Reducing unnecessary hospital days to improve quality of care through physician accountability: a cluster randomised trial

Abstract

BackgroundOver 20% of hospital bed use is inappropriate, implying a waste of resources and the increase of patient iatrogenic risk.MethodsThis is a cluster, pragmatic, randomised controlled trial, carried out in a large University Hospital of Northern Italy, aiming to evaluate the effect of a strategy to reduce unnecessary hospital days. The primary outcome was the percentage of patient-days compatible with discharge. Among secondary objectives, to describe the strategy’s effect in the long-term, as well as on hospital readmissions, considered to be a marker of the quality of hospital care. The 12 medical wards with the longest length of stay participated. Effectiveness was measured at the individual level on 3498 eligible patients during monthly index days. Patients admitted or discharged on index days, or with stay >90 days, were excluded. All ward staff was blinded to the index days, while staff in the control arm and data analysts were blinded to the trial’s objectives and interventions. The strategy comprised the distribution to physicians of the list of their patients whose hospital stay was compatible with discharge according to a validated Delay Tool, and of physician length of stay profiles, followed by audits managed autonomously by the physicians of the ward.ResultsDuring the 12 months of data collection, over 50% of patient-days were judged to be compatible with discharge. Delays were mainly due to problems with activities under medical staff control. Multivariate analysis considering clustering showed that the strategy reduced patient-days compatible with discharge by 16% in the intervention vs control group, (OR=0.841; 95% CI, 0.735 to 0.963; P=0.012). Follow-up at 1 year did not yield a statistically significant difference between the percentages of patient-days judged to be compatible with discharge between the two arms (OR=0.818; 95% CI, 0.476 to 1.405; P=0.47). There was no significant difference in 30-day readmission and mortality rates for all eligible patients (N=3498) between the two arms.ConclusionsResults indicate that a strategy, involving physician direct accountability, can reduce unnecessary hospital days. Relatively simple interventions, like the one assessed in this study, should be implemented in all hospitals with excessive lengths of stay, since unnecessary prolongation may be harmful to patients.Trial registrationClinicalTrials.gov, identifier NCT01422811.

Duración de la estancia hospitalaria. Metodologías para su intervención

“…En los factores asociados al personal de salud, se destacan factores propios relacionados con el criterio y competencia médica y la conciencia con respecto a la estancia del paciente en el hospital (18). Esto se traduce en no prestar atención a la necesidad de generar el alta una vez conseguido el propósito de la hospitalización (15)(16)(17)(18)(19)(20)(21)(22)(23). Además, fallas al ingreso del paciente por falta de un diagnóstico claro al ingreso (18,19,(24)(25)(26)(27) y una admisión prematura (16,18,19,(28)(29)(30).…”

Implementation of a strategy involving a multidisciplinary mobile unit team to prevent hospital admission in nursing home residents: protocol of a quasi-experimental study (MMU-1 study)

“…In the last two decades, the University Hospital of Parma has implemented several innovative initiatives to manage the hospital flow of frail multimorbid patients and their complex needs. These initiatives included bed management to avoid ‘bed-blockers’,21 physician accountability for the discharge process22 and creation of a dedicated hospital unit, organised by intensity of care to anticipate the needs of these patients preserving high-performance indices 23. The multidisciplinary mobile unit (MMU) team will be based in this unit, called Internal Medicine and Critical Subacute Care.…”

“…At our institution, different projects have been carried out for many years to improve care of the elderly, primarily targeting hospital organisation, with the main objective to reduce unnecessary, avoidable length of stay (LOS) 21–23. These efforts benefit inhospital patients but are not designed to prevent hospitalisations.…”

Utilisation of beds on the general medical unit by ‘non‐acute medical’ patients: a retrospective study of incidence and cost in two Tasmanian regional medical hospital units

“…Notwithstanding, relatively simple measures, such as physician direct accountability tools supporting physician audits of patient hospital stays, have been shown to be effective in reducing excessive hospital bed use 33 and have fairly direct applicability to rural and regional settings. While the literature suggests that there are savings to be made by developing different models of care delivery, 33,34 more work needs to be done to explore whether and how specific service strategies would work in the distinctive settings of rural and regional hospitals.…”