BACKGROUND: The impact of delayed discharge on patients, health-care staff and hospital costs has been incompletely characterized. AIM: To systematically review experiences of delay from the perspectives of patients, health professionals and hospitals, and its impact on patients' outcomes and costs. METHODS: Four of the main biomedical databases were searched for the period 2000-2016 (February). Quantitative, qualitative and health economic studies conducted in OECD countries were included. RESULTS: Thirty-seven papers reporting data on 35 studies were identified: 10 quantitative, 8 qualitative and 19 exploring costs. Seven of ten quantitative studies were at moderate/low methodological quality; 6 qualitative studies were deemed reliable; and the 19 studies on costs were of moderate quality. Delayed discharge was associated with mortality, infections, depression, reductions in patients' mobility and their daily activities. The qualitative studies highlighted the pressure to reduce discharge delays on staff stress and interprofessional relationships, with implications for patient care and well-being. Extra bed-days could account for up to 30.7% of total costs and cause cancellations of elective operations, treatment delay and repercussions for subsequent services, especially for elderly patients. CONCLUSIONS: The poor quality of the majority of the research means that implications for practice should be cautiously made. However, the results suggest that the adverse effects of delayed discharge are both direct (through increased opportunities for patients to acquire avoidable ill health) and indirect, secondary to the pressures placed on staff. These findings provide impetus to take a more holistic perspective to addressing delayed discharge.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/hex.12619

Impact and experiences of delayed discharge: A mixed-studies systematic review

Hospital bed-blocking occurs when hospital patients are ready to be discharged to a nursing home, but no place is available, so that hospital care acts as a more costly substitute for long-term care. We investigate the extent to which greater supply of nursing home beds or lower prices can reduce hospital bed-blocking using a new Local Authority (LA) level administrative data from England on hospital delayed discharges in 2009–2013. The results suggest that delayed discharges respond to the availability of care home beds, but the effect is modest: an increase in care home beds by 10% (250 additional beds per LA) would reduce social care delayed discharges by about 6–9%. We also find strong evidence of spillover effects across LAs: more care home beds or fewer patients aged over 65 years in nearby LAs are associated with fewer delayed discharges. © 2015 The Authors. Health Economics Published by John Wiley & Sons Ltd.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1002/hec.3150

Testing the bed-blocking hypothesis: does nursing and care home supply reduce delayed hospital discharges?

Objective: This study aimed to investigate the factors associated with the delayed discharge of older people from hospital and their length of stay (LOS).
Methods: Data were collected retrospectively from inpatient records and adult social care services on older patients referred to the latter prior to hospital discharge.
Results: Data on two related measures?delayed discharge and LOS?were analysed separately within a four-stage sequential framework. Using bivariate analysis, we found that cognitive impairment and dependency were significantly associated with delay. Patients admitted to trauma and orthopaedics specialties were significantly more likely to be delayed on discharge. Respiratory illness was negatively associated with delay. Factors related to care received as an inpatient associated with delayed discharge from hospital were not being in the responsible consultant?s bed for part of their stay, two or more moves between specialties and receipt of rehabilitation services. Admission to a care home and receipt of domiciliary care if returning to a private dwelling on discharge were associated with delay. In the multivariate analysis, dependence and cognitive impairment impacted differently on delay and LOS. Hospital variables were the most important predictors of LOS and social care variables in respect of delayed discharge.
Conclusion: Patient characteristics and especially the organisation of care in hospital and the provision of services on discharge are related to the likelihood of delayed discharge and LOS. Improved services and structures to systematically assess and treat patient needs in hospital, together with the timely provision of services providing post-discharge services tailored to individual circumstances, are required.

An examination of factors influencing delayed discharge of older people from hospital.

The delay in discharge or transfer of care back to the community following an acute admission to the hospital in older adults has long been a recognized challenge in the UK. We examined the determinants and outcomes of delayed transfer of care in older adults. A prospective observational study was conducted in a district general hospital with a catchment population of 250,000 in England, UK. Those >= 65 years admitted to two care of the elderly wards during February 2007 were identified and prospectively followed-up till their discharge. Data was presented descriptively. 36.7% (58/158) of patients had a delay in transfer of care. They tended to be older, had poorer pre-morbid mobility, and were more likely to be confused at the time of admission. Compared to the 2003 National Audit Report, a significantly higher percentage (29.3%vs.17%) awaited therapist assessments or (27.6%vs.9%) domiciliary care, with a lower percentage (< 1%vs.14%) awaiting further NHS care. Of 18 in-patient deaths, five occurred during the delay. Seven patients developed medical conditions during the delay making them unfit for discharge. The number of extra bed days attributable to delayed discharges in this study was 682 (mean = 4.8) days. Awaiting therapy and domiciliary care input were significant contributing factors in delayed transfer of care. Similar local assessments could provide valuable information in identifying areas for improvement. Based on available current evidence, efficacy driven changes to the organisation and provision of support, for example rapid response delayed discharge services at the time of "fit to discharge" may help to improve the situation.

/pdf/delayed-transfer-of-care-from-nhs-secondary-care-to-primary-2naehmot32.pdf

Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over.

Prevention and management of delayed transfer of older people from hospital to community settings is an enduring issue in industrialised societies and is the subject of many recent policies in the United Kingdom. A deeper, evidence-based understanding of the complex organizational and interprofessional issues which contribute to delays in transfer has emerged in recent years. Despite this, and the relative success of recent policies, two recent reviews of the area highlight the lack of studies on patients' perspectives. We sought to address this deficit by using conversational interviews and a phenomenological approach to explore and interpret participants' perceptions of delayed transfer from hospital into the community. A purposive sampling strategy was employed to incorporate participants from different categories of delay identified on weekly Situation Reports. Participants aged 65 years and over (mean age 82 +/- 5.4 years) and with a mean delay of 32 days (+/- 26) were recruited from three hospitals based in two NHS Trusts in the South of England. This paper focuses on their perceptions of the effects of delayed transfer into the community, their involvement in discharge planning and future community care needs. Our findings show that participants actively or passively relinquished their involvement in the processes of discharge planning because of the perceived expertise of others and also feelings of disempowerment secondary to poor health, low mood, dependency, lack of information and the intricacies of discharge planning processes for complex community care needs. Participants expressed a longing for continuity, emphasised the importance of social contact and sometimes appeared unrealistic about their future care needs. While current policies may have helped reduce overall numbers of delayed patients in the UK, our study suggests that there is scope for improvement in the involvement of delayed patients in planning their discharge into the community.

Delayed transfer from hospital to community settings: the older person's perspective

In recent years, there has been significant concern, and policy activity, in relation to the problem of delayed discharges from hospital. Key elements of policy to tackle delays include new investment, the establishment of the Health and Social Care Change Agent Team, and the implementation of the Community Care (Delayed Discharge) Act 2003. Whilst the problem of delays has been widespread, some authorities have managed to tackle delays successfully. The aim of the qualitative study reported here was to investigate discharge practice and the organisation of services at sites with consistently low rates of delay, in order to identify factors supporting such good performance. Six 'high performing' English sites (each including a hospital trust, a local authority, and a primary care trust) were identified using a statistical model, and 42 interviews were undertaken with health and social services staff involved in discharge arrangements. Additionally, the authors set out to investigate the experiences of patients in the sites to examine whether there was a cost to patient care and outcomes of discharge arrangements in these sites, but unfortunately, it was not possible to secure sufficient patient participation. Whilst acknowledging the lack of patient experience and outcome data, a range of service elements was identified at the sites that contribute to the avoidance of delays, either through supporting efficiency within individual agencies or enabling more efficient joint working. Sites still struggling with delays should benefit from knowledge of this range. The government's reimbursement scheme appears to have been largely helpful in the study sites, prompting efficiency-driven changes to the organisation of services and discharge systems, but further focused research is required to provide clear evidence of its impact nationally, and in particular, how it impacts on staff, and patients and their families.

Organisation and features of hospital, intermediate care and social services in English sites with low rates of delayed discharge.

The Community Care (Delayed Discharges) Act 2003 announced a new reimbursement scheme which was intended to accelerate the downward trend in rates of delayed discharges and strengthen joint working between acute health trusts and social services. Under the new scheme hospitals and social services were to agree new inter-agency discharge planning protocols and communication systems, and to operate new legal notification systems that required hospitals to give social services formal notification at least 3 days in advance of a patient’s planned discharge. Agencies were required to agree the numbers of delays each agency was responsible for each week, and acute trusts could charge local authorities for any delays for which they were responsible. Critics warned that the scheme was unsuited to the task, and that its implementation might put partnership working and patient care at risk. This paper explores health and social care staff views on the early working of the reimbursement scheme taken from a broader study of the factors associated with low rates of delays in six sites where performance (in terms of rates of delayed discharge) was exceptionally good. Forty-three qualitative interviews were undertaken between June 2004 and March 2005 with a range of health and social care professionals responsible for, or involved in, discharge arrangements in the six sites. For the majority of staff, the scheme has largely supported joint working; it provided substantial new funding to social services departments for joint commissioning, it has required joint implementation of new interagency notification systems, and close monitoring and interagency communication around delays. Whilst those working with new notification systems have experienced some difficulties with reaching a shared understanding of what is required, the notification system appears to have supported clear and timely communication around discharge between ward and social services staff. Impacts on patients were not clear cut, but there were concerns from some social services staff that, as a result of reimbursement, there was greater likelihood of ‘hurried’ discharges. This paper offers important insights into the early working of the scheme in sites where agencies were already performing well in terms of delayed discharges. It should be of interest to those involved in implementing the reimbursement scheme or with a role in discharge arrangements.

/pdf/implementing-the-reimbursement-scheme-views-of-health-and-3oit3ac65f.pdf

Implementing the reimbursement scheme - views of health and social care staff in six high performing sites

Purpose: The importance of addressing mental well-being while stroke patients are in hospital has been recognized by policy makers but there is a gap between rhetoric and reality. This study explored the potential for using a person-centred, artist facilitated, one-to-one arts programme to improve the emotional and mental well-being of patients, which may be adversely affected as a result of the negative experiences arising from stroke and hospitalization. Method: The study focused on those patients remaining in hospital for above average durations and included patients with functional, cognitive and speech or language impairments. After participation in the arts programme and before discharge, semi-structured interviews were undertaken with sixteen patients, and in the case of two patients with severe cognitive loss, a relative, as a proxy, was interviewed. Interviews explored the experience of stroke and hospital stay and the meaning and value of taking part in Time Being Stroke and the data was analysed thematically. To underpin and contextualize the interview material, clinical status and treatment information routinely collected by the multi-disciplinary stroke team was obtained and analysed; in addition material on the content of each session was recorded by artists and analysed. Results: Patients’ accounts suggest that participation in a personcentred arts programme contributed to their mental well-being. As might be expected from a person-centred intervention, benefits varied across the sample, but the most commonly mentioned positive aspects of participation included the experiences of: pleasure and enjoyment, a sense of connection with the artists, mental stimulation, learning and creativity, engagement in purposeful occupation and relief from boredom, and reconnection with valued aspects of the self. These experiences of participation contrast strongly with the acute

The meaning and value of taking part in a person-centred arts programme to hospital-based stroke patients: findings from a qualitative study

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Organisation and features of hospital, intermediate care and social services in English sites with low rates of delayed discharge.

Implementing the reimbursement scheme - views of health and social care staff in six high performing sites

The meaning and value of taking part in a person-centred arts programme to hospital-based stroke patients: findings from a qualitative study