Delays in discharging elderly psychiatric in-patients

AIMS AND METHOD

The issue of elderly psychiatric patients remaining in hospitalsafter being declared medically fit is of concern to doctors,hospital managers and politicians alike. This article setsout the findings from a study involving elderly psychiatricpatients at a district general hospital, undertaken to establishthe actual lengths, reasons for and financial implications ofdelays in discharge. The study involved 50 in-patients, allof whom had been discharged over the 3-month study period.

RESULTS

More than half of the patients in the sample were subject tosome delay in discharge and for patients waiting for ElderlyMentally Infirm (EMI) placements this averaged 50 days. Collectively,nearly 25% of the time spent in hospital was due to delay.The cost to the hospital was estimated at more than £700000 in 1 year.

CLINICAL IMPLICATIONS

Patients are being put at extra risk in terms of their healthby being delayed in hospital. Issues of institutionalisation,nosocomial infections and falls are of primary concern.

Introduction

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Introduction

Every day, around 4000 elderly psychiatric patients (National Audit Office, 2003) are stuck unnecessarily in hospitals across England. Thesepatients are referred to as ‘delayed discharges’– or more commonly ‘bed blockers’ –because they occupy beds when they no longer need the careprovided in a hospital setting.

The Community Care Act 2003 (Department of Health, 2003), whichreceived Royal Assent on 8 April 2003, was introduced to producea real and sustained reduction in delayed transfers of carefrom hospital. Specific government funding (the Delayed DischargeGrant) of £300 million over 3 years was made availableto support the development of services to deal with this. However,the Act concerned only patients in ‘acute care’and decreed that ‘there will be further discussion inParliament before mental health patients are brought into thescope of the Act’ (Department of Health, 2003). Thus,elderly psychiatric patients continue to remain as the subgroupof patients most exposed to delays in hospital discharge. Astudy conducted in 2000 (Angunawela et al) examined the impactof the Community Care Act 1990. It was found that there hadbeen delays in the care management process by social servicesin discharges for people with dementia requiring residentialor nursing home placements.

The present study was carried out at Leigh Infirmary (Wrightington,Wigan and Leigh National Health Service (NHS) Trust), a districtgeneral hospital in Lancashire, in the old age psychiatry unit.There are two 25-bed in-patient wards there: one for functionalpatients and one for patients with dementia. The departmentis led by three consultants and their respective teams who are responsible for the mental health needs of around 48 000 residentsaged 65 years and over in the catchment area.

Patients who are admitted to the wards undergo assessment bythe medical and nursing teams, an occupational therapist anda social worker, together deciding on the level of care requiredby the patient. These recommendations are then put to the familywho, with the help of the social worker, choose an appropriatepackage of care for their relative.

Method

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Method

We considered all elderly psychiatric in-patients dischargedfrom Leigh Infirmary in the period between 1 October and 31December 2005. Our initial source of information about patientadmissions, discharges and transfers was the daily ward listingkept by each ward.

Once a patient was listed as ‘discharged’ on thedaily ward listing, their file was retrieved and informationclassified according to the pro forma template. The templatecontained essential demographic data plus the following:

Date for the patient fit for discharge, as entered in the notesby the medical team.
Total length of in-patient stay (thenumber of days from dateof admission to date of discharge,excluding time spent onmedical wards (other than psychiatrywards) or in accidentand emergency if the patient’s physical health declined).
Delay incurred (the number of days elapsedfrom ‘patientfit for discharge’ to ‘dateof discharge’).
Patient destination, namely home, ElderlyMentally Infirm (EMI)unit, nursing home, residential homeor sheltered accommodation.
Cause of delay, for example carerdecision resulting in delay, non-availability of residentialor nursing home, patient goingout of area, medical/nursing/physiotherapy/occupationaltherapydelay.

Results

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Results

A total of 50 patients were discharged during the study period(five became physically unwell during their stay, whereuponthey were transferred to accident and emergency and passedaway; they were not included in the study). There were 32 womenand 18 men in this group, aged 61–97 (mean 76.3) yearsold.

In terms of the conditions the patients were diagnosed with,24 (48%) had a primary diagnosis of dementia, 15 (30%) depression,3 (6%) bipolar illness, 3 (6%) psychosis, 2 (4%) had organicproblems and 5 (10%) had ‘other’ problems (persistentdelusional disorder, alcohol dependence and no formal diagnosis).

The discharge destination was as follows: 24 patients were dischargedto their homes, 9 went to an EMI unit (5 to nursing and 4 toresidential homes), 7 into sheltered accommodation, 6 intoa residential home and 4 into a nursing home.

In-patient stay and delay
The total length of in-patient stay for all patients (excludingtime spent on other medical or surgical wards) varied between4 and 326 days (mean stay was 60 days). The total length ofdelay varied between no delay up to 201-day delay (mean delaywas 14 days; Fig. 1).

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Fig. 1. Delay between ‘patient fit for discharge’ and actual discharge.

There were a number of causes for the delay in discharge: anunavailable destination placement caused a total of 229 days’delay (affecting 12 patients); a 201-day delay happened becauseof patient ‘out-of-area’ (only one case); carerdelay accounted for 117 days (12 patients); funding issueswere the reason behind 84 days of delay (4 patients); nursingand residential home assessment and feedback resulted in 59 days’ delay (5 patients); delays in patient transferto destination cost 9 days’ delay (2 patients); and setupof homecare cost 7 days (3 patients).

Consequences of delay
These include ‘bed-blocking’, of particular relevancein mental healthcare units as patients who are in crisis inthe community may not be able to access hospital care; increasedcarer stress; risk of nosocomial infections (Lim et al, 2006)and financial costs to the NHS.

Cost of delay
The 50 patients in the study spent a total of 2997 days on thetwo hospital wards being observed; the total number of delayeddays arising from their stay was 706; this figure represents23.5% of the total number of in-patient days.

The average cost of a hospital bed in the Trust was put at £250per day, and so for 706 delayed days this equates to a costof delay of £176 500 for the 3-month period we collecteddata for. If extrapolated for 12 months, over £700 000would be spent on unnecessarily keeping patients in hospital.

For the 50 patients, the delay cost £3530 per person over3 months; since there were 27 patients delayed 1 day or more,this brings a cost of £6540 per delayed patient over3 months. Of the patients experiencing delay, 19 were diagnosedwith dementia, 6 with depression, 1 with bipolar affectivedisorder and 1 with an organic illness. If we consider how the destination of the patient affects the delay, it is clear thatthose awaiting EMI placements are affected most, followed bythose awaiting a nursing home place (Table 1).

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Table 1. Destination of patients after discharge, delay incurred and its cost

Discussion

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Discussion

We found that there exists a significant delay in dischargingelderly psychiatric patients. In our study, 23.5% of totalin-patient stay was attributed to delay; most delay was dueto non-availability of placement (especially EMI and nursinghomes) and carer delay. A study looking at the delays in dischargingpsychiatric in-patients with learning disabilities (Watts et al, 2000) found that those who remained in hospital longer were the leastable and most challenging – the equivalent in patientswith dementia would be those awaiting EMI placements, as theyoften have the highest level of care needs. It must be emphasisedthat timely and not early discharge should be the goal as thelatter may result in the elderly patient being discharged toan inappropriate placement, potentially leading to hospitalreadmission.

The financial cost of delay to Leigh Infirmary over 12 monthswas estimated at £706 000, for elderly psychiatric in-patientsonly.

The demand for hospital beds is immense and one measure of theefficiency of a hospital is its throughput; therefore, whena blockage occurs in the system, it has a knock-on effect atother levels of care. Delayed discharge not only exposes thepatient to health risks such as infection, social isolation,increased dependency and loss of skills (Lambourne et al, 2005)but also affects the health and well-being of those awaiting hospital admission and their carers.

Limitations
This study was conducted at a district general hospital andas such it may not be relevant to elderly psychiatric patientsin other locations. Other considerations were the relativelysmall number of patients (n=50) and a short time frame of thestudy (3 months). We assumed the entries in the daily wardlisting for the date a patient was medically fit for dischargehad been accurate – prior to commencement of the study,an information sheet was distributed to the teams asking topay particular attention to accuracy. Confounding factors identifiedin previous studies in this area which may also delay dischargesuch as age, severity of illness, complex comorbid physical health problems, poor mobility and informal status (Watts et al, 2000) were not taken into account in this study. It may be expectedthat the rate of staff turnover in social services and changesin care coordinators could have an effect on the length ofin-patient stay and this would be a useful consideration fora future study.

Recommendations

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Recommendations

Proactive discharge planning with emphasis on carer involvementshould be encouraged together with the appointment of an elderlydischarge coordinator to facilitate and monitor discharge.

Ways of improving inter-disciplinary communication between healthand social services should be examined – our observationshighlighted the importance of social worker attendance at theweekly multidisciplinary team ward reviews (the fact that socialworkers were based in the hospital greatly helped here); whensocial workers are based externally, regular updated reportsfrom the ward (and vice versa) should be agreed upon. Assertive outreach services have been established nationwide for certaingroups of adult mental healthcare users and extension to older-ageclients should also be investigated. At Leigh Infirmary, adocument detailing results of medical tests and investigationswas completed for each patient to expedite provision of themedical report and early completion of a Part I discharge summarywas widely encouraged among medical staff.

Increased care home provision is paramount if the problems ofdelayed discharge are to be adequately addressed (Epstein et al, 2001); another factor for consideration here would be ‘step-down’ facilities to act as a buffer between ward and eventual placementto reduce unnecessary in-patient stay.

Bed-blocking is a result of finite resources being used inappropriately.To quote Dr Andrew Murrison, MP for Westbury, ‘It costs£1630 to have someone in hospital for a week and £319for a week in a care home. Where is the sense in that?’(Parliament Publications, 2002).

References

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