1Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Initiatives for improving delayed discharge from a hospital setting: a scoping review

Lauren Cadel ,1,2 Sara J T Guilcher ,2,3,4,5 Kristina Marie Kokorelias,3 Jason Sutherland,6 Jon Glasby,7 Tara Kiran,4,5,8,9 Kerry Kuluski1,4

To cite: Cadel L, Guilcher SJT, Kokorelias KM, et al. Initiatives for improving delayed discharge from a hospital setting: a scoping review. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

► Prepublication history and additional material for this paper is available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2020- 044291).

Received 31 August 2020Revised 18 January 2021Accepted 25 January 2021

For numbered affiliations see end of article.

Correspondence toLauren Cadel; lauren. cadel@ thp. ca

Original research

© Author(s) (or their employer(s)) 2021. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.

ABSTRACTObjective The overarching objective of the scoping review was to examine peer reviewed and grey literature for best practices that have been developed, implemented and/or evaluated for delayed discharge involving a hospital setting. Two specific objectives were to review what the delayed discharge initiatives entailed and identify gaps in the literature in order to inform future work.Design Scoping review.Methods Electronic databases and websites of government and healthcare organisations were searched for eligible articles. Articles were required to include an initiative that focused on delayed discharge, involve a hospital setting and be published between 1 January 2004 and 16 August 2019. Data were extracted using Microsoft Excel. Following extraction, a policy framework by Doern and Phidd was adapted to organise the included initiatives into categories: (1) information sharing; (2) tools and guidelines; (3) practice changes; (4) infrastructure and finance and (5) other.Results Sixty- six articles were included in this review. The majority of initiatives were categorised as practice change (n=36), followed by information sharing (n=19) and tools and guidelines (n=19). Numerous initiatives incorporated multiple categories. The majority of initiatives were implemented by multidisciplinary teams and resulted in improved outcomes such as reduced length of stay and discharge delays. However, the experiences of patients and families were rarely reported. Included initiatives also lacked important contextual information, which is essential for replicating best practices and scaling up.Conclusions This scoping review identified a number of initiatives that have been implemented to target delayed discharges. While the majority of initiatives resulted in positive outcomes, delayed discharges remain an international problem. There are significant gaps and limitations in evidence and thus, future work is warranted to develop solutions that have a sustainable impact.

INTRODUCTIONA delayed hospital discharge (known as alternate level of care (ALC) in Canada and delayed transfer of care in the UK) occurs when a patient is medically approved to be discharged, but remains in hospital for non- medical reasons (eg, waiting for a long- term care bed to become available or to transfer

home with services).1 While waiting for their next destination, patients’ level of care and activation often decrease or stop entirely. Delayed discharge can result in hospital patient flow issues (eg, emergency service backlogs, cancelled surgeries, delays in medically necessary care),2 increased health-care costs,3 an increased risk of functional decline,4 5 falls,6 hospital- related adverse events (eg, medication error, exposure to infectious disease),6 7 mortality,8 as well as poor patient and family experiences.9

Patients who experienced a delayed discharge in previous studies exhibited the following characteristics: female,10 older,10 11 physically or cognitively impaired.4 12–15 Patients have also shown to exhibit aggressive behaviours,16 use assistive devices17 and have psychiatric conditions,10 neurological disorders15 and/or multimor-bidity.17 In addition to these patient- level factors, there are a number of system- level factors that contribute to delayed discharges, including long wait lists for long- term care facilities,5 17–19 rehabilitation or other postacute care (eg, home care),11 12 20–23 the lack of culturally and religiously diverse long- term care facilities,15 limited or absent hospital services on weekends24 and organ-isational delays (eg, administrative delays, delayed assessments).24 25 There are also

Strengths and limitations of this study

► To our knowledge, this is the first scoping review to identify best practices for delayed discharges in-volving a hospital setting.

► The Preferred Reporting Items for Systematic Reviews and Meta- Analyses extension for Scoping Reviews Checklist was followed.

► A comprehensive search of peer reviewed and grey literature was conducted.

► A critical appraisal of the interventions was not performed.

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different pressures and priorities across sectors, with little incentive to work together as a system. For example, while hospitals may be focused on efficiency and throughput, community- based organisations may be focused on empowerment, longer- term quality of life outcomes and working at a pace that works for patients and families. The funding structure of hospitals and healthcare systems can also have an impact on overall patient flow, including discharge delays. Although there is wide variation in funding structures within and across countries, there is potential for funding to either incentivise or disincen-tivise timely hospital discharges.26–30

The combination of patient- level and system- level factors contributing to delayed discharges can also have a large financial impact on patients, families, healthcare providers and the healthcare system.3 A recent system-atic review reported that delayed discharges cost approx-imately £200–565 ($C320–$C900) per patient, per day.3 Further, it was estimated that the National Health Service (NHS) (England) spends £820 million ($C1.3 billion) every year on patients who have a discharge delay.31 Simi-larly, a recent report from Canada stated that three hospi-tals located in Ottawa, Ontario, spend approximately $C250 000 per day (combined) on patients occupying beds at a level of care they no longer require.32 In addi-tion to large costs for hospitals and healthcare systems, delayed hospital discharges can result in out- of- pocket costs for patients and families.33 Increased out- of- pocket costs, in addition to the other uncertainties associated with a delay, can heighten stress for patients and families, contribute to poor experiences and compromise quality of life.9

Overall, delayed hospital discharges are problematic internationally, highlighting a need to identify best prac-tices and current initiatives that are concentrating on solutions to this complex problem. To date, the majority of published literature on delayed discharge has focused on risk factors and characteristics of patients who experi-ence delayed discharge. There has been a limited focus on initiatives that address the delayed discharge problem. Therefore, the purpose of this scoping review was to examine peer reviewed and grey literature (literature published through non- traditional means) for initiatives that have been developed and/or evaluated for delayed discharge from a hospital setting, with the goal of iden-tifying best practices for reducing delayed discharge. A scoping review methodology was appropriate for addressing this goal, in order to identify the types of avail-able evidence on this topic, examine key characteristics relating to initiatives for delayed discharge and to identity knowledge gaps.34

METHODSThis review followed the scoping review methodology outlined by Levac et al,35 as well as the recently developed Preferred Reporting Items for Systematic Reviews and Meta- Analyses extension for Scoping Reviews (see online

supplemental table 1).36 A protocol for this scoping review was developed in consultation with a librarian at the University of Toronto, with continuous input from members of the research team.

Stage 1: identifying the research questionThe research question developed to lead this scoping review was: what is known in the literature about initia-tives (eg, strategies, programmes, interventions) that have been developed, implemented and/or evaluated for delayed discharge involving a hospital setting? The two main aims were: (1) to review what delayed discharge initiatives entail (eg, characteristics, outcomes) and (2) to identify gaps in the literature in order to inform future studies.

Stage 2: identifying relevant articlesThe search strategy was developed with a librarian at the University of Toronto and through consultations with an advisory group and collaborators who have experience in clinical practice or administration (see online supple-mental table 2 for Medline search strategy). Each search strategy was adapted for the specific database using appro-priate command line syntax and indexing. The following are examples of keywords searched using Boolean oper-ators, proximity operators, wild cards and truncations: ALC, delayed discharge, delayed transfer, bed blocking, strategy, model, intervention, programme, policy.

Electronic databases were searched for relevant articles. The following electronic databases were searched on 16 August 2019: MEDLINE (Ovid Interface), EMBASE (Ovid Interface), AMED (Ovid Interface), Cumulative Index to Nursing and Allied Health Literature (EBSCO Inter-face) and Cochrane Library. Grey literature was searched on the following databases and repositories: OpenGrey, Health Services Research Projects in Progress, UpToDate, Community Research and Development Information Services and TSpace, as well as on numerous national and international healthcare and government websites. We also reached out to key stakeholders, including members of our advisory group, to send us relevant reports and presentations.

Stage 3: study selectionFor inclusion, articles (peer- reviewed and grey literature) were required to meet the following criteria: (1) focused on delayed discharge, (2) included an initiative to address delayed discharge, (3) involved a hospital setting, (4) published between 1 January 2004 and 16 August 2019 and (5) peer- reviewed or grey literature. We focused our inclusion on initiatives involving a hospital setting because this is where the problem of delayed discharges surfaces. Articles were excluded if they met any one of the following criteria: (1) focused on changing the threshold/timing of discharge (early discharge), (2) books, book chapters, opinion pieces or editorials, (3) grey literature that did not sufficiently describe the initiative implemented (eg, implementation process, location, population, impact);

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(4) protocols, trial papers or chart reviews or (5) confer-ence abstracts or articles without an accessible full text. Articles were excluded for criteria one (changing the threshold/timing of discharge) because the rationale for having an earlier discharge was often focused on other factors such as cost- savings by reducing length of stay, rather than specifically addressing a delayed discharge. Articles were excluded if they met criteria two (books, book chapters, opinion pieces or editorials) to elimi-nate articles with potential personal biases and summa-ries of peer- reviewed literature. Grey literature that did not provide sufficient details on the initiative (such as lacking a description of the components of the initiative) were excluded. Articles published more than 15 years ago, before 1 January 2004, were excluded to ensure the initiatives included in this scoping review were relevant to more current health service practices.

Articles identified from the database searches were imported into EndNote X9, a reference management software, where they were deduplicated following Bram-er’s method.37 The initial database searches identified 22 704 articles, which were reduced to 15 824 following deduplication (figure 1). The titles and abstracts of the articles were reviewed on Covidence, a software platform for systematic and scoping reviews.38 The research team (LC, KK, SJTG, KMK and JK) independently screened the titles and abstracts of 40 articles to test their agreement. The reviewers had a good per cent agreement (85%), so the remaining articles were divided among the team and screened by single reviewers (LC, KMK and JK). All disagreements were discussed in- person by the reviewers until a consensus was reached; minor revisions were made to the eligibility criteria to ensure clarity and consistency. Following title and abstract screening, articles were

reviewed at the full- text level. Thirty full- text articles were independently screened by the research team (LC, KK, SJTG, KMK, JK and MA) to test their interrater agree-ment. The remaining full- text articles (peer- reviewed and grey literature) were double screened by four reviewers (LC, KMK, JK and MA).

Stage 4: charting the dataThe data were charted by two reviewers (LC and KMK) using a data extraction form in Microsoft Excel. The form was developed and tested by the research team in a series of team meetings prior to the extraction of all data. We conducted spot checking of extracted data from 15% of the included articles to ensure complete-ness and accuracy of the extracted data. Any questions that arose during the charting process were discussed by the team. Charted data contained the following information: general information, study characteristics, population characteristics, initiative characteristics, characteristics of delayed discharge, study outcomes and conclusions.

Stage 5: collating, summarising and reporting resultsMicrosoft Excel was used to conduct a descriptive quanti-tative analysis of the included articles, as well as facilitate qualitative thematic analysis. The thematic analysis of the charted data was an inductive and iterative process, in which the team (LC, SJTG, KMK and KK) met in- person to discuss high level concepts and identified common themes across the included articles. When reviewing the extracted data, we found that the strategies appeared to cluster into core categories, which aligned with a concep-tual framework developed by Doern and Phidd.39 This framework classifies policy instruments/tools along a continuum (from those that are least coercive like infor-mation sharing to those that are more coercive like public ownership or, in our case, new infrastructure). We deduc-tively applied Doern and Phidd’s categories to classify our findings, with some minor adaptations. The five adapted categories were not mutually exclusive and included: (1) information sharing (live information sharing and docu-mented recommendations); (2) tools and guidelines; (3) practice changes; (4) infrastructure and finance and (5) other (see table 1 for category descriptions and exam-ples). The categories assisted with the organisation and presentation of the data.

Stage 6: consultationThe research team presented findings of the scoping review to key stakeholders (eg, hospital staff, patient and caregiver partners) through the planning process and analysis of results. These meetings were used to inform search terms, gather relevant documents, obtain feedback on the categorisation/organisation of initiatives, as well as identify knowledge gaps in order to develop targeted and actionable recommendations for future practice, policy and research.

Figure 1 PRISMA flow diagram of included articles. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta- Analyses.

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Patient and public involvementAn advisory council (patient and caregiver partners), along with providers, managers and organisational leaders identified the lack of understanding about the state of evidence around best practices for delayed discharges, which informed the research question for this scoping review. The advisory council was involved with planning meetings where they provided feedback on the search terms and analysis. Results will be disseminated to the advisory council through presentations and a lay summary.

RESULTSStudy characteristicsThe database search identified 15 824 unique articles that were screened for eligibility; following title/abstract and full- text review, 66 articles were included in this scoping review, 49 articles from the database searches and 17 articles from the grey literature searches (figure 1). The majority of included articles were quantitative studies (n=34), with a few qualitative (n=5), mixed methods (n=6) or other designs (policy analyses, reviews, case studies and presentations; n=21). There was a large variety of study designs, with few randomised trials and prospective studies. Most initiatives were evaluated (n=42), with different types of evaluations such as process evaluations and outcome evaluations. The UK (n=21), USA (n=18) and Canada (n=17) were the most common countries where studies were conducted. Based on the year of publication, there was a fairly even distribution of peer- reviewed articles across the years of inclusion (from 2004 to 2019); however, the majority of grey literature was published in the last 10 years. Table 2 describes the char-acteristics of included articles.

The initiatives most commonly targeted adults and older adults; however, there were some initiatives targeting the paediatric population. Specific characteristics of the study population (ie, age, sex, gender, ethnicity/race, income level, education, marital status, household composition, employment status, comorbidities) were not reported in the majority of articles. Most peer- reviewed articles (n=31) defined a delayed discharge; however, there was a wide variety of definitions for these terms (see online supplemental table 3). The most common definition for delayed discharge was when a patient was identified as medically ready for discharge, but remained in hospital. Table 3 describes the initiative characteristics.

Based on Doern and Phidd’s adapted framework,39 we categorised the included initiatives as: information sharing (n=19); tools and guidelines (n=19); practice changes (n=36); infrastructure and finance (n=10); or other (n=3), which are described in detail below (see figure 2). Numerous articles used a combination of cate-gories in their initiatives (eg, information sharing and practice change).

Information sharingThe information sharing category included initiatives that promoted communication, leadership from senior staff and information exchange within or across organi-sations.2 40–55 The majority of information sharing initia-tives included team meetings and huddles to facilitate communication through in- person interactions between staff, and less often between staff and patients/fami-lies.40 41 43 44 46 Information sharing was promoted between multidisciplinary teams and patients to improve length of stay and continuity of care. For example, Adlington et al implemented Plan Do Study Act cycles during weekly quality improvement meetings, in which driver diagrams

Table 1 Categories, descriptions and examples of initiative categorisation

Category name Description Examples

Information SharingA—live sharingB—recommended initiatives— calls to action

► A—information sharing through in- person or technology- based communication (synchronous communication)

► B—information sharing through documents which share suggestions, recommendations or for information purposes (motivation)

► A—rounding, team meetings, one- on- on communication

► B—examples: suggested strategies (or ‘calls to action’) which ranged from recommending investments in new long- term care beds, increasing funding for behavioural supports, audits and reports, encouraging team building

Tools and guidelines ► Tangible/concrete guides to inform practice ► Implemented tool/guidance document that is being used in the healthcare system

► Toolkits, guidelines, escalation processes, frameworks

Practice changes ► A change in how care is delivered ► Nurse- led discharges, roles of providers and/or composition of team are organised differently

Infrastructure and finance ► Tangible structural or financial changes ► Financial penalties/incentives, building more hospital, rehabilitation or long- term care beds

Other initiatives ► Different initiative that does not fit into any of the above categories

► Statistical models (predictive modelling)

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Tab

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265

►

Imp

rove

d e

ffici

ency

aro

und

d

isch

arge

of e

lect

ive

shor

t- st

ay e

ar,

nose

, thr

oat

pat

ient

s

►95

% o

f ear

, nos

e, t

hroa

t p

atie

nts

(for

sim

ple

dis

char

ge) a

re

dis

char

ged

on

time

Boy

d (2

017)

41U

SA

Exp

lore

the

lead

ersh

ip s

trat

egie

s us

ed

by

hosp

ital b

usin

ess

adm

inis

trat

ors

to

red

uce

del

ayed

dis

char

ges

and

imp

rove

p

rofit

abili

ty

Qua

litat

ive

Mul

tiple

cas

e st

udy

Hos

pita

l ad

min

istr

ator

s3

►

Effe

ctiv

e le

ader

ship

from

hos

pita

l ad

min

istr

ator

s co

ntrib

utes

to

pos

itive

out

com

es fo

r p

atie

nts,

st

aff a

nd t

he e

cono

my

Bra

nklin

e (2

009)

47U

SA

Pro

vid

e th

e ap

pro

pria

te le

vel o

f car

e an

d p

atie

nt c

hoic

e w

hen

the

pat

ient

is

med

ical

ly r

ead

y fo

r tr

ansf

er

Qua

ntita

tive

Pilo

t st

udy

Med

ical

floo

rs w

ith p

rimar

ily e

lder

ly

pat

ient

s w

ho r

equi

re n

ursi

ng h

ome

pla

cem

ent

afte

r d

isch

arge

25

►Im

pro

ved

info

rmat

ion

exch

ange

b

etw

een

hosp

itals

and

nur

sing

ho

mes

Bro

wn

(200

8)64

US

AD

eter

min

e if

the

leng

th o

f pat

ient

sta

y is

red

uced

in t

he p

osta

naes

thes

ia c

are

unit

whe

n nu

rses

use

dis

char

ge c

riter

ia

Qua

ntita

tive

Pro

spec

tive

clin

ical

st

udy

Ad

ult,

AS

A p

hysi

cal s

tatu

s I,

II, a

nd

III p

atie

nts

(18+

) req

uirin

g ge

nera

l an

aest

hesi

a

1198

►

Dec

reas

ed p

osta

naes

thes

ia c

are

unit

leng

th o

f sta

y an

d d

isch

arge

d

elay

s w

hile

mai

ntai

ning

pat

ient

st

atus

Bur

r (2

017)

56C

anad

aD

evel

op a

fram

ewor

k th

at w

ould

su

pp

ort

ALC

avo

idan

ce s

trat

egie

s ac

ross

the

Tor

onto

Cen

tral

Loc

al H

ealth

In

tegr

atio

n N

etw

ork

Cas

e st

udy

Cas

e st

udy

ALC

pat

ient

s3

hosp

itals

►

ALC

avo

idan

ce r

educ

es b

urd

en o

n p

atie

nts,

fam

ilies

and

pro

vid

ers

►

Long

- ter

m s

olut

ions

to

imp

rove

p

atie

nt fl

ow a

nd a

void

ALC

sho

uld

b

e su

stai

nab

le a

nd a

lign

with

oth

er

initi

ativ

es

Cam

initi

(2

013)

42Ita

lyE

valu

ate

the

effe

ctiv

enes

s of

a s

trat

egy

aim

ed t

o re

duc

e d

elay

ed h

osp

ital

dis

char

ge

Qua

ntita

tive

Clu

ster

, par

alle

l gro

up,

rand

omis

ed t

rial/q

ualit

y im

pro

vem

ent

Hos

pita

l uni

ts: g

eria

tric

, med

icin

e,

long

- ter

m c

are

3498

►

Phy

sici

an d

irect

acc

ount

abili

ty c

an

red

uce

unne

cess

ary

and

avo

idab

le

hosp

ital d

ays,

esp

ecia

lly w

hen

del

ays

are

with

in s

taff

cont

rol

Chi

dw

ick

(201

7)54

Can

ada

Dis

cuss

con

cep

ts a

nd id

eas

that

led

to

low

est

ALC

day

s in

the

pro

vinc

eM

ixed

met

hod

sQ

ualit

y im

pro

vem

ent

ALC

pat

ient

sN

R

►Im

pro

ved

pat

ient

flow

and

re

duc

ed A

LC d

ays

thro

ugh

the

imp

lem

enta

tion

of a

m

ultid

imen

sion

al a

pp

roac

h

El-

Eid

(201

5)73

Leb

anon

Ass

ess

the

effe

ctiv

enes

s of

the

Six

S

igm

a m

etho

d in

imp

rovi

ng d

isch

arge

p

roce

sses

Qua

ntita

tive

Pre

and

pos

t-

inte

rven

tion

stud

y

NR

17 0

54

►S

ix S

igm

a ca

n ha

ve a

pos

itive

and

su

stai

nab

le im

pac

t on

pat

ient

flow

an

d le

ngth

of s

tay

►

Dis

char

ge d

elay

s sh

ould

be

add

ress

ed t

hrou

gh p

rinci

ple

s of

S

ix S

igm

a, r

athe

r th

an in

stitu

tion-

sp

ecifi

c in

terv

entio

ns

Tab

le 2

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

7Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

(yea

r)C

oun

try

Ob

ject

ive

Met

hod

Stu

dy

des

ign

Par

tici

pan

tsS

amp

le s

ize

Key

co

nclu

sio

ns

Gau

ghan

(2

015)

101

Eng

land

Inve

stig

ate

the

red

uctio

n in

hos

pita

l b

ed- b

lock

ing

due

to

a gr

eate

r su

pp

ly o

f nu

rsin

g ho

me

bed

s or

red

uced

cos

ts

Qua

ntita

tive

Sta

tistic

al m

odel

ling

- E

mp

irica

l ana

lysi

s

Pat

ient

s w

aitin

g fo

r ho

spita

l d

isch

arge

NR

►

Imp

rove

d c

oord

inat

ion

bet

wee

n he

alth

and

long

- ter

m c

are

is

esse

ntia

l for

ad

dre

ssin

g d

elay

ed

dis

char

ges

Gra

ham

(2

012)

74U

KE

valu

ate

the

effe

ct o

f the

lap

aros

cop

ic

nurs

e sp

ecia

list

on p

atie

nt d

isch

arge

Qua

ntita

tive

Ret

rosp

ectiv

e co

mp

aris

on

Lap

aros

cop

ic c

hole

cyst

ecto

my

and

la

par

osco

pic

ingu

inal

her

nia

rep

air

pat

ient

s

128

►

Nur

se- l

ed d

isch

arge

may

incr

ease

d

isch

arge

pos

tlap

aros

cop

ic s

urge

ry

with

out

imp

actin

g p

atie

nt c

are

Gut

man

is

(201

6)65

Can

ada

Out

line

chan

ge s

trat

egie

s an

d t

heir

imp

act

heal

th s

yste

m t

rans

form

atio

n an

d t

hose

livi

ng w

ith r

esp

onsi

ve

beh

avio

urs

and

the

ir fa

mily

mem

ber

s

Mix

ed m

etho

ds

Qua

lity

imp

rove

men

tIn

div

idua

ls w

ith r

esp

onsi

ve

beh

avio

urs

NR

►

Imp

rove

d c

oord

inat

ion

and

co

mm

unic

atio

n ac

ross

sec

tors

►

Pro

vid

ed h

ealth

care

pro

vid

ers

with

le

arni

ng o

pp

ortu

nitie

s

Hen

woo

d

(200

6)48

UK

Exa

min

e th

e p

artn

ersh

ip b

etw

een

heal

th

and

soc

ial c

are

by

exp

lorin

g is

sues

with

ho

spita

l dis

char

ges

Cas

e st

udy

Cas

e st

udy

Inp

atie

nts

NR

►

Ad

dre

ssin

g an

d im

pro

ving

del

ayed

d

isch

arge

s re

qui

res

par

tner

ship

s b

etw

een

heal

th a

nd s

ocia

l car

e an

d

a w

hole

sys

tem

s- b

ased

ap

pro

ach

Hol

land

(2

016)

57U

SA

Rep

ort

the

dev

elop

men

t an

d e

valu

atio

n of

a d

isch

arge

del

ay t

rack

ing

and

re

por

ting

mec

hani

sm

Qua

ntita

tive

Pra

ctic

e im

pro

vem

ent

pro

ject

Inp

atie

nts

NR

►

Dis

char

ge d

elay

s ca

n b

e re

duc

ed

if sy

stem

and

pro

cess

bre

akd

owns

ar

e id

entifi

ed a

nd a

dd

ress

ed

Kat

salia

ki

(200

5)10

2U

KD

escr

ibe

a p

roje

ct in

vest

igat

ing

pot

entia

l car

e p

athw

ays

for

eld

erly

p

eop

le a

fter

dis

char

ge fr

om h

osp

ital

Qua

ntita

tive

Dis

cret

e- ev

ent

sim

ulat

ion,

sim

ulat

ion

mod

el

Inp

atie

nts

NR

►

Sim

ulat

ion

is a

sui

tab

le

met

hod

olog

y fo

r re

cord

ing

and

ev

alua

ting

the

new

pos

tacu

te

pac

kage

s

Lees

- Deu

tsch

(2

019)

66U

KId

entif

y co

re c

hara

cter

istic

s of

pat

ient

d

isch

arge

crit

eria

, rec

ord

ed in

clin

ical

m

anag

emen

t p

lans

or

case

not

es

Qua

ntita

tive

Sys

tem

atic

ob

serv

atio

nal

retr

osp

ectiv

e re

view

Pat

ient

s d

isch

arge

d fr

om t

he a

cute

m

edic

ine

unit

and

sho

rt- s

tay

units

50

►C

riter

ia- l

ed d

isch

arge

may

be

suita

ble

for

sele

ct p

atie

nts

in

imp

rovi

ng t

imel

ines

s of

dis

char

ge

Levi

n (2

019)

94S

cotla

ndE

xam

ine

the

imp

act

of In

term

edia

te

Car

e an

d t

he 7

2- ho

ur t

arge

t on

del

ayed

ho

spita

l dis

char

ge

Qua

ntita

tive

Con

trol

led

inte

rrup

ted

tim

e se

ries

des

ign

Pat

ient

s ag

ed 7

5+10

7 02

2

►Im

med

iate

imp

act

on d

ays

del

ayed

, but

incr

easi

ng r

ates

day

s d

elay

ed o

ver

time

sugg

ests

tha

t In

term

edia

te C

are

serv

ices

may

ne

ed t

o b

e ad

apte

d

Lian

(200

8)58

Sin

gap

ore

Dev

elop

met

hod

s to

red

uce

the

hosp

ital

leng

th o

f sta

y fo

r p

rem

atur

e in

fant

s b

y 30

%, w

ithin

6 m

onth

s

Qua

ntita

tive

Ret

rosp

ectiv

e re

view

Pre

mat

ure

infa

nts

78

►D

isch

arge

pla

nnin

g sh

ould

beg

in

on h

osp

ital a

dm

issi

on

►N

urse

s sh

ould

coa

ch p

aren

ts t

o p

rep

are

them

to

care

for

thei

r in

fant

at

hom

e

Mae

ssen

(2

008)

75N

ethe

rland

sA

sses

s th

e ef

fect

of e

nhan

ced

rec

over

y af

ter

surg

ery

pro

gram

me

on d

isch

arge

d

elay

s

Qua

ntita

tive

Ret

rosp

ectiv

e/

pro

spec

tive

stud

y

Pat

ient

s un

der

goin

g el

ectiv

e co

lore

ctal

res

ectio

n17

3

►A

dd

ition

al r

ecov

ery

stat

istic

s sh

ould

be

add

ed a

s ou

tcom

es o

f th

e E

RA

S p

rogr

amm

e

Tab

le 2

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

8 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

(yea

r)C

oun

try

Ob

ject

ive

Met

hod

Stu

dy

des

ign

Par

tici

pan

tsS

amp

le s

ize

Key

co

nclu

sio

ns

Mah

ant

(200

8)59

Can

ada

Det

erm

ine

if an

aud

it- an

d- f

eed

bac

k in

terv

entio

n re

duc

es d

elay

ed d

isch

arge

in

a g

ener

al p

aed

iatr

ic in

pat

ient

uni

t

Qua

ntita

tive

Pro

spec

tive

obse

rvat

iona

l stu

dy

Pae

dia

tric

inp

atie

nt31

94

►R

educ

ed in

app

rop

riate

hos

pita

l d

ays,

with

out

imp

actin

g re

adm

issi

on r

ates

►

Iden

tified

pro

cess

es t

hat

imp

act

inap

pro

pria

te h

osp

ital d

ays

Mah

to (2

009)

76U

KD

eter

min

e th

e ef

fect

of a

dia

bet

es

outr

each

ser

vice

on

del

ayed

dis

char

ges

and

avo

idab

le a

dm

issi

ons

Qua

ntita

tive

Cro

ss- s

ectio

nal a

udit

Acu

tely

ad

mitt

ed p

atie

nts

with

d

iab

etes

137

►

The

rest

ruct

ured

hos

pita

l dia

bet

es

outr

each

ser

vice

imp

rove

d

outc

omes

for

inp

atie

nts

with

d

iab

etes

Mal

oney

(2

007)

49U

SA

Dev

elop

a w

eb- b

ased

sof

twar

e ap

plic

atio

n us

ed t

o fa

cilit

ate

timel

y p

atie

nt d

isch

arge

Qua

ntita

tive

Qua

lity

imp

rove

men

t p

ilot

pro

ject

Inp

atie

nts

NR

►

Hea

lthca

re in

form

atio

n te

chno

logy

ca

n fa

cilit

ate

bed

man

agem

ent

effic

ienc

ies

►

Imp

rove

d c

oord

inat

ion

and

ove

rall

inp

atie

nt fl

ow

Man

ville

(2

014)

95C

anad

aD

eter

min

e if

pro

vid

ing

inte

rdis

cip

linar

y ca

re o

n a

tran

sitio

nal c

are

unit

will

res

ult

in im

pro

ved

clin

ical

out

com

es a

nd lo

wer

co

sts

Qua

ntita

tive

Bef

ore-

and

- aft

er

stru

ctur

ed r

etro

spec

tive

char

t au

dit

Eld

erly

ALC

pat

ient

s (7

0+)

135

►

Imp

rove

d h

ealth

func

tiona

l ou

tcom

es, d

eliv

ered

at

a lo

wer

cos

t

Mee

han

(201

8)77

UK

Exp

lore

pat

ient

s’ e

xper

ienc

es o

f ho

spita

l dis

char

ge w

ith t

he d

isch

arge

to

asse

ss s

chem

e

Qua

litat

ive

Des

crip

tive

Pat

ient

s d

isch

arge

d t

hrou

gh

dis

char

ge t

o as

sess

30

►P

atie

nts

and

car

egiv

ers

rep

orte

d

pos

itive

and

neg

ativ

e ex

per

ienc

es

with

the

sch

eme,

but

it m

ay b

e b

enefi

cial

in im

pro

ving

out

com

es

for

som

e p

atie

nts

Moe

ller

(200

6)60

Can

ada

Ass

ess

pat

ient

and

phy

sici

an- r

elat

ed

bar

riers

to

dis

char

ging

pat

ient

s w

ho

have

met

ob

ject

ive

crite

ria

Mix

ed m

etho

ds

Ret

rosp

ectiv

e as

sess

men

t

Pat

ient

s w

ith c

omm

unity

- acq

uire

d

pne

umon

ia31

►

Pat

ient

s ou

tcom

es c

an b

e im

pro

ved

by

stan

dar

dis

ing

care

th

roug

h a

criti

cal p

athw

ay

►P

atie

nts

with

poo

r fu

nctio

nal

cap

acity

(usi

ng t

he H

iera

rchi

cal

Ass

essm

ent

of B

alan

ce a

nd

Mob

ility

) may

nee

d a

dd

ition

al

serv

ices

to

imp

rove

dis

char

ge t

ime

afte

r cl

inic

al s

tab

ility

Mur

- Vee

man

(2

011)

61Th

e N

ethe

rland

sE

xpla

in t

he t

heor

y of

buf

fer

man

agem

ent

and

dis

cuss

rel

ated

p

revi

ous

assu

mp

tions

NR

Rev

iew

/ th

eore

tical

p

aper

Bed

blo

cker

sN

R

►To

pra

ctic

ally

ap

ply

buf

fer

man

agem

ent,

cur

rent

rou

tines

, p

rinci

ple

s an

d b

elie

fs s

houl

d

shift

to

focu

s on

flow

bet

wee

n or

gani

satio

ns r

athe

r th

an w

ithin

one

or

gani

satio

n

Nie

mei

jer

(201

0)62

Net

herla

nds

Red

uce

the

aver

age

leng

th o

f sta

y to

cr

eate

mor

e ad

mis

sion

cap

acity

and

re

duc

e co

sts

Mix

ed m

etho

ds

Effi

cien

cy im

pro

vem

ent

pro

ject

(ret

rosp

ectiv

e an

d p

rosp

ectiv

e d

ata

colle

ctio

n)

Trau

ma

pat

ient

s20

06:1

114

2007

:112

4

►Le

an S

ix S

igm

a is

effe

ctiv

e in

re

duc

ing

leng

th o

f sta

y an

d

imp

rovi

ng fi

nanc

ial e

ffici

ency

in

trau

ma

care

Tab

le 2

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

9Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

(yea

r)C

oun

try

Ob

ject

ive

Met

hod

Stu

dy

des

ign

Par

tici

pan

tsS

amp

le s

ize

Key

co

nclu

sio

ns

Pan

is (2

004)

78N

ethe

rland

sR

educ

e in

app

rop

riate

hos

pita

l sta

y b

y ad

just

ing

pat

ient

logi

stic

s, in

crea

sing

ef

ficie

ncy

and

pro

vid

ing

com

fort

able

su

rrou

ndin

gs

Qua

ntita

tive

Ret

rosp

ectiv

e co

hort

st

udy

Mot

hers

of n

ewb

orn

pat

ient

s28

89 d

ays

of h

osp

ital

stay

of

gyna

ecol

ogy

and

ob

stet

rics

pat

ient

s

►

Dis

char

ge c

riter

ia c

an r

educ

e in

app

rop

riate

pat

ient

sta

ys r

elat

ed

to d

isch

arge

pro

cess

es

►S

hift

ing

mat

erni

ty c

are

to

outp

atie

nt s

ettin

gs c

an r

educ

e ho

spita

l len

gth

of s

tay

Pat

el (2

019)

43U

SA

Eva

luat

e th

e im

pac

t of

tea

m- b

ased

m

ultid

isci

plin

ary

roun

ds

on d

isch

arge

p

lann

ing

and

car

e ef

ficie

ncy

Mix

ed m

etho

ds

Qua

lity

imp

rove

men

t in

itiat

ive

Dis

satis

fied

pat

ient

s w

ith d

elay

ed

dis

char

ge15

84

►M

ultid

isci

plin

ary

dis

char

ge r

ound

s ca

n im

pro

ve d

isch

arge

effi

cien

cy,

leng

th o

f sta

y an

d 3

0- d

ay

read

mis

sion

s

Ali

Pira

ni

(201

0)44

Pak

ista

nE

mp

hasi

se t

he r

ole

of n

urse

s to

d

eter

min

e fa

ctor

s le

adin

g to

a la

ck o

f d

isch

arge

pla

nnin

g

NR

Rev

iew

/ su

mm

ary

Thos

e ex

per

ienc

ing

del

ayed

d

isch

arge

NR

►

Nur

ses

pla

y a

key

role

in d

eliv

erin

g p

atie

nt- c

entr

ed c

are

and

can

im

pro

ve d

isch

arge

pla

nnin

g p

roce

sses

►

Nur

ses

mus

t ha

ve t

he a

pp

r op

riate

kn

owle

dge

ab

out

dis

char

ge

pla

nnin

g an

d h

ave

the

abili

ty t

o co

mm

unic

ate,

coo

rdin

ate

and

ed

ucat

e p

atie

nts

Qin

(201

7)10

3A

ustr

alia

Iden

tify

whi

ch b

arrie

rs t

o d

isch

arge

in

fluen

ce h

osp

ital o

ccup

ancy

whe

n ta

rget

ed b

y a

hosp

ital-

wid

e p

olic

y

Qua

ntita

tive

Sim

ulat

ion

mod

ellin

gN

RN

R

►H

osp

ital o

ccup

ancy

rat

es a

nd

over

crow

din

g ca

n b

e im

pro

ved

by

imp

rovi

ng d

isch

arge

pro

cess

es

Rae

(200

7)96

New

Zea

land

Illus

trat

e ho

w t

he D

elay

ed D

isch

arge

P

roje

ct s

olve

d a

bed

cris

is a

nd

cont

rolle

d e

xpen

ditu

re

Qua

ntita

tive

Con

tinuo

us q

ualit

y im

pro

vem

ent

pro

ject

Acu

te g

ener

al m

edic

al20

034

►

The

pro

ject

alte

red

sta

ff b

ehav

iour

ar

ound

pat

ient

dis

char

ge r

esul

ting

in a

bet

ter

use

of r

esou

rces

►

The

syst

em c

rash

ed 2

yea

rs p

ost-

im

ple

men

tatio

n

►Th

ere

is t

oo m

uch

focu

s on

leng

th

of s

tay

and

bed

allo

catio

ns le

adin

g to

poo

r d

ecis

ion

mak

ing

Rob

erts

(2

013)

50A

ustr

alia

Und

erta

ke a

pre

limin

ary

tria

l of t

he G

oal

Leng

th o

f Sta

y to

ol a

t a

reha

bili

tatio

n ce

ntre

Qua

ntita

tive

Pro

spec

tive

stud

yIn

pat

ient

s in

tw

o un

its: S

RU

or

BIR

U20

2

►Th

e p

rogr

amm

e d

id n

ot r

educ

e le

ngth

of s

tay

and

was

per

ceiv

ed

nega

tivel

y b

y st

aff

Sam

pso

n (2

006)

79U

KD

escr

ibe

bed

occ

upan

cy d

ata

in

peo

ple

with

dia

bet

es b

efor

e an

d a

fter

th

e in

trod

uctio

n of

a d

iab

etes

inp

atie

nt

spec

ialis

t nu

rse

serv

ice

Qua

ntita

tive

Ret

rosp

ectiv

e st

udy

Dia

bet

es in

pat

ient

s15

2 08

0

►D

iab

etes

inp

atie

nt s

pec

ialis

t nu

rse

red

uced

exc

ess

bed

occ

upan

cy

Sha

h (2

007)

97E

ngla

ndE

xam

ine

the

imp

act

of t

he C

omm

unity

C

are

(Del

ayed

Dis

char

ge) A

ct o

n b

ed o

ccup

ancy

and

leng

th o

f sta

y in

G

eria

tric

Med

icin

e (G

M) a

nd O

ld A

ge

Psy

chia

try

(OA

P) s

ervi

ces

Qua

ntita

tive

Ret

rosp

ectiv

e st

udy

Inp

atie

nt -

sp

ecia

lties

of G

M a

nd

OA

P s

ervi

ces

NR

►

Mor

e p

atie

nts

wer

e ad

mitt

ed t

o G

M

serv

ices

and

had

a s

hort

er le

ngth

of

sta

y th

an O

AP

Tab

le 2

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

10 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

(yea

r)C

oun

try

Ob

ject

ive

Met

hod

Stu

dy

des

ign

Par

tici

pan

tsS

amp

le s

ize

Key

co

nclu

sio

ns

Sob

otka

(2

017)

51U

SA

Des

crib

e a

hosp

ital-

to- h

ome

tran

sitio

nal

care

mod

elC

ase

stud

yIll

ustr

ativ

e ca

se d

esig

n/

revi

ew

Pae

dia

tric

inp

atie

nt1

►

Tran

sitio

nal c

are

pro

gram

mes

ca

n im

pro

ve c

are

for

vuln

erab

le

pop

ulat

ions

by

red

ucin

g he

alth

and

d

evel

opm

enta

l diff

eren

ces

Sta

rr-

Hem

bur

row

(2

011)

80

Can

ada

Min

imis

e th

e nu

mb

er o

f pos

t- ac

ute

pat

ient

s tr

ansi

tioni

ng fr

om h

osp

ital

to lo

ng- t

erm

car

e an

d d

evel

op a

n in

tegr

ated

pla

n fo

r ap

pro

pria

te c

are

and

p

lace

men

t

Qua

ntita

tive

Qua

lity

imp

rove

men

tA

LC p

atie

nts

NR

►

Inte

r an

d in

tra-

pro

fess

iona

l co

llab

orat

ion

is im

por

tant

to

stan

dar

dis

e d

isch

arge

pro

cess

es,

bui

ld t

rust

and

res

pec

t an

d im

pro

ve

coor

din

atio

n of

car

e

Sut

herla

nd

(201

3)45

Can

ada

Des

crib

e st

ruct

ural

cha

lleng

es t

o re

duc

e th

e im

pac

t of

ALC

pat

ient

s an

d

to p

rop

ose

pol

icy

alte

rnat

ives

tha

t co

uld

re

duc

e oc

cup

ancy

NR

Dis

cuss

ion

and

deb

ate

artic

le

ALC

pat

ient

sN

R

►A

col

lab

orat

ive

app

roac

h co

mb

inin

g th

e th

ree

stra

tegi

es

shou

ld b

e co

nsid

ered

to

add

ress

A

LC

Tab

er (2

013)

81U

SA

Test

a p

rogr

amm

e to

imp

rove

leng

th

of s

tay,

del

ayed

dis

char

ges

and

ear

ly

read

mis

sion

s fo

r ki

dne

y tr

ansp

lant

re

cip

ient

s

Qua

ntita

tive

Ob

serv

atio

nal s

tud

yA

dul

t ki

dne

y tr

ansp

lant

rec

ipie

nts

476

►

Imp

rovi

ng m

edic

atio

n sa

fety

pos

t ki

dne

y tr

ansp

lant

can

imp

rove

cl

inic

al o

utco

mes

(acu

te r

ejec

tion

and

infe

ctio

n ra

tes,

rea

dm

issi

on

rate

s)

Ud

ayai

(201

2)82

Ind

iaR

educ

e p

atie

nt d

isch

arge

tim

e th

roug

h a

Six

Sig

ma

pro

ject

Qua

ntita

tive

Tim

e m

otio

n st

udy

Cas

h p

atie

nts

NR

►

Imp

rovi

ng d

isch

arge

tim

e al

low

ed

for

mor

e p

atie

nts

to b

e m

anag

ed,

imp

rovi

ng r

even

ue

►Le

ader

ship

sup

por

t an

d e

mp

loye

e p

artic

ipat

ion

wer

e es

sent

ial f

or

succ

ess

Will

iam

s (2

010)

52A

ustr

alia

Exa

min

e th

e im

pac

t of

a c

ritic

al c

are

outr

each

ser

vice

on

freq

uenc

y of

d

isch

arge

del

ay fr

om t

he in

tens

ive

care

un

it

Qua

ntita

tive

Pro

spec

tive

coho

rt

stud

y

Pat

ient

s d

isch

arge

d fr

om t

he IC

U11

23

►Th

e cr

itica

l car

e ou

trea

ch r

ole

did

no

t d

ecre

ase

del

ayed

dis

char

ges

►

Red

ucin

g d

elay

s r e

qui

res

a co

llab

orat

ive

app

roac

h fo

cusi

ng o

n ho

spita

l flow

, rat

her

than

just

the

d

isch

arge

pro

cess

Youn

is (2

011)

53U

KC

omp

are

the

effe

ct o

f an

enha

nced

re

cove

ry p

rogr

amm

e w

ith p

reop

erat

ive

stom

a ed

ucat

ion

on t

he n

umb

er o

f p

atie

nts

with

pro

long

ed h

osp

ital s

tay

Qua

ntita

tive

Pro

spec

tive

stud

yP

atie

nts

und

ergo

ing

ante

rior

rese

ctio

n w

ith t

he fo

rmat

ion

of a

lo

op il

eost

omy

120

►

Pre

- op

erat

ivel

y in

tegr

atin

g st

oma

man

agem

ent

educ

atio

n in

to a

n en

hanc

ed r

ecov

ery

pro

gram

me

can

red

uce

del

ayed

dis

char

ges

Gre

y lit

erat

ure

Ano

nym

ous

(200

8)99

US

AC

reat

e an

exp

edite

d d

isch

arge

fund

to

pay

for

good

s an

d s

ervi

ces

inhi

biti

ng a

p

atie

nt’s

dis

char

ge (m

edic

al e

qui

pm

ent,

m

edic

atio

n an

d t

rans

por

tatio

n)

N/A

New

s ar

ticle

Uni

nsur

ed p

atie

nts

NR

►

Pat

ient

s ca

n b

e sa

fely

dis

char

ged

th

roug

h su

pp

ort

from

the

dis

char

ge

fund

Ano

nym

ous

(201

0)46

US

AIm

pro

ve p

atie

nt fl

ow t

hrou

gh in

itiat

ives

th

at d

ecre

ase

leng

th o

f sta

y an

d

incr

ease

cap

acity

N/A

New

s ar

ticle

NR

NR

►

NR

Tab

le 2

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

11Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

(yea

r)C

oun

try

Ob

ject

ive

Met

hod

Stu

dy

des

ign

Par

tici

pan

tsS

amp

le s

ize

Key

co

nclu

sio

ns

Cal

vele

y (2

007)

83U

KC

reat

e a

tier

of s

upp

ort

to r

educ

e th

e un

nece

ssar

y an

d c

ostly

occ

upat

ion

of

hosp

ital b

eds

N/A

Rev

iew

NR

NR

►

Hea

lthca

re s

olut

ions

sho

uld

be

dev

elop

ed in

par

tner

ship

with

he

alth

and

com

mun

ity s

ervi

ce

pro

vid

ers

Man

zano

- S

anta

ella

(2

009)

100

UK

Ana

lyse

the

rel

atio

nshi

p b

etw

een

Pay

men

t b

y R

esul

ts a

nd t

he D

elay

ed

Dis

char

ges

Act

N/A

Pol

icy

anal

ysis

NR

NR

►

Qua

ntita

tive

mea

sure

s (d

ays

del

ayed

and

cos

ts) c

onfli

ct w

ith t

he

soci

al a

spec

ts o

f ove

rall

heal

th a

nd

wel

l- b

eing

Kry

stal

(201

9)86

Can

ada

NR

Mix

ed m

etho

ds

Con

tinuo

us q

ualit

y im

pro

vem

ent

and

ev

alua

tion

Med

ical

ly a

nd s

ocia

lly c

omp

lex

and

fr

ail e

lder

ly10

0+

►E

ngag

ing

par

tner

s ea

rly in

the

co

ncep

tion

of t

he p

rogr

amm

e w

as

criti

cal t

o its

suc

cess

Wal

ker

(201

1)2

Can

ada

Dev

elop

rec

omm

end

atio

ns o

f car

e fo

r fr

ail C

anad

ians

N/A

N/A

NR

NR

►

Com

mun

ity s

upp

orts

sho

uld

be

incr

ease

d t

o ke

ep p

eop

le in

the

ir ho

me

as lo

ng a

s p

ossi

ble

►

Pro

gram

mes

and

ser

vice

s sh

ould

b

e ai

med

at

rest

orat

ion

and

re

activ

atio

n

Nor

th W

est

Com

mun

ity

Car

e A

cces

s C

entr

e (2

011)

88

Can

ada

Cre

ate

a fa

ct s

heet

of t

he b

enefi

ts o

f st

ayin

g at

hom

e an

d u

sing

Wai

t at

H

ome

(enh

ance

d h

ome

care

ser

vice

s w

hile

peo

ple

wai

t fo

r lo

ng- t

erm

car

e)

N/A

N/A

Sen

iors

wai

ting

for

LTC

pla

cem

ent

NR

►

Sta

ying

hom

e p

rovi

des

ben

efits

fo

r se

nior

s in

clud

ing

few

er r

isks

(g

erm

s/ v

iruse

s) a

nd a

fam

iliar

se

ttin

g co

mp

ared

with

the

hos

pita

l

Toro

nto

Cen

tral

C

omm

unity

C

are

Acc

ess

Cen

tre

(201

5)67

Can

ada

NR

N/A

N/A

NR

NR

►

This

fram

ewor

k ca

n he

lp im

pro

ve

resu

lts a

roun

d A

LC a

void

ance

and

m

anag

emen

t

Pro

vinc

e of

N

ew B

runs

wic

k (2

017)

92

Can

ada

Iden

tify

prio

rity

stra

tegi

c in

itiat

ives

and

im

ple

men

t co

mm

unity

sup

por

t or

der

s ac

ross

the

pro

vinc

e

N/A

Ann

ual r

epor

tN

RN

R

►N

R

NH

S

Imp

rove

men

t (2

018)

104

UK

Cre

ate

a ho

w- t

o gu

ide

exp

lain

ing

imp

lem

enta

tion

app

roac

hes

to r

educ

e le

ngth

of s

tay

N/A

Gui

de

NR

NR

►

Clin

ical

lead

ersh

ip is

ess

entia

l for

im

ple

men

ting

thes

e in

itiat

ives

Sta

rr-

Hem

bur

row

(2

010)

91

Can

ada

Imp

rove

pat

ient

flow

thr

ough

the

im

ple

men

tatio

n of

cha

nge

man

agem

ent

initi

ativ

es

Qua

ntita

tive

Qua

lity

imp

rove

men

tN

RN

R

►C

ultu

re c

hang

e re

qui

res

sup

por

t an

d a

tten

tion

to b

e su

stai

ned

ove

r tim

e

LHIN

C

olla

bor

ativ

e (2

011)

87

Can

ada

Hel

p s

upp

ort

pat

ient

s in

the

ir ho

mes

for

as lo

ng a

s p

ossi

ble

by

pro

vid

ing

them

w

ith c

omm

unity

sup

por

ts

N/A

Imp

lem

enta

tion

guid

e an

d t

oolk

it

Pat

ient

s (s

pec

ifica

lly h

igh

need

s se

nior

s)N

R

►H

ome

Firs

t sh

ould

be

imp

lem

ente

d

as a

sys

tem

- wid

e ap

pro

ach

Tab

le 2

C

ontin

ued

Con

tinue

d

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j.com/

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J Open: first published as 10.1136/bm

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Open access

Aut

hor

(yea

r)C

oun

try

Ob

ject

ive

Met

hod

Stu

dy

des

ign

Par

tici

pan

tsS

amp

le s

ize

Key

co

nclu

sio

ns

Sha

h (2

011)

90C

anad

aE

nsur

e th

e ap

pro

pria

te c

omm

unity

re

sour

ces

are

in p

lace

to

sup

por

t th

e p

atie

nt o

n d

isch

arge

N/A

Imp

lem

enta

tion

guid

e an

d t

oolk

it

Hig

h ne

ed s

enio

rs (7

5+)

NR

►

Key

suc

cess

fact

ors

incl

uded

: el

imin

atin

g lo

ng d

isch

arge

p

roce

sses

, hav

ing

enga

ged

le

ader

ship

, hav

ing

mea

sura

ble

ta

rget

s, m

onito

ring

per

form

ance

an

d e

duc

atin

g p

atie

nts

and

p

rovi

der

s

Cen

tral

Eas

t LH

IN A

LC T

ask

Gro

up (2

008)

84

Can

ada

Und

erst

and

the

imp

act

of d

elay

ed

dis

char

ges

in t

he C

entr

al E

ast

regi

ons

of

Ont

ario

(rev

iew

ing

dat

a, r

ead

ing

rep

orts

, in

itiat

ing

a p

ilot

stud

y, d

evel

opin

g a

pat

ient

flow

map

)

N/A

Rep

ort

ALC

pat

ient

sN

R

►A

LC is

a c

omp

lex

issu

e an

d

req

uire

s co

ord

inat

ion

acro

ss

sect

ors

►

Imp

lem

enta

tion

of t

he

reco

mm

end

atio

ns w

ill h

elp

to

red

uce

ALC

day

s an

d im

pro

ve

pat

ient

flow

Ad

ams,

Car

e &

R

epai

r E

ngla

nd

(201

7)98

UK

Ass

ist

old

er p

atie

nts

in r

etur

ning

hom

e fr

om h

osp

ital q

uick

ly a

nd s

afel

yC

ase

stud

yC

ase

stud

yO

lder

pat

ient

s1

►

Larg

e sa

ving

s fo

r th

e he

alth

sy

stem

can

be

gene

rate

d w

ith t

he

imp

lem

enta

tion

of t

his

inte

rven

tion

Sha

h (2

010)

89C

anad

aD

escr

ibe

the

Hom

e Fi

rst

app

roac

h, a

p

hilo

sop

hy fo

r re

duc

ing

ALC

Qua

ntita

tive

Qua

lity

imp

rove

men

tE

lder

ly p

atie

nts

NR

►

Allo

ws

pat

ient

s th

e op

por

tuni

ty t

o re

gain

ind

epen

den

ce a

nd r

etur

n ho

me

►

ALC

sol

utio

ns n

eed

a c

olla

bor

ativ

e,

cros

s- se

ctor

al a

pp

roac

h

Join

t Im

pro

vem

ent

Team

(201

3)85

Sco

tland

Iden

tify

10 a

ctio

n ite

ms

to t

rans

form

d

isch

arge

pro

cess

esN

/AQ

ualit

y im

pro

vem

ent/

st

akeh

old

er

enga

gem

ent

N/A

NR

►

Ther

e ar

e a

num

ber

of f

acto

rs t

o su

cces

sful

ly r

educ

e d

elay

s

ALC

, alte

rnat

e le

vel o

f car

e; B

IRU

, bra

in in

jury

reh

abili

tatio

n un

it; G

M, g

eria

tric

med

icin

e; IC

U, i

nten

sive

car

e un

it; N

/A, n

ot a

pp

licab

le; N

R, n

ot r

epor

ted

; OA

P, o

ld a

ge p

sych

iatr

y; S

RU

, str

oke

reha

bili

tatio

n un

it.

Tab

le 2

C

ontin

ued

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j.com/

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jopen-2020-044291 on 11 February 2021. D

ownloaded from

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Open access

Tab

le 3

In

itiat

ive

char

acte

ristic

s

Aut

hor

Init

iati

veD

escr

ipti

on/

cont

ent

Targ

et p

op

ulat

ion

Set

ting

Init

iati

ve

cate

go

ry*

Res

ults

Dat

abas

e S

earc

hes

Ad

lingt

on40

Qua

lity

imp

rove

men

t p

rogr

amm

e

►W

eekl

y q

ualit

y im

pro

vem

ent

mee

tings

with

d

river

dia

gram

s to

imp

lem

ent

Pla

n D

o S

tud

y A

ct c

ycle

s

Old

er a

dul

ts (>

65) o

n p

sych

iatr

ic w

ard

Hos

pita

lM

ile E

nd H

osp

ital

(Lea

den

hall

War

d),

26 b

eds

Info

rmat

ion

shar

ing

live

►

Leng

th o

f sta

y w

as r

educ

ed fr

om a

n av

erag

e of

47

day

s to

30

day

s

►B

ed o

ccup

ancy

was

red

uced

from

77%

to

54%

Ard

agh63

10 p

rom

isin

g in

itiat

ives

►

Sp

ecia

l bed

s, h

osp

ital o

per

atio

ns p

lann

ing,

d

isch

arge

pla

nnin

g, a

cces

s to

imag

ing,

re

spon

sive

acu

te s

econ

dar

y se

rvic

es,

pat

hway

s fo

r ac

ute

pat

ient

s, a

cute

dem

and

m

itiga

tion,

enh

ance

d E

D la

yout

, enh

ance

d E

D

seni

or s

taffi

ng, e

ngag

emen

t of

sta

ff

NR

Hos

pita

lsTo

ols

and

gu

idel

ines

Pra

ctic

e ch

ange

s

►

Iden

tified

top

10

chal

leng

es a

nd 1

0 p

rom

isin

g in

itiat

ives

rel

ated

to

pat

ient

flow

and

em

erge

ncy

dep

artm

ent

over

crow

din

g

Are

ndts

68A

llied

hea

lth a

sses

smen

t

►A

com

pr e

hens

ive

asse

ssm

ent

of p

atie

nts

by

an a

llied

hea

lth t

eam

with

in h

ours

of

pre

sent

atio

n to

the

hos

pita

l thr

ough

the

em

erge

ncy

dep

artm

ent

Pat

ient

s (>

65)

dia

gnos

ed w

ith

one

or m

ore

of

six

pre

det

erm

ined

co

nditi

ons

Hos

pita

lsTw

o A

ustr

alia

n te

rtia

ry

hosp

itals

Pra

ctic

e ch

ange

s

►N

o b

enefi

t in

red

ucin

g ho

spita

l len

gth

of s

tay

Bau

man

n55N

/A ►

Qua

litat

ive

stud

y to

iden

tify

fact

ors

asso

ciat

ed

with

low

rat

es o

f del

ayed

dis

char

ges

Hea

lth/

soci

al

serv

ices

sta

ff w

ith m

anag

eria

l in

volv

emen

t in

d

isch

arge

s

Hos

pita

ls (6

site

s)4

sout

hern

site

s, 2

nor

ther

n si

tes

Initi

ativ

es

des

crib

ed t

ouch

on

all

cate

gorie

s

►

6 hi

gh- p

erfo

rmin

g ho

spita

l site

s id

entifi

ed

issu

es im

pac

ting

del

ayed

dis

char

ges

(cap

acity

, int

erna

l hos

pita

l effi

cien

cies

and

in

tera

genc

y ef

ficie

ncie

s)

►R

esou

rces

and

tea

ms

to p

reve

nt a

void

able

ad

mis

sion

s

►D

isch

arge

tea

ms

to s

upp

ort

nurs

es'

dis

char

ge p

lann

ing,

►

Sys

tem

s fo

r m

onito

ring

and

com

mun

icat

ing

pat

ient

s' p

rogr

ess,

►

Pat

ient

cho

ice

pro

toco

ls

►E

nsur

e av

aila

bili

ty o

f res

pon

sive

tr

ansp

orta

tion

and

dis

char

ge lo

unge

s

Beh

an93

Com

mun

ity C

are

(Del

ayed

Dis

char

ge) A

ct 2

003

►

Loca

l aut

horit

ies

are

finan

cial

ly r

esp

onsi

ble

(p

aym

ents

) to

acut

e ho

spita

l whe

n p

atie

nts

rem

ain

in h

osp

ital b

ecau

se c

omm

unity

car

e ar

rang

emen

ts h

ave

not

bee

n m

ade

NR

7 ar

eas

acro

ss t

he U

KIn

fras

truc

ture

and

fin

ance

►

Nat

iona

l dec

reas

e in

del

ayed

dis

char

ges

bet

wee

n 20

03 a

nd 2

004

Bél

and

69In

tegr

ated

car

e

►C

omm

unity

- bas

ed m

ultid

isci

plin

ary

team

s w

ho

pr o

vid

e in

tegr

ated

car

e an

d c

oord

inat

e he

alth

an

d s

ocia

l ser

vice

Frai

l eld

erly

Com

mun

ity s

ervi

ce c

entr

es/

orga

nisa

tions

Pra

ctic

e ch

ange

s

►S

igni

fican

t (5

0%) r

educ

tion

in t

he n

umb

er

of p

atie

nts

in t

he in

tegr

ated

car

e gr

oup

tha

t b

ecam

e A

LC

►N

o si

gnifi

cant

diff

eren

ces

in u

tilis

atio

n or

co

sts

bet

wee

n gr

oup

s

►In

crea

sed

car

egiv

er s

atis

fact

ion

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

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Open access

Aut

hor

Init

iati

veD

escr

ipti

on/

cont

ent

Targ

et p

op

ulat

ion

Set

ting

Init

iati

ve

cate

go

ry*

Res

ults

Ble

cker

707

day

hos

pita

l ini

tiativ

e

►In

crea

sed

hos

pita

l ser

vice

s on

the

wee

kend

(e

g, d

iagn

ostic

imag

ing,

wee

kend

dis

char

ges,

p

hysi

cian

and

car

e m

anag

emen

t se

rvic

es)

Non

- ob

stet

ric

hosp

italis

ed p

atie

nts

Hos

pita

lTi

sch

Hos

pita

l, 70

5 b

eds

Pra

ctic

e ch

ange

s

►D

ecre

ased

ave

rage

leng

th o

f sta

y b

y 13

%

►In

crea

sed

pro

por

tion

of w

eeke

nd d

isch

arge

s b

y 12

%

►D

ecre

ased

30-

day

rea

dm

issi

ons

►

No

chan

ges

in m

orta

lity

Bou

tett

e71S

ubac

ute

care

uni

t fo

r fr

ail e

lder

ly

►S

ubac

ute

car e

in a

res

tora

tive

envi

ronm

ent

(inte

grat

ed c

are

and

res

tora

tion)

Frai

l old

er p

atie

nts

who

are

at

risk

of

dec

ond

ition

ing

asso

ciat

ed w

ith a

lo

ng h

osp

italis

atio

n

Hos

pita

lsO

ttaw

a H

osp

ital;

Per

ley

and

R

idea

u Ve

tera

ns’ H

ealth

C

entr

e

Pra

ctic

e ch

ange

s

►N

/A

Bow

en72

Nur

se- l

ed d

isch

arge

►

Allo

ws

nurs

es t

o fa

cilit

ate

dis

char

ge b

ased

on

sp

ecifi

c cr

iteria

tha

t w

as d

evel

oped

to

guid

e th

e d

isch

arge

pro

cess

(als

o al

low

s fo

r d

isch

arge

in e

veni

ngs

and

on

wee

kend

s)

Ad

ult

ear,

nose

, th

roat

pat

ient

s ha

ving

ro

utin

e, e

lect

ive,

sh

ort-

stay

sur

gery

Hos

pita

lU

nive

rsity

Hos

pita

l of S

outh

M

anch

este

r

Pra

ctic

e ch

ange

s

►S

igni

fican

t re

duc

tion

in r

ate

of d

elay

ed

dis

char

ges

in b

oth

aud

its

Boy

d41

Com

mun

icat

ion

and

lead

ersh

ip

►E

ffici

ent

com

mun

icat

ion

and

lead

ersh

ip fr

om

hosp

ital a

dm

inis

trat

ors

NR

Hos

pita

ls (2

)P

art

of a

hos

pita

l co

nglo

mer

ate

in C

hica

go

Info

rmat

ion

shar

ing

live

►

Str

ateg

ies

for

imp

rovi

ng d

elay

ed d

isch

arge

s an

d r

educ

ing

finan

cial

bur

den

incl

uded

ef

ficie

nt c

omm

unic

atio

n an

d e

ffect

ive

lead

ersh

ip

Bra

nklin

e47Te

chno

logy

- ass

iste

d r

efer

rals

►

The

use

of t

echn

olog

y to

imp

r ove

info

rmat

ion

exch

ange

and

pro

cess

es, i

ncre

ase

dat

a ac

cura

cy a

nd p

rod

uce

doc

umen

ts

Eld

erly

pat

ient

s w

ho

req

uire

nur

sing

hom

e p

lace

men

t af

ter

hosp

ital d

isch

arge

Aca

dem

ic M

edic

al C

entr

eIn

form

atio

n sh

arin

g liv

eTo

ols

and

gu

idel

ines

►

Dec

reas

ed le

ngth

of s

tay

and

imp

rove

d

timel

y d

isch

arge

s of

pat

ient

s re

sulte

d in

cos

t sa

ving

s

►In

crea

sed

com

mun

icat

ion

with

in a

nd b

etw

een

the

hosp

ital a

nd n

ursi

ng h

omes

Bro

wn64

Dis

char

ge c

riter

ia

►N

urse

imp

lem

enta

tion

of p

red

eter

min

ed

dis

char

ge c

riter

ia (a

ctiv

ity, r

esp

iratio

ns, p

ulse

, b

lood

pre

ssur

e, p

ain,

etc

)

Ad

ult,

AS

A p

hysi

cal

stat

us I,

II, a

nd II

I p

atie

nts,

18

year

s or

old

er, r

equi

ring

gene

ral a

naes

thes

ia

Hos

pita

lP

osto

per

ativ

e re

cove

ry a

rea

of a

larg

e, t

ertia

ry- c

are,

ac

adem

ic h

osp

ital

Tool

s an

d

guid

elin

esP

ract

ice

chan

ges

►

Dec

reas

ed le

ngth

of s

tay

in t

he p

ost-

an

aest

hesi

a ca

re u

nit

by

24%

►

Red

uced

dis

char

ge d

elay

s w

ith n

urse

- led

d

isch

arge

►

No

chan

ge in

ad

vers

e ev

ents

(airw

ay

obst

ruct

ion,

rei

ntub

atio

n, a

rres

t)

Bur

r56A

LC a

void

ance

fram

ewor

k

►A

fram

ewor

k of

str

ateg

ies

to r

educ

e A

LC

num

ber

s an

d p

rom

ote

ALC

avo

idan

ce

ALC

pat

ient

sH

osp

itals

(3)

1.

Mic

hael

Gar

ron

Hos

pita

l2.

H

umb

er R

iver

Hos

pita

l3.

To

ront

o G

ener

al H

osp

ital

Tool

s an

d

guid

elin

es

►(1

) MG

H—

exce

eded

ALC

tar

get

by

20%

, re

duc

ed n

umb

er o

f ALC

pat

ient

s w

aitin

g fo

r lo

ng- t

erm

car

e

►(2

) HR

H—

cultu

re s

hift

aft

er im

ple

men

tatio

n of

A

LC fr

amew

ork

reco

mm

end

atio

ns

►(3

) TG

H—

imp

rove

d n

umb

er o

f ALC

ad

mis

sion

av

oid

ance

cas

es

Cam

initi

42P

hysi

cian

acc

ount

abili

ty

►P

hysi

cian

mot

ivat

ion

and

acc

ount

abili

ty

thr o

ugh

mon

thly

rep

orts

and

aud

its (c

an

com

par

e th

eir

leng

th o

f sta

y re

sults

to

othe

r st

aff)

Hos

pita

l Uni

ts:

geria

tric

, med

icin

e,

long

- ter

m c

are

Hos

pita

lU

nive

rsity

Hos

pita

l of P

arm

a,

1267

bed

s

Info

rmat

ion

shar

ing

live

►

Red

uctio

n in

unn

eces

sary

, avo

idab

le h

osp

ital

day

s

►N

o si

gnifi

cant

cha

nges

in 3

0- d

ay r

ead

mis

sion

or

mor

talit

y

Tab

le 3

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

15Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

Init

iati

veD

escr

ipti

on/

cont

ent

Targ

et p

op

ulat

ion

Set

ting

Init

iati

ve

cate

go

ry*

Res

ults

Chi

dw

ick54

Cha

nge

idea

s

►Id

entifi

catio

n of

cha

nge

conc

epts

, fol

low

ed

by

the

dev

elop

men

t an

d im

ple

men

tatio

n of

ch

ange

idea

s to

pro

mot

e b

ehav

iour

cha

nge

ALC

pat

ient

sH

osp

ital

Will

iam

Osl

er H

ealth

Sys

tem

Pra

ctic

e ch

ange

sTo

ols

and

gu

idel

ines

Info

rmat

ion

shar

ing

live

►

Low

est

ALC

day

s in

Ont

ario

►

Elim

inat

ed e

thic

al e

rror

s, im

pro

ved

pat

ient

d

isch

arge

exp

erie

nce

and

dec

reas

ed p

atie

nt

conf

usio

n

El-

Eid

73H

osp

ital t

hrou

ghp

ut p

roje

ct u

sing

Six

Sig

ma

Met

hod

olog

y

►Th

e us

e of

Six

Sig

ma

Met

hod

olog

y to

im

ple

men

t el

ectr

onic

pat

ient

req

uest

s, a

floo

r cl

erk

and

a b

illin

g of

ficer

NR

Hos

pita

l (te

rtia

ry c

are

teac

hing

hos

pita

l)A

mer

ican

Uni

vers

ity o

f Bei

rut

Med

ical

Cen

tre,

386

bed

s

Pra

ctic

e ch

ange

s

►S

igni

fican

t re

duc

tion

in le

ngth

of s

tay

pos

t- in

terv

entio

n

►D

ecre

ased

dis

char

ge t

ime

(2.2

hou

rs t

o 1.

7 ho

urs)

Gau

ghan

101

Incr

easi

ng s

upp

ly o

f nur

sing

hom

e b

eds

►

The

use

of m

odel

ling

to e

xplo

re t

he e

ffect

of

incr

ease

d s

upp

ly o

f nur

sing

hom

e b

eds

or

low

er p

rices

of n

ursi

ng h

ome

bed

s on

bed

b

lock

ing

Pat

ient

s w

aitin

g fo

r ho

spita

l dis

char

geH

osp

ital

Oth

er in

itiat

ive

►

Incr

easi

ng h

ome

care

bed

s b

y 10

% w

ould

d

ecre

ase

soci

al c

are

del

ayed

dis

char

ges

by

6%–9

%

Gra

ham

74N

urse

- led

dis

char

ge

►N

urse

- led

dis

char

ge fo

llow

ing

list

of c

riter

ia

(that

eac

h p

atie

nt m

ust

mee

t)

Pat

ient

s re

ceiv

ing

lap

aros

cop

ic

chol

ecys

tect

omy

and

la

par

osco

pic

ingu

inal

he

rnia

rep

air

Hos

pita

lLe

ices

ter

Roy

al In

firm

ary

Pra

ctic

e ch

ange

s

►N

urse

- led

dis

char

ge g

roup

wer

e si

gnifi

cant

ly

mor

e lik

ely

to b

e d

isch

arge

d o

n th

e d

ay o

f su

rger

y

►N

o si

gnifi

cant

diff

eren

ce in

rea

dm

issi

on

rate

s or

pat

ient

s se

ekin

g p

rimar

y ca

re

pos

tdis

char

ge

Gut

man

is65

Beh

avio

ural

Sup

por

ts O

ntar

io

►A

qua

lity

imp

rove

men

t in

itiat

ive

for

old

er

adul

ts w

ith r

esp

onsi

ve b

ehav

iour

s th

roug

h th

e id

entifi

catio

n of

cha

nge

stra

tegi

es a

nd

know

led

ge t

rans

latio

n b

est

pra

ctic

es

Ind

ivid

uals

with

re

spon

sive

b

ehav

iour

s

Sou

th W

est

LHIN

Pra

ctic

e ch

ange

sTo

ols

and

gu

idel

ines

►

Dec

reas

ed A

LC c

are

case

s am

ong

per

sons

w

ith b

ehav

iour

al n

eed

s

►Im

pro

ved

per

cep

tions

from

fam

ilies

and

cl

ient

s ar

ound

pat

ient

car

e

Hen

woo

d48

Cha

nge

Age

nt T

eam

►

A t

eam

par

tner

ship

bet

wee

n he

alth

and

soc

ial

care

to

exp

lore

the

issu

es a

roun

d d

elay

ed

dis

char

ges

Inp

atie

nts

Info

rmat

ion

shar

ing

live

Tool

s an

d

guid

elin

es

►

The

Cha

nge

Age

nt T

eam

hel

ped

sup

por

t im

ple

men

tatio

n of

con

tinge

ncy

arra

ngem

ents

at

the

loca

l lev

el

Hol

land

57Tr

acki

ng a

nd r

epor

ting

syst

em

►D

evel

opm

ent

and

eva

luat

ion

of a

dis

char

ge

del

ay t

rack

ing

and

rep

ortin

g m

echa

nism

Inp

atie

nts

Hos

pita

l (ac

adem

ic m

edic

al

cent

re)

Tool

s an

d

guid

elin

es

►In

div

idua

l pat

ient

dis

char

ges

may

be

imp

rove

d b

y tr

acki

ng fa

ctor

s th

at c

ause

d

elay

s

►N

urse

s to

ok t

he t

ime

to p

rovi

de

com

men

ts

rega

rdin

g p

atie

nt d

elay

s

Kat

salia

ki10

2In

term

edia

te c

are

serv

ices

►

Sta

tistic

al s

imul

atio

ns t

o in

vest

igat

e p

oten

tial

care

pat

hway

s an

d a

ssoc

iate

d c

osts

Inp

atie

nts

Ham

psh

ire S

ocia

l Ser

vice

sO

ther

initi

ativ

e

►50

0 ne

w p

lace

s w

ill h

elp

to

bal

ance

the

d

eman

d a

nd c

apac

ity fo

r in

term

edia

te c

are

serv

ices

by

avoi

din

g a

det

erio

ratio

n of

del

ay

times

Tab

le 3

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

16 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

Init

iati

veD

escr

ipti

on/

cont

ent

Targ

et p

op

ulat

ion

Set

ting

Init

iati

ve

cate

go

ry*

Res

ults

Lees

- Deu

tsch

66C

riter

ia le

d d

isch

arge

- S

elec

tion

of P

atie

nts

for

Effi

cien

t an

d E

ffect

ive

Dis

char

ge

►P

atie

nt d

isch

arge

is g

uid

ed b

y a

set

of c

linic

al

crite

ria; o

nce

the

pat

ient

mee

ts t

he c

riter

ia, a

m

emb

er o

f the

tea

m c

an fa

cilit

ate

dis

char

ge

Pat

ient

s d

isch

arge

d

from

the

AM

U a

nd

bot

h sh

ort-

stay

war

ds

Hos

pita

l (ac

ute

med

icin

e se

rvic

e w

ith fo

ur c

linic

al

area

s)

Tool

s an

d

guid

elin

esP

ract

ice

chan

ges

►

27 p

atie

nts

wer

e su

itab

le fo

r cr

iteria

led

d

isch

arge

, 23

wer

e no

t

►M

ean

wai

t tim

e fo

r th

e 27

sui

tab

le p

atie

nts

prio

r to

dis

char

ge w

as 4

hou

rs a

nd 5

1 m

in

►D

isch

arge

del

ays

wer

e of

ten

caus

ed b

y sy

stem

del

ays

Levi

n94S

tep

- up

inte

rmed

iate

car

e un

its

►A

brid

ging

ser

vice

bet

wee

n ho

spita

l and

hom

e fo

r in

div

idua

ls r

ead

y fo

r d

isch

arge

from

acu

te

care

; allo

ws

for

reco

very

and

reg

aini

ng o

f in

dep

end

ence

Age

d 7

5+H

osp

ital

Infr

astr

uctu

re a

nd

finan

ce

►R

educ

ed b

ed d

ays

del

ayed

►

Rat

e of

day

s d

elay

ed in

crea

sed

ove

r tim

e

Lian

58N

ew d

isch

arge

gui

del

ines

for

pre

mat

ure

bab

ies

►

Dev

elop

men

t of

new

dis

char

ge g

uid

elin

es fo

r p

rem

atur

e ne

onat

es

Pre

mat

ure

infa

nts

Hos

pita

lS

inga

por

e G

ener

al H

osp

ital

Tool

s an

d

guid

elin

es

►R

educ

ed m

edia

n d

urat

ion

of h

osp

italis

atio

n fr

om 5

8.2

day

s to

34.

9 d

ays

►

Cos

t sa

ving

s of

$61

74/in

fant

Mae

ssen

75E

nhan

ced

rec

over

y af

ter

surg

ery

►

Red

uctio

n in

the

pos

top

erat

ive

r eco

very

per

iod

to

red

uce

over

all h

osp

ital l

engt

h of

sta

y

Pat

ient

s un

der

goin

g el

ectiv

e co

lore

ctal

re

sect

ion

Hos

pita

lP

ract

ice

chan

ges

►

No

sign

ifica

nt d

iffer

ence

in p

rop

ortio

n of

p

atie

nts

with

a d

isch

arge

del

ay p

ost-

ER

AS

p

r ogr

amm

e

►A

pp

roxi

mat

ely

90%

of p

atie

nts

pre

and

p

ost-

ER

AS

wer

e no

t d

isch

arge

d o

n th

e d

ay

dis

char

ge c

riter

ia/

func

tiona

l rec

over

y w

ere

met

Mah

ant

(200

8)59

Med

ical

Car

e A

pp

rop

riate

ness

Pro

toco

- aud

it an

d

feed

bac

k

►A

too

l tha

t p

rovi

des

info

rmat

ion

on h

osp

ital

bed

use

(qua

lified

and

non

qua

lified

hos

pita

l d

ays)

Pae

dia

tric

inp

atie

nts

Hos

pita

lH

osp

ital f

or S

ick

Chi

ldre

nTo

ols

and

gu

idel

ines

►

Sig

nific

antly

low

er r

isk

of in

app

rop

riate

ho

spita

l day

s

►D

urin

g th

e in

terv

entio

n, 3

3% o

f bed

day

s w

ere

nonq

ualifi

ed, c

omp

ared

with

47%

pre

- in

terv

entio

n

►N

o ch

ange

in 4

8- ho

ur r

ead

mis

sion

rat

e

Mah

to 76

Hos

pita

l dia

bet

es o

utre

ach

serv

ice

►

A s

ervi

ce t

o p

reve

nt a

dm

issi

on t

hrou

gh a

nu

mb

er o

f str

ateg

ies

(imp

rove

d a

cces

s to

se

rvic

es, m

anag

emen

t of

med

ical

pro

ble

ms,

ea

rly d

isch

arge

pla

nnin

g, o

rgan

isat

ion

of

follo

w- u

p c

are)

Acu

tely

ad

mitt

ed

pat

ient

s w

ith d

iab

etes

Hos

pita

lN

ew C

ross

Hos

pita

l, 70

0 b

eds

Pra

ctic

e ch

ange

s

►R

educ

tion

in b

ed o

ccup

ancy

, ina

pp

rop

riate

ad

mis

sion

s, d

elay

ed d

isch

arge

s an

d e

ffect

ive

dis

char

ge p

lann

ing

Mal

oney

49P

atie

nt t

rack

er

►A

web

- bas

ed a

pp

licat

ion

to fa

cilit

ate

the

dis

char

ge p

roce

ss b

y en

hanc

ing

com

mun

icat

ion

bet

wee

n d

isci

plin

es

Inp

atie

nts

Hos

pita

lP

rimar

y C

hild

ren’

s M

edic

al

Cen

tre

Tool

s an

d

guid

elin

esIn

form

atio

n sh

arin

g liv

e

►

Dec

reas

ed n

umb

er o

f can

celle

d s

urge

ries,

m

edia

n em

erge

ncy

dep

artm

ent

leng

th o

f sta

y an

d a

vera

ge n

umb

er o

f inp

atie

nt a

dm

issi

ons

Man

ville

95Tr

ansi

tiona

l car

e un

it

►A

reh

abili

tatio

n- st

yle

unit

with

enh

ance

d

nurs

ing

and

reh

abili

tatio

n se

rvic

es fo

r el

der

ly

pat

ient

s

Eld

erly

ALC

pat

ient

s (7

0+)

Hos

pita

lS

t Jo

sep

h’s

Hos

pita

l, 22

- bed

tr

ansi

tiona

l car

e un

it

Infr

astr

uctu

re a

nd

finan

ce

►Im

pro

ved

hea

lth o

utco

mes

and

dis

char

ge

dis

pos

ition

, dec

reas

ed le

ngth

of s

tay

and

co

sts

per

pat

ient

Tab

le 3

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

17Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

Init

iati

veD

escr

ipti

on/

cont

ent

Targ

et p

op

ulat

ion

Set

ting

Init

iati

ve

cate

go

ry*

Res

ults

Mee

han77

Dis

char

ge t

o A

sses

s

►

Pat

ient

s w

ho r

equi

re c

are

sup

por

t ar

e d

isch

arge

d h

ome,

or

to t

he c

omm

unity

, fo

r a

need

s as

sess

men

t in

the

ir p

erso

nal

envi

ronm

ent

Pat

ient

s d

isch

arge

d

thro

ugh

D2A

Hos

pita

lP

ract

ice

chan

ges

►

Ass

ists

with

ear

ly a

nd e

ffect

ive

hosp

ital

dis

char

ge

►60

% o

f pat

ient

s an

d c

areg

iver

s re

por

ted

a

pos

itive

exp

erie

nce

with

D2A

►

Com

mun

icat

ion

was

not

ed a

s an

issu

e

Moe

ller

60C

ritic

al p

athw

ay

►C

riter

ia fo

r th

e m

anag

emen

t an

d d

isch

arge

of

pat

ient

s ad

mitt

ed w

ith c

omm

unity

- acq

uire

d

pne

umon

ia

Pat

ient

s w

ith

com

mun

ity- a

cqui

red

p

neum

onia

Hos

pita

lQ

ueen

Eliz

abet

h II

Hea

lth

Sci

ence

s C

entr

e, 6

37 b

eds

Tool

s an

d

guid

elin

es

►58

% o

f pat

ient

s w

ith a

pro

long

ed le

ngth

of

stay

felt

they

wer

e re

ady

to g

o ho

me

once

re

achi

ng c

linic

al s

tab

ility

, com

par

ed w

ith 9

2%

of p

atie

nts

with

out

a p

rolo

nged

leng

th o

f sta

y

►H

iera

rchi

cal A

sses

smen

t of

Bal

ance

and

M

obili

ty s

core

at

clin

ical

sta

bili

ty w

as

sign

ifica

ntly

ass

ocia

ted

with

phy

sici

ans’

an

d fa

mili

es’ a

sses

smen

t of

the

pat

ient

s’

dis

char

ge r

ead

ines

s

Mur

- Vee

man

61B

uffe

r m

anag

emen

t

►A

too

l tha

t ai

ms

to b

alan

ce p

atie

nt fl

ow

bet

wee

n ho

spita

l and

nur

sing

hom

es b

y m

axim

isin

g p

atie

nt t

hrou

ghp

ut

Bed

blo

cker

sH

osp

ital t

o nu

rsin

g ho

me

(inte

rmed

iate

car

e d

epar

tmen

t)

Tool

s an

d

guid

elin

es

►Th

e la

ck o

f coo

per

atio

n is

an

inhi

bito

r of

b

uffe

r m

anag

emen

t

►E

ffort

s sh

ould

focu

s on

imp

rovi

ng

coop

erat

ion

bet

wee

n p

rovi

der

s

Nie

mei

jer62

Lean

Six

Sig

ma

►

An

initi

ativ

e b

ased

on

Lean

Six

Sig

ma

to

red

uce

leng

th o

f sta

y, im

pro

ve d

isch

arge

p

roce

dur

es, c

reat

e ad

mis

sion

cap

acity

and

re

duc

e co

sts

Trau

ma

pat

ient

sH

osp

ital

Uni

vers

ity M

edic

al C

entr

e G

roni

ngen

, 133

9 b

eds

Tool

s an

d

guid

elin

es

►A

vera

ge le

ngth

of s

tay

of a

ll p

atie

nts

(sur

gica

l and

tra

uma)

dec

reas

ed b

y 2.

9 d

ays

pos

t- in

terv

entio

n

►A

vera

ge le

ngth

of s

tay

of t

raum

a p

atie

nts

dec

reas

ed b

y 3.

3 d

ays

Pan

is78

Dut

ch e

valu

atio

n p

roto

col

►

Alte

ring

dis

char

ge p

roce

dur

es t

o as

sess

in

app

rop

riate

hos

pita

l sta

y, e

ffici

ency

and

p

atie

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gist

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Mot

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of n

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sH

osp

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Mat

erni

ty u

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of 1

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(715

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ital b

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educ

tion

in in

app

rop

riate

pat

ient

sta

y b

y 6.

1%

►D

ecr e

ase

in le

ngth

of s

tay

by

0.7

day

s

Pat

el43

Mul

tidis

cip

linar

y te

am- b

ased

str

uctu

re fo

r d

isch

arge

rou

nds

►

Inte

rven

tions

bas

ed a

r oun

d m

ultid

isci

plin

ary

team

- bas

ed d

isch

arge

pla

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noon

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cian

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)

Dis

satis

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nive

rsity

of C

olor

ado

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pita

l, 67

3 b

eds

Info

rmat

ion

shar

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►

Hig

her

pro

por

tion

of p

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dis

char

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b

efor

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on, l

ower

leng

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d 3

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ay

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mis

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t te

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with

co

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l

Pira

ni44

Nur

se p

artic

ipat

ion

and

pat

ient

and

fam

ily

invo

lvem

ent

►

Com

mun

icat

ion

bet

wee

n th

e nu

rse

and

p

atie

nt/

fam

ily t

o p

rom

ote

cont

inui

ty o

f car

e an

d c

oord

inat

ion

of s

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ces

Thos

e ex

per

ienc

ing

del

ayed

dis

char

geN

RIn

form

atio

n sh

arin

g liv

e

►E

nhan

cing

nur

se in

volv

emen

t in

the

dis

char

ge

pla

nnin

g p

roce

ss c

an im

pro

ve d

elay

ed

dis

char

ges

Qin

103

Sim

ulat

ion

mod

ellin

g

►S

tatis

tical

sim

ulat

ions

to

exp

lore

pat

ient

flow

an

d d

iffer

ent

dis

char

ge s

trat

egie

s th

at c

ould

re

duc

e ho

spita

l occ

upan

cy

Varie

s b

ased

on

mod

elH

osp

ital

Flin

der

s M

edic

al C

entr

e (F

MC

)

Oth

er in

itiat

ive

►

Hos

pita

l occ

upan

cy c

an b

e si

gnifi

cant

ly

red

uced

, with

a r

educ

tion

from

281

.5 t

o 22

.8 d

ays

in t

he b

est

scen

ario

(ins

tant

aneo

us

dis

char

ge fo

r 24

hou

rs)

Tab

le 3

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

18 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

Init

iati

veD

escr

ipti

on/

cont

ent

Targ

et p

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ion

Set

ting

Init

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Res

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Rae

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elay

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pro

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Loca

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horit

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finan

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ly r

esp

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) to

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ture

and

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ance

►

Mea

n le

ngth

of s

tay

dec

reas

ed b

y 2.

6 d

ays

(from

6.5

to

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day

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f ser

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iver

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ed n

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ivid

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Inp

atie

nts

in t

wo

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U (s

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U (B

rain

Inju

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Reh

abili

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nit

Hos

pita

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amp

stea

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ehab

ilita

tion

Cen

tre,

128

bed

s

Tool

s an

d

guid

elin

esIn

form

atio

n sh

arin

g liv

e

►

Tota

l dis

char

ge d

elay

s fr

om t

he 2

uni

ts

tota

led

631

1 d

ays

►

Leng

th o

f sta

y w

as n

ot d

ecre

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Neg

ativ

e p

erce

ptio

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f the

pro

gram

me

from

st

aff

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pso

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inp

atie

nt s

pec

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rse

►

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bet

es m

anag

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ased

on

stru

ctur

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p e

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n, fo

r al

l dia

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pat

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folk

and

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nive

rsity

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pita

l NH

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ctic

e ch

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s

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n ex

cess

bed

day

s b

y 0.

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ays

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1.9

to

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h97C

omm

unity

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e (D

elay

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isch

arge

) Act

200

3

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cal a

utho

ritie

s ar

e fin

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ally

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pon

sib

le

(pay

men

ts) t

o ac

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hosp

ital w

hen

pat

ient

s re

mai

n in

hos

pita

l bec

ause

com

mun

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ngem

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Inp

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sp

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Age

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pita

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truc

ture

and

fin

ance

GM

:

►D

ecre

ased

med

ian

and

mea

n le

ngth

of s

tay

►

Incr

ease

d n

umb

er o

f fini

shed

ep

isod

es

(inp

atie

nt d

isch

arge

s)

►N

o re

latio

nshi

p w

ith n

umb

er o

f bed

day

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AP

:

►In

crea

sed

med

ian

and

mea

n le

ngth

of s

tay

►

Dec

reas

ed n

umb

er o

f fini

shed

ep

isod

es

(inp

atie

nt d

isch

arge

s)

►In

crea

sed

num

ber

of b

ed d

ays

Sob

otka

51H

osp

ital-

to- h

ome

tran

sitio

nal c

are

pro

gram

me

at

AH

K

►

A p

rogr

amm

e to

sup

por

t an

d e

duc

ate

fam

ilies

on

pro

vid

ing

care

for

med

ical

ly s

tab

le c

hild

ren

at h

ome

Pae

dia

tric

inp

atie

ntTr

ansi

tiona

l and

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pite

C

entr

eA

lmos

t H

ome

Kid

s

Pra

ctic

e ch

ange

sIn

form

atio

n sh

arin

g liv

e

►

2 m

onth

s fo

llow

ing

sup

por

t at

AH

K, t

he

pat

ient

tra

nsiti

oned

hom

e to

be

care

d fo

r b

y hi

s m

othe

r an

d h

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care

tea

m

Sta

rr-

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bur

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80H

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Firs

t

►A

pr o

gram

me

des

igne

d t

o he

lp k

eep

pat

ient

s in

the

ir ho

mes

(with

com

mun

ity s

upp

orts

) for

as

long

as

pos

sib

le; f

ocus

ing

on p

rovi

din

g ac

cess

to

need

ed s

ervi

ces

ALC

pat

ient

sH

osp

itals

Pra

ctic

e ch

ange

s

►R

ate

of A

LC p

atie

nts

dec

reas

ed b

y at

leas

t 50

% a

cros

s th

e re

gion

of s

tud

y

Sut

herla

nd45

Bui

ld m

ore;

Inte

grat

ed c

are;

and

Fin

anci

al

ince

ntiv

es

►Th

ree

stra

tegi

es t

o im

pro

ve A

LC im

pac

t on

ho

spita

ls (b

uild

mor

e b

eds,

inte

grat

ed c

are,

fin

anci

al in

cent

ives

for

pos

t- ac

ute

pro

vid

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ALC

pat

ient

sH

osp

itals

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rmat

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shar

ing

reco

mm

end

atio

n d

ocum

ent

►

N/A

Tab

le 3

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

19Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

Init

iati

veD

escr

ipti

on/

cont

ent

Targ

et p

op

ulat

ion

Set

ting

Init

iati

ve

cate

go

ry*

Res

ults

Tab

er81

Com

pre

hens

ive

inte

rdis

cip

linar

y im

pro

vem

ent

initi

ativ

e

►A

pro

gram

me

imp

lem

ente

d b

y a

mul

tidis

cip

linar

y te

am t

o im

pro

ve le

ngth

of

sta

y, d

elay

ed d

isch

arge

s an

d e

arly

re

adm

issi

ons

thro

ugh

key

initi

ativ

es

Ad

ult

kid

ney

tran

spla

nt r

ecip

ient

sH

osp

ital

Med

ical

Uni

vers

ity o

f Sou

th

Car

olin

a

Pra

ctic

e ch

ange

s

►D

elay

ed d

isch

arge

s d

ecre

ased

by

14%

►

Rea

dm

issi

on r

ate

(7 d

ay) d

ecre

ased

by

50%

►

Acu

te r

ejec

tion

and

infe

ctio

n ra

tes

dec

reas

ed

Ud

ayai

82Im

pro

vem

ent

in d

isch

arge

pro

cess

- S

ix S

igm

a

►Th

e im

ple

men

tatio

n of

str

ateg

ies

usin

g S

ix

Sig

ma

to im

pro

ve d

isch

arge

pro

cess

es (b

illin

g ho

ur, p

atie

nt a

udits

, offi

ce e

xecu

tive,

prio

rity

for

dis

char

ge, w

ard

boy

s, d

isch

arge

pro

cess

flo

w)

NR

Hos

pita

lP

ract

ice

chan

ges

►

Dis

char

ge t

ime

was

dec

reas

ed b

y 21

% (f

rom

24

7 to

195

min

)

►P

atie

nts

had

imp

rove

d s

atis

fact

ion

with

the

d

isch

arge

pro

cess

Will

iam

s52C

ritic

al c

are

outr

each

rol

e

►Th

e im

ple

men

tatio

n of

a c

ritic

al c

are

outr

each

ro

le t

o fa

cilit

ate

com

mun

icat

ion

bet

wee

n IC

U

and

war

d s

taff

Pat

ient

s d

isch

arge

d

from

the

ICU

Hos

pita

lR

oyal

Per

th H

osp

ital,

22- b

ed

ICU

(570

tot

al b

eds)

Pra

ctic

e ch

ange

sIn

form

atio

n sh

arin

g liv

e

►

Del

ayed

dis

char

ges

incr

ease

d b

y 4%

(fro

m

27%

to

31%

)

Youn

is53

Enh

ance

d r

ecov

ery

pro

gram

me

►

A p

rogr

amm

e p

ost-

colo

rect

al s

urge

ry t

o im

pro

ve s

tom

a m

anag

emen

t an

d e

xped

ite

dis

char

ge t

ime

Pat

ient

s un

der

goin

g an

terio

r re

sect

ion

with

the

form

atio

n of

a

loop

ileo

stom

y

Hos

pita

lS

ingl

e d

istr

ict

gene

ral

hosp

ital

Pra

ctic

e ch

ange

Info

rmat

ion

shar

ing

live

►

Ave

rage

leng

th o

f sta

y d

ecre

ased

by

6 d

ays

►

Sig

nific

ant

dec

reas

e in

per

cent

of p

atie

nts

exp

erie

ncin

g d

elay

ed d

isch

arge

due

to

ind

epen

den

t st

oma

man

agem

ent

Gre

y lit

erat

ure

Ano

nym

ous99

Exp

edite

d d

isch

arge

fund

►

A h

osp

ital f

und

to

pay

for

serv

ices

tha

t ar

e ho

ldin

g up

a p

atie

nt’s

dis

char

ge (m

edic

al

equi

pm

ent,

pha

rmac

eutic

als,

phy

sica

l and

oc

cup

atio

nal t

hera

py,

tra

nsp

orta

tion,

etc

.)

Uni

nsur

ed p

atie

nts

Hos

pita

lIo

wa

City

, Uni

vers

ity o

f Iow

a H

osp

ital,

700

bed

s

Infr

astr

uctu

re a

nd

finan

ce

►A

pat

ient

from

a r

ural

are

a w

as p

rovi

ded

with

$4

0/w

eek

for

med

icat

ions

and

gas

to

trav

el

to a

hos

pita

l tha

t p

rovi

ded

sp

ecia

lised

wou

nd

care

►

A s

ocia

l wor

ker

foun

d a

gro

up h

ome

for

peo

ple

with

a m

enta

l hea

lth d

iagn

osis

for

a p

atie

nt w

ho h

ad n

o so

cial

sup

por

t or

fund

ing

Ano

nym

ous46

Mee

tings

►

Dai

ly a

nd w

eekl

y m

eetin

gs t

o d

iscu

ss is

sues

w

ith p

atie

nt t

hrou

ghp

ut a

nd s

trat

egie

s fo

r el

imin

atin

g b

arrie

rs

NR

Hos

pita

lU

nive

rsity

of C

inci

nnat

i H

ealth

Uni

vers

ity H

osp

ital,

693

bed

s

Info

rmat

ion

shar

ing

live

►

Dec

reas

ed a

vera

ge le

ngth

of s

tay

by

5.34

hou

rs

►In

crea

sed

acc

urac

y of

pre

dic

ting

next

day

d

isch

arge

s fr

om t

he m

edic

al/s

urgi

cal u

nits

b

y 40

%

Cal

vele

y83Ti

ered

com

mun

ity- b

ased

ser

vice

s

►Th

ree

tiers

of s

ervi

ces

to a

llow

for

peo

ple

to

be

care

d fo

r in

the

ir ow

n ho

mes

or

resi

den

tial

units

, ins

tead

of i

n ho

spita

l

NR

Hos

pita

lFo

ur S

easo

ns H

ealth

care

, 18

000

bed

s

Pra

ctic

e ch

ange

s

►N

R

Tab

le 3

C

ontin

ued

Con

tinue

d

on January 15, 2022 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2020-044291 on 11 February 2021. D

ownloaded from

20 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access

Aut

hor

Init

iati

veD

escr

ipti

on/

cont

ent

Targ

et p

op

ulat

ion

Set

ting

Init

iati

ve

cate

go

ry*

Res

ults

Man

zano

- S

anta

ella

100

Pay

men

t b

y R

esul

ts a

nd D

elay

ed D

isch

arge

s A

ct

►P

aym

ent

by

Res

ults

pay

s p

r ovi

der

s a

fixed

p

rice

for

each

ind

ivid

ual c

ase,

whi

le w

ith t

he

Del

ayed

Dis

char

ges

Act

, loc

al a

utho

ritie

s ar

e fin

anci

ally

res

pon

sib

le w

hen

pat

ient

s re

mai

n in

hos

pita

l bec

ause

com

mun

ity c

are

has

not

bee

n ar

rang

ed

NR

NR

Infr

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and

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isch

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86S

outh

lake

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ome

►

A t

eam

des

igne

d t

o m

eet

the

pat

ient

s ca

r e

need

s th

roug

h p

artn

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ips

with

com

mun

ity

and

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ary

care

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egra

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prim

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, ho

spita

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e an

d h

ome

and

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to d

evel

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Open access

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J Open: first published as 10.1136/bm

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Open access

(visual displays) were used to share information with the multidisciplinary project team on issues affecting length of stay and hospital bed occupancy.40 This information was used to guide practice changes aimed at improving communication during the discharge process (daily rounds, focusing on long- stay patients), bed management (nursing support to prevent deterioration) and commu-nity services (email updates and involvement of care coordinators). The majority of initiatives shared informa-tion though in- person communication; however, some used technology. Caminiti et al used technology- assisted communication to develop reports and audits to moti-vate and hold physicians accountable,42 as in some health systems, physicians play a key role in designating patients as having a delayed discharge. Profiles for each physician were created monthly using hospital administrative data (containing length of stay, number of patients discharged that month). All information sharing initiatives resulted in positive outcomes (eg, reduced length of stay and a decrease in delayed discharges).

Tools and guidelinesThe tools and guidelines category included initiatives with actionable, concrete steps or processes in the form of tools, guidelines and models to inform practice.47–50 54–67 Physicians and multidisciplinary teams (eg, nurses, social workers, discharge planners) frequently implemented tool and guideline initiatives. A promising initiative within this category included the ALC Avoidance Frame-work, developed by Burr and colleagues, with the goal of preventing ALC designations and reducing ALC rates.56 67 This framework contains 12 leading practices, with specific strategies for organisational assessment. Some of the leading practices include: providing patients and substitute decision makers with an estimated date of discharge, identifying high- risk patients of becoming A

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Tab

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C

ontin

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Figure 2 Categories of initiatives for improving delayed hospital discharges.

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ALC and implementing escalation processes for the management of ALC challenges. Additional initiatives focused on improving patient flow through criteria- led discharges (discharging patients once a predetermined set of criteria had been met) and critical pathways/discharge guidelines.

The majority of initiatives categorised as tools and guidelines had positive results,47–49 54–60 62 64–66 which included a reduction in hospital days and length of stay. However, one initiative, the Goal Length of Stay Tool, did not have positive outcomes on length of stay.50 This initia-tive incorporated information sharing into a computer- based programme to identify patients whose length of stay exceeded their benchmark figure. It had no change on length of stay and was perceived negatively by staff because they did not believe the benchmark figure was an accurate representation of a patient’s current functional status and readiness for discharge.

Practice changesThis category included initiatives that altered how usual care was delivered.51–55 63–66 68–92 Common practice change initiatives included hospital- based, nurse- led discharges and cross- sectoral transitional programmes (eg, Home First, Discharge to Assess, Hospital to Home). Most were implemented by nurses and multidisciplinary teams. Nurse- led and criteria- led discharges often involved a predetermined list of criteria (clinical parameters) that a patient was required to meet in order to be discharged from hospital by a member of the discharge team. For example, Graham et al conducted a retrospective study (N=128) to compare nurse- led and doctor- led discharge (standard discharge pathway) postlaparoscopic surgery.74 For nurse- led discharge, the patient had to meet 13 pre- established criteria (stable vital signs and comparable to baseline on admission; achieved optimal mobility; minimal nausea, vomiting and dizziness; adequate pain control; received written and verbal instructions about postoperative care, etc). When compared with the doctor- led discharge group (n=64), patients in the nurse- led group (n=64) were significantly more likely to be discharged on the day of surgery. Incomparing reasons for the success of the nurse- led model, the authors did not tieit to patient factors but rather the ready availability of the nurse specialistwho was able to implement the clearly outlined discharge criteria (specific fornurse- led discharge) much more quickly than the doctor- led group (who did not use suchcriteria).

Another unique example of a practice change initiative was the 7- day Hospital Initiative implemented by Blecker et al.70 The purpose of this observational study was to eval-uate the impact of increasing weekend staff (hospitalists, care managers, social workers) and services on length of stay, percent of patients discharged on weekends, 30- day readmission rate and in- hospital mortality rate. This multifaceted intervention resulted in a decreased average length of stay, an increased proportion of

weekend discharges and no impact on readmission rates or mortality.

The majority of initiatives categorised as a practice change resulted in positive outcomes on length of stay and rate of discharge delays. However, there were several initia-tives that were perceived negatively by patients,77 or had no change68 75 or a negative impact52 on study outcomes (increase in delayed discharges). Meehan et al explored patient experiences with a programme (Discharge to Assess) that discharged patients who were clinically ready but still required support, in order for their needs to be assessed in their own environment (ie, at home).77 Nega-tive experiences were described by participants (patients and caregivers) who indicated feeling ignored, had poor communication with their healthcare providers and were not involved in the decision- making process. Negative outcomes were also identified in Williams et al prospective cohort study.52 This study evaluated the impact of a crit-ical care outreach role on delays in discharge and iden-tified that discharge delays from the intensive care unit increased over the study period with the implementation of this role. The authors emphasised the importance of a multifaceted and collaborative approach (involving multiple stakeholders/ team members), focusing on patient flow throughout the hospital in order to address the numerous factors impacting delays.

Infrastructure and financeThe infrastructure and finance category included initia-tives that involved tangible structural or financial changes (eg, building more long- term care beds to facilitate the transition of patients out of hospital, financial penalties for remaining in hospital after being medically ready for discharge).55 92–100 The Community Care (Delayed Discharges) Act in the UK was an initiative identified in multiple articles.93 96 97 100 This initiative required local authorities to make payments to acute hospitals when patients could not be discharged because appropriate community care arrangements had not been made. Although this measure was not necessarily enforced, it created incentive for the hospital and community to work together more collaboratively. Additionally, transitional care units94 95 and discharge funds98 99 were common initiatives implemented to address delayed discharges among elderly patients. Transitional care units focused on rehabilitation to promote recovery and the regaining of independence, while discharge funds paid for services that were preventing the patient from being discharged or returning home (eg, medical equipment, medications, transportation, home repairs). All initiatives categorised as infrastructure and finance had positive results on study outcomes, including reductions in discharge delays, length of stay and cost.93–98

Other initiativesThe other initiatives category included statistical and predictive modelling of initiatives to improve delayed discharges.101–103 These models explored the impact of

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increasing the supply of nursing home beds,101 potential care pathways for the elderly and reimbursement costs102 and discharge strategies to reduce hospital occupancy.103 Gaughan et al's modelling and empirical analysis iden-tified that increasing the supply of long- term care beds can decrease delayed discharges caused by a lack of social care.101 Their models further emphasised the importance of communication between hospitals and the long- term care sector to reduce social care delayed discharges. Simi-larly, Katsaliaki et al used discrete- event simulations to determine care pathways and associated costs, in which they identified that adding new beds in hospital or inter-mediate care could reduce delay times.102

Recommended initiatives: calls to actionSeveral articles were not evaluations but reports or reviews consisting of recommended initiatives to address delayed hospital discharges, which often combined a number of the categories illustrated above.2 45 92 104 Sutherland and Crump outlined three key solutions for improving delayed discharges in Canada: building more acute and postacute care beds, increasing integrated care and creating finan-cial incentives to improve the quality, quantity and effec-tiveness of healthcare.45 The authors discussed challenges and limitations to implementing each of these options and emphasised that a potential solution to addressing delayed discharges was to combine the three strategies. Another Canadian report developed recommendations for providing care to the ageing population and those experiencing a delayed discharge.2 Walker outlined recommendations for improving primary care, the care continuum and senior friendly acute care, responding to special needs populations (eg, persons with mental health concerns, addiction and neurological conditions, on dial-ysis or ventilators), and implementing an ‘Assess and Restore’ model (a programme to help patients maintain or regain functional independence, transition to home and remain in the community for as long as possible).

The NHS improvement (UK) also released a guide in 2019 on reducing long hospital stays.104 This guide contained several recommendations for tackling delayed discharges including: a patient flow bundle (a tool to reduce delays for patients on inpatient wards), Red2Green Days (a visual tool to reduce unnecessary waiting by patients by supporting the rounding process), long- stay patient reviews (weekly reviews of long- stay patients (>20 days), to help tackle obstacles that are delaying discharge) and multiagency discharge events (review of individual patient journeys by bringing together senior staff from the local health and social care system).

DISCUSSIONThe purpose of this scoping review was to identify best practices for reducing delayed discharges, examine the characteristics of identified initiatives and develop recom-mendations for future work. Based on the 66 included articles, our findings showed that: (1) initiatives are

focused on quantitative outcomes, with limited assess-ment of the impact on patient, caregiver and provider experiences; (2) the sustainability of initiatives overtime is not measured (3) there is a lack of important contex-tual information reported (eg, population characteris-tics, setting, implementation processes) and (4) there are inconsistencies in how delayed discharges are defined.

This review highlighted where the majority of efforts around addressing delayed discharges have been placed. Practice change was the most common categorisation of initiatives (n=36), followed by information sharing (n=19) and infrastructure and finance (n=19). All initiatives cate-gorised as information sharing and infrastructure and finance reported positive outcomes. Despite reporting positive outcomes, many information sharing initiatives promoted communication between staff, with a limited number targeting communication with patients and families. Additionally, there were more initiatives imple-mented in a single sector (eg, in hospital) in comparison to cross- sectoral initiatives (eg, hospital and home care).

Length of stay was the most common outcome measured in this scoping review, with a limited number of articles exploring patient, caregiver and provider experiences. For example, could it be considered a success if an initia-tive does not result in a reduced length of stay, but allows patients to obtain broader goals related to their care (ie, being able to return home) or enhance their care expe-rience? Qualitative methods, including the capturing of patient, caregiver and provider experiences, would allow for a deeper exploration and understanding of success from the perspectives of different stakeholders involved in the initiative.105–107 Experiential evidence on whether an intervention is working is required. As noted in our review, a tool developed to better understand delayed discharge was deemed irrelevant by care providers who felt that the tool captured the wrong information.50 There-fore, capturing providers’ experiences and perspectives are essential in understanding effectiveness of strategies as well as uptake. Most articles included in this scoping review used a quantitative study design, with limited arti-cles using mixed methods or qualitative approaches; thus highlighting a key focus for future research.

The majority of initiatives had an intervention or follow- up period of 1 year, but this ranged from 4 months to 3 years. Based on the limited number initiatives with a follow- up period of longer than 1 year (n=8), there is a need for more formal evaluations with longer follow- up periods to measure the sustainability of initiatives over time. For example, Shelton et al’s Integrated Sustain-ability Framework consists of five categories of factors associated with the sustainability of interventions across different contexts and settings: outer context (eg, poli-cies, leadership, funding), inner context (eg, culture, mission, funding), intervention characteristics (eg, cost, adaptability, benefit), processes (eg, partnership, training/support, planning, capacity building) and implementer and population characteristics (eg, imple-mentation skills/expertise, attitudes/motivation).108

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Shelton et al recommended prospective, multi- level and mixed methods study designs for studying the impact and sustainability of interventions. Overall, the initiatives included in this scoping review had positive short- term impacts, but it is unclear if these outcomes are main-tained over time. This emphasises the need to design and implement interventions with sustainability in mind.

The majority of categories of initiatives resulted in posi-tive outcomes; however, initiatives classified as practice change had the most mixed outcomes (positive, negative and no change). Practice changes often require a greater number of resources and are more complex to implement than static solutions (ie, hosting daily rounds, developing a framework, etc). A recent systematic review (2018) conducted by Geerligs et al identified implementation barriers and facilitators of patient- focused, in- hospital interventions,109 highlighting the complex interplay of factors that can impact implementation. Three domains, with the potential to impact the implementation process, were identified: system (environmental context, culture, communication processes and external requirements), staff (commitment and attitudes, understanding and awareness, role identity and skills, ability and confidence) and intervention (ease of integration, face validity, safety and legality and supportive components). Thus, it is important for interventions to be nimble and adaptable to support the changing need of patients, caregivers, providers, organisations and policy contexts over time.

It was also unclear if some initiatives moved prob-lems from one sector to another. For example, adding more intermediate care beds may alleviate pressures in acute care in the short- term but eventually also be at full capacity if community resources are not available. The 7- day hospital discharge initiative highlighted in this review, improved hospital throughput but had no impact on re- admissions,70 suggesting that thinking beyond one sector is required. It is encouraging that most practice change initiatives resulted in improved outcomes, but more clarity is needed to understand what the trade- offs were, as well as how to scale- up the successful initiatives.

Health systems also need to consider their broader goals around delayed hospital discharge—should it only be about reducing delays or should we place an equal focus on optimising patient and caregiver experiences and outcomes? The health system context, including the funding environment, will ultimately shape what inter-ventions get implemented and how they are sustained over time. Some interventions may be considered low value in some countries and contexts and high value in others. Additionally, certain initiatives may be more effective in different environments, as variations in the number of hospital and long- term care beds per capita, infrastructure financing and degree of integration across sectors may impact the outcomes of an initiative. Future research needs to better understand why some strategies may thrive in some environments and not others.

Another key finding identified in the scoping review was the lack of information and details on the implementation

strategy (how strategies were implemented, over what time period, how implementation challenges were dealt with), setting (where was it implemented) and popu-lation characteristics (who was it implemented for). The implementation of initiatives can be impacted by differences in healthcare system structure and funding. Further, this contextual information is essential for both understanding outcomes, scaling- up and sustainability of interventions because it is not only important to know if the intervention was effective, but also for whom and in what context it was effective.110 111

Finally, this review highlighted a lack of consistency in how delayed discharge was defined, both within and across countries. While there was one definition that was used more frequently (a patient was identified as medi-cally ready/fit for discharge, but remained in hospital), there can be different interpretations of when a patient is considered ‘medically fit’ and who makes this deci-sion. Inconsistent definitions can lead to variations in the reported rates of delayed discharge, which can further impact the perceived applicability and effectiveness of an intervention. Our finding was echoed in a narrative review conducted by Glasby et al, who further explained the challenges differing definitions create when attempting to compare findings.112 In order to mitigate these chal-lenges, it is critical to be more consistent around how delayed discharges are defined.

Future workFrom this review, we have identified areas for future research. First, patient, family and provider needs and experiences should be explored during the development and implementation of initiatives aimed at improving delayed discharges. Patient and family engagement is both important and recommended by healthcare and govern-ment organisations; however, they are often excluded in the development and write- up of best practice guide-lines.113 Second, evaluation studies that track outcomes over a longer period of time should be conducted to study the sustainability of initiatives over time, how they are adapted (developmental evaluations), as well as their impact on other sectors (eg, primary and commu-nity care). Third, initiatives should be implemented and integrated across sectors (hospital, primary care and home and community care) to help get at the root of the problem and ensure the implementation of an initiative in one setting does not simply shift the problem to another. Fourth, a review should be conducted to assess the state of knowledge around initiatives that are more upstream in nature (eg, hospital admission avoidance, emergency department diversion and delivery models that proactively address the health and social care needs of individuals in community settings). Finally, there is an opportunity for future research to consider a realist review of the liter-ature on delayed hospital discharge to understand the context, mechanisms of impact, outcomes and theories of change, given that addressing a delayed discharge is a complex problem. As a first step, we sought to include

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interventions that included hospitals, and this revealed a single sector and reactive approach to addressing delayed discharge.

LimitationsThere are a few limitations of this review that should be noted. It is possible that some relevant articles were missed because the search was limited from 1 January 2004 and 16 August 2019 and conducted in English. Our search strategy was comprehensive and we conducted an in- depth search of grey literature to minimise the poten-tial of missed articles. While we did not limit the inclusion of articles to the English language, our search strategy was in English, so there is a possibility that articles published in different languages were not identified. We excluded studies that changed the threshold/timing of discharge (early discharge), as they often focused on cost- savings. We acknowledge that some of these initiatives may have transferable lessons to address discharge delays, and thus, note their exclusion as a potential limitation of this review. Although it is not a requirement for scoping reviews,36 the interventions in this review were not criti-cally appraised, and thus, we cannot make recommenda-tions on which interventions should be scaled up. Given concerns with regression toward the mean, especially for quality improvement projects, any positive results need to be interpreted with caution. Health systems are complex, evolving environments, where various iterations of strat-egies are regularly implemented, but not necessarily formally reported or published. Future work by our team will include a process evaluation on how strategies are actually implemented in different health system contexts, as well as why they work or do not work.

Ethical considerationsThere are a few ethical concerns associated with scoping reviews to be noted. These concerns include authorship, transparency and plagiarism. All authors met the Inter-national Committee of Medical Journal Editors’ recom-mended criteria for authorship and author order was based on overall contribution to the review. We clearly outlined our methods at each stage of the scoping review to ensure transparency and replicability. We also acknowl-edged individuals who contributed to the review, but who did not warrant authorship. Lastly, when reporting the results of individual studies, we wrote them in our own words and cited appropriately to avoid plagiarism.

CONCLUSIONSThis scoping review identified a variety of initiatives addressing delayed discharges across five categories: infor-mation sharing, tools and guidelines, practice changes, infrastructure and finance and other. The majority of initiatives were focused on practice changes and many incorporated more than one category. Initiatives were often implemented in a single sector, rather than across sectors. It appears that many strategies implemented in

hospitals including communication huddles, nurse- led discharges, home first programmes and building more infrastructure had positive short- term impacts. Many initiatives that led to positive outcomes were implemented by a multidisciplinary team and included a number of components (eg, monthly reports and education). The success of these initiatives is based on a service- led defini-tion of success (effective use of hospital resources), rather than success from the patient and family perspective. This highlights the need to shift to a more patient- centred approach that focuses on improving outcomes and expe-riences, rather than system and hospital outcomes (ie, length of stay and hospital occupancy) alone. Despite the number of unique initiatives aimed at addressing delayed discharges, current strategies may not be getting at the root of the problem (initiatives/intervention prior to hospital admission) and there is a need for solutions to this problem that have a long- term and sustainable impact.

Author affiliations1Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada2Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada3Rehabiliation Sciences Institute, University of Toronto, Toronto, Ontario, Canada4Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada5Quality Division, Ontario Health, Toronto, Ontario, Canada6Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada7School of Social Policy, University of Birmingham, Edgbaston, Birmingham, UK8Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada9MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada

Twitter Kristina Marie Kokorelias @kmkokorelias

Acknowledgements The authors would like to thank the University of Toronto librarian for their contribution to the search strategy, as well as Juliane Koropeski (JK) and Maliha Asif (MA) for their help screening articles. We would like to thank the involvement of our stakeholders who provided feedback on our search terms and sent us grey literature. Lastly, we would like to thank our Alternate Level of Care Advisory Council and Ida McLaughlin (chair of council) for their continual support and feedback on this programme of work.

Contributors KK, SJTG, JS, JG and TK were responsible for the conception and design of the study, as well as acquisition of funding for the study. LC, SJTG, KMK and KK led the screening of articles and the analysis and interpretation of data, but all authors contributed to the analysis and interpretation. Drafts of the manuscript were reviewed and revised by all authors. All of the authors read and approved the final manuscript.

Funding This work was supported by the Canadian Institutes of Health Research- Transitions in Care Strategic Funding Initiative on Best and Wise Practices (Grant #163064). KK holds the Dr Mathias Gysler Research Chair in Patient and Family Centred Care. SJTG and TK are funded by the Canadian Institutes of Health Research Embedded Scientist Salary Award on Transitions in Care working with Ontario Health (Quality); the award also supported staff to assist with screening.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement All data relevant to the study are included in the article or uploaded as online supplemental information.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer- reviewed. Any opinions or recommendations discussed are solely those

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of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

ORCID iDsLauren Cadel http:// orcid. org/ 0000- 0001- 6925- 8163Sara J T Guilcher http:// orcid. org/ 0000- 0002- 9552- 9139

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