Abirami Kirubarajan1,2, Saeha Shin3, Michael Fralick4,5, Janice Kwan4,5, Lauren Lapointe-Shaw4,6,7, Jessica Liu4,5,6, Terence Tang4,8, Adina Weinerman4,9, Fahad Razak2,3,4, Amol Verma2,3,4. 1. Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. 2. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. 3. Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada. 4. Department of Medicine, University of Toronto, Toronto, Ontario, Canada. 5. Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada. 6. Division of General Internal Medicine, University Health Network, Toronto, Canada. 7. Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. 8. Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada. 9. Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Abstract
BACKGROUND: Many initiatives seek to increase the number of morning hospital discharges to improve patient flow, but little evidence supports this practice. OBJECTIVE: To determine the association between the number of morning discharges and emergency department (ED) length of stay (LOS) and hospital LOS in general internal medicine (GIM). DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective cohort study involving all GIM patients discharged between April 1, 2010, and October 31, 2017, at seven hospitals in Ontario, Canada. MAIN MEASURES: The primary outcomes were ED LOS and hospital LOS, and secondary outcomes were 30-day readmission and in-hospital mortality. The number of morning GIM discharges (defined as the number of patients discharged alive between 8:00 AM and 12:00 PM) on the day of each hospital admission was the primary exposure. Multivariable regression models were fit to control for patient characteristics and situational factors, including GIM census. RESULTS: The sample included 189,781 patient admissions. In total, 36,043 (19.0%) discharges occurred between 8:00 AM and 12:00 PM. The average daily number of morning discharges and total discharges per hospital was 1.7 (SD, 1.4) and 8.4 (SD, 4.6), respectively. The median ED LOS was 14.5 hours (interquartile range [IQR], 10.0- 23.1), and the median hospital LOS was 4.6 days (IQR, 2.4-9.0). After multivariable adjustment, there was not a significant association between morning discharge and hospital LOS (adjusted rate ratio [aRR], 1.000; 95% CI, 0.996-1.000; P = .997), ED LOS (aRR, 0.999; 95% CI, 0.997-1.000; P = .307), 30-day readmission (aRR, 1.010; 95% CI, 0.991-1.020; P = .471), or in-hospital mortality (aRR, 0.967; 95% CI, 0.920-1.020; P = .183). The lack of association between morning discharge and LOS was generally consistent across all seven hospitals. At one hospital, morning discharge was associated with a 1.9% shorter ED LOS after multivariable adjustment (aRR, 0.981; 95% CI, 0.966-0.996; P = .013). CONCLUSIONS: The number of morning discharges was not significantly associated with shorter ED LOS or hospital LOS in GIM. Our findings suggest that increasing the number of morning discharges alone is unlikely to substantially improve patient throughput in GIM, but further research is needed to determine the effectiveness of specific interventions.
BACKGROUND: Many initiatives seek to increase the number of morning hospital discharges to improve patient flow, but little evidence supports this practice. OBJECTIVE: To determine the association between the number of morning discharges and emergency department (ED) length of stay (LOS) and hospital LOS in general internal medicine (GIM). DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective cohort study involving all GIM patients discharged between April 1, 2010, and October 31, 2017, at seven hospitals in Ontario, Canada. MAIN MEASURES: The primary outcomes were ED LOS and hospital LOS, and secondary outcomes were 30-day readmission and in-hospital mortality. The number of morning GIM discharges (defined as the number of patients discharged alive between 8:00 AM and 12:00 PM) on the day of each hospital admission was the primary exposure. Multivariable regression models were fit to control for patient characteristics and situational factors, including GIM census. RESULTS: The sample included 189,781 patient admissions. In total, 36,043 (19.0%) discharges occurred between 8:00 AM and 12:00 PM. The average daily number of morning discharges and total discharges per hospital was 1.7 (SD, 1.4) and 8.4 (SD, 4.6), respectively. The median ED LOS was 14.5 hours (interquartile range [IQR], 10.0- 23.1), and the median hospital LOS was 4.6 days (IQR, 2.4-9.0). After multivariable adjustment, there was not a significant association between morning discharge and hospital LOS (adjusted rate ratio [aRR], 1.000; 95% CI, 0.996-1.000; P = .997), ED LOS (aRR, 0.999; 95% CI, 0.997-1.000; P = .307), 30-day readmission (aRR, 1.010; 95% CI, 0.991-1.020; P = .471), or in-hospital mortality (aRR, 0.967; 95% CI, 0.920-1.020; P = .183). The lack of association between morning discharge and LOS was generally consistent across all seven hospitals. At one hospital, morning discharge was associated with a 1.9% shorter ED LOS after multivariable adjustment (aRR, 0.981; 95% CI, 0.966-0.996; P = .013). CONCLUSIONS: The number of morning discharges was not significantly associated with shorter ED LOS or hospital LOS in GIM. Our findings suggest that increasing the number of morning discharges alone is unlikely to substantially improve patient throughput in GIM, but further research is needed to determine the effectiveness of specific interventions.