assignment on hospital admission and discharge

Discharge planning assessment tool

Shorten delays, improve safety, reduce costs.

• Hospital discharge delays can result in patient safety issues, reduced patient satisfaction, and increased costs.
• An assessment tool that goes into effect at admission can help the patient and healthcare team prepare for discharge.

Hospital discharge delay, defined as more than 2 hours from the time of a written order, can negatively impact patients and hospitals. In addition to patients experiencing some level of unhappiness or frustration, they also may face adverse clinical outcomes, such as falls or hospital-acquired infections. According to Bai and colleagues, the consequences for hospitals range from overcrowding in the emergency department (ED) to inappropriate use of high-cost hospital beds for care better provided in alternate settings. A study by Rojas-Garcia and colleagues found that between 8% and 10% of beds in an acute care hospital were occupied by patients whose discharge had been delayed. The causes behind delays must be addressed, and discharge discussions should begin at admission.

The problem

Many nurses are overwhelmed by a heavy workload that includes an increased number of patients with a high acuity level, so they might not be aware of the barriers resulting in discharge delays. On the 32-bed medical/surgical unit at our community hospital, the average discharge time (from the time the provider wrote the order to the time when the patient was physically discharged) was 5 hours and 6 minutes. The unit patient experience Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) discharge category score was 71.1 (national average 68.5).

Safe, effective, and timely discharge requires good communication among the healthcare team, the patient, and the family. According to a study by Meo and colleagues, effective healthcare team member communication during daily rounds can help reduce length of stay by 21%.

The solution

To help bedside nurses effectively communicate with patients, families, and providers in preparation for discharge, an interprofessional team at our organization developed a six-question discharge-planning assessment tool, which we piloted on the medical-surgical unit. We provided unit nurses with a written copy of the tool and explained its purpose—to expedite safe and effective hospital discharge. We instructed the nurses to use the tool as a prompt for discussing different aspects of discharge preparation during shift changes and at daily rounds with other healthcare team members. (See Ask the right questions .)

Ask the right questions

The discharge planning assessment tool includes the following questions to help staff expedite safe discharges.

• What is the anticipated discharge date of the patient?
• Where is the anticipated discharge destination?
• Is the family aware of discharge planning?
• Are their questions being answered?
• Do they have any concerns?
• Does the patient need any resources at home?
• Home health (PT, OT, RN, or aide)
• DME (oxygen, walker, beside commode)
• Does the patient have a central line or a urinary catheter?
• Is the patient going home with it?
• Confirm the patient’s pharmacy.
• Is the pharmacy open?
• Does the patient use meds by mail?

DME = durable medical equipment, OT = occupational therapy, PT = physical therapy

Between November 1, 2020, to May 31, 2021, 1,788 patients were discharged from the unit (1,552 discharged home and 236 discharged to a facility). The pre-data collection period began on November 1; the next 6 months included the implementation and post-implementation phases of the pilot.

Question 1: Discharge date

The discharge planning assessment tool begins with the question, “What is the anticipated discharge date of the patient?” Using information about a patient’s diagnosis, lab values, test results, and admission status before transfer from the ED and admission to the unit, nurses can anticipate an approximate discharge date and discuss it with the patient and family when they arrive on the unit. The patient and family can continue that discussion with the provider and then make necessary arrangements with their place of employment and other family members or friends who may offer assistance.

Question 2: Discharge destination

The nurse asks, “Where is the anticipated discharge destination?” Assuming a patient’s discharge location acts as a significant cause for delay. For example, some patients may live alone or have no family in the area so they won’t be able to care for themselves. Others may be unhoused and living on the streets. Asking this simple question at admission can help start the discharge process before it even begins.

Question 3: Family concerns

Asking, “Is the family aware of discharge planning? Are their questions being answered? Do they have any concerns?” acknowledges the caregivers’ role in the discharge process, including managing vital tasks, such as transportation and treatment options. Nurses may think that all questions were answered at admission, but family members can’t be expected to retain all the information relayed on a stressful day. Nurses and other members of the healthcare team must continue to address families’ questions and concerns throughout the patient’s hospital stay. They can help guide family members and reduce their anxiety by offering compassion and engaging with them about their loved one’s diagnosis and treatment plan.

Question 4: Patient needs

The need for resources creates another barrier to discharge, so the nurse should ask, “Does the patient need any resources at home? Do they need home health, physical therapy, or a nurse aide? Do they need any medical equipment, such as oxygen, a walker, or a bedside commode?” Waiting to coordinate resources or medical equipment delivery can delay discharge from a couple of hours to an entire day. In some cases, an insurance company won’t cover all of the resources, so the family will need time to research options so they can make informed decisions.

Question 5: Invasive lines

Invasive lines can create another barrier to timely discharge, so nurses should ask, “Does the patient have a central line or a urinary catheter? Are they going home with it?” For a patient with an invasive line, the healthcare team should begin addressing it the day or night before the anticipated discharge. Central lines require a provider order to continue or discontinue access as well as the necessary dose of heparin to maintain patency after discharge. A urinary catheter also will require a provider order for continuation or removal. If the provider orders removal, the patient must void within 4 to 6 hours before discharge, which creates the potential for delays. If the patient can’t void within that timeframe, the provider may order reinsertion of the catheter. Addressing these issues during the shifts prior to discharge can help prevent a delay.

Question 6: Medications

To avoid delays related to discharge medications, the healthcare team should ask, “Which pharmacy does the patient prefer, and do they receive meds by mail?” Many hospitals send new discharge medications electronically to the patient’s preferred pharmacy rather than writing a paper prescription, but what if a patient is discharged over a weekend, on a holiday, or after hours when the pharmacy isn’t open? Medications delivered by mail can reduce costs and provide convenience, but this delivery option won’t accommodate patients who need to start medications immediately. Asking the provider for a written prescription before discharge, providing the patient with a list of 24-hour pharmacies in the area that can fill their medications, and sharing information about medications with discounted price coupons can help expedite the patient’s discharge and improve their overall experience.

Believing in the process

Using this tool in combination with collaboration among healthcare team members during daily rounds improved the discharge time on this pilot unit by 57 minutes. In addition, patient experience scores on the HCAHPS discharge process questions improved by 16.4 points. (See Steady improvement .)

The change and improvement didn’t happen quickly. It required continuing education and reinforcement with the staff. Slowly, the times from the discharge order to actual discharge decreased, and patient experience scores improved. As the results came in every month, the staff began believing in the process, and it became a natural part of their bedside care.

Steady improvement

Both discharge times and patient satisfaction scores improved during the discharge planning assessment tool pilot project.

A noticeable decrease in discharge times occurred from November 1, 2020, to May 31, 2021.

During the same period, we also observed a noticeable improvement in patient experience HCAHPS scores. (In March 2021, a decline occurred during a high vacation time when float pool nurses covered the unit.) Patients answer three questions about discharge as part of HCAHPS:

• When I left the hospital, I had a good understanding of things I was responsible for in managing my health.
• When I left the hospital, I clearly understood the purpose for taking each of my medications.
• Did you get information in writing about symp or health problems to look out for after you left the hospital?

The authors work at Houston Methodist West Hospital in Houston, Texas. Heather Stein is an operations administrator, Keshia S. Duhon is a case manager, and Jose Sepulveda is a social worker.

American Nurse Journal. 2023; 18(6). Doi: 10.51256/ANJ062314

Bai AD, Dai C, Srivastava S, Smith CA, Gill SS. Risk factors, costs and complications of delayed hospital discharge from internal medicine wards at a Canadian academic medical centre: Retrospective cohort study. BMC Health Serv Res . 2019;19(1):935. doi:10.1186/s12913-019-4760-3

Centers for Medicare and Medicaid Services. HCAHPS: Patients’ perspectives of care survey. December 1, 2021. cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS

Family Caregiver Alliance. Hospital discharge planning: A guide for families and caregivers. caregiver.org/resource/hospital-discharge-planning-guide-families-and-caregivers

Ibrahim H, Harhara T, Athar S, Nair SC, Kamour AM. Multi-disciplinary discharge coordination team to overcome discharge barriers and address the risk of delayed discharges. Risk Manag Healthc Policy . 2022;15:141-9. doi:10.2147/RMHP.S347693

Meo N, Bann M, Sanchez M, Reddy A, Cornia PB. Getting unstuck: Challenges and opportunities in caring for patients experiencing prolonged hospitalization while stable for discharge. Am J Med . 2020;133(12):1406-10. doi:10:1016/j.amjmed.2020.05.024

Rojas-Garcia A, Turner S, Pizzo E, Hudson E, Thomas J, Raine R. Impact and experiences of delayed discharge: A mixed-studies systematic review. Health Expect . 2018; 21(1):41-56. doi:10:1111/hex.12619

Key words: discharge planning, assessment tool, cost reduction, discharge delays, patient safety

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Hospital Admission and Discharge: Lessons Learned from a Large Programme in Southwest Germany

Johanna forstner, maximilian pilz, cornelia straßner, nicola litke, lorenz uhlmann, frank peters-klimm, frank aluttis, annika baldauf, marion kiel, markus qreini, petra kaufmann-kolle, janina schubert-haack, nadja el-kurd, katrin tomaschko-ubeländer, sarah treffert, bärbel handlos, gökce karakas, michel wensing, joachim szecsenyi.

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CORRESPONDING AUTHOR: Johanna Forstner University Hospital Heidelberg, Department for General Practice and Health Services Research; Im Neuenheimer Feld 130.3, Marsilius Arkaden, Turm West, D-69120 Heidelberg, DE [email protected]

Received 2022 Feb 28; Accepted 2023 Jan 17; Collection date 2023 Jan-Mar.

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/ .

Introduction:

In the context of a GP-based care programme, we implemented an admission, discharge and follow-up programme.

Description:

The VESPEERA programme consists of three sets of components: pre-admission interventions, in-hospital interventions and post-discharge interventions. It was aimed at all patients with a hospital stay participating in the GP-based care programme and was implemented in 7 hospitals and 72 general practices in southwest Germany using a range of strategies. Its’ effectiveness was evaluated using readmissions within 90 days after discharge as primary outcome. Questionnaires with staff were used to explore the implementation process.

Discussion:

A statistically significant effect was not found, but the effect size was similar to other interventions. Intervention fidelity was low and contextual factors affecting the implementation, amongst others, were available resources, external requirements such as legal regulations and networking between care providers. Lessons learned were derived that can aid to inform future political or scientific initiatives.

Conclusion:

Structured information transfer at hospital admission and discharge makes sense but the added value in the context of a GP-based programme seems modest. Primary care teams should be involved in pre- and post-hospital care.

Keywords: care transition, admission management, post-discharge provider follow-up, patient readmission, continuity of patient care, strong primary care, integrated care

Einleitung:

Im Rahmen der hausarztzentrierten Versorgung wurde ein Programm zur Verbesserung von Krankenhausaufnahmen und -entlassungen sowie der Nachsorge implementiert.

Beschreibung:

Das VESPEERA-Programm bestand aus verschiedenen Komponenten, die vor der Aufnahme, während des Krankenhausaufenthalts sowie nach der Entlassung durchgeführt wurden. Das Programm richtete sich an alle Patienten mit einem Krankenhausaufenthalt, die an der hausarztzentrierten Versorgung teilnahmen und wurde in 7 Krankenhäusern und 72 Hausarztpraxen in Südwestdeutschland unter Anwendung einer Reihe von Strategien implementiert. Seine Wirksamkeit wurde anhand des primären Endpunkts “Rehospitalisierungen innerhalb von 90 Tagen nach der Entlassung” bewertet. Anhand einer Fragebogenbefragung beim Personal wurde der Implementierungsprozess untersucht.

Diskussion:

Ein statistisch signifikanter Effekt konnte nicht gefunden werden, die Effektgröße war jedoch ähnlich wie bei anderen Interventionen. Die Interventionstreue war gering. Kontextfaktoren, die die Implementierung beeinflussten, waren unter anderem verfügbare Ressourcen, externe Anforderungen wie gesetzliche Vorschriften und die Vernetzung von Leistungserbringern. Es wurden Schlussfolgerungen gezogen, die für künftige politische oder wissenschaftliche Initiativen hilfreich sein können.

Schlussfolgerung:

Eine strukturierte Informationsweitergabe bei der Aufnahme und Entlassung aus dem Krankenhaus ist sinnvoll, doch scheint der zusätzliche Nutzen im Rahmen der hausarztzentrierten Versorgung begrenzt. Teams der Primärversorgung sollten in die prä- und poststationäre Versorgung einbezogen werden.

Hospital discharges are critical moments regarding continuity of care. They can have negative impacts on quality of care and outcomes of patients [ 1 , 2 , 3 ], providers’ satisfaction [ 3 ] and health system efficiency [ 4 ]. Improving care transitions and reducing hospital readmissions is of relevance in many health systems. There is a range of interventions that have shown benefits, especially those consisting of multiple pre- and post-discharge components. The majority of these interventions are hospital-based and mostly provided around or after hospital discharge [ 5 , 6 , 7 , 8 , 9 , 10 , 11 ].

Strong primary care, including a central role in hospital admission and discharge [ 12 ], improves care coordination, reduces hospital admissions in ambulatory care sensitive conditions and hospital readmissions [ 13 , 14 , 15 , 16 ]. Nevertheless, few studies that involved primary care in interventions after hospital discharge showed measurable positive effects. For example, Brooke et al. [ 17 ] found that early primary care follow-up after hospital discharge significantly reduced the number of readmissions within 30 days in patients after high-risk surgery. In a study conducted by Balaban et al. [ 18 ], patients who received follow-up care by a primary care provider had fewer undesirable outcomes. An umbrella review conducted by Straßner et al. [ 6 ] showed that admission management was considered to be crucial but that it was lacking in all of the studies included. Therefore, the authors recommend including admission management in future studies. Lee et al. [ 19 ] demand to ‘focus on providing transitional care within the entire cycle of care […] from time of admission to final transition to the primary care setting’ [ 19 ](p. 8).

In southwest Germany, a programme to develop strong primary care was initiated more than a decade ago (general practitioner (GP)-based care programme) [ 16 ]. A logical next step was to include primary care in care transitions and readmission prevention programmes including standardised care pathways between primary care and hospital care. Thus, vertical integration of care can be improved [ 20 ]. Consequently, the VESPEERA programme addressed at adults with all-cause hospitalisation was developed as an add-on to the GP-based care programme. The VESPEERA programme is a complex multi-component transitional care intervention that was implemented in a complex context (such as different types of organisations). Therefore, the effectiveness evaluation was accompanied by an extensive process evaluation. In this paper we present insights into the effects of the VESPEERA programme, experiences with its’ implementation as well as the lessons learned during implementation and evaluation.

Description of the care practice

The VESPEERA programme was developed based on the following several pillars: It was informed by a review of the international research evidence [ 6 ] as well as a review of quality deficits and potential for improvement in Germany [ 21 ]. Additionally, the programme was aligned with a legal regulation obligating hospitals to implement comprehensive measures to improve discharge management, which came into place in October 2017 ( Rahmenvertrag Entlassmanagement ) [ 22 ]. This regulation demands to improve and intensify information flow and communication between hospitals and other care providers, to identify patients with complex care needs, to consider information about the patients’ situation before hospital admission and to inform patients about measures taken regarding their discharge. Furthermore, the programme was aligned with the GP-based care programme, which places general practitioners in a coordinating role. The experiences and requirements by the stakeholders were considered by involving them in the development process in the form of workshops in which they discussed the intervention components (see also ‘Implementation strategies’). In the following, the intervention, its implementation, the methodological approach and the results of the evaluation will be presented.

Context, in which the care practice was implemented

Hospital care and ambulatory care in Germany have traditionally been strongly separated and insufficiently coordinated. Typically, hospitals should only be accessed when the possibilities of the outpatient sector are not sufficient for meeting patients’ care needs. In this case, ambulatory physicians (GPs or other specialists) admit patients to a hospital, which the patient can choose freely [ 23 ]. The admitting physician is encouraged to provide the hospital with all relevant information about the patient’s medical history as well as diagnostics and therapy that were already applied prior to admission [ 24 ]. However, the amount and quality of information differ. Even though technically, access to hospitals is restricted, many patients enter the hospital through the emergency department and without the involvement of any ambulatory physicians [ 23 ]. During the hospital stay, contact between hospital staff and ambulatory physicians is rare [ 12 ]. At discharge, discharge letters are mandatory [ 24 ] but often arrive late and with missing information. Personal contact, i.e. via telephone, is not required and thus depends on individual motivation [ 25 ]. The legal regulation mentioned above aims at standardising and improving hospital discharges ( Rahmenvertrag Entlassmanagement, § 39 Abs. 1a, Social Code Book V) . Primary care is predominantly provided by physicians, nurses are rarely involved in primary care in Germany. Physicians are supported by medical assistants, who mostly have administrative and simple medical tasks [ 26 ]. In 2008, the concept of the care assistant in general practice (VERAH, Versorgungsassistentin in der Hausarztpraxis ) was introduced with the aim to reduce physician burden and to take over more comprehensive tasks. After having absolved an additional training, VERAHs can take over tasks such as case management, coordination of care, routine home visits etc. [ 27 ].

Description of intervention components

The VESPEERA programme consists of a set of components that were applied depending on the type of hospital admission and time point of study enrolment (see Figure 1 ). The three sets of components were: pre-admission interventions, in-hospital interventions and post-discharge interventions.

Components of the VESPEERA programme, figure by Forstner et al. [ 29 ] licensed under CC BY 4.0.

Pre-admission interventions were delivered in the general practice, mainly by the VERAH under the responsibility of the GP and in a separate room. They include a structured and standardised computer-aided assessment before admission resulting in an admission letter . The information on the reason for hospital admission, the patient’s medical history, medication, living situation, long-term care situation including the availability of medical aids and appliances as well as the patient’s legal situation were collected by the VERAH in a designated additional software (“CareCockpit”) and automatically included in the admission letter. Furthermore, the letter included contact and reachability information of the general practice. The time of application was not pre-defined and depended on the urgency of the admission but recommended to be as close to the admission as possible to ensure that the information was up to date. Furthermore, the patients received a paper-based patient brochure that aids in preparing for a hospital stay with information on relevant documents and items to bring, patients’ rights and obligations as well as information on contact points for further support. The brochure was written in simple language and complemented by pictograms.

Hospitals were responsible for integrating the VESPEERA admission letter into their processes in a way that it was accessible by all health professionals involved. Other in-hospital interventions were performed around discharge: In cases where needed, a telephonic discharge conversation of the hospital staff with the GP was performed. No sharp criteria were defined for cases where this conversation might have been necessary but a list was provided as orientation (one-page pdf-file, provision to staff by hospital management according to internal processes). The decision on whether a physician, a nurse or another health professional was responsible for the discharge conversation of individual patients was made by the hospitals. The HOSPITAL score [ 28 ] was to be computed before discharge and shared with the general practice via the discharge letter. The HOSPITAL score consists of seven items (low haemoglobin, discharge from oncological services, low sodium, procedures, emergency admission, number of hospital admissions in the preceding year, and length of stay) and can help to identify patients with an increased risk for readmission. Patients received a paper-based patient discharge information in simple language, providing an overview of documents, next appointments with the GP and the hospital, as well as contact information of the hospital and self-help groups. If hospitals had already implemented a similar document, it was not necessary to provide the patient with the VESPEERA discharge information but adaption to its contents was recommended.

Post-discharge interventions in the general practice were also conducted in the CareCockpit software by the VERAH and include a structured and standardised assessment for planning of follow-up care after discharge . It includes medical, social, long-term needs such as wounds, pain, medication, involvement of other health professionals and the option to compute the HOSPITAL score in case it was not provided by the hospital. It was recommended to perform this assessment timely after discharge, if possible, on the next working day. The patient received a brief paper-based summary of the arranged care plan which could be printed from the software. Patients with an increased risk for readmission (HOSPITAL score ≥ 5) were included in a structured and standardised three-month telephone monitoring which included a monitoring of symptoms as well as of the arranged care plan. If patients were in the practice regularly, the monitoring could be combined with in-practice visits and did not need to be additional telephonic appointments. In case of need, paper-based sheets could be printed from the software to bring these to a home visit. The telephone monitoring included two mandatory appointments: one within a time frame of two weeks after discharge and one closing appointment three months after discharge. The number and frequency of in-between appointments was to be determined by the GP, based on their appraisal of the patients’ needs and adherence, the medical urgency and other possibly relevant factors.

Implementation strategies

Several strategies were applied to implement the intervention in general practices and hospitals. First, representatives of hospitals, general practices, health insurers and patients were involved in the development of the intervention to increase the acceptance of the programme. All components and their items were discussed in detail regarding their relevance, wording, design etc. Second, hospitals were able to adapt the delivery of the intervention according to organisational resources. They could independently decide whether they work paper-based or electronically or which kind of health profession they give responsibility for implementing the intervention components. A description of the individual implementation was to be provided to the study team. Third, the intervention components in general practices were delivered using the CareCockpit software which is a self-developed case management software. Its’ previous version, the PraCMan-Cockpit, is widely used in southwest Germany [ 28 ] and has been enhanced by integrating the VESPEERA assessments. The assessments within the CareCockpit software are standardised and questions are phrased in a way so that they could directly be asked to patients. Fourth, GPs and VERAHs were trained in the handling of the software in a role-play format and the study related procedures in a 2.5h training using a train-the-trainer strategy. The training mostly focused on the contents of the assessments, function of the software and requirements regarding the study design. Fifth, hospitals and general practices were provided with various different educational materials (such as flowcharts or video tutorials) and handling guidelines. Sixth, in addition to the educational materials, the whole study team provided ongoing consultation by telephone and by site visit, if necessary. This included support with study-related procedures such as obtaining informed consent, checking the status of and support with implementation or IT-support with the CareCockpit software. Seventh, feedback was provided to hospitals and general practices in the form of annual feedback reports and two feedback meetings within three years. The feedback reports included individualised results of the evaluation to point out potential for improvement. The feedback meetings gave an opportunity to bring together care providers from hospitals and general practices and offered an opportunity to exchange ideas, experiences and perspectives. Finally, several financial incentives such as fee-for-service financing for the provision of health care services and lump sums for study participation for hospitals were offered. A more detailed description of the implementation strategies and their intention can be found in the study protocol of the process evaluation [ 30 ].

Evaluation design and methods

Study design, participants and setting.

The VESPEERA programme was implemented in seven hospitals and 72 general practices in nine pre-defined districts in southwest Germany. It was expected that 7,088 patients resulting in 11,340 hospital admissions would participate in the multi-centre controlled study, which was conducted between May 2018 and September 2019. Inclusion criteria were admission to/discharge from hospital, age 18 years and older and participation in the GP-based care programme of the health insurer AOK Baden-Wuerttemberg (this implies that the GP provides comprehensive healthcare and coordinates hospital access [ 16 ]). Patients residing in nursing homes were excluded from study participation.

The effectiveness study was accompanied by a structured survey among care providers from participating general practices and hospital departments to explore the implementation processes between November 2019 and April 2020.

Outcomes and data sources

The effectiveness of the VESPEERA programme was measured by the primary outcome ‘number of readmissions due to the same indication within a time frame of 90 days’ (same indication was defined as the same three-digit ICD-10-GM code as the main diagnosis at discharge) as well as a range of secondary outcomes such as the number of admissions due to ambulatory care-sensitive diagnoses, delayed prescriptions of medications or medical aids and appliances and referrals to rehabilitation therapeutics on a case level. The analysis was conducted using a data set consisting of claims data (so called secondary data according to Social Code Book V ) and data collected within the CareCockpit (so called primary data).

Questionnaires used in the quantitative survey were self-developed as paper-based questionnaires and based on preceding qualitative interviews with care providers involved in the VESPEERA programme [ 29 ]. They included statements on the working mechanism of the programme, acceptance of the individual intervention components, various contextual factors, perceived outcomes, attractiveness and acceptance of the intervention and sociodemographic information. Five-point Likert scales were used to indicate whether agreement by the participants with the statements was ‘not at all true’ up to ‘very true’.

Data analysis

The endpoints were analysed using difference-in-difference models [ 31 ]. The change of the primary outcome (six months before vs. three months after the intervention) of the intervention group was compared to the change in the control group, which was built from claims data using propensity score matching. As the outcomes are binary and data has a hierarchical structure, random and fixed effects were considered resulting in a mixed logistic regression model. As a sensitivity analysis, the primary endpoint was evaluated using interrupted time series models that take time trends into account [ 32 ]. Furthermore, several subgroups were analysed in order to identify populations with high or low effectiveness of the intervention conducting the primary analyses in those groups.

A fidelity score was created using the respondents’ replies to whether they have used each of the intervention component at least once or are familiar with its content (the latter applies to brochures that are handed out to patients). The maximum number of components to be used was set to 1 (=100%), the result is a score between 0 and 1 indicating the degree of fidelity.

Ethical considerations

The effectiveness evaluation was registered (DRKS00014294 on DRKS/Universal Trial Number (UTN): U1111-1210-9657) and approved by the ethics committee of the Medical Faculty Heidelberg prior to the start of the study (S-071/2018), as well as the ethics committee of the State Chamber of Physicians of Baden-Württemberg (B-F-2018-023). The process evaluation was registered (DRKS00015183 on DRKS/Universal Trial Number (UTN: U1111-1218-0992) and approved by the ethics committee of the Medical Faculty Heidelberg prior to the start of the study (S-352/2018). Data linkage for the data set for the effectiveness evaluation was carried out by an independent institute using pseudonymised patient IDs. After data linkage and before the transfer to the evaluating institution, IDs were pseudonymised once again. All patients and care providers participating in the study gave their informed written consent.

Methodological remarks

The TIDieR checklist was used for the description of the intervention [ 33 ]. There is one deviation to the methods of the effectiveness evaluation as published in the study protocol. Originally, for the primary analysis, study arm 1 (patients with a planned admission in a participating hospital) was to be compared to the control group. However, no patient received in-hospital interventions, which renders study arm 2 (patients with a planned admission in a non-participating hospital) obsolete. Furthermore, the overall sample size was much lower than expected. Consequently, we decided to combine all study arms for the analysis of the intervention vs. the control group to increase the chance of detecting the underlying effect of the intervention.

Detailed information on the methods of the effectiveness and the process evaluation can be found in the respective study protocols [ 30 , 34 ].

Results of the effectiveness evaluation

During the intervention phase, 371 patients who fulfilled the inclusion criteria were admitted in 986 hospital admission cases. In total, 742 patients with 1,971 cases were considered in the analysis.

In total, the patients were between 18 and 99 years and on average 70 years (standard deviation (SD) 16) old. Male and female gender was equally represented. Patients in the intervention group were admitted on average 2.7 times (SD 2.3). The average length of stay was 7.4 days (SD 9.1) with a range of 0 to 69 days in the intervention group and 0 to 135 days in the control group. Using the classification of Huang et al. [ 35 ], patients had moderate comorbidity. The top five main diagnoses of the overall study population as well as those of patients with readmissions were mostly related to diseases of the heart and the lung. An overview of the characteristics of patients included in the study participants can be found in additional file 1.

Regarding the primary outcome (readmissions within 90 days due to the same indication), the rate after the intervention period was almost the same in both groups. In the control group, the readmission rate increased by 3.5% from 9.5% to 13%. In the intervention group, a decrease by 2.5% from 15.8% to 13.3% was observed. Altogether, a difference of 6% regarding readmission rates between intervention and control group was thus observed. Additional file 2 provides an overview of the descriptive results of the primary and secondary outcomes. The primary analysis did not show a significant effect (p = 0.385), although the intervention patients showed a slightly better outcome (odds ratio (OR) = 0.662). No significance tests were performed for any secondary outcomes. Additional file 3 provides an overview of the results of the statistical analysis. The sensitivity analysis confirmed the results of the primary analysis. Subgroup analyses showed that in most subgroups the OR was in favour of the intervention group. Regarding patients with severe comorbidity (high Charlson Comorbidity Index (CCI)), the likelihood for readmission was remarkably lower in the intervention group than in the control group (OR = 0.113, see additional file 4).

Results of the survey with care providers

The majority of care providers who participated in the quantitative survey were from general practices and, on average, the participants had 23 years of professional experience. Experience with the VESPEERA programme differed, participants on average had taken care of 9.1 patients (SD 21, see additional file 5).

Most of the intervention components were used at least once/known by about half of participants. Individual fidelity according to self-reports is 0.4, i.e. 40% on average, with quite high variation (see additional file 6).

The participants are rather indecisive when asked to rate the benefit over the expenses to use the intervention components with a tendency to a positive balance (means between 3.2 and 3.7). Regarding the assessment before admission and the admission letter, no clear recommendation for its utilisation is given by the participants. An additionally conducted linear regression model showed that the factor ‘nstitution’ was the only significant influencing factor, participants from hospitals rated its benefit higher than participants from general practices. As to the working mechanism of these intervention components, the participants think that they partially contribute to obtaining relevant information about the patient, especially social information relevant for social services. The participants do not think that admission processes in the clinic are accelerated by an admission letter. Approx. half of the participants believe that the benefits of the assessment/the admission letter are worth the effort. The assessment for planning of follow-up care after discharge is evaluated positively by the respondents from general practices. They agree that it is a suitable instrument to plan the patient’s care after discharge in a structured and complete way. Despite the positive evaluation, the effort to conduct the assessment is seen as quite high compared to the benefit. Regarding the telephone monitoring, participants from general practices see it as a suitable tool to check adherence to therapy and to identify further needs for patients with rather complex health care needs. Furthermore, they think that it can contribute to help to avoid rehospitalizations. More than half of the participants believe that the benefits of the telephone monitoring exceeds the effort. More results on the working mechanism of the intervention components can be found in additional file 7.

Several aspects regarding contextual factors have been addressed in the questionnaires. Concerning networking aspects, most of the participants stated that they have been working with the care providers in their region for many years. However, the utilisation of networking opportunities as well as personal contacts between care providers vary greatly. In general, the resources available for implementing the VESPEERA programme and admission and discharge management in general is described as insufficient by the majority of participants. Furthermore, many participants agree that external requirements such as legal regulations concerning data protection hinder cross-sectoral care (see additional file 8).

Almost half of the participants agreed that their awareness of the importance of cross-sectoral cooperation increased as a result of the VESPEERA programme. However, agreement with statements to improve cross-sectoral cooperation as a result of the VESPEERA programme (closer contact, new contacts, better provision of information and in general) are low (see additional file 9). On the other hand, there is a tendency for participants to wish for more comprehensive implementation of the VESPEERA programme, such as implementing it in all hospitals. Participants partially agree that the VESPEERA programme strengthens the role of the GP and the VERAH. Although implementation can be delegated to some extent, the majority of participants see the implementation as unwieldy (too bureaucratic, associated with double documentation and difficult to integrate into internal processes, see additional file 10).

The aim of this study was to examine the effects of an admission, discharge and follow-up intervention consisting of several components in hospitals and general practices and factors determining its implementation. A statistically significant effect of the intervention on patients’ hospital readmission rates could not be found. However, the results of the statistical analysis showed trends that patients might have benefitted from the intervention. For most outcomes, the odds ratios are in favour of the intervention group. Intervention fidelity was low and contextual factors that affected the implementation of the intervention are available resources, external requirements such as legal regulations, networking between care providers and belief in its working mechanism.

Evaluation of the effectiveness of the VESPEERA programme

There are various explanations for the absence of statistically significant effects. We can observe lower rates of readmission than assumed and low rates compared to studies looking at similar populations [ 15 ]. Furthermore, patients who participate in the GP-based care programme show lower readmission rates than patients outside of the programme [ 15 ] to start with, therefore, we can expect a potential overlay of effects of the GP-based care programme and the intervention. Together with an overall small sample size and a heterogeneous and overall low intervention fidelity, this is the most probable explanation for the absence of effects. The low sample size also required adjustments of the planned evaluation: as we did not achieve statistical power, we had to merge the different study arms into one. Therefore, and even though this is a common difficulty in the evaluation of multicomponent interventions [ 6 ], we were not able to detect the contribution of the intervention components to potential effects. The low sample size can partly be explained by a lower number of participating general practices than expected, misunderstandings regarding study participation (e.g. practices thought that they could only include patients if they were admitted to one of the participating hospitals, or thought that patients could only be included before hospital admission), pre-selection of patients by general practices presumably leads to a selection bias (which we also could not control for by the propensity score matching) and problems regarding implementation. The comprehensiveness of the intervention components hindered patient study inclusion and data collection. Our evaluation benefited from using claims data. Even though insurance claims data are associated with limitations, they probably provide valid and comprehensive data on hospital admissions and they do not induce attention bias (or Hawthorne effect) as other types of data-collection might. Relying on claims data allowed us to analyse readmissions within 90 days without a recall bias, a time frame not typical in evaluations of interventions to reduce readmissions [ 36 ].

Nevertheless, the decrease in readmission rates in the intervention group and the increase in the control group (which corresponds to the overall trend in this population [ 15 ]) adds up to an effect of 6%. Compared to a meta-analysis on the effect of continuity of care interventions on readmissions between 30 and 90 days after discharge in elderly patients with chronic conditions [ 36 ], the reported risk ratio of 0.74 (95% CI, 0.65–0.84, p < 0.001) translates into an odds ratio of 0.82, which is similar to our result of an effect size of 6% with an odds ratio of 0.66. We therefore assume that there is an effect of our intervention on readmissions within 90 days after discharge and that we would have been able to show its significance within a larger study population.

Implementation of the VESPEERA programme

The process evaluation provided insights into the working mechanisms of the intervention components, acceptance of the intervention and intervention fidelity and offers explanations for the small sample size. It showed that there were context-related barriers to the implementation of the VESPEERA programme such as limited resources in the organisation (e.g. staff, working places) or external regulations (e.g. data protection). Especially, the participation rate on the side of hospitals was low. They were occupied with the implementation of the legal regulation to improve discharge management ( Rahmenvertrag Entlassmanagement ) running parallel in time. Consequently, the number of participating hospitals was lower than originally planned (we expected 25 hospitals to participate) and those participating had little to no capacity to implement the intervention. The combination of barriers to implementation in general practices and hospitals resulted in the fact that no patient received in-hospital intervention components. Also, there were determinants to implementation that can be attributed to the programme itself. The programme is rated to be too elaborate and difficult to integrate into everyday processes. Concerning the assessment before admission, its benefit was rated lower by general practices than by hospitals. They did not have a direct positive benefit from it and might have seen their efforts wasted. Therefore, many general practices thus decided not to apply this intervention component and only include patients into the programme after hospital discharge. Intervention components such as the assessment for planning of follow-up care after discharge or the telephone monitoring were evaluated positively regarding its working mechanism, but the benefit is rated worth the effort by only approx. half of the participants. However, the effectiveness evaluation indicates that both the subgroup who received telephone monitoring (who are at high risk for readmission) and the subgroup without telephone monitoring (lower risk for readmission) profited from the intervention.

Including primary care in admission and discharge management

Strong primary care is associated with utilisation of secondary care, such as hospital admission [ 37 ], readmission [ 38 ], admission due to ambulatory care sensitive conditions [ 39 ] or emergency services [ 40 ] and can support admission and discharge processes. Van Walraven et al. [ 41 ] and Leppert et al. [ 42 ] found that primary care follow-up after hospital discharge reduces risk of readmissions. Still, most interventions aiming at the reduction of readmissions take place before or after discharge [ 6 ]. Our intervention, however, covered the whole cross-sectoral care process beginning with pre-admission intervention components in general practice, followed by intervention components during the hospital stay and at hospital discharge and concluding in general practice. Including primary care into multi-component care transition-interventions thus represents an opportunity to contribute to the reduction of readmissions and further strengthen primary care [ 43 , 44 , 45 , 46 ]. This especially but not only applies to countries with traditionally weak primary care systems, such as Germany and other countries with social health insurance systems [ 47 , 48 ].

Lessons learned

We have learned many lessons developing the VESPEERA programme, designing and conducting its evaluation and exchanging ideas and experiences within the project team and with all the participants from general practices and hospitals.

The simultaneity of implementing a new care programme and conducting a study makes acceptance more difficult, as time-consuming additional data collection and other efforts are necessary for the evaluation. Another consequence was that a randomised evaluation design deemed unfeasible. Complex interventions with the possibility of including patients in the study at different points in time face particular challenges due to the high workload of physicians in the reality of care. For future studies, we recommend to reduce the burden of data-collection on study participants when designing studies. Furthermore, we recommend planning with fewer study arms from the beginning. In addition, we recommend keeping the number of intervention components lower. Potential shares of the individual intervention components in the overall effect could then be determined based on subgroup analyses. Further comparison to non-GP-based care is recommended.

Addressing practice and policy, the following are our take-home messages:

The VESPEERA programme hardly reached clinical decision makers in hospital. The parallelism of the implementation of a project and the mandatory implementation of legal regulations aiming at similar outcomes has inhibited the implementation of VESPEERA in hospitals. Incompatibility of our programme with the information systems in hospitals further added to these barriers. Our collaboration with support staff in hospitals did not yield much impact.

The focus on patients of one large health insurer (covering 45% of the population in that region), who were referred by GPs, may have been too narrow to be of interest to hospitals. In Germany, many patients enter hospital by admission of specialist physicians or as emergency cases, not as planned hospital admissions by general practitioners.

‘Talking to each other’ is the be-all and end-all in cross-sectoral care. The workshops with the stakeholders to develop the intervention components and the feedback meetings have, in our opinion, moved a lot and increased acceptance for the problems and challenges of the respective ‘other side’ - quite independently of the VESPEERA programme. Regional initiatives such as joint quality circles and regulars’ tables, as already established among ambulatory physicians, could help to stabilise communication.

When co-designing care programmes with all relevant stakeholders, care should be taken that, even though efforts are made to consider the requirements and needs of all, the intervention does not become too comprehensive. Another possibility would be to make parts of the programme mandatory and others optional.

Admission and discharge management should not be reduced to the times of admission and discharge. The provision of more information by GPs at admission, for example by means of a mandatory and structured admission letter, should be promoted. In addition, GPs should be more involved in follow-up care. Admission and discharge management should become a shared cross-sectoral task and early planning of hospital discharge should start at the time of admission.

Risk assessments at discharge provided by either the discharging hospital or the GP providing follow-up care, for example by means of the HOSPITAL score, can help identify patients at risk of unplanned readmission. These patients can then be closely monitored and taken care of, for example through telephone follow-up.

For future studies, we recommend planning with fewer study arms from the beginning. If sample sizes are sufficiently large, the effect of intervention components could then be separated by conducting sub group analyses.

The results of our study on development, implementation and evaluation of an admission, discharge and follow-up intervention emphasise the relevance of treating admission and discharge management as a cross-sectoral task. Patients can possibly benefit from the intervention. It is of high importance to not only leave this responsibility to the inpatient sector but to involve primary care teams in both pre and post hospital care.

Data Accessibility Statements

Datasets are available upon reasonable request with the data owner.

Additional File

Tables on the results of the effectiveness analysis and results of the quantitative survey.

Acknowledgements

We would like to thank Johannes Vey for support with the statistical analyses. We thank all research assistants for their contribution to the study conduction. Moreover, we thank the participating hospitals, general practice teams, and patients for their valuable contribution to this study.

Funding Statement

Federal Joint Committee (G-BA), Innovation Fund (funding code: 01NVF17024). The funder had no role in the design of the study and not involved in its execution, data analysis and dissemination of results.

Abbreviations

Ethics and consent.

The study protocol for the effectiveness evaluation has been submitted to and approved by the ethics committee of the Medical Faculty Heidelberg prior to the start of the study (S-071/2018), as well as the ethics committee of the State Chamber of Physicians of Baden-Württemberg (B-F-2018-023). The study protocol for the process evaluation has been submitted to and approved by the ethics committee of the Medical Faculty Heidelberg prior to the start of the study (S-352/2018). All participants gave their written informed consent.

Dr Rachel Spencer , Associate Professor, Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK.

Luke Testa, Postdoctoral Research Fellow , Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW, AUSTRALIA.

Funding information

Competing interests.

Joachim Szecsenyi is a founder and holds stocks of the aQua-Institute. The other authors declare that they have no competing interest.

Author contributions

JF and MP: draft of the original manuscript. LU: provision of statistical expertise, MP: conduction of statistical analyses. JF: project management and study conduction, support with development of the intervention, implementation, data collection, data preparation, and data analysis. CS: project management and development of the intervention, data collection (survey). AW and NL: implementation of the intervention, data collection (survey). FPK: development of the intervention. AB and MK: support with the development of the intervention and its implementation. FA and MQ: development of the software for the intervention, support with its implementation, and involvement in data collection. PKK and JSH: data management, data linkage and data preparation, operationalisation of indicators for databased feedback reports. NEK, KTU and ST: overall project management and administration, recruitment of hospitals as well as provision of claims-data. RR: recruitment of general practices, organisation of feedback meetings. BH and GK: support with the development of the intervention by bringing in the patient perspective. MW: responsibility for the process evaluation and provision of methodological expertise. JS: design of the study and securing of funding. All authors contributed to the design of the study, the development of intervention components, and its implementation. All authors read and approved the final manuscript.

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• Published: 28 June 2012

Standardizing admission and discharge processes to improve patient flow: A cross sectional study

• Berta Ortiga 1 ,
• Albert Salazar 2 ,
• Albert Jovell 3 ,
• Joan Escarrabill 4 ,
• Guillem Marca 5 &
• Xavier Corbella 6  

BMC Health Services Research volume  12 , Article number:  180 ( 2012 ) Cite this article

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The aim of this study was to evaluate how hospital capacity was managed focusing on standardizing the admission and discharge processes.

This study was set in a 900-bed university affiliated hospital of the National Health Service, near Barcelona (Spain). This is a cross-sectional study of a set of interventions which were gradually implemented between April and December 2008. Mainly, they were focused on standardizing the admission and discharge processes to improve patient flow. Primary administrative data was obtained from the 2007 and 2009 Hospital Database. Main outcome measures were median length of stay, percentage of planned discharges, number of surgery cancellations and median number of delayed emergency admissions at 8:00 am. For statistical bivariate analysis, we used a Chi-squared for linear trend for qualitative variables and a Wilcoxon signed ranks test and a Mann–Whitney test for non-normal continuous variables.

The median patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009 (p < 0.051). The percentage of patients admitted the same day as surgery increased from 64.87% in 2007 to 86.01% in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009 (p < 0.01). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients in 2007 and 3 patients in 2009 (p < 0.01).

Conclusions

In conclusion, standardization of admission and discharge processes are largely in our control. There is a significant opportunity to create important benefits for increasing bed capacity and hospital throughput.

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At the moment, hospitals face an increasing demand for hospitalization, for medical staff due to the introduction of innovative technology in diagnostic and therapeutic procedures, for higher standards in clinical safety and, finally, an increasing patient demand for better quality services [ 1 , 2 ]. Optimal bed management is a strategic aim in any hospital as the provision of an inpatient bed, together with the staff and supplies involved, accounts for much of its most complex and expensive activity. The way beds are managed affects the way other hospital departments perform since many are dependent on bed availability, such as emergency services, operating theatres, etc. At the same time, these other hospital departments have an impact on bed usage [ 3 ]. Therefore, it is essential to have an efficient and correct bed management in order to improve service delivery.

From patient experience, an admission to a bed as an inpatient in an acute hospital is a major event, independent of this admission being an emergency or from a waiting list. First of all, patient experience will depend on the availability of beds. That is to say, that when patients need an emergency admission, it is important to be admitted quickly and to an appropriate bed, avoiding unnecessary waiting times in the emergency room. On the other hand, if patients are being admitted from a waiting list for elective surgery, it is important to minimize the number of occasions that admissions are cancelled as a result of there being no bed available [ 4 ].

The hospitalization process has three main stages: an admission, an inpatient period and a final stage with the discharge process. An inefficient bed management in any of the three stages of the hospitalization can cause a mismatch between demand and capacity. It has been proved that when bed demand exceeds capacity, patient admissions and scheduled surgical procedures can be delayed or cancelled. Traditionally, it has been assumed that the variability in the demand comes from the emergency patient. Interventions focused primarily on emergency departments have had limited success [ 5 ]. However, repeated case studies have shown that elective admissions are often the major cause of variation as they are more unpredictable than the emergency admissions [ 6 , 7 ]. In addition, the greatest variation is typically in the number of discharges and, therefore, efforts to reduce variation should start with the discharge process and not in the admission process [ 8 ]. Then, to have information about planned discharges 24-h in advance would allow a higher planning and an optimal bed assignment. Moreover, the discharge process should start at the point of admission in the case of planned admissions, as in some cases the estimated length of stay without a medical complication is known. Discharge planning allows for a better and quicker bed assignment in hospitals and the development of nurses and other staff working in discharge coordinator roles [ 9 ]. In this sense, it has been proved that multidisciplinary teams can improve the delivery of health services and patient care [ 10 – 12 ]. All admissions and discharges of the hospital should be centrally managed [ 13 ] and planned, as single-department solutions may create or worsen bottlenecks in other areas.

During the hospitalization process, patient flow is a strategic aim for the healthcare enterprise. Hospitals can combine process management with information technology to redesign patient flow for maximum efficiency and clinical outcomes. Information is the foundation of any patient flow initiative. Patient flow is built upon the capture, integration and sharing of information, both within and across the different departments and staff [ 14 ]. This critical foundation can be immensely challenging to hospitals both with numerous information systems and departments that operate as silos [ 15 ]. Actionable information triggers patient care events and enables automated reminders. The aim of this study was to evaluate how hospital capacity was improved through focusing on standardizing the admission and discharge processes.

This study was set in a 900-bed university affiliated hospital located in the metropolitan area of Barcelona (Spain) that belongs to the National Health System. It attends more than 120,000 emergency visits annually and the mean number of monthly elective admissions is 1,650 (95% CI 1,609 to 1,691), not taking into account day surgery. For our study, we created an interdisciplinary team of clinicians, hospital administrators and patients/families to examine bottlenecks and improvement areas in service delivery. We then selected high impact interventions focused on reducing the variation in the admission process for elective admissions, avoiding unnecessary cancellations of surgery interventions that have an impact on waiting lists, and on planning and standardizing the discharge process. All the interventions were implemented between April and December 2008. See Table 1 for intervention lists.

Standardization of the admission process included admission on the same day as surgery and promoting day-surgery rather than inpatient care, both aimed to free up bed days for emergency admissions and to admit major elective patients from a waiting list. To promote planning discharges 24-h in advance consisted in educating the clinicians on entering the discharge information in the electronic patient report. Then the house officers daily worked together with the physician in order to plan the discharge of the patient: discharge report, pharmacy prescriptions, the need of transportation to home, etc. At the same time, the nurse became the patient manager as he or she knew the discharges for the following day and that allowed an optimized task organization for the day, to identify possible home care arrangements for the patient, to collect patient documents from the house officer, and personally give them to the patient so that the patient could ask about any possible doubts. At the same time, the patient/family did not need to go personally to the house officer to collect the information and could get more feedback from their nurse manager. When the patient left the bed, the nurse entered the information in the system, which also prevented the patient/family to personally go and communicate their discharge to the admission unit when leaving the hospital. Bed management was done through a centralized team, with the help of the Information System, which placed emergency and elective patients in the most appropriate beds, allowed patient transfers between wards and checked patient discharge status, in order to have a correct patient allocation and a global vision of the hospital occupancy at all times.

For this study, we included all patients admitted to hospital wards before the multi-intervention, between the 1 st of January and the 31 st of December 2007, and after the implementation, between the 1 st of January and the 31 st of December 2009.

The following variables were recorded through the Hospital General Database: patient demographics, main diagnosis and procedure, admission and discharge dates, date of surgery, number of emergency patients waiting for a bed at 8:00 am, causes of patient cancellation, percentage of planned discharges 24-h in advance, number of patient outliers and number of day-surgery interventions. We did not look for ethical approval, as the organizational change described in this study did not cause any change in the clinical management of the patients and did not make any intervention to the individual patient.

The main outcome measures were: median length of stay, proportion of patients admitted on the same day of surgery, percentage of planned discharges, number of surgery cancellations, proportion of day-surgery, median number of delayed emergency admissions at 8:00 am due to lack of bed and median number of patient outliers, risk-adjusted mortality rate and risk-adjusted readmissions rate.

To describe categorical variables we used the total number of cases (N, days) and the percentage of each category and we used the Chi-squared for linear trend in bivariate analysis. All continuous variables were expressed as median ± interquartile range, and changes were assessed using the Wilcoxon signed ranks test and the Mann–Whitney test. A P value of less than 0.05 was considered statistically significant. All statistical analysis was conducted using the Statistical Software Program [ 16 ] for Windows (version 14).

We included 53,361 admissions, of which 27,784 were done in 2007 and 28,577 were done during 2009. Table 2 shows the general activity information during these two years, 2007 and 2009. The number of patient admissions for scheduled surgery was 13,824 patients in 2007 and 14,548 patients in 2009. The proportion of patients admitted on the same day of surgery significantly increased, from 64.87% in 2007 to 86.01% in 2009 (p < 0.05) (Table 3 ). The patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009, without day surgery patients. The scheduled admitted patients length of stay was 4.85 days in 2007 and 4.54 days in 2009, especially caused by the “same day admission” policy implemented, as the pre-surgery length of stay was reduced from 0.58 days in 2007 to 0.26 days in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of day-surgery interventions per day increased, especially due to the increase in day-case rates for the procedures: knee arthroscopy, varicose veins and bunions (Table 2 ).

The standardization of the discharge process was based on discharge planning and teamwork building (Figure 1 ). In this sense, the median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009.

Comparison of percentage of planned discharges during 2007 and 2009, by months.

The median number of patients placed out of service in 2007 was 70 patients and 62 patients in 2009 (p < 0.05). That is to say, the percentage of inpatient outliers diminished from 9.71% in 2007 to 7.30% in 2009 (p < 0.05). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients per day in 2007 and 3 patients per day in 2009 (P < 0.01). The percentage of emergency visits that were finally admitted to the hospital was 10.46% in 2007 and 10.49% in 2009. The percentage of emergency admissions over global admissions was 50.19% in 2007 and 49.10% in 2009. Risk-adjusted mortality rate diminished from 1.02 in 2007 to 0.89 in 2009 [ 17 ] (Table 4 ).

The optimization of hospital care resources by managing variation in the admission and discharge processes has proven to be effective. This multiple intervention project increased hospital productivity. Firstly, the main consequence due to the admission process has been the reduction of the length of stay, especially in scheduled admissions due to the reduction in the pre-surgery stay as a high percentage of patients were admitted on the same day as surgery. In addition, day surgery was considered as the first option for some surgery processes. Secondly, the significant increase in planned discharges helped sharing information among staff and enhanced teamwork. House officers were able to prepare all the information and patient arrangements for the day. In addition, patients and their families awaited comfortably in their rooms instead of being the messengers of information among the hospital silos. However, the implementation of these high impact changes required leadership, multidisciplinary teamwork and board level commitment as they affected the whole organization. All interventions were based on “lean” concepts, basically to reduce waste in terms of human resources, public health services and patient quality of care as well as to gain flexibility in hospital capacity.

Interventions included in this study are mostly dependent on the leadership and control of the management team [ 18 ] in order to assess the appropriateness of acute bed usage. There is an opportunity by process reengineering to increase bed capacity and productivity with the same fixed costs. In this sense, actions that lead to an increase of productivity without diminishing the service quality, or even increasing it, should be considered as successful key factors for best practices and a competitive advantage for any hospital. Bed management issues therefore warrant high consideration within the hospital’s management team. Some Boards have recognised the importance of hospital operations and that the person in charge of this area of management should be a senior member of the hospital’s executive committee.

In our study we have seen how redesigning operational aspects of the care delivery process that do not affect quality of care, can reduce scheduled admissions cancellations and the number of emergency admissions waiting for a bed. It is crucial not to block beds for elective admissions in advance, as supply of available beds will come through the discharges of the day. The way beds are managed has consequences on all organization levels: emergency and accident departments, surgery theatres, as in both cases their activity depends upon bed availability. However, there are many other aspects to consider when analysing bed capacity such as its efficient use. Departments that are inefficient can lengthen hospital stays and use beds unnecessarily [ 19 ].

Around 50 per cent of hospital admissions involve non-emergency patients who have been on a waiting list, mostly for a surgical operation. Waiting dominates many citizens’ perceptions of hospital care. While they are waiting, patients may be in considerable pain and discomfort and this interferes with their normal lifestyle and it adds to the workload of primary care [ 20 ]. On the other hand, in order to avoid last moment surgery cancellations due to lack of beds, a lot of professionals are likely to admit their patients the day before surgery and waste a one-day bed unnecessarily. It is then important to reach a consensus between the physicians and the management team in order to maximize profit for both parties, including patients and their families. The intervention for scheduled surgery consisted in a surgery admission unit [ 21 ] where the patient was admitted on the same day as surgery and was prepared without being given a bed. In this context, when patients were admitted each morning there were not any free beds in hospital wards, and they had to wait until other patients left the hospital. A possible drawback was that there could be a delay in bed assignments, which could have an impact on the rotation of patients in recovery theatres after the surgery and then in operating theatre flows.

In our hospital we reached 85% of planned discharges (Figure 1 ). Delayed discharge triggered waits on trolleys in the emergency room and in operating theatres. Planning ensured an early and certain discharge as well as a better bed assignment because there was information about which beds would be available. Therefore, the number of patient outliers in the hospital significantly diminished. A limitation of planning discharge was that not all of them were effectively real the following day. The percentage of cancelled discharges was usually less than 10%. However, the importance of the planning was precisely to avoid improvisation of all the staff that participated in the discharge: physician, nurse, house officer, sanitary transport, families and patients and others. In fact, discharge process should start in the admission point, as it is the mismatch between demand and supply of beds that promotes delays and bottlenecks in the system [ 8 , 22 ].

Another limitation of our study was that this multi-intervention was only implemented in one hospital, so the study’s generalizability is limited. In our experience, it is crucial that management leaders focus on efforts to promote admission on the same day as surgery and to promote an early hospital discharge so that other patients can be placed in the most appropriate bed as soon as possible.

In conclusion, admission and discharge standardization and therefore length of stay are largely in our control. There is a significant opportunity to redesign patients’ pathways and improve patient flow to create important benefits for bed management and hospital throughput, which ultimately improve quality and the safeness of patient care.

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Acknowledgements

No funding was received by any of the authors for this study or preparation of the manuscript.

For the help and support in the implementation of the actions described in this study: Cristina Capdevila (Deputy Medical Director, Ambulatory Area), Carlos Bartolomé (Deputy Medical Director, Surgery Area), Antonia Casado (Nurse Director), Mari Fe Viso (Nurse Director Assistant), Lluís Murgui (Head of Information Systems), Rosa Redón (Information Systems), Sílvia Millat (Chief Administrative Area), Sílvia Salgado (Chief of Admissions), Jose Luís Parra (Security Officer) and Sergi López (Chief of Caretakers). For the support in statistical analysis: Nuria Ortega (statistician).

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Clinical Services, Hospital Universitari de Bellvitge IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Berta Ortiga

Hospital Universitari de Bellvitge IDIBELL, C. Feixa Llarga s.n, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

Albert Salazar

Universidad Autónoma de Barcelona, Fundació Josep Laporte, Barcelona, 08041, Spain

Albert Jovell

Health Department, Institut d’Estudis de la Salut, Barcelona, 08005, Spain

Joan Escarrabill

Universidad de Vic, Vic, 08500, Spain

Guillem Marca

Hospital Universitari de Bellvitge, IDIBELL, L’Hospitalet de Llobregat, Barcelona, 08907, Spain

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There are not any financial and non-financial competing interests in relation to this manuscript.

Authors’ contributions

BO contributed to conception and design, acquisition of data, performed the statistical analysis and interpretation of data, as well as drafting the manuscript and adding all the comments from other authors; AS contributed to conception of the study as well as to the interpretation of data and to drafting the discussion of the manuscript; AJ and JE contributed to revising the manuscript critically for important intellectual content; GM participated in the conception, program design and in revising the draft manuscript; XC participated in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

Berta Ortiga, Albert Salazar contributed equally to this work.

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Ortiga, B., Salazar, A., Jovell, A. et al. Standardizing admission and discharge processes to improve patient flow: A cross sectional study. BMC Health Serv Res 12 , 180 (2012). https://doi.org/10.1186/1472-6963-12-180

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Received : 11 October 2011

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