Older patients and delayed discharge from hospital

Abstract

Older people (those aged 65 years and over) are the major users of health care services, especially acute hospital beds. Since the creation of the NHS there has been concern that older people inappropriately occupy acute hospital beds when their needs would be best served by other forms of care. Many factors have been associated with delayed discharge (age, sex, multiple pathology, dependency and administrative inefficiencies). However, many of these factors are interrelated (or confounded) and few studies have taken this into account. Using data from a large study of assessment of older patients upon discharge from hospital in England, this paper examines the extent of delayed discharge, and analyses the factors associated with such delays using a conceptual model of individual and organisational factors. Specifically, this paper evaluates the relative contribution of the following factors to the delayed discharge of older people from hospital: predisposing factors (such as age), enabling factors (availability of a family carer), vulnerability factors (dependency and multiple pathology), and organisational/administrative factors (referral for services, type of team undertaking assessments). The study was a retrospective patient case note review in three hospitals in England and included four hundred and fifty-six patients aged 75 years and over admitted from their own homes, and discharged from specialist elderly care wards. Of the 456 patients in the sample, 27% had a recorded delay in their discharge from hospital of three plus days. Multivariate statistical analysis revealed that three factors independently predicted delay in discharge: absence of a family carer, entry to a nursing/residential home, and discharge assessment team staffing. Delayed discharge was not related to the hypothesised vulnerability factors (multiple dependency and multiple pathology) nor to predisposing factors (such as age or whether the older person lived alone). The delayed discharge of older people from hospital is a topic of considerable policy relevance. Our study indicated that delay was independently related to two organisational issues. First, entry into long-term care entailed lengthy assessment procedures, uncertainty over who pays for this care, and waiting lists. Second, the nature of the team assessing people for discharge was associated with delay (the nurse-coordinated team made the fewest referrals for multidisciplinary assessments and had the longest delays). Additionally, the absence of a family carer was implicated in delay, which underlines the importance of family and friends in providing posthospital care and in maintaining older people in the community. Our study suggests that considerable delay in discharging older people from hospital originates from administrative/organisational issues; these were compounded by social services resource constraints. There is still much to be done therefore to improve coordination of care in order to provide a truly 'seamless service'.

An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge

“…27,48 According to Victor et al, 49 nearly 30% of older people experience some delay in their hospital discharge, which is known to expose patients to additional hospital-related risks, create emotional and physical dependency, incur additional hospital costs and restrict the availability of inpatient beds. In parallel, premature discharge or discharge without appropriate arrangements for onward care can also lead to complications for patient recovery.…”

Factors associated with prolonged length of stay in older patients

“…(7) Demographic factors such as age, ethnicity, gender and income have been explored. According to Falcone et al, older age was associated with prolonged hospitalisation.…”

Discharge delay in acute care: reasons and determinants of delay in general ward patients

“…[1][2][3][4] Delayed discharge has become a major issue because it leads to unanticipated length of stay and bed block. 2,[5][6][7] Both the quality and cost-effectiveness of care may be compromised as a result. 3,8 In the Australian context, delayed discharge is a major reason for the unavailability of beds in major acute care hospitals.…”