for this relationship does not currently exist. Further work is required to understand the relationship between breaches of the 4-hour target and numbers of DTOCs.

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“…Interventions to decrease ED crowding are routinely developed and implemented [ 3 , 4 ]. Reducing and eliminating ED boarding time thereby minimizing the numbers of boarders is one of the targets to reduce relative crowding [ 5 – 7 ]. Strategies to reduce / eliminate ED boarding include moving boarders to inpatient unit hallways [ 6 , 8 ] and transferring boarders to ED observation units or admission holding units [ 9 – 11 ].…”

Section: Introductionmentioning

confidence: 99%

“…An important step in avoidance of ED crowding is high efficiency release of hospital beds driven by reduction of the disposition to discharge interval. Recent studies investigated the final bottleneck of ED outflow pathways by identifying inpatients experiencing delayed discharge from the hospital [ 5 , 12 ]. Cross-sectional computer model analysis demonstrated the potential to reduce ED boarding by improving the hospital discharge process [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

“…Similar modeling illustrated an anticipated 27–57% decrease in ED borders and a reduction of 7–14 h on an average ED length of stay in the setting of a high efficiency hospital discharge process [ 14 ]. Hospital metrics provide evidence that delayed inpatient discharges directly contribute to ED crowding [ 5 ]. Therefore, it is worthwhile to identify risks affecting delayed inpatient discharge.…”

Section: Introductionmentioning

confidence: 99%

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Risks predicting prolonged hospital discharge boarding in a regional acute care hospital

Shaikh

Robinson

Cheeti

et al. 2018

BMC Health Serv Res

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Background: Prolonged hospital discharge boarding can impact patient flow resulting in upstream Emergency Department crowding. We aim to determine the risks predicting prolonged hospital discharge boarding and their direct and indirect effects on patient flow. Methods: Retrospective review of a single hospital discharge database was conducted. Variables including type of disposition, disposition boarding time, case management consultation, discharge medications prescriptions, severity of illness, and patient homeless status were analyzed in a multivariate logistic regression model. Hospital charges, potential savings of hospital bed hours, and whether detailed discharge instructions provided adequate explanations to patients were also analyzed. Results: A total of 11,527 admissions was entered into final analysis. The median discharge boarding time was approximately 2 h. Adjusted Odds Ratio (AOR) of patients transferring to other hospitals was 7.45 (95% CI 5.35-10.37), to court or law enforcement custody was 2.51 (95% CI 1.84-3.42), and to a skilled nursing facility was 2.48 (95% CI 2.10-2.93). AOR was 0.57 (95% CI 0.47-0.71) if the disposition order was placed during normal office hours (0800-1700). AOR of early case management consultation was 1.52 (95% CI 1.37-1.68) versus 1.73 (95% CI 1.03-2.89) for late consultation. Eighty-eight percent of patients experiencing discharge boarding times within 2 h of disposition expressed positive responses when questioned about the quality of explanations of discharge instructions and follow-up plans based on satisfaction surveys. Similar results (86% positive response) were noted among patients whose discharge boarding times were prolonged (> 2 h, p = 0.44). An average charge of $6/bed/h was noted in all hospital discharges. Maximizing early discharge boarding (≤ 2 h) would have resulted in 16,376 hospital bed hours saved thereby averting $98,256.00 in unnecessary dwell time charges in this study population alone. Conclusion: Type of disposition, case management timely consultation, and disposition to discharge dwell time affect boarding and patient flow in a tertiary acute care hospital. Efficiency of the discharge process did not affect patient satisfaction relative to the perceived quality of discharge instruction and follow-up plan explanations. Prolonged disposition to discharge intervals result in unnecessary hospital bed occupancy thereby negatively impacting hospital finances while delivering no direct benefit to patients.

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‘Delayed discharges and boarders’: a 2-year study of the relationship between patients experiencing delayed discharges from an acute hospital and boarding of admitted patients in a crowded ED

Cited by 21 publications

References 16 publications

An interrupted time-series analysis of the impact of emergency department reconfiguration on regional emergency department trolley numbers in Ireland from 2005 to 2015

An interrupted time-series analysis of the impact of emergency department reconfiguration on regional emergency department trolley numbers in Ireland from 2005 to 2015

The impact of delayed transfers of care on emergency departments: common sense arguments, evidence and confounding

Risks predicting prolonged hospital discharge boarding in a regional acute care hospital

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