A Nobili

A Szekely

BA Ponce

BH Tess

D Foer

Gad Segal

I D’Ilio

JA Heit

KJ Verhaegh

KS Palmer

M Charlson

Maya Rosman

MU Majeed

Omer Segal

Orna Rachminov

PW New

RL Kane

BMC Health Services Research

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RESEARCH ARTICLE Open AccessProlonged patients’ In-Hospital WaitingPeriod after discharge eligibility is associatedwith increased risk of infection, morbidityand mortality: a retrospective cohort analysisMaya Rosman1, Orna Rachminov2, Omer Segal3 and Gad Segal1*AbstractBackground: Prolonged, inappropriate hospital stay after patients’ eligibility for discharge from internal medicinedepartments is a world-wide health-care systems’ problem. Nevertheless, the extent to which such surplus hospitalstays are associated with infectious complications, their time frame of appearance and their long-term implicationswas not previously addressed.Methods: We conducted a retrospective cohort analysis of patients experiencing an In-hospital Waiting Period(IHWP) after discharge eligibility in a single, tertiary hospital.Results: We screened the records of 245 patients out of which 104 patients fulfilled our inclusion criteria. The meanlength of IHWP was 15.7 ± 4.79 day during which 9(8.7 %) patients died. The study primary composite end-point,in-hospital mortality or hospital acquired infection (pneumonia, UTI or sepsis) occurred in 32(31 %) patients. Themost hazardous time was during the first 3 IHWP days: 63.7 % of patients experienced a complication and 44 % ofthe total complications occurred during this period. The occurrence of any complication during IHWP wasassociated, with statistical significance, with increased risk of mortality during the first year after IHWP initiation(HR = 6.02, p = 0.014).Conclusion: Prolongation of hospital stay after patients are deemed to be discharged from internal medicinedepartments is associated with increased morbidity and mortality, mainly during the first surplus days of in-hospitalstay. Efforts should be made to shorten such hospital stays as much as possible.Keywords: Nosocomial infection, Hospital acquired infection, Hospital stay, In-hospital mortality, Pneumonia,Urinary tract infection, SepsisBackgroundThere is a large body of evidence supporting the factthat prolonged hospitalizations are associated with in-creased risk for in-hospital complications including in-fections and deep venous thrombosis [1, 2]. However,most of the published data deal with pre-specified popu-lations and the prolonged hospital stay is considered asan outcome rather than a causative factor for complica-tions (e.g., after a certain surgical procedure like orthopedicsurgery [3] or a coronary artery bypass graft surgery [4]).Only few researchers addressed this issue with relation tothe general, most often frail and elderly population admit-ted to internal medicine departments. Many of these pa-tients experience unnecessary, prolonged hospitalizationperiods while waiting for a suitable nursing or rehabilita-tion facility.In the current study we addressed the issue of surplusinfectious complications potentially resulting from pro-longed, inappropriate hospital stay, for patients that weredefined as eligible for hospital discharge from internalmedicine departments, either for rehabilitation or a nurs-ing home. The reasons for prolonged hospital stay were* Correspondence: gad.segal@sheba.health.gov.il1Department of internal medicine “T’, Chaim Sheba Medical Center@, RamatGan, IsraelFull list of author information is available at the end of the article© 2015 Rosman et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Rosman et al. BMC Health Services Research  (2015) 15:246 DOI 10.1186/s12913-015-0929-6mainly low availability of rehabilitation and nursing bedsin the aforementioned facilities. We did not include pa-tients that were mechanically ventilated or patients foundto be carriers of Carbapenemase resistant bacteria, bothpopulations deemed to experience prolonged hospitalstays that are especially difficult to shorten. Our patientpopulation comprised mainly of patients diagnosed of suf-fering from stroke and patients recovering from severe,acute illness. These two groups of patients are routinelychecked by a specialist in geriatric medicine who recom-mended a rehabilitation period or functional decondition-ing, respectively.MethodsAfter approval of an institutional review board, the eth-ics committee of the Sheba medical center, patients’medical records were analyzed by a single investigator.Study patients were all consecutive patients from in-ternal medicine departments in our hospital. As such,the study population is considered representative of ourgeneral population of patients admitted to internal medi-cine departments. The following items were collected:patients’ demographics (e.g., age and gender); clinicalbackground (Charlson Comorbidity Index (CCI), agecorrected) [5] and records of the following infectiouscomplications diagnosed during their in-hospital waitingperiod: pneumonia, urinary tract infection (UTI), sepsis,clostridium difficile associated colitis and death. Theprimary composite end-point of the study was the oc-currence of in-hospital mortality or hospital acquiredinfection (pneumonia, UTI or sepsis). The risk for separ-ate complications as well as the risk for the primarycomposite endpoint was calculated per each day duringthe IHWP. In light of the results of analyses, with con-sideration of IHWP on a day-by-day level, and in orderto achieve a better understanding of the effects men-tioned above, it was concluded that IHWP days shouldbe divided according to time periods as follows: the firstthree days of the IHWP, days 4 to 7 of IHWP and the8th day and forth of the IHWP. In-hospital mortality wasdetermined according to the patients’ medical recordwhile long-term; post discharge mortality data were ob-tained from the national population registry.Statistical analysisVariables were expressed as mean ± SE, and categoricaldata were summarized as frequencies and percentages.The clinical characteristics of the patients at baselinewere compared between the subgroups, with the use ofthe chi-square test for dependency of dichotomous vari-ables. The Binary Logistic Regression model was usedfor testing the effect of IHWP length on occurrence ofthe primary complications, including patients’ mortality.The Kaplan–Meier method was used to determinecumulative probabilities of the occurrence of the variouscomplications in patients, including patients’ mortality.The Hierarchical Binary Logistic Regression model wasused to estimate the effect of IHWP length on the oc-currence of various complications in patients, under theconfounder variable CCI (age adjusted).ResultsThe study was conducted in a tertiary hospital. Electronicmedical records (EMR) of 245 consecutive patients thatwere eligible for discharge from internal medicine depart-ments during the period between 1st of January to the 30thof June 2013 and stayed for an in-hospital waiting periodwere initially screened. Patients’ demographic characteris-tics are detailed in Table 1.The in-hospital waiting period (IHWP) was, in mostcases, a result of their need for a follow-up stay in achronic medical facility (geriatric rehabilitation depart-ment, chronic hospitalization due to on-going chronicdiseases etc.). Only 104 patients’ records that fulfilledthe inclusion criteria and had sufficient data were in-cluded in our final analysis. The mean length of IHWPwas 15.7 ± 4.79 days. A total of 9(8.7 %) patients diedduring IHWP. The primary composite end-point oc-curred in 32(31 %) patients. 9(8.7 %) patients sufferedfrom pneumonia, 14(13 %) had UTI, 9(8.7 %) had sepsisand 1(0.96 %) patient was infected with clostridium diffi-cile during the IHWP. The mean duration to occurrenceof any complication was 6.2 days (o to 46 days). Themean length of IHWP of patients who died during thisperiod was 10 days (2 to 42 days). Figure 1 describes theun-adjusted risk of the primary composite endpoint (oc-currence of in-hospital mortality or hospital acquired in-fection) during the IHWP.The risk of death during the first 3 days of IHWP wasthe greatest (22.72 %, p = 0.05) and was significantlygreater than the risk of death during days 4 to 7 (2.04 %,p = NS) and the risk of death at day 8 and beyond(9.09 %, p =NS). The risk of experiencing the study’s pri-mary composite end-point (in-hospital mortality or hos-pital acquired infection was at its height at IHWPinitiation: the risk during the first 3 days of IHWP was63.7 % (p = 0.005). The risk reduced to 20.44 % (p =NS)at days 4 to 7. On day 8 and beyond to IHWP, the riskTable 1 Patients’ baseline demographic characteristicsPatients’ characteristics ValueAge (years, mean ± SE) 76 ± 11Male gender (%) 52.9 %Charlson Comorbidity Index (age adjusted, mean ± SE) 6.83 ± 2.8Norton score (mean ± SE) 11.9 ± 2.52Length of hospital stay (days prior to IHWP, mean ± SE) 14.1 ± 2.83Length of IHWP (days, mean ± SE) 15.7 ± 4.8Rosman et al. BMC Health Services Research  (2015) 15:246 Page 2 of 5of in-hospital mortality or hospital acquired infection was24.25 % until the end of the IHWP. 44 % of all complica-tions occurred during the first 3 days of IHWP, 31 % dur-ing days 4 to 7, 12 % during days 10 to 12 and 13 % afterday 11. As a whole, the results can evidently imply, thatthe cumulative burden of complications increases as theIHWP lengthens (Fig. 2). The differences between the sec-tions of the IHWP, with regard to the risk of the study’smain outcome, were not affected after adjusting therelative risk for the possible confounding effect of theCharlson Comorbidity Index (CCI age adjusted).The occurrence of any complication during IHWP wasassociated, with statistical significance, with increased riskof mortality during the first year from IHWP initiation(HR = 6.02, p = 0.014).DiscussionDuring daily rounds in internal medicine departments, itis a custom to encourage, both patients and families, togo home as soon as it is considered appropriate. How-ever, many patients are staying in-hospital after dis-charge eligibility: some due to family incompetence orfailure in reassurance by the attending physician, somedue to objective obstacles in assuring appropriate treat-ment continuity in the setting of primary medicine andsome due to lack of vacant beds at their next, rehabilitationFig. 1 Un-adjusted risk of the primary composite endpoint (occurrence of in-hospital mortality or hospital acquired infection) during the IHWPFig. 2 Cumulative burden of any complications along the whole length of IHWPRosman et al. BMC Health Services Research  (2015) 15:246 Page 3 of 5or nursing facility. We wanted to make sure, that ourstringent policy of advancing discharge due to fear ofnosocomial infections is indeed justified. We did not findin the relevant literature, previous studies that fully an-swered our needs with regard to the population of elderlypatients hospitalized in internal medicine departments.Harkanen and co. showed that prolonged hospital staywas associated with increased risk for adverse drug reac-tions [6]. In another study [7], prolonged hospitalizationwas associated with increased in-hospital mortality. Majeedand co. [8] showed that especially the elderly population issubject to increased vulnerability and subsequent highfrequency of nosocomial complications from prolongedhospital stays. D’illo and co. in a study from Italy showedthat 55 % of patients, eligible for discharge after acutehospitalization, were discharged later than expected dueto low availability of rehabilitation resources [9]. A total of4505 inappropriate hospitalization days were documentedfor a cohort of 1083 individuals only. New and co. [10],describing the “patient flow as a major problem in hospi-tals”, appreciated that overall, 12 % of the length of theacute hospital stay, amongst 360 patients they included intheir study, were surplus length of stay after these patientswere deemed ready for transfer for rehabilitation. Theproblem of patient flow and its impact on hospital stay issignificant in the United States also, as reflected in a re-view by Kane [11], describing the transfer from hospital topost-hospital care as the “big leap”. In a retrospective ob-servational pilot study, Foer et al. [12] found that non-medical factors accounted for nearly one third of all“long-stay” hospitalizations. They also found out delays infinding a placement in a nursing facility to be the mostcommon reason for such stays. Indeed, the best timing forhospital discharge after a stay in the internal medicinedepartment is largely unknown. Many studies showedand healthcare professionals agree that this should be assoon as possible, for the vast majority of patients. Previ-ous publications address relevant issues that are aimed atdifferent end-points, such as diminishing re-admissionrates [13, 14].ConclusionsThe main finding of our study is that, whatever was thecause for discharge delay, inappropriate in-hospital stayis associated with increased risk of infection and bothshort- and long-term mortality. We found that the mosthazardous time is during the first three days after dis-charge is deemed appropriate. We can only speculatewhy the risk is reduced thereafter: it could be that themedical attention is significantly reduced during the firstdays, maybe too soon. Also, it is possible that during thefollowing days, after 4 days of surplus hospital stay, re-duced medical attention could even harbor advantagesfor the surviving patients: reduced intensity of invasiveprocedures and medication changes could promote sta-bilization on behalf of the recovering patient. It is plaus-ible to think that after a certain period, the patientbecomes more of a tenant, less inflicted by nosocomialthreats.Nevertheless, our findings show that short-term com-plications, during the initiation of surplus hospital stayshould not be overlooked, even if their occurrence isdiminishing, since these complications are significantlyassociated with increased risk of long-term mortality.Study limitationsOur study has several limitations: it is a retrospectivestudy and therefore, no causality could be inferred fromits results. Furthermore, prospective studies are war-ranted in order to affirm these findings although itwould not be easy to design a study in which a certaingroup of patients would be randomized to stay in-hospital after deemed eligible for discharge. A potentiallimitation is the fact that there could be geographical al-terations in the causes for prolonged, inappropriate in-hospital waiting. Such diversity could potentially affectour results.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsRM: study initiation and ideation, data collection and processing, manuscriptwriting. RO: data collection and processing, manuscript writing and proof.SO: data collection and processing, statistical analysis, proof. SG: studydesign, statistical analysis, manuscript writing, editing and proof. All authorsread and approved the final manuscript.Author details1Department of internal medicine “T’, Chaim Sheba Medical Center@, RamatGan, Israel. 2Department of Nursing Management, Chaim Sheba MedicalCenter@, Ramat Gan, Israel. 3Sackler faculty of Medicine, Tel-Aviv University,Tel-Aviv, Israel.Received: 5 January 2015 Accepted: 19 June 2015References1. Tess BH et al. Incidence of hospital-acquired infection and length of hospitalstay. Eur J Clin Microbiol Infect Dis. 1993;12(2):81–6.2. Heit JA et al. Risk factors for deep vein thrombosis and pulmonaryembolism: a population-based case–control study. Arch Intern Med.2000;160(6):809–15.3. Ponce BA et al. Diabetes as a risk factor for poorer early postoperativeoutcomes after shoulder arthroplasty. J Shoulder Elbow Surg.2014;23(5):671–8.4. Szekely A et al. A multinational study of the influence of health-relatedquality of life on in-hospital outcome after coronary artery bypass graftsurgery. Am Heart J. 2011;161(6):p. 1179–1185.e2.5. Charlson M et al. Validation of a combined comorbidity index. J ClinEpidemiol. 1994;47(11):1245–51.6. Harkanen M, et al. Patient-specific risk factors of adverse drug events inadult inpatients - evidence detected using the Global Trigger Tool method.J Clin Nurs. 2015;24(3-4):582–91.7. Nobili A et al. Polypharmacy, length of hospital stay, and in-hospital mortalityamong elderly patients in internal medicine wards. The REPOSI study. Eur J ClinPharmacol. 2011;67(5):507–19.Rosman et al. BMC Health Services Research  (2015) 15:246 Page 4 of 58. Majeed MU et al. Delay in discharge and its impact on unnecessary hospitalbed occupancy. BMC Health Serv Res. 2012;12:410.9. D’Ilio I et al. Waiting time between acute event and rehabilitation:continuity of nursing care and rehabilitation. Analysis and suggestions for aService of Protected Discharge. Prof Inferm. 2014;67(2):67–74.10. New PW et al. Reducing the length of stay for acute hospital patientsneeding admission into inpatient rehabilitation: a multicentre study ofprocess barriers. Intern Med J. 2013;43(9):1005–11.11. Kane RL. Finding the right level of posthospital care: “We didn’t realize therewas any other option for him”. JAMA. 2011;305(3):284–93.12. Foer D et al. Nonmedical factors associated with prolonged hospital lengthof stay in an urban homebound population. J Hosp Med. 2012;7(2):73–8.13. Verhaegh KJ et al. Transitional care interventions prevent hospitalreadmissions for adults with chronic illnesses. Health Aff (Millwood).2014;33(9):1531–9.14. Palmer KS et al. Activity-based funding of hospitals and its impact on mortality,readmission, discharge destination, severity of illness, and volume of care: asystematic review and meta-analysis. PLoS One. 2014;9(10):e109975.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color ﬁgure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitRosman et al. BMC Health Services Research  (2015) 15:246 Page 5 of 5

Prolonged patients’ In-Hospital Waiting Period after discharge eligibility is associated with increased risk of infection, morbidity and mortality: a retrospective cohort analysis

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Prolonged patients’ In-Hospital Waiting Period after discharge eligibility is associated with increased risk of infection, morbidity and mortality: a retrospective cohort analysis

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