Discussion

Appropriate use of acute vascular surgery beds is increasingly important as services are reconfigured into vascular networks and MAC in the UK. Delayed discharges pose a significant imposition on the delivery of effective vascular inpatient services and have a potentially large financial impact. This study has identified that delayed discharge contributes greatly to overall LoS in a specialist vascular ward. Delays due to the provision of social care followed by awaiting an inpatient rehabilitation bed contribute most to excess bed days. Factors that contribute to a potentially delayed discharge include major lower limb amputation and emergency admission.

The strengths of this study include prospective data collection of patients declared MFFD, a reasonably long study period of 4 months with >2500 total bed days included and a large enough number of 57 patients remaining an inpatient while MFFD for detailed analysis of the causes of their delays in discharge. There were no missing data for any of the patients included. The decision as to when a patient was deemed MFFD, while subjective, was consistently made at a daily consultant-led multidisciplinary ward round.

There were limitations to this study. Initially, only patients experiencing delayed discharge were studied as part of an ongoing quality improvement project aimed at reducing the impact of delayed discharge on inpatient services at our centre. This study was retrospectively broadened to all patients admitted to the ward during the study period, to allow both calculation of impact on delayed discharge on overall LoS and limited comparison with patients who did not encounter delays in discharge. Thus, the data for patients not experiencing delayed discharge are less robust, limiting the reliability of the conclusions. The difference in median LoS of patients with delayed discharge was almost double the median delay in discharge, suggesting that they are sicker, more complex patients. However, the far larger proportion of planned admissions (such as patients undergoing carotid endarterectomy or endovascular aneurysm repair who typically stay only one night in our unit) will have significantly reduced the overall median LoS of patients without delayed discharge. Clearly, the two groups of delayed and non-delayed patients are heterogeneous; however, patient data regarding presenting disease (eg, peripheral arterial disease, diabetic foot disease or aortic aneurysm) or management during admission were not collected prospectively and could not be reliably collected retrospectively. As such, no analysis of the impact of these factors on LoS, risk of delay or length of delay could be made. The study was carried out at a single centre limiting how generalisable the conclusions are. The study being carried out during a service reorganisation may underestimate the prevalence and impact of delayed discharge due to lower numbers of inpatients during the first month of the study prior to reconfiguration. Conversely, since the study period included Christmas when both elective operating and community health and social care provision are reduced, this may cause an overestimation of the prevalence and impact of delayed discharge. No independent verification of MFFD status or reason for delay was undertaken and was subjectively determined, potentially introducing bias and reducing how generalisable the conclusions are. However, the decision that a patient is MFFD was made by a consultant-led multidisciplinary ward round in the same consistent way across the study period, and these data were collected prospectively from patient records. No independent verification was made of reason for delayed discharge; however, this was consistently categorised as the final provision required to facilitate discharge as determined by the MDT and documented in the medical notes. There were 30 patients (including 9 with delayed discharges) who had admissions that extended prior to or beyond the study period included in the study. Only data from within the study period were included for analysis to ensure accurate calculation of excess bed days within the study period, but this may have underestimated the length of delays from some causes of delayed discharge. Furthermore, no assessment of wider indirect effects of delays in discharge, such as delays in admissions, transfers from intensive care or a network hospital, cancelled elective operating, or numbers of vascular surgery outliers, was measured during this study. Clearly, these will have financial implications for service delivery and also for the quality of care delivered to patients.

Considering the huge impact that delayed discharges have on the provision of inpatient surgical care, there is relatively little published literature on the subject. A recent systematic review including medical, surgical and psychiatric patients found that structured discharge planning potentially results in a moderate reduction in LoS and unscheduled readmission rate for older patients. However, the review identifies that effectiveness of communication with community services, impact on the overall bed usage and potential cost savings were not measured in the trials.8 Patient and admission factors associated with delayed discharge identified by our study include emergency admissions and social care provision on discharge. These findings are largely consistent with recent published articles assessing the causes for delayed discharges from acute care settings. However, while there was a tendency for older patients to have a longer length of delay in our study, age was not found to be independently associated with either increased risk of delayed discharge or length of delay. It is likely that this is due to a very small number of young patients with a considerable delay in discharge due to provision of suitable accommodation following major lower limb amputation. In our experience, it is not unusual for a vascular ward to have a small minority of patients similar to this in any given year. A recent UK based prospective study of vascular and general surgery patients found most significant delays in discharge in emergency admissions and elderly patients.9 A study looking into causes for delayed discharges from a single medical ward also found that most delays were due to social care requirements. This study noted that there was a trend of increasing delays to discharge experienced by patients of increasing age. This particular study estimated the annual cost of delayed discharges from a single ward to be over £500 000,10 similar to our estimates. A recent large study in Northern Italy similarly showed that a greater proportion of urgent admissions experienced delayed discharge, with social factors and wait for an inpatient rehabilitation bed by far the most common reasons for delay.11 Our study was also able to identify additional vascular surgery-specific factors that can potentially lead to delays in discharge. These are major lower limb amputation and, to a lesser extent, complex wounds requiring ongoing community NPT. Patients delayed waiting community NPT had all started negative pressure wound therapy during their admission and were awaiting capacity for this to be continued by community nursing teams prior to discharge. These patients typically included those undergoing minor lower limb amputation or debridement for diabetic foot disease. While these patients did not have long delays, there were a large number of patients who experienced delays due for this reason, meaning community NPT contributed to 10.7% of all excess bed days during the study period. Vascular patients, owing to their impaired mobility, advanced age, multiple comorbidities, frailty and complex wounds, tend to necessitate complex discharges. This has been evidenced in a previous study assessing surgical patients awaiting discharge once declared MFFD from acute surgical beds. It showed that there are a disproportionate number of vascular patients among this subset of patients.12 However, to the best of our knowledge, in-depth analysis of delays in discharge of vascular patients in the UK has not been published previously.

The study highlights the reliance of acute hospitals on outside health and social care providers to facilitate efficient safe discharges and handover of care within the community. With the numbers of over 65s projected to rise from 11 million currently to 16 million by 2034,13 the pressures on social services to provide adequate social care are only set to increase. Despite this knowledge, there has been a fall in spending on social care in England of £770 million since 2010.13 The number of over 65 s receiving social services funded home care has also fallen from 415 000 to 372 000. The numbers receiving social services funded residential care and nursing home care places have also fallen from 145 000 to 138 000 since 2011–2012.14 In contrast, there remain a number of targets on acute hospitals to treat and admit patients; however, there are no targets regarding timely discharges on either acute trusts or community health and social care services. Also, there are no robust national standards or guidelines that would facilitate audit of discharge processes. Therefore, with ongoing financial constraints on social care provision in the community and the increasingly ageing population, we believe that this reliance will become more prominent. Subsequently, it will be essential for acute hospitals to develop strong links with local social and healthcare providers in the community to lessen the impact on inpatient services.

Following on from this study, we are implementing ways of improving written and verbal communication around discharge goals and planning within the MDT. This has also been extended to include outside care agencies providing ongoing health and social care in the communities the vascular network covers. We plan to undertake further research to identify, on admission, patients at risk of needing complex discharge planning and implementing interventions early to prevent subsequent predictable delays in discharge. We hope that by identifying at-risk patients early in their admission and communicating effectively within and outside the MDT, we can reduce delays in discharge and LoS. If all delays to discharge could be eradicated, based on the data in this study, it would reduce mean LoS by 2 days per admission. While this is unrealistic in the short term, even a moderate reduction in delays in discharge will have beneficial implications in terms of service delivery, costs and quality of patient care. Further research to formally assess the indirect impact of delayed discharge on vascular services is needed. We believe this would aid in the creation of national guidelines and standards to facilitate ongoing audit and standardise care provided at vascular units across the UK.