Bed ‘traffic jams’ dictate surgical discharge policy
MedWire News: Surgeons adjust their discharge practices to accommodate the availability of beds and surgical schedules, potentially compromising the quality of care, US researchers believe.
"Discharge decisions are made with bed-capacity constraints in mind," commented Bruce Golden (University of Maryland, College Park), the study's lead author, in a press statement.
"Patient traffic jams present hospitals and medical teams with major, practical concerns, but they can find better answers than sending the patient home at the earliest possible moment."
Golden and colleagues analyzed discharge data for the 2007 fiscal year at a large academic medical center. During this period 6470 surgical patients were admitted for a total of 35,478 days.
Using statistical modeling, Golden's team looked for factors that were correlated with discharge practices.
The major factor was downstream bed utilization, which was positively albeit weakly correlated with discharge rates. In particular, when utilization increased above a threshold of 93%, the discharge rate also rose, report Golden et al in Health Care Management.
The proportion of patients who remained in hospital for at least 6 days was 48% when the recovery ward was not full (utilization <93%), but 43% when the ward was full (utilization >93%).
Other factors that influenced discharge rates were the patients' age, the type of surgery (elective or not), and bed utilization as a continuous rather than dichotomous variable.
Interestingly, surgical volume (ie, the number of surgeries scheduled for a given day) was not related to discharge practices. This suggests that doctors take the state of the intensive care unit and the future surgical schedule into account when making discharge decisions, say the researchers.
Also, while bed utilization is known to follow a cyclical pattern, increasing over the course of the working week and then emptying out at weekends, patients were no more or less likely to be discharged on any given day of the week, after controlling for other variables.
Taken together, these data indicate that "as recovery beds fill up, and supply becomes tight, the probability of discharge increases, regardless of how it is measured," write Golden et al.
They note that discharging patients before they are ready might compromise the recovery course and raise the risk for readmission "both of which could raise cost and decrease quality."
"Future work could look into the effects of discharge practices on readmission rates," the authors conclude. "For example, we would like to track individual physicians and monitor their decisions, as well as track the health outcomes of patients discharged from a recovery ward that is full, and compare the outcomes with patients discharged from a less-than-full ward."
By Joanna Lyford