Discharge Delay in Head and Neck Free Flap Surgery: Risk Factors and Strategies to Minimize Hospital Days

Abstract

Objective Length of stay (LOS) includes time medically necessary in the hospital and time waiting for discharge (DC) afterward. This DC delay is determined in head and neck free flap patients. Reasons for and factors leading to DC delay, as well as associated adverse outcomes, are elucidated. Methods Retrospective chart review was performed for all head and neck free flap surgeries from 2012 to 2017. Data including demographics, comorbidities, and perioperative factors were collected. Regression analyses were performed to identify factors associated with DC delay. Results In total, 264 patients were included. Mean total LOS was 13.1 days. DC delay occurred in 65% of patients with a mean of 4.8 days. Factors associated with DC delay on univariate analysis included Medicaid/self-pay insurance, DC to a facility, and not having children (P < .05). Multivariate analysis showed prolonged medically necessary LOS and surgery on a Monday/Friday (P < .05) were associated with DC delay. Top reasons for DC delay included case management shortages, rejection by facility, and awaiting supplies. Eleven percent experienced complications during the DC delay. Discussion DC delay can add days and complications to the LOS. Prevention begins preoperatively with DC planning involving the patient’s closest family. Understanding limitations of the patient’s insurance may help plan DC destination. Optimizing hospital resources when available should be a focus. Implications for Practice Head and neck free flap patients require a team of teams unified in optimizing quality of care. DC delay is a novel quality metric reflecting the team’s overall performance. Through strategic DC planning and capitalizing on available resources, DC delay can be minimized.

Association Between Insurance Type and Outcomes of Reconstructive Head and Neck Cancer Surgery

“…In their study, Medicaid/self-pay patients had a 4.4-fold higher risk for discharge delay, experiencing a mean 2.8 days of delay. 11 Similarly, our study found that insurance type was significantly associated with increased odds of extended LOS, even after controlling for illness severity, suggesting that attention should be focused on hospital practice differences. Quality improvement projects have demonstrated that these disparities can be improved.…”

“…[27][28][29] Additional unnecessary days spent in the hospital are associated with higher rates of hospital-acquired infections, morbidity, and mortality. 11,30 Extended LOS has also been suggested as a contributor to delays in the interval from surgery to initiation of postoperative radiation therapy (S-PORT). 31 Timeliness of care impacts survival outcomes in head and neck cancer, but a majority (55.7%) of patients failed to achieve the recommended S-PORT interval of 6 weeks, and patients with Medicaid were disproportionately affected by these delays.…”

“…Head and neck cancers are also among the most expensive cancers to treat, and inpatient costs are a major contributor to those costs 27–29 . Additional unnecessary days spent in the hospital are associated with higher rates of hospital‐acquired infections, morbidity, and mortality 11,30 . Extended LOS has also been suggested as a contributor to delays in the interval from surgery to initiation of postoperative radiation therapy (S‐PORT) 31 .…”

“…9 Previous studies have shown that head and neck free-flap patients are prone to discharge delays and prolonged hospitalizations, which not only increase the patient's risk of complications but also increase costs of care. [10][11][12][13] Not all of these single-institution studies identified insurance as a significant risk factor, but larger studies of trauma patients have emphasized insurance type as a significant driver of unnecessarily prolonged hospitalizations. [14][15][16][17] Given the complexity of head and neck cancer reconstructive surgeries, we hypothesize that this relationship also exists at the national level.…”

“…Postoperative length of stay (LOS) is an important quality metric applicable to the immediate postoperative period 9 . Previous studies have shown that head and neck free‐flap patients are prone to discharge delays and prolonged hospitalizations, which not only increase the patient's risk of complications but also increase costs of care 10–13 . Not all of these single‐institution studies identified insurance as a significant risk factor, but larger studies of trauma patients have emphasized insurance type as a significant driver of unnecessarily prolonged hospitalizations 14–17 .…”