Editor—Black and Pearson identified the complex factors driving up length of stay and causing palpable tensions in every hospital in the United Kingdom.1 The NHS is unique among health services in having no effective lever to discharge patients who no longer require hospital care. Black and Pearson say that patients can elect to remain in hospital until a final placement is found. In reality it is not so much patients seeking placements at rest homes and nursing homes but their families, who have the power to adopt an approach of masterful inactivity to discharge.
In North America and most of Europe powerful financial incentives mitigate unnecessary delays to discharge from hospital. We have the ludicrous situation whereby many frail acutely ill elderly people are being discharged home too early in an attempt to reduce their length of stay by one or two days, with all the concomitant risks of failed discharge and readmission. At the other end of the spectrum many discharges grind to a halt, with inordinately long length of stay far outweighing the occupied bed days saved by risky premature discharge. We are compromising the care of acutely ill elderly people at the expense of neglecting the delayed discharges of a relatively small number of patients with very long length of stay.
In our own unit a spot survey in October last year showed that out of 398 beds in the department, 152 were occupied by patients whose discharge had been delayed. Of the 172 patients in continuing care, four were deemed to have had their discharge delayed owing to patient or family choice. These patients had an average delay of about 210 days from the time they were deemed fit for discharge—the equivalent of lopping two days off the length of stay of 100 acute patients.
We need to tackle the politically sensitive issue of discharging patients from hospital against patients', or more realistically patients' families', wishes rather than invest huge effort in trying to prevent admission of acutely ill patients with a variety of ill conceived and untested initiatives for intermediate care. We suspect that this will not happen so long as politicians and policy makers fear the adverse publicity from a few individual cases more than the less dramatic media coverage of delayed discharges and cancelled operations.
References
- 1.Black D, Pearson M. Average length of stay, delayed discharge, and hospital congestion. BMJ. 2002;325:610–611. doi: 10.1136/bmj.325.7365.610. . (21 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]