(Stroke. 1997;28:137-140.)
© 1997 American Heart Association, Inc.
Articles |
Length of Hospital Stay and Discharge Delays in Stroke Patients
the Institute of Social Medicine (A. van S., G.A.M. van den B.), the Department of Neurology (A. van S., M.L.), and the Department of Clinical Epidemiology and Biostatistics (J. van der M.), Academic Medical Center, University of Amsterdam (Netherlands).
Correspondence to A. van Straten, Institute of Social Medicine, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, Netherlands. E-mail a.vanstraten@amc.uva.nl.
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Abstract |
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Background and Purpose In The Netherlands, many stroke patients stay in the hospital for some time merely waiting for discharge placement. This indicates an inefficient use of hospital resources, as well as a possible deficiency in the quality of care, because hospitals are not adequately equipped to care for these patients. In this study, we tried to quantify this "waiting problem."
Methods Six hospitals and 29 neurologists participated in this prospective study. The neurologists were asked during weekly interviews to specify for 154 patients the rea son for retention in the hospital on a day-to-day basis. The reasons were noted on a list specified by the authors in advance.
Results The mean length of hospital stay was 28 days. On average, there were "hard" medical reasons for 15 days (54%) and "soft" medical reasons for 3 days (10%), whereas the remaining 10 days (36%) were explained by nonmedical reasons (most frequently, waiting for placement in a nursing home).
Conclusions The length of hospital stay for stroke patients in The Netherlands can be reduced considerably without compromising the quality of care. This might be realized by increasing the capacity of long-term care facilities, improving the efficiency of the discharge procedures, or creating "stroke services."
Key Words: hospitalization • Netherlands • quality of health care • stroke management
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Most stroke patients in The Netherlands are admitted to the hospital during the acute phase of their illness.1 2 Almost all Dutch stroke patients are admitted to neurological wards, and only very few are referred to internal medicine or geriatric wards.3 The main reason for hospitalization is to perform diagnostic procedures, followed by therapeutic interventions to prevent the occurrence of new strokes or other vascular problems, and to provide necessary nursing care during the acute phase. A further important aspect in the treatment of stroke patients is mobilization and rehabilitation to optimize functional recovery.
The mean length of hospital stay for stroke patients in The Netherlands is high (25 days) compared with that of all patients (10 days).4 Because of the disabling character of the disease, a substantial number of patients (approximately 20%)1 are in need of long-term care after hospital discharge. Patients are discharged to a rehabilitation center if the potential for recovery is such that the patient will be able to live independently again, with or without disabilities, after a limited period of extensive rehabilitation. Patients are discharged to a nursing home if functional independence is not expected at all or within a considerable period. The transition from hospital to long-term care facilities is problematic because of the long waiting lists for both "extramural" facilities (home help, aids, home adaptations) and "intramural" facilities (home for the elderly, nursing home, rehabilitation center). Therefore, many stroke patients stay in the hospital for some time merely waiting for discharge placement. This indicates an inefficient use of hospital resources, as well as a deficiency in the quality of care, because hospitals are not adequately equipped to care for these patients. A recent meta-analysis concerning so-called "stroke units"—units that aim to enhance the quality of care—showed that the outcomes of care were improved, while at the same time the length of stay was reduced.5
Therefore, in this study we focused on the hospital course of stroke patients in an attempt to examine how long patients stay in the hospital waiting for discharge placement.
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Subjects and Methods |
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Six hospitals and 29 neurologists participated in this prospective study. Hospitals of different types (one university, one university-affiliated, and four community hospitals) and of three different sizes (two hospitals with >400 beds, three with 200 to 400 beds, and one with <200 beds) were included. Each participating neurologist was interviewed weekly. In this way, 154 stroke patients consecutively admitted within 1 week after stroke onset were traced. All patients were followed up from hospital admission until discharge or death. Stroke was defined as the sudden onset of a focal neurological dysfunction or loss of consciousness lasting more than 24 hours or leading to death.6 The study was approved by the medical ethical committees of the participating hospitals and carried out between November 1992 and January 1994. All patients gave their informed consent.
Before the start of the interviews, a list of possible reasons for hospital stay was prepared by the authors (see Table 1
). The reasons for hospital stay were arranged into three categories: (1) "hard" medical reasons, (2) "soft" medical reasons, and (3) nonmedical reasons. There is a hard medical reason for hospitalization if a diagnostic or therapeutic procedure is performed that can only be done in a hospital. There is a soft medical reason if a procedure is performed that could be done outside the hospital provided that care for stroke patients were organized differently. There is a nonmedical reason if the patient is merely waiting for discharge placement ("waiting days").
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During the weekly interviews, the neurologists were asked to specify the reason(s) for continued hospitalization for each patient during the last week on a day-to-day basis. We classified the reasons into one of the three categories. If more than one reason was applicable, we scored the most important one, using the hierarchy from "hard" medical to nonmedical reasons. After recording the reason for hospital stay, we asked the neurologist whether other disciplines were involved in preparing the discharge procedures (eg, input from social worker, occupational therapist, or rehabilitation physician) and the date that these services were ordered. Finally, we recorded the date of the actual application for long-term care facilities.
ANOVA or simple t tests were performed to analyze differences in the mean number of waiting days in different subgroups of patients.
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Results |
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The mean±SD age of our study group was 71±13 years (range, 27 to 95 years), and men constituted 49% of the population (Table 2
). Of all 154 patients, 13% died during hospitalization, 43% returned home at discharge, and 27% were discharged to a nursing home and 7% to a rehabilitation center, and 10% went to a home for the elderly.
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The mean±SD length of stay for all 154 patients was 28±23 days (range, 1 to 138 days) (Table 3). On average, there were hard medical reasons for 15 days (54%), soft medical reason for 3 days (10%), and nonmedical reasons for 10 days (36%) (Table 1
). There were no differences in length of hospital stay among hospitals of different types (P=.60) or sizes (P=.87). The most frequent hard medical reason was the performance of diagnostic procedures concerning stroke. This reason explained 31% of the total length of hospital stay. The most frequent soft medical reasons were improving mobility and functional health, observing recovery, and discussing the discharge destination. These reasons explained 5% and 4%, respectively, of the total length of hospital stay. The most frequent nonmedical reason was waiting for nursing home placement, which explained 28% of the total length of hospital stay.
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About half of all patients (47%) stayed in the hospital at least 1 day waiting for discharge placement (Table 3). The total length of hospital stay of these patients was longer not only because of these waiting days but also because of a longer length of stay for medical reasons (21 versus 15 days for patients with and without waiting days, respectively; P=.002).
At the beginning of the first week, all patients were hospitalized for medical reasons. At the beginning of the second week, 4% of the original cohort of 154 patients were staying in the hospital for nonmedical reasons, waiting for discharge placement (Fig 1). Starting at the beginning of the fifth week after admission, more patients had a nonmedical reason for hospital stay then a medical one. After 10 weeks, all patients had nonmedical reasons for hospital stay.
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The mean length of hospital stay for nonmedical reasons was strongly related to the discharge destination (P<.001; Fig 2). On average, a patient discharged home waited 3 days (range, 0 to 40 days), a patient discharged to a rehabilitation center 20 days (range, 7 to 40 days), and a patient discharged to a nursing home 24 days (range, 0 to 103 days). However, not every patient had to wait in the hospital. Waiting days occurred in 14 of 67 patients (21%) discharged home, in all 10 patients (100%) discharged to a rehabilitation center, and in 39 of 41 patients (95%) discharged to a nursing home. Of the 20 patients who died in the hospital, 4 died while awaiting discharge to a nursing home.
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For 38 of the 41 patients (93%) discharged to a nursing home, the applications for admission were prepared by a social worker. For 16 of these 38 patients (42%), the neurologist asked for the social worker's assistance only when the medical reasons for hospital stay had expired (for 4 patients this date was missing). For 30 of the 38 patients (79%), the actual application took place after the medical reasons for hospital stay had expired. These delayed applications alone explained 5% of all hospital days, 14% of all waiting days, and 18% of all the waiting days for patients discharged to a nursing home.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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This study of discharge delays of stroke patients showed that on average stroke patients spent 36% of their days in the hospital for nonmedical reasons while waiting for discharge placement. Most of these waiting days were related to patients finally discharged to a nursing home. For at least 42% of all nursing home patients, the discharge procedures were started only after the medical reasons for hospital stay had expired, which suggests inefficient discharge procedures.
The instrument most often used to measure inappropriate hospital use (both admissions and days) is the Appropriateness Evaluation Protocol (AEP).7 The AEP is based on explicit criteria and is considered to be independent of diagnosis. Although the approach of the AEP is rather similar to ours, we did not use this instrument for two reasons. First, we did not think it was specific enough for stroke patients; for example, one of the AEP criteria indicates simply that a hospital day is appropriate if a stroke (or myocardial infarction) has occurred within 14 days of review. Second, there was poor agreement between the medical reasons for hospital stay included in the AEP and those considered to be important by the expert neurologists consulted during the preparation phase of our study. Furthermore, because of the lack of evidence-based criteria for continued hospitalization, we preferred to ask the neurologists whether the hospital stay was medically indicated. Since it is the neurologist who decides if a patient is ready for discharge, we believe that the results obtained in this manner reflect which reductions in the length of stay are feasible in daily practice. Moreover, a recent study showed that clinicians were as capable of judging unjustified hospital stays as was a specific algorithm that was designed by several clinicians and included a number of patient and treatment variables.8
The mean length of hospital stay in this study (28 days) was 3 days longer than the mean length of stay for stroke patients in The Netherlands.4 This difference might be caused by a slight overrepresentation of patients discharged to nursing homes (27% versus 20%).9 If we assume that all the extra days in our sample were waiting days and subtract these from the total number of observed hospital days, the percentage of waiting days decreases from 36% to 28%. These figures are comparable with findings from previous Dutch studies of unjustified hospital stay for neurological patients in general (20%)10 and for stroke patients (33%).11 They are also within the range of results presented in other studies that were performed in different countries with various organizations of care and different patient populations (range, 8% to 46%).8 12 13 14 15 16 17 18 This indicates that discharge placement after hospital admission is an important problem in The Netherlands, as well as in other western countries.
These studies on inappropriate hospital use suggest that there are four mechanisms underlying prolonged hospital stay for nonsurgical patients. The first mechanism relates to waiting for the performance of diagnostic tests, as well as their results. In our study, this was not mentioned as a reason for hospital stay by the neurologists.
The second mechanism relates to "conservative management"14 (the tendency of physicians to observe the patient's recovery for a period of time), which is considered in our study as a "soft" medical reason for hospital stay. During this period of stay, the physician also tries to improve the mobility and functional health of the patient while preparing the patient for discharge. In our view, this care could be provided in stroke units that need not be situated in hospitals but might be located in nursing homes or separate specialized units. These units could be incorporated in a "stroke service." A stroke service can be defined as a set of facilities aimed at delivering effective interventions to stroke patients and their caregivers.19 20 Such a service can reduce the length of hospital stay for both "soft" medical and nonmedical reasons.
The third and most important cause for prolonged hospital stay is the limited capacity of long-term care facilities. Hospital stays for nonmedical reasons might be reduced by increasing this capacity. However, increasing the long-term care capacity might also increase the demand by changing the indication for these facilities. Therefore, increasing the capacity of nursing homes will probably solve the problem of discharge delays only partially and temporarily.21
The last mechanism underlying prolonged hospital stays relates to the inefficiency of discharge procedures. Nowadays, various approaches have been reported to improve the efficiency of hospital care and to decrease costs: (1) creating structural arrangements between the various disciplines and institutions involved in the care for stroke patients, (2) putting a "key worker" (or case manager) in charge of the hospital course of individual patients, and (3) developing "care pathways" (or critical care pathways) in which clear clinical goals are specified, as well as the sequencing and timing of interventions needed to reach those goals. Implementation of any one of the above methods has been shown to be effective in reducing the length of hospital stay while preserving or even improving quality of care (expressed as either mortality, number of hospital readmissions, number of complications, discharge disposition, or patient satisfaction).5 22 23 24 25 26 27 28 29 30 Implementation of these measures could raise hospital efficiency for stroke patients in The Netherlands. However, further research is needed to determine the benefits in terms of length of stay, costs, and quality of care in our country.
We conclude from this study that in The Netherlands a considerable proportion of the hospital stay of stroke patients is unnecessary from a medical point of view. Therefore, the length of hospital stay may be reduced while maintaining or even improving the quality of care. This might be realized by increasing the capacity of long-term care facilities, creating "stroke services," and by improving the efficiency of discharge procedures.
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Acknowledgments |
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This study was funded by The Netherlands Heart Foundation (NHS 42.018). The authors would like to thank the participating hospitals and the neurologists for their cooperation. They thank professor R.A. Spasoff, University of Ottawa, Canada, for his helpful advice during the preparation of this manuscript. Dr Limburg is a clinical investigator of The Netherlands Heart Foundation.
Received April 16, 1996; revision received September 12, 1996; accepted September 16, 1996.
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