Delayed discharges in acute health settings : a case study

Abstract

This thesis aims to investigate delayed discharges in an acute hospital setting, through the use of a case study carried out in a public primary acute tertiary teaching general hospital in Malta. A Yinian approach was used, incorporating a post-positivist approach with a triangulated methodology, that blended qualitative and quantitative research data collection tools. The study sought to investigate this phenomenon from a strategic, tactical and operational standpoint as this allowed for a more holistic interpretation of results and ultimately the case. Such an approach. Such an approach also paved the way for the researcher to present study contributions and practice implications more comprehensively to each managerial stratum accordingly. An in-depth literature review was carried out before the start of the study, which allowed the researcher to investigate delayed discharges from both a conceptual and operational standpoint. This served, along with literature review findings related to determinants, effects and mitigation strategies related to delayed discharges contributed to the building of model for the phenomenon. This model formed, in turn, a very solid basis for the construction of the research tools utilised in Phase 1 of this study. The research was carried out in two phases. In Phase 1 the researcher adopted the qualitative triangulated approach through twenty-eight interviews (n = 28) and two interdisciplinary focus groups with health professionals, with both the sampling process (theoretical sampling) and the interview questions themselves being based on the findings of an in-depth scoping literature review on delayed discharges and the emerging evidence-based model derived from this review. Respondents’ answers were audiotaped, transcribed verbatim and subjected to the thematic analysis method, deriving 7 themes, namely: a) Long-term care/social cases as a major cause of delayed discharges, b) Faulty system which is open to abuse and inefficiency, c) The impact of COVID-19 (Corona Virus Disease 2019) on discharge delays and hospital dynamics, d) Stakeholder suggestions to management to counteract delayed discharges, e) Inter-stakeholder interactions, f) The impact of external factors on delayed discharges, and g) Procedural delays directly impacting delayed discharges. In Phase 2 document analysis was conducted on 220 medical records from two admission units. The collected data were analysed using the Appropriateness Evaluation Protocol (AEP). These records were analysed in detail and delayed discharges were represented quantitatively in the form of ‘inappropriate days’. The extent, causes, and timing of inappropriate days which may have led to delayed discharges were calculated, and through an extrapolative exercise associated costing values were assigned to the respective causes of delays. Among the most prominent source of financial burden were patients awaiting long-term care/rehabilitation, patients awaiting geriatric/social worker reviews, patients awaiting medical imaging procedures and patients kept in hospital solely for intravenous antibiotic therapy administration. The findings from Phase 1 and Phase 2 were compared and contrasted, with differences and commonalities being identified and compared with the general literature. This research study contributed actionable insights to address hospital discharge inefficiencies. It is the first study of its kind in Malta and it offers a combination of study contributions and implications for practice from strategic, tactical and operational viewpoints. Study strengths and limitations were also addressed, most particularly from a methodological standpoint, where the extent of result generalisability and application was discussed.