BMJ Open 4:e004773 doi:10.1136/bmjopen-2013-004773
  • Health services research
    • Research

Unexpectedly long hospital stays as an indicator of risk of unsafe care: an exploratory study

  1. Gert P Westert1
  1. 1Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud university medical centre, Nijmegen, The Netherlands
  2. 2Dutch Health Care Inspectorate (IGZ), Utrecht, The Netherlands
  3. 3Dutch Hospital Data (DHD), Utrecht, The Netherlands
  1. Correspondence to Dr Ine Borghans; hj.borghans1{at}
  • Received 30 December 2013
  • Revised 15 April 2014
  • Accepted 16 May 2014
  • Published 5 June 2014


Objectives We developed an outcome indicator based on the finding that complications often prolong the patient's hospital stay. A higher percentage of patients with an unexpectedly long length of stay (UL-LOS) compared to the national average may indicate shortcomings in patient safety. We explored the utility of the UL-LOS indicator.

Setting We used data of 61 Dutch hospitals. In total these hospitals had 1 400 000 clinical discharges in 2011.

Participants The indicator is based on the percentage of patients with a prolonged length of stay of more than 50% of the expected length of stay and calculated among survivors.

Interventions No interventions were made.

Outcome measures The outcome measures were the variability of the indicator across hospitals, the stability over time, the correlation between the UL-LOS and standardised mortality and the influence on the indicator of hospitals that did have problems discharging their patients to other health services such as nursing homes.

Results In order to compare hospitals properly the expected length of stay was computed based on comparison with benchmark populations. The standardisation was based on patients’ age, primary diagnosis and main procedure. The UL-LOS indicator showed considerable variability between the Dutch hospitals: from 8.6% to 20.1% in 2011. The outcomes had relatively small CIs since they were based on large numbers of patients. The stability of the indicator over time was quite high. The indicator had a significant positive correlation with the standardised mortality (r=0.44 (p<0.001)), and no significant correlation with the percentage of patients that was discharged to other facilities than other hospitals and home (r=−0.15 (p>0.05)).

Conclusions The UL-LOS indicator is a useful addition to other patient safety indicators by revealing variation between hospitals and areas of possible patient safety improvement.

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