Table 3.

Initiative characteristics

Author	Initiative Description/content	Target population	Setting	Initiative category*	Results
Database Searches
Adlington40	Quality improvement programme Weekly quality improvement meetings with driver diagrams to implement Plan Do Study Act cycles	Older adults (>65) on psychiatric ward	Hospital Mile End Hospital (Leadenhall Ward), 26 beds	Information sharing live	Length of stay was reduced from an average of 47 days to 30 days Bed occupancy was reduced from 77% to 54%
Ardagh63	10 promising initiatives Special beds, hospital operations planning, discharge planning, access to imaging, responsive acute secondary services, pathways for acute patients, acute demand mitigation, enhanced ED layout, enhanced ED senior staffing, engagement of staff	NR	Hospitals	Tools and guidelines Practice changes	Identified top 10 challenges and 10 promising initiatives related to patient flow and emergency department overcrowding
Arendts68	Allied health assessment A comprehensive assessment of patients by an allied health team within hours of presentation to the hospital through the emergency department	Patients (>65) diagnosed with one or more of six predetermined conditions	Hospitals Two Australian tertiary hospitals	Practice changes	No benefit in reducing hospital length of stay
Baumann55	N/A Qualitative study to identify factors associated with low rates of delayed discharges	Health/ social services staff with managerial involvement in discharges	Hospitals (6 sites) 4 southern sites, 2 northern sites	Initiatives described touch on all categories	6 high-performing hospital sites identified issues impacting delayed discharges (capacity, internal hospital efficiencies and interagency efficiencies) Resources and teams to prevent avoidable admissions Discharge teams to support nurses' discharge planning, Systems for monitoring and communicating patients' progress, Patient choice protocols Ensure availability of responsive transportation and discharge lounges
Behan93	Community Care (Delayed Discharge) Act 2003 Local authorities are financially responsible (payments) to acute hospital when patients remain in hospital because community care arrangements have not been made	NR	7 areas across the UK	Infrastructure and finance	National decrease in delayed discharges between 2003 and 2004
Béland69	Integrated care Community-based multidisciplinary teams who provide integrated care and coordinate health and social service	Frail elderly	Community service centres/ organisations	Practice changes	Significant (50%) reduction in the number of patients in the integrated care group that became ALC No significant differences in utilisation or costs between groups Increased caregiver satisfaction
Blecker70	7 day hospital initiative Increased hospital services on the weekend (eg, diagnostic imaging, weekend discharges, physician and care management services)	Non-obstetric hospitalised patients	Hospital Tisch Hospital, 705 beds	Practice changes	Decreased average length of stay by 13% Increased proportion of weekend discharges by 12% Decreased 30-day readmissions No changes in mortality
Boutette71	Subacute care unit for frail elderly Subacute care in a restorative environment (integrated care and restoration)	Frail older patients who are at risk of deconditioning associated with a long hospitalisation	Hospitals Ottawa Hospital; Perley and Rideau Veterans’ Health Centre	Practice changes	N/A
Bowen72	Nurse-led discharge Allows nurses to facilitate discharge based on specific criteria that was developed to guide the discharge process (also allows for discharge in evenings and on weekends)	Adult ear, nose, throat patients having routine, elective, short-stay surgery	Hospital University Hospital of South Manchester	Practice changes	Significant reduction in rate of delayed discharges in both audits
Boyd41	Communication and leadership Efficient communication and leadership from hospital administrators	NR	Hospitals (2) Part of a hospital conglomerate in Chicago	Information sharing live	Strategies for improving delayed discharges and reducing financial burden included efficient communication and effective leadership
Brankline47	Technology-assisted referrals The use of technology to improve information exchange and processes, increase data accuracy and produce documents	Elderly patients who require nursing home placement after hospital discharge	Academic Medical Centre	Information sharing live Tools and guidelines	Decreased length of stay and improved timely discharges of patients resulted in cost savings Increased communication within and between the hospital and nursing homes
Brown64	Discharge criteria Nurse implementation of predetermined discharge criteria (activity, respirations, pulse, blood pressure, pain, etc)	Adult, ASA physical status I, II, and III patients, 18 years or older, requiring general anaesthesia	Hospital Postoperative recovery area of a large, tertiary-care, academic hospital	Tools and guidelines Practice changes	Decreased length of stay in the post-anaesthesia care unit by 24% Reduced discharge delays with nurse-led discharge No change in adverse events (airway obstruction, reintubation, arrest)
Burr56	ALC avoidance framework A framework of strategies to reduce ALC numbers and promote ALC avoidance	ALC patients	Hospitals (3) Michael Garron Hospital Humber River Hospital Toronto General Hospital	Tools and guidelines	(1) MGH—exceeded ALC target by 20%, reduced number of ALC patients waiting for long-term care (2) HRH—culture shift after implementation of ALC framework recommendations (3) TGH—improved number of ALC admission avoidance cases
Caminiti42	Physician accountability Physician motivation and accountability through monthly reports and audits (can compare their length of stay results to other staff)	Hospital Units: geriatric, medicine, long-term care	Hospital University Hospital of Parma, 1267 beds	Information sharing live	Reduction in unnecessary, avoidable hospital days No significant changes in 30-day readmission or mortality
Chidwick54	Change ideas Identification of change concepts, followed by the development and implementation of change ideas to promote behaviour change	ALC patients	Hospital William Osler Health System	Practice changes Tools and guidelines Information sharing live	Lowest ALC days in Ontario Eliminated ethical errors, improved patient discharge experience and decreased patient confusion
El-Eid73	Hospital throughput project using Six Sigma Methodology The use of Six Sigma Methodology to implement electronic patient requests, a floor clerk and a billing officer	NR	Hospital (tertiary care teaching hospital) American University of Beirut Medical Centre, 386 beds	Practice changes	Significant reduction in length of stay post-intervention Decreased discharge time (2.2 hours to 1.7 hours)
Gaughan101	Increasing supply of nursing home beds The use of modelling to explore the effect of increased supply of nursing home beds or lower prices of nursing home beds on bed blocking	Patients waiting for hospital discharge	Hospital	Other initiative	Increasing home care beds by 10% would decrease social care delayed discharges by 6%–9%
Graham74	Nurse-led discharge Nurse-led discharge following list of criteria (that each patient must meet)	Patients receiving laparoscopic cholecystectomy and laparoscopic inguinal hernia repair	Hospital Leicester Royal Infirmary	Practice changes	Nurse-led discharge group were significantly more likely to be discharged on the day of surgery No significant difference in readmission rates or patients seeking primary care postdischarge
Gutmanis65	Behavioural Supports Ontario A quality improvement initiative for older adults with responsive behaviours through the identification of change strategies and knowledge translation best practices	Individuals with responsive behaviours	South West LHIN	Practice changes Tools and guidelines	Decreased ALC care cases among persons with behavioural needs Improved perceptions from families and clients around patient care
Henwood48	Change Agent Team A team partnership between health and social care to explore the issues around delayed discharges	Inpatients		Information sharing live Tools and guidelines	The Change Agent Team helped support implementation of contingency arrangements at the local level
Holland57	Tracking and reporting system Development and evaluation of a discharge delay tracking and reporting mechanism	Inpatients	Hospital (academic medical centre)	Tools and guidelines	Individual patient discharges may be improved by tracking factors that cause delays Nurses took the time to provide comments regarding patient delays
Katsaliaki102	Intermediate care services Statistical simulations to investigate potential care pathways and associated costs	Inpatients	Hampshire Social Services	Other initiative	500 new places will help to balance the demand and capacity for intermediate care services by avoiding a deterioration of delay times
Lees-Deutsch66	Criteria led discharge - Selection of Patients for Efficient and Effective Discharge Patient discharge is guided by a set of clinical criteria; once the patient meets the criteria, a member of the team can facilitate discharge	Patients discharged from the AMU and both short-stay wards	Hospital (acute medicine service with four clinical areas)	Tools and guidelines Practice changes	27 patients were suitable for criteria led discharge, 23 were not Mean wait time for the 27 suitable patients prior to discharge was 4 hours and 51 min Discharge delays were often caused by system delays
Levin94	Step-up intermediate care units A bridging service between hospital and home for individuals ready for discharge from acute care; allows for recovery and regaining of independence	Aged 75+	Hospital	Infrastructure and finance	Reduced bed days delayed Rate of days delayed increased over time
Lian58	New discharge guidelines for premature babies Development of new discharge guidelines for premature neonates	Premature infants	Hospital Singapore General Hospital	Tools and guidelines	Reduced median duration of hospitalisation from 58.2 days to 34.9 days Cost savings of $6174/infant
Maessen75	Enhanced recovery after surgery Reduction in the postoperative recovery period to reduce overall hospital length of stay	Patients undergoing elective colorectal resection	Hospital	Practice changes	No significant difference in proportion of patients with a discharge delay post-ERAS programme Approximately 90% of patients pre and post-ERAS were not discharged on the day discharge criteria/ functional recovery were met
Mahant (2008)59	Medical Care Appropriateness Protoco-audit and feedback A tool that provides information on hospital bed use (qualified and nonqualified hospital days)	Paediatric inpatients	Hospital Hospital for Sick Children	Tools and guidelines	Significantly lower risk of inappropriate hospital days During the intervention, 33% of bed days were nonqualified, compared with 47% pre-intervention No change in 48-hour readmission rate
Mahto 76	Hospital diabetes outreach service A service to prevent admission through a number of strategies (improved access to services, management of medical problems, early discharge planning, organisation of follow-up care)	Acutely admitted patients with diabetes	Hospital New Cross Hospital, 700 beds	Practice changes	Reduction in bed occupancy, inappropriate admissions, delayed discharges and effective discharge planning
Maloney49	Patient tracker A web-based application to facilitate the discharge process by enhancing communication between disciplines	Inpatients	Hospital Primary Children’s Medical Centre	Tools and guidelines Information sharing live	Decreased number of cancelled surgeries, median emergency department length of stay and average number of inpatient admissions
Manville95	Transitional care unit A rehabilitation-style unit with enhanced nursing and rehabilitation services for elderly patients	Elderly ALC patients (70+)	Hospital St Joseph’s Hospital, 22-bed transitional care unit	Infrastructure and finance	Improved health outcomes and discharge disposition, decreased length of stay and costs per patient
Meehan77	Discharge to Assess Patients who require care support are discharged home, or to the community, for a needs assessment in their personal environment	Patients discharged through D2A	Hospital	Practice changes	Assists with early and effective hospital discharge 60% of patients and caregivers reported a positive experience with D2A Communication was noted as an issue
Moeller 60	Critical pathway Criteria for the management and discharge of patients admitted with community-acquired pneumonia	Patients with community-acquired pneumonia	Hospital Queen Elizabeth II Health Sciences Centre, 637 beds	Tools and guidelines	58% of patients with a prolonged length of stay felt they were ready to go home once reaching clinical stability, compared with 92% of patients without a prolonged length of stay Hierarchical Assessment of Balance and Mobility score at clinical stability was significantly associated with physicians’ and families’ assessment of the patients’ discharge readiness
Mur-Veeman61	Buffer management A tool that aims to balance patient flow between hospital and nursing homes by maximising patient throughput	Bed blockers	Hospital to nursing home (intermediate care department)	Tools and guidelines	The lack of cooperation is an inhibitor of buffer management Efforts should focus on improving cooperation between providers
Niemeijer62	Lean Six Sigma An initiative based on Lean Six Sigma to reduce length of stay, improve discharge procedures, create admission capacity and reduce costs	Trauma patients	Hospital University Medical Centre Groningen, 1339 beds	Tools and guidelines	Average length of stay of all patients (surgical and trauma) decreased by 2.9 days post-intervention Average length of stay of trauma patients decreased by 3.3 days
Panis78	Dutch evaluation protocol Altering discharge procedures to assess inappropriate hospital stay, efficiency and patient logistics	Mothers of newborn patients	Hospital Maternity unit of 17 beds (715 total hospital beds)	Practice changes	Reduction in inappropriate patient stay by 6.1% Decrease in length of stay by 0.7 days
Patel43	Multidisciplinary team-based structure for discharge rounds Interventions based around multidisciplinary team-based discharge planning rounds (afternoon huddles, pilot teams for physician continuity)	Dissatisfied patients with delayed discharge	Hospital University of Colorado Hospital, 673 beds	Information sharing live	Higher proportion of patients discharged before noon, lower length of stay and 30-day readmission rate in pilot team compared with control
Pirani44	Nurse participation and patient and family involvement Communication between the nurse and patient/ family to promote continuity of care and coordination of services	Those experiencing delayed discharge	NR	Information sharing live	Enhancing nurse involvement in the discharge planning process can improve delayed discharges
Qin103	Simulation modelling Statistical simulations to explore patient flow and different discharge strategies that could reduce hospital occupancy	Varies based on model	Hospital Flinders Medical Centre (FMC)	Other initiative	Hospital occupancy can be significantly reduced, with a reduction from 281.5 to 22.8 days in the best scenario (instantaneous discharge for 24 hours)
Rae96	Delayed discharge project Local authorities are financially responsible (payments) to acute hospital when patients remain in hospital because community care arrangements have not been made	Acute general medical patients	Hospital Dunedin hospital	Infrastructure and finance	Mean length of stay decreased by 2.6 days (from 6.5 to 3.9 days) Decreased costs of service delivery by $2.4 million Bed numbers decreased by 24 (from 56 to 32) No change in readmission rates
Roberts50	Royal Rehabilitation Centre, Sydney, goal length of stay tool A tool that reports the length of stay benchmark figures on an individual patient basis	Inpatients in two units: SRU (stroke rehabilitation unit) or BIRU (Brain Injury Rehabilitation Unit	Hospital Hampstead Rehabilitation Centre, 128 beds	Tools and guidelines Information sharing live	Total discharge delays from the 2 units totaled 6311 days Length of stay was not decreased Negative perceptions of the programme from staff
Sampson79	Diabetes inpatient specialist nurse Diabetes management, based on structured group education, for all diabetes inpatients	Diabetes inpatients	Hospital Norfolk and Norwich University Hospital NHS Trust, 989 beds	Practice changes	Decreased mean excess bed days by 0.7 days (from 1.9 to 1.2)
Shah97	Community Care (Delayed Discharge) Act 2003 Local authorities are financially responsible (payments) to acute hospital when patients remain in hospital because community care arrangements have not been made	Inpatient - specialties of Geriatric Medicine (GM) and Old Age Psychiatry (OAP) services	Hospitals	Infrastructure and finance	GM: Decreased median and mean length of stay Increased number of finished episodes (inpatient discharges) No relationship with number of bed days OAP: Increased median and mean length of stay Decreased number of finished episodes (inpatient discharges) Increased number of bed days
Sobotka51	Hospital-to-home transitional care programme at AHK A programme to support and educate families on providing care for medically stable children at home	Paediatric inpatient	Transitional and Respite Centre Almost Home Kids	Practice changes Information sharing live	2 months following support at AHK, the patient transitioned home to be cared for by his mother and home care team
Starr-Hemburrow80	Home First A programme designed to help keep patients in their homes (with community supports) for as long as possible; focusing on providing access to needed services	ALC patients	Hospitals	Practice changes	Rate of ALC patients decreased by at least 50% across the region of study
Sutherland45	Build more; Integrated care; and Financial incentives Three strategies to improve ALC impact on hospitals (build more beds, integrated care, financial incentives for post-acute providers)	ALC patients	Hospitals	Information sharing recommendation document	N/A
Taber81	Comprehensive interdisciplinary improvement initiative A programme implemented by a multidisciplinary team to improve length of stay, delayed discharges and early readmissions through key initiatives	Adult kidney transplant recipients	Hospital Medical University of South Carolina	Practice changes	Delayed discharges decreased by 14% Readmission rate (7 day) decreased by 50% Acute rejection and infection rates decreased
Udayai82	Improvement in discharge process - Six Sigma The implementation of strategies using Six Sigma to improve discharge processes (billing hour, patient audits, office executive, priority for discharge, ward boys, discharge process flow)	NR	Hospital	Practice changes	Discharge time was decreased by 21% (from 247 to 195 min) Patients had improved satisfaction with the discharge process
Williams52	Critical care outreach role The implementation of a critical care outreach role to facilitate communication between ICU and ward staff	Patients discharged from the ICU	Hospital Royal Perth Hospital, 22-bed ICU (570 total beds)	Practice changes Information sharing live	Delayed discharges increased by 4% (from 27% to 31%)
Younis53	Enhanced recovery programme A programme post-colorectal surgery to improve stoma management and expedite discharge time	Patients undergoing anterior resection with the formation of a loop ileostomy	Hospital Single district general hospital	Practice change Information sharing live	Average length of stay decreased by 6 days Significant decrease in percent of patients experiencing delayed discharge due to independent stoma management
Grey literature
Anonymous99	Expedited discharge fund A hospital fund to pay for services that are holding up a patient’s discharge (medical equipment, pharmaceuticals, physical and occupational therapy, transportation, etc.)	Uninsured patients	Hospital Iowa City, University of Iowa Hospital, 700 beds	Infrastructure and finance	A patient from a rural area was provided with $40/week for medications and gas to travel to a hospital that provided specialised wound care A social worker found a group home for people with a mental health diagnosis for a patient who had no social support or funding
Anonymous46	Meetings Daily and weekly meetings to discuss issues with patient throughput and strategies for eliminating barriers	NR	Hospital University of Cincinnati Health University Hospital, 693 beds	Information sharing live	Decreased average length of stay by 5.34 hours Increased accuracy of predicting next day discharges from the medical/surgical units by 40%
Calveley83	Tiered community-based services Three tiers of services to allow for people to be cared for in their own homes or residential units, instead of in hospital	NR	Hospital Four Seasons Healthcare, 18 000 beds	Practice changes	NR
Manzano-Santaella100	Payment by Results and Delayed Discharges Act Payment by Results pays providers a fixed price for each individual case, while with the Delayed Discharges Act, local authorities are financially responsible when patients remain in hospital because community care has not been arranged	NR	NR	Infrastructure and finance	Payment by Results and the Delayed Discharges Act are related policies
Krystal86	Southlake@Home A team designed to meet the patients care needs through partnerships with community and primary care (integrates primary care, hospital care and home and community care to develop a personalised care plan)	Medically and socially complex and frail elderly	Hospital Southlake Regional Health Centre	Practice changes	Reduction in ALC days (average of 10.6 days) 1088 ALC days avoided Positive patient and provider experiences
Walker2	Recommendations for improving care for the ageing population Numerous recommendations to improve ALC in acute and community care ranging from proactively identifying patients at risk of decline in primary care to making hospitals more ‘senior friendly.’	NR	NR	Information sharing recommendation document	NR
North West Community Care Access Centre88	Wait at home Allows seniors to get their healthcare needs from their home through a variety of services for a up to 90 days	Seniors waiting for LTC placement	NR	Practice changes	NR
Toronto Central Community Care Access Centre67	ALC avoidance framework To create a standardised approach to avoid delayed discharges through 12 leadings practices and associated strategies (identifying a date of discharge, engaging with substitute decision makers, etc)	NR	NR	Tools and guidelines	NR
Province of New Brunswick92	ALC collaborative committee A committee developed to identify and implement priority strategic initiatives	NR	NR	Information sharing live Practice changes Infrastructure and finance	Reduction in percentage of acute hospital days used by patients waiting for discharge from 19.6% to 17.5%
NHS Improvement104	SAFER patient flow bundle A tool to reduce delays for patients on inpatient wards	NR	NR	Information sharing recommendation document	Most effective when used with Red2Green days Supports decision making by allowing staff to visualise plans
	Red2Green days A tool to reduce unnecessary waiting by patients	NR	NR		A board (electronic or white) should act as a focal point for rounds
	Long-stay patient reviews Weekly reviews of long-stay patients (>20 days), to help address obstacles that are delaying discharge	NR	NR		Weekly long-stay patient reviews can reduce the number of inpatients with a length of stay >20 days by up to 50%
	Multiagency Discharge Event Review of individual patient journeys by bringing together senior staff from health and social care	NR	NR		Greatest impact on patients with a length of stay >6 days
Central East LHIN ALC Task Group84	Home First A programme designed to help keep patients in their homes (with community supports) for as long as possible by connecting patients to their needed resources	NR	Hospital Halton Health Services, 459 beds	Practice changes	Percent of ALC (acute) reduced from 22%–28% to 4%–6%
Adams, Care and Repair England98	Home First A programme designed to help keep high needs seniors in their homes (with community supports) for as long as possible and involve the family in care	Patients (specifically high needs seniors)	NR	Practice changes	NR
Shah89	Home First A programme designed to help keep patients in their homes (with enhanced home care supports) as they wait for long-term care	High need seniors (75+)	Trillium Health Partners, various community and long-term care organisations	Practice changes	2-fold reduction in monthly average of ALC patients 30.5% reduction in number of ALC to LTC hospital referrals
Joint Improvement Team85	NR	ALC patients	9 community hospital corporations, 14 hospital sites and a mental health centre in one Ontario region 1642 beds across the facilities	Practice changes	Expected to reduced ALC days by 30% over the next 3 years
Adams, Care and Repair England98	West of England care and repair Enables older patients to return home from hospital quickly and safely by organising and repairing home (cleaning, clearing clutter, small adaptations)	Older patients	West of England Care and Repair	Infrastructure and finance	Substantial cost savings in hospital bed days, housing interventions and hospital staff time
Shah89	Home First A programme designed to help keep patients in their homes (with community supports)	Elderly patients	Hospital/ community in Mississauga Halton Local Health Integration Network	Practice changes	The equivalent of 35 acute care beds have been saved over 2 years 250 people have been diverted from LTC placement
Joint Improvement Team85	Home First – 10 actions to transform discharge Actions to improve the pathway from hospital to home focusing on achieving safe, timely and person-centred care	NR	NR	Practice changes	Factors in reducing delays include: identifying estimated date of discharge, using a framework for admissions, transfers and discharges, appointing a provider for coordinating the patients discharge plan, screening for frailty, using transitional and intermediate care services, adopting a home first culture

*Initiative category is based on Doern and Phidd’s adapted framework Hosseus and Pal.³⁹

AHK, almost home kids; ALC, alternate level of care; D2A, discharge to assess; ED, emergency department; ERAS, enhanced recovery after surgery; GM, geriatric medicine; HRH, Humber River Hospital; ICU, intensive care unit; LHIN, local health integration network; LTC, long-term care; MGH, Michael Garron Hospital; N/A, not available; NR, not reported; OAP, old age psychiatry; TGH, Toronto General Hospital.