A mixed methods study exploring delays amongst patients ready to be discharged home in an acute surgical unit in New Zealand

Abstract

Objective: This study aims to explore the reasons for hospital discharge-delay in an acute surgical unit (ASU) and the ways in which discharge-delays can be minimised.

Background: Discharge-delay, the period of continued hospital stay after a patient is deemed medically fit to leave hospital, is one of the most significant barriers to optimal patient flow within the hospital system. Discharge-delay retains non-acute patients in the acute environment unnecessarily, while preventing acutely presenting patients from accessing services in a timely manner. It results in overcrowded emergency departments (ED) with delayed admissions, slowed theatre schedules, and bed blocking in critical care, as well as negatively impacting patient experience.

Methods: A two phased, mixed methods design was employed in this research. Phase one obtained qualitative data through semi-structured interviews with nine staff members occupying different roles within the health care team. Themes derived from phase one informed the development of an audit and survey form utilised in phase two, which involved collecting quantitative data through its completion by registered nurses working in the ASU during the study period. This audit recorded the time a patient was cleared for discharge, and the time they left the ward, from which the amount of discharge-delay could be calculated. The survey recorded delaying factors that occurred for each patient discharged from the ward during the audit period.

Results: Thematic analysis of the interview transcriptions revealed three core themes: (i) It takes a village to discharge a patient; (ii) Preparation, clearance, home; and (iii) Challenges and solutions to discharge-delay. The survey was completed by Registered Nurses regarding 40 discharging patients who they provided care for. Analysis revealed a mean patient discharge-delay of 225 minutes across the 40 patients. The most frequently recorded delay factors were ‘waiting for paperwork’ (55%) and ‘waiting for transport’ (40%).

Conclusions: This study found that to reduce discharge-delay system-wide optimisation across the entire patient journey, with particular focus on reducing paperwork related delay, is required. Introducing a ‘discharge-focused clinician’ and improving the utilisation of transit lounge will especially help to reduce discharge-delay.

What is already known about the topic?

• Unnecessarily long hospital admissions negatively impact patient experience and outcomes.


• Slow acute discharges effects patient flow organisation wide, including EDs, critical care, and theatre.

What this paper adds?

• This paper focuses on the time between a patient being medically cleared and physically leaving the acute ward environment, allowing the specific period of discharge-delay to be quantified, understood and addressed.


• It clearly identifies specific discharge-delay causing factors in the context of an ASU and proposes solutions to optimise the discharge process.