C. M. Rajasingh1, L. A. Graham3, J. Richman2,3, M. W. Mell1, M. S. Morris2,3, M. T. Hawn1 1Stanford University,Department Of Surgery,Stanford, CA, USA 2University Of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA 3Birmingham VA Medical Center,Birmingham, AL, USA
Introduction: Prolonged hospital stays contribute to avoidable healthcare costs and negative patient outcomes. We hypothesized that surgical patients discharged to facilities other than home are less frequently discharged on the weekend, leading to longer than expected lengths of stay.
Methods: The National Veterans Affairs Surgical Quality Improvement Program data on inpatient general and vascular surgery from 2008 to 2014 were merged with laboratory, vital signs, prior healthcare utilization, and postoperative complications data from the VA Corporate Data Warehouse. Patients were stratified into two groups by discharge location: home or facility. Outcomes of interest were day of week of discharge and excess length of stay (LOS). Excess LOS was defined as the difference between the observed and expected LOS with expected LOS calculated using a stratified negative binomial model adjusted for patient and operative characteristics.
Results: Our sample included 135,875 patients with 92% (N=124,797) discharged home and 8% (N=11,078) discharged to a facility. Patients discharged to a facility were older (mean age 67 vs. 64 years, p<0.001) and more frequently had an ASA class of 4 or 5 (36% vs. 16%, p<0.001). They had higher rates of emergency cases (19% vs. 12%, p<0.001) and pre-discharge complications (16% vs. 7%, p<0.001). Patients discharged to facilities represented a much smaller fraction of patients discharged on Saturday and Sunday than patients discharged during the week (Figure 1). Of patients discharged to facilities, 43% had an observed LOS >1 day greater than expected, and these patients account for a disproportionate fraction of the total number of excess days in the early week (Figure 1). The average excess LOS for patients discharged to a facility on a Monday, Tuesday, or Wednesday was 1.5 days, compared with 0.3 days for patients discharged to home.
Conclusion: Compared with patients discharged to home, patients discharged to facilities were older with more medical comorbidities, and more often underwent emergent procedures. They were less frequently discharged over the weekend and significantly contributed to excess LOS, especially in the early week. This highlights the challenges with discharge planning over the weekend for complex patients. Improving resources available for weekend discharge planning or anticipating discharge needs earlier may improve efficiency of post-surgery hospital care.
