Abstract
BackgroundHospital length of stay (HLOS) is a commonly used measure of hospital quality and is influenced by clinical and non-clinical factors. To reduce HLOS, it is key to identify factors placing patients at increased risk of lengthy HLOS and discharge delays.MethodsThis was a retrospective cohort study of patients age ≥ 18 admitted to four level 1 trauma centers between 1/1/2015 and 3/31/2018 with traumatic brain injury (TBI). The primary outcome was discharge delay, defined as discharge ≥24 h after case management notes indicated the patient was ready for discharge. The independent variables of interest were primary insurance provider and discharge destination. Chi-square, Fisher exact, and unadjusted and adjusted logistic regression analyses were used to assess associations between discharge delay and the two primary independent variables, as well as other patient demographic and clinical characteristics. Complications developing during the delay period were also examined.ResultsA total of 1543 patients with TBI were included. The median age was 61 years, and the median HLOS was 5 days. Approximately half of patients were discharged home (54%). The most common insurance providers were Medicare (35%) and commercial/private (35%). Two-hundred ten (14%) patients experienced a discharge delay. The median delay period was 3 days, and the most common reasons for delay were insurance authorization (52%) and lack of accepting bed (41%). Compared to being discharged home, patients discharged to a skilled nursing facility (adjusted odds ratio (AOR) = 10.35) or intermediate care facility (AOR = 10.64) had the highest odds of discharge delay. Compared to Medicare patients, uninsured/self-pay patients (AOR = 2.98) and those with Medicaid (AOR = 2.83) or commercial/private insurance (AOR = 2.22) had higher odds of delay. Thirty-two patients (15% of those delayed) experienced at least one complication during the delay, some of which were clinically severe.ConclusionsA substantial portion of TBI patients in this study experienced discharge delays, and discharge destination and primary insurance provider were significant drivers of these delays. Evaluation of a facility’s quality of care should consider the specific causes of these delays.
Highlights
Hospital length of stay (HLOS) is a commonly used measure of hospital quality and is influenced by clinical and non-clinical factors
The aim of this study was to focus on a specific group of trauma patients, those with traumatic brain injury (TBI), and examine what clinical and non-clinical factors are associated with increased HLOS attributable to discharge delays
Hospital length of stay is often used to assess the quality of care provided at a facility, as lengthy HLOS and discharge delays have been associated with in-hospital complications, patient mortality, and increased cost to the Odds ratio (OR)
Summary
Hospital length of stay (HLOS) is a commonly used measure of hospital quality and is influenced by clinical and non-clinical factors. A key first step in intervening on this issue is identifying factors that place patients at increased risk for lengthy HLOS and delays in hospital discharge. Multiple factors, both clinical and non-clinical, influence HLOS and discharge delays. Other studies using data from level 1 trauma centers and the National Trauma Data Bank found that the strongest predictor of lengthy HLOS was discharge destination [7, 12] These previous findings point to HLOS being determined by factors that are both under a facility’s control to intervene upon (e.g., hospital operational delays) and those that are not (e.g., patient clinical characteristics, discharge destination availability)
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