. 2021 Feb 11;11(2):e044291. doi: 10.1136/bmjopen-2020-044291

Table 2.

Characteristics of included articles

Author (year)	Country	Objective	Method Study design	Participants	Sample size	Key conclusions
Database searches
Adlington (2018)⁴⁰	UK	Reduce length of stay, bed occupancy and delays in discharge and promote care in the appropriate setting among functional older adults on a psychiatric ward	Quantitative Quality Improvement	Older adults (65+) on psychiatric ward	NR	Daily rounds and management focusing on long-stay patients were effective in improving length of stay and bed occupancy Sustained improvements needed support from the quality improvement programme and community team
Ardagh (2011)⁶³	New Zealand	Identify 10 common challenges and promising initiatives relating to patient flow and emergency department overcrowding	Qualitative NR	NR	NR	To improve patient flow and emergency department overcrowding the following are needed: a comprehensive, systematic approach changes to resource usage sharing of expertise and experience
Arendts (2013)⁶⁸	Australia	Determine if hospital length of stay for older patients is reduced when an allied health intervention is introduced in the emergency department (ED)	Quantitative Non-randomised prospective pragmatic study	ED patients (65+) diagnosed with one or more of six conditions (cerebrovascular insufficiency; fractured neck of femur; cardiac failure; myocardial ischaemia; exacerbation of chronic airways disease; respiratory tract infection)	3572	Multidisciplinary allied health team assessment in the emergency department has no benefit in reducing hospital length of stay
Baumann (2007)⁵⁵	UK	Identify the factors causing good discharge practice performance and organisation of services	Qualitative Descriptive	Health/social services staff with managerial involvement in discharges	42	Future research needs to explore the impact of the identified issues on patients, families and staff
Behan (2005)⁹³	UK	Explore the experience of service users across the UK during the first 6 months of the implementation of the Community Care (Delayed Discharges) Act	Qualitative Explorative	NR	NR	Fines have resulted in a reduction of delayed discharges The act has brought health and social care together
Béland (2006)⁶⁹	Canada	Assess the transformation of the organisation and delivery of health and social services with additional interventions for frail elderly people	Quantitative Randomised controlled trial	Frail elderly	1309	Changing delivery of care for frail elderly persons is feasible Integrated care can reduce hospital and nursing home use, without impacting cost
Blecker (2015)⁷⁰	USA	Evaluate the impact of a weekend hospital intervention on care processes, clinical outcomes and length of stay	Quantitative Interrupted time series observational study	Non-obstetric patients hospitalised	57 163	Increased care on weekends may contribute to improved hospital flow, without negatively impacting clinical outcomes (30-day readmissions and mortality)
Boutette (2018)⁷¹	Canada	Serve frail elderly patients at risk of deconditioning and/or disability, caused by prolonged hospitalisation	NR Review/ description of programme	Frail older patients who are at risk of deconditioning and/or disability	NR	Key features of the model: proactive, restorative, collaborative and integrated, client-centred and cost-effective
Bowen (2014)⁷²	UK	Demonstrate that nurse-led discharges can improve efficiency on a short stay surgical ward, without impacting patients safety	Quantitative Case study	Adult ear, nose, throat patients having routine, elective, short stay surgery	265	Improved efficiency around discharge of elective short-stay ear, nose, throat patients 95% of ear, nose, throat patients (for simple discharge) are discharged on time
Boyd (2017)⁴¹	USA	Explore the leadership strategies used by hospital business administrators to reduce delayed discharges and improve profitability	Qualitative Multiple case study	Hospital administrators	3	Effective leadership from hospital administrators contributes to positive outcomes for patients, staff and the economy
Brankline (2009)⁴⁷	USA	Provide the appropriate level of care and patient choice when the patient is medically ready for transfer	Quantitative Pilot study	Medical floors with primarily elderly patients who require nursing home placement after discharge	25	Improved information exchange between hospitals and nursing homes
Brown (2008)⁶⁴	USA	Determine if the length of patient stay is reduced in the postanaesthesia care unit when nurses use discharge criteria	Quantitative Prospective clinical study	Adult, ASA physical status I, II, and III patients (18+) requiring general anaesthesia	1198	Decreased postanaesthesia care unit length of stay and discharge delays while maintaining patient status
Burr (2017)⁵⁶	Canada	Develop a framework that would support ALC avoidance strategies across the Toronto Central Local Health Integration Network	Case study Case study	ALC patients	3 hospitals	ALC avoidance reduces burden on patients, families and providers Long-term solutions to improve patient flow and avoid ALC should be sustainable and align with other initiatives
Caminiti (2013)⁴²	Italy	Evaluate the effectiveness of a strategy aimed to reduce delayed hospital discharge	Quantitative Cluster, parallel group, randomised trial/quality improvement	Hospital units: geriatric, medicine, long-term care	3498	Physician direct accountability can reduce unnecessary and avoidable hospital days, especially when delays are within staff control
Chidwick (2017)⁵⁴	Canada	Discuss concepts and ideas that led to lowest ALC days in the province	Mixed methods Quality improvement	ALC patients	NR	Improved patient flow and reduced ALC days through the implementation of a multidimensional approach
El-Eid (2015)⁷³	Lebanon	Assess the effectiveness of the Six Sigma method in improving discharge processes	Quantitative Pre and post-intervention study	NR	17 054	Six Sigma can have a positive and sustainable impact on patient flow and length of stay Discharge delays should be addressed through principles of Six Sigma, rather than institution-specific interventions
Gaughan (2015)¹⁰¹	England	Investigate the reduction in hospital bed-blocking due to a greater supply of nursing home beds or reduced costs	Quantitative Statistical modelling - Empirical analysis	Patients waiting for hospital discharge	NR	Improved coordination between health and long-term care is essential for addressing delayed discharges
Graham (2012)⁷⁴	UK	Evaluate the effect of the laparoscopic nurse specialist on patient discharge	Quantitative Retrospective comparison	Laparoscopic cholecystectomy and laparoscopic inguinal hernia repair patients	128	Nurse-led discharge may increase discharge postlaparoscopic surgery without impacting patient care
Gutmanis (2016)⁶⁵	Canada	Outline change strategies and their impact health system transformation and those living with responsive behaviours and their family members	Mixed methods Quality improvement	Individuals with responsive behaviours	NR	Improved coordination and communication across sectors Provided healthcare providers with learning opportunities
Henwood (2006)⁴⁸	UK	Examine the partnership between health and social care by exploring issues with hospital discharges	Case study Case study	Inpatients	NR	Addressing and improving delayed discharges requires partnerships between health and social care and a whole systems-based approach
Holland (2016)⁵⁷	USA	Report the development and evaluation of a discharge delay tracking and reporting mechanism	Quantitative Practice improvement project	Inpatients	NR	Discharge delays can be reduced if system and process breakdowns are identified and addressed
Katsaliaki (2005)¹⁰²	UK	Describe a project investigating potential care pathways for elderly people after discharge from hospital	Quantitative Discrete-event simulation, simulation model	Inpatients	NR	Simulation is a suitable methodology for recording and evaluating the new postacute packages
Lees-Deutsch (2019)⁶⁶	UK	Identify core characteristics of patient discharge criteria, recorded in clinical management plans or case notes	Quantitative Systematic observational retrospective review	Patients discharged from the acute medicine unit and short-stay units	50	Criteria-led discharge may be suitable for select patients in improving timeliness of discharge
Levin (2019)⁹⁴	Scotland	Examine the impact of Intermediate Care and the 72-hour target on delayed hospital discharge	Quantitative Controlled interrupted time series design	Patients aged 75+	107 022	Immediate impact on days delayed, but increasing rates days delayed over time suggests that Intermediate Care services may need to be adapted
Lian (2008)⁵⁸	Singapore	Develop methods to reduce the hospital length of stay for premature infants by 30%, within 6 months	Quantitative Retrospective review	Premature infants	78	Discharge planning should begin on hospital admission Nurses should coach parents to prepare them to care for their infant at home
Maessen (2008)⁷⁵	Netherlands	Assess the effect of enhanced recovery after surgery programme on discharge delays	Quantitative Retrospective/ prospective study	Patients undergoing elective colorectal resection	173	Additional recovery statistics should be added as outcomes of the ERAS programme
Mahant (2008)⁵⁹	Canada	Determine if an audit-and-feedback intervention reduces delayed discharge in a general paediatric inpatient unit	Quantitative Prospective observational study	Paediatric inpatient	3194	Reduced inappropriate hospital days, without impacting readmission rates Identified processes that impact inappropriate hospital days
Mahto (2009)⁷⁶	UK	Determine the effect of a diabetes outreach service on delayed discharges and avoidable admissions	Quantitative Cross-sectional audit	Acutely admitted patients with diabetes	137	The restructured hospital diabetes outreach service improved outcomes for inpatients with diabetes
Maloney (2007)⁴⁹	USA	Develop a web-based software application used to facilitate timely patient discharge	Quantitative Quality improvement pilot project	Inpatients	NR	Healthcare information technology can facilitate bed management efficiencies Improved coordination and overall inpatient flow
Manville (2014)⁹⁵	Canada	Determine if providing interdisciplinary care on a transitional care unit will result in improved clinical outcomes and lower costs	Quantitative Before-and-after structured retrospective chart audit	Elderly ALC patients (70+)	135	Improved health functional outcomes, delivered at a lower cost
Meehan (2018)⁷⁷	UK	Explore patients’ experiences of hospital discharge with the discharge to assess scheme	Qualitative Descriptive	Patients discharged through discharge to assess	30	Patients and caregivers reported positive and negative experiences with the scheme, but it may be beneficial in improving outcomes for some patients
Moeller (2006)⁶⁰	Canada	Assess patient and physician-related barriers to discharging patients who have met objective criteria	Mixed methods Retrospective assessment	Patients with community-acquired pneumonia	31	Patients outcomes can be improved by standardising care through a critical pathway Patients with poor functional capacity (using the Hierarchical Assessment of Balance and Mobility) may need additional services to improve discharge time after clinical stability
Mur-Veeman (2011)⁶¹	The Netherlands	Explain the theory of buffer management and discuss related previous assumptions	NR Review/ theoretical paper	Bed blockers	NR	To practically apply buffer management, current routines, principles and beliefs should shift to focus on flow between organisations rather than within one organisation
Niemeijer (2010)⁶²	Netherlands	Reduce the average length of stay to create more admission capacity and reduce costs	Mixed methods Efficiency improvement project (retrospective and prospective data collection)	Trauma patients	2006:1114 2007:1124	Lean Six Sigma is effective in reducing length of stay and improving financial efficiency in trauma care
Panis (2004)⁷⁸	Netherlands	Reduce inappropriate hospital stay by adjusting patient logistics, increasing efficiency and providing comfortable surroundings	Quantitative Retrospective cohort study	Mothers of newborn patients	2889 days of hospital stay of gynaecology and obstetrics patients	Discharge criteria can reduce inappropriate patient stays related to discharge processes Shifting maternity care to outpatient settings can reduce hospital length of stay
Patel (2019)⁴³	USA	Evaluate the impact of team-based multidisciplinary rounds on discharge planning and care efficiency	Mixed methods Quality improvement initiative	Dissatisfied patients with delayed discharge	1584	Multidisciplinary discharge rounds can improve discharge efficiency, length of stay and 30-day readmissions
Ali Pirani (2010)⁴⁴	Pakistan	Emphasise the role of nurses to determine factors leading to a lack of discharge planning	NR Review/ summary	Those experiencing delayed discharge	NR	Nurses play a key role in delivering patient-centred care and can improve discharge planning processes Nurses must have the appropriate knowledge about discharge planning and have the ability to communicate, coordinate and educate patients
Qin (2017)¹⁰³	Australia	Identify which barriers to discharge influence hospital occupancy when targeted by a hospital-wide policy	Quantitative Simulation modelling	NR	NR	Hospital occupancy rates and overcrowding can be improved by improving discharge processes
Rae (2007)⁹⁶	New Zealand	Illustrate how the Delayed Discharge Project solved a bed crisis and controlled expenditure	Quantitative Continuous quality improvement project	Acute general medical	20 034	The project altered staff behaviour around patient discharge resulting in a better use of resources The system crashed 2 years post-implementation There is too much focus on length of stay and bed allocations leading to poor decision making
Roberts (2013)⁵⁰	Australia	Undertake a preliminary trial of the Goal Length of Stay tool at a rehabilitation centre	Quantitative Prospective study	Inpatients in two units: SRU or BIRU	202	The programme did not reduce length of stay and was perceived negatively by staff
Sampson (2006)⁷⁹	UK	Describe bed occupancy data in people with diabetes before and after the introduction of a diabetes inpatient specialist nurse service	Quantitative Retrospective study	Diabetes inpatients	152 080	Diabetes inpatient specialist nurse reduced excess bed occupancy
Shah (2007)⁹⁷	England	Examine the impact of the Community Care (Delayed Discharge) Act on bed occupancy and length of stay in Geriatric Medicine (GM) and Old Age Psychiatry (OAP) services	Quantitative Retrospective study	Inpatient - specialties of GM and OAP services	NR	More patients were admitted to GM services and had a shorter length of stay than OAP
Sobotka (2017)⁵¹	USA	Describe a hospital-to-home transitional care model	Case study Illustrative case design/ review	Paediatric inpatient	1	Transitional care programmes can improve care for vulnerable populations by reducing health and developmental differences
Starr-Hemburrow (2011)⁸⁰	Canada	Minimise the number of post-acute patients transitioning from hospital to long-term care and develop an integrated plan for appropriate care and placement	Quantitative Quality improvement	ALC patients	NR	Inter and intra-professional collaboration is important to standardise discharge processes, build trust and respect and improve coordination of care
Sutherland (2013)⁴⁵	Canada	Describe structural challenges to reduce the impact of ALC patients and to propose policy alternatives that could reduce occupancy	NR Discussion and debate article	ALC patients	NR	A collaborative approach combining the three strategies should be considered to address ALC
Taber (2013)⁸¹	USA	Test a programme to improve length of stay, delayed discharges and early readmissions for kidney transplant recipients	Quantitative Observational study	Adult kidney transplant recipients	476	Improving medication safety post kidney transplant can improve clinical outcomes (acute rejection and infection rates, readmission rates)
Udayai (2012)⁸²	India	Reduce patient discharge time through a Six Sigma project	Quantitative Time motion study	Cash patients	NR	Improving discharge time allowed for more patients to be managed, improving revenue Leadership support and employee participation were essential for success
Williams (2010)⁵²	Australia	Examine the impact of a critical care outreach service on frequency of discharge delay from the intensive care unit	Quantitative Prospective cohort study	Patients discharged from the ICU	1123	The critical care outreach role did not decrease delayed discharges Reducing delays requires a collaborative approach focusing on hospital flow, rather than just the discharge process
Younis (2011)⁵³	UK	Compare the effect of an enhanced recovery programme with preoperative stoma education on the number of patients with prolonged hospital stay	Quantitative Prospective study	Patients undergoing anterior resection with the formation of a loop ileostomy	120	Pre-operatively integrating stoma management education into an enhanced recovery programme can reduce delayed discharges
Grey literature
Anonymous (2008)⁹⁹	USA	Create an expedited discharge fund to pay for goods and services inhibiting a patient’s discharge (medical equipment, medication and transportation)	N/A News article	Uninsured patients	NR	Patients can be safely discharged through support from the discharge fund
Anonymous (2010)⁴⁶	USA	Improve patient flow through initiatives that decrease length of stay and increase capacity	N/A News article	NR	NR	NR
Calveley (2007)⁸³	UK	Create a tier of support to reduce the unnecessary and costly occupation of hospital beds	N/A Review	NR	NR	Healthcare solutions should be developed in partnership with health and community service providers
Manzano-Santaella (2009)¹⁰⁰	UK	Analyse the relationship between Payment by Results and the Delayed Discharges Act	N/A Policy analysis	NR	NR	Quantitative measures (days delayed and costs) conflict with the social aspects of overall health and well-being
Krystal (2019)⁸⁶	Canada	NR	Mixed methods Continuous quality improvement and evaluation	Medically and socially complex and frail elderly	100+	Engaging partners early in the conception of the programme was critical to its success
Walker (2011)²	Canada	Develop recommendations of care for frail Canadians	N/A N/A	NR	NR	Community supports should be increased to keep people in their home as long as possible Programmes and services should be aimed at restoration and reactivation
North West Community Care Access Centre (2011)⁸⁸	Canada	Create a fact sheet of the benefits of staying at home and using Wait at Home (enhanced home care services while people wait for long-term care)	N/A N/A	Seniors waiting for LTC placement	NR	Staying home provides benefits for seniors including fewer risks (germs/ viruses) and a familiar setting compared with the hospital
Toronto Central Community Care Access Centre (2015)⁶⁷	Canada	NR	N/A N/A	NR	NR	This framework can help improve results around ALC avoidance and management
Province of New Brunswick (2017)⁹²	Canada	Identify priority strategic initiatives and implement community support orders across the province	N/A Annual report	NR	NR	NR
NHS Improvement (2018)¹⁰⁴	UK	Create a how-to guide explaining implementation approaches to reduce length of stay	N/A Guide	NR	NR	Clinical leadership is essential for implementing these initiatives
Starr-Hemburrow (2010)⁹¹	Canada	Improve patient flow through the implementation of change management initiatives	Quantitative Quality improvement	NR	NR	Culture change requires support and attention to be sustained over time
LHIN Collaborative (2011)⁸⁷	Canada	Help support patients in their homes for as long as possible by providing them with community supports	N/A Implementation guide and toolkit	Patients (specifically high needs seniors)	NR	Home First should be implemented as a system-wide approach
Shah (2011)⁹⁰	Canada	Ensure the appropriate community resources are in place to support the patient on discharge	N/A Implementation guide and toolkit	High need seniors (75+)	NR	Key success factors included: eliminating long discharge processes, having engaged leadership, having measurable targets, monitoring performance and educating patients and providers
Central East LHIN ALC Task Group (2008)⁸⁴	Canada	Understand the impact of delayed discharges in the Central East regions of Ontario (reviewing data, reading reports, initiating a pilot study, developing a patient flow map)	N/A Report	ALC patients	NR	ALC is a complex issue and requires coordination across sectors Implementation of the recommendations will help to reduce ALC days and improve patient flow
Adams, Care & Repair England (2017)⁹⁸	UK	Assist older patients in returning home from hospital quickly and safely	Case study Case study	Older patients	1	Large savings for the health system can be generated with the implementation of this intervention
Shah (2010)⁸⁹	Canada	Describe the Home First approach, a philosophy for reducing ALC	Quantitative Quality improvement	Elderly patients	NR	Allows patients the opportunity to regain independence and return home ALC solutions need a collaborative, cross-sectoral approach
Joint Improvement Team (2013)⁸⁵	Scotland	Identify 10 action items to transform discharge processes	N/A Quality improvement/ stakeholder engagement	N/A	NR	There are a number of factors to successfully reduce delays

ALC, alternate level of care; BIRU, brain injury rehabilitation unit; GM, geriatric medicine; ICU, intensive care unit; N/A, not applicable; NR, not reported; OAP, old age psychiatry; SRU, stroke rehabilitation unit.