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Exploring discharge delay from an acute surgical unit

Background: Within the hospital system, efficient patient flow is essential. Discharge delay, the period of continued hospital stay after a patient is deemed medically fit to leave hospital, is one of the most significant barriers to optimal patient flow. Discharge delay retains non-acute patients in the acute environment unnecessarily, while preventing acutely presenting patients from accessing services in a timely manner. It results in overcrowded emergency departments with delayed admissions, slowed theatre schedules, and bed blocking in critical care, as well as negatively impacting on patient experience. In the context of a public health system under pressure, reducing discharge delay is critical to improving overall function of the system. This study aims to explore the features in the context of an acute surgical unit that cause discharge delay, the impacts of discharge delay, and the ways discharge delay could be minimised. Methods: A two phased, mixed methods design was employed in this research. Phase one obtained qualitative data through semi-structured interview with staff members occupying different roles within the health care team within Te Whatu Ora – Waikato. Themes derived from phase one informed the development of an audit form utilised in phase two, which collected quantitative data through its completion by registered nurses working in the acute surgical unit during the two-week audit time period. This audit recorded discharge related times and delaying factors that occurred for all the patients discharged from the ward during the audit period. Findings: Interviews were undertaken with nine participants (Hospital management n=2, Acute Surgical Unit management n=2, Registered Nurse n=1, Surgical Fellow n=1, Surgical Registrar n=1, Surgical House officer n=1, and multi-disciplinary team member n=1). Thematic analysis of the transcriptions revealed three core themes: (i) It takes a village to discharge a patient; (ii) Preparation, clearance, home; and (iii) Challenges and solutions to discharge delay. The survey was completed by 44 Registered Nurses and on analysis revealed a mean patient delay of 225 minutes, or 3.75 hours. For the audited patients, the most frequently occurring factor was ‘waiting for paperwork’ (55%) followed by ‘waiting for transport’ (40%). Conclusions: This study found that to reduce discharge delay a coordinated, system-wide approach with discharge focused optimisation across the entire patient journey, and particular focus on reducing the amount of delay caused by discharge paperwork, is required. Introducing a ‘discharge-focused clinician’, would effectively reduce discharge delay by ensuring the prioritisation of discharges, allowing discharge paperwork to be completed promptly. In addition to the introduction of a discharge-focused clinician, the systems and policies surrounding discharge paperwork could also be improved. Additionally, improving the utilisation of transit lounge by routinely sending all appropriate patients to transit lounge to wait for their transport, will also reduce discharge delay.
Type of thesis
The University of Waikato
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