Unexpectedly long hospital stays as an indicator of risk of unsafe care: an exploratory study

Abstract

ObjectivesWe developed an outcome indicator based on the finding that complications often prolong the patient's hospital stay. A higher percentage of patients with an unexpectedly long length of stay (UL-LOS) compared to the national average may indicate shortcomings in patient safety. We explored the utility of the UL-LOS indicator.SettingWe used data of 61 Dutch hospitals. In total these hospitals had 1 400 000 clinical discharges in 2011.ParticipantsThe indicator is based on the percentage of patients with a prolonged length of stay of more than 50% of the expected length of stay and calculated among survivors.InterventionsNo interventions were made.Outcome measuresThe outcome measures were the variability of the indicator across hospitals, the stability over time, the correlation between the UL-LOS and standardised mortality and the influence on the indicator of hospitals that did have problems discharging their patients to other health services such as nursing homes.ResultsIn order to compare hospitals properly the expected length of stay was computed based on comparison with benchmark populations. The standardisation was based on patients’ age, primary diagnosis and main procedure. The UL-LOS indicator showed considerable variability between the Dutch hospitals: from 8.6% to 20.1% in 2011. The outcomes had relatively small CIs since they were based on large numbers of patients. The stability of the indicator over time was quite high. The indicator had a significant positive correlation with the standardised mortality (r=0.44 (p<0.001)), and no significant correlation with the percentage of patients that was discharged to other facilities than other hospitals and home (r=−0.15 (p>0.05)).ConclusionsThe UL-LOS indicator is a useful addition to other patient safety indicators by revealing variation between hospitals and areas of possible patient safety improvement.

Can differences in length of stay between Dutch university hospitals and other hospitals be explained by patient characteristics? A cross-sectional study

“…Previous research defined UL-LOS as the percentage of clinically admitted patients with an actual hospital stay that was more than 50% longer than expected 2. The expected LOS was estimated by indirect standardisation based on age, main diagnosis and main procedure 2…”

“…Length of stay (LOS) is such a screening tool, as research has shown that hospital adverse events often result in a longer LOS 2 8–14. In the Netherlands, an unexpectedly long LOS (UL-LOS) indicator has been introduced to identify potential shortcomings in the quality and safety of care 2 15. All hospitals receive their outcomes in detail and the Dutch Health and Youth Care Inspectorate uses this indicator in their indicator framework.…”

Investigating Adverse Event Free Admissions in Medicare Inpatients as a Patient Safety Indicator

“…22 This has improved with time. 23 However, administrative data in the United States are widely used and the individual outcomes here have been reported previously using administrative data [9][10][11]24,25 and for colorectal surgery. [26][27][28][29][30][31] We have also chosen outcomes which have been researched and approved by the CMS 10,11 and AHRQ, 15 who have published experience with these data.…”

“…Other ways to define long LOS have been proposed, such as 50% above the median. 32 Finally, the numbers have been grouped by CCS multilevel diagnosis groups to summarize these large and complex datasets for illustration purposes. For any inference to be drawn for differences between specialties, further work should concentrate on procedure and diagnosis specific complications to be added to the definition of adverse events.…”

Quantifying the effect of complications on patient flow, costs and surgical throughputs

“…The move toward “same-day surgery” programs was a response to avoid unnecessary LOS that adds cost and might not add value to the patient’s care [ 53 ]. In general, prolonged hospitalisation is associated with an increased risk of complications [ 54 ] and may indicate shortcomings in patient safety [ 55 ].…”