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The recent article by Wise (1) made the important point that barriers to the discharge of patients from elsewhere in the hospital system can contribute to problems with emergency department access. This is a crucial issue that has received scant attention in most discussions and publications on this topic.
Surveys in Australia of key stakeholders (n=101) in sub-acute patient flow (2) and specialists in spinal rehabilitation units in ten countries (3) have highlighted that most settings have major problems with patient flow. Respondents reported barriers to the transfer of acute hospital patients into subacute hospitals and barriers to the discharge of these patients. These perceptions of barriers to patient flow have been substantiated by studies that reported a noteworthy proportion of patients’ hospital stay is spent in the wrong setting. Among patients waiting for rehabilitation, the proportion of the total acute hospital admission that was spent waiting for transfer ranged from 12% for general rehabilitation patients (4) to 34% for those waiting for specialist spinal rehabilitation. (5) General rehabilitation patients spent 21% of total bed-days waiting for barriers to discharge to be resolved (6) while among patients with spinal cord damage 18% of bed-days were spent waiting for barriers to discharge to be addressed. (7)
Addressing the causes of discharge barriers from acute and subacute hospitals will help improve patient outcomes by facilitating patient transfer to a more appropriate setting, reduce the risk of iatrogenic complications (e.g. falls and medication errors), and improve the flow of patients throughout the whole hospital system, including the emergency department. Policy makers and healthcare managers should consider allocating greater resources to addressing subacute patient flow inefficiencies and not just focus on the emergency department. This strategy is patient-centred, which patient wants to be in the wrong setting, and is likely to be more cost-effective.
1. Wise J. Royal college calls on hospitals to tackle emergency department “exit block” to hospital beds. BMJ. 2015;350:h849.
2. New PW, Cameron PA, Olver JH, Stoelwinder JU. Key stakeholders’ perception of barriers to admission and discharge from inpatient subacute care in Australia. Med J Aust. 2011;195:538-41.
3. New PW, Scivoletto G, Smith É, Townson A, Gupta A, Reeves RK, et al. International survey of perceived barriers to admission and discharge from spinal cord injury rehabilitation units. Spinal Cord. 2013;51:893-7.
4. New PW, Andrianopoulos N, Cameron PA, Olver JH, Stoelwinder JU. Reducing the length of stay for acute hospital patients needing admission into inpatient rehabilitation: a multicentre study of process barriers. Intern Med J. 2013;43:1005-11.
5. New PW. Reducing process barriers in acute hospital for spinal cord damage patients needing spinal rehabilitation unit admission. Spinal Cord. 2014;52:472–6.
6. New PW, Jolley DJ, Cameron PA, Olver JH, Stoelwinder JU. A prospective multicentre study of barriers to discharge from inpatient rehabilitation. Med J Aust. 2013;198:104-8.
7. New PW. Prospective study of barriers to discharge from a spinal rehabilitation unit. Spinal Cord. In press. Epub September 30, 2014. doi: 10.1038/sc.2014.166
Competing interests:
No competing interests
24 February 2015
Peter W New
Rehabilitation Physician
1. Department of Epidemiology and Preventive Medicine, Monash University, Australia. 2. Rehabilitation and Aged Services, Department of Medicine, Monash Health, Victoria, Australia. 3. Spinal Rehabilitation Service, Alfred Health, Victoria, Australia. 4. Epworth-Monash Rehabilitation Medicine Unit, Monash University, Melbourne, Victoria, Australia
Kingston Centre, Warrigal Rd, Cheltenham 3192. Victoria. Australia
‘Rehabilitation patient flow’
The recent article by Wise (1) made the important point that barriers to the discharge of patients from elsewhere in the hospital system can contribute to problems with emergency department access. This is a crucial issue that has received scant attention in most discussions and publications on this topic.
Surveys in Australia of key stakeholders (n=101) in sub-acute patient flow (2) and specialists in spinal rehabilitation units in ten countries (3) have highlighted that most settings have major problems with patient flow. Respondents reported barriers to the transfer of acute hospital patients into subacute hospitals and barriers to the discharge of these patients. These perceptions of barriers to patient flow have been substantiated by studies that reported a noteworthy proportion of patients’ hospital stay is spent in the wrong setting. Among patients waiting for rehabilitation, the proportion of the total acute hospital admission that was spent waiting for transfer ranged from 12% for general rehabilitation patients (4) to 34% for those waiting for specialist spinal rehabilitation. (5) General rehabilitation patients spent 21% of total bed-days waiting for barriers to discharge to be resolved (6) while among patients with spinal cord damage 18% of bed-days were spent waiting for barriers to discharge to be addressed. (7)
Addressing the causes of discharge barriers from acute and subacute hospitals will help improve patient outcomes by facilitating patient transfer to a more appropriate setting, reduce the risk of iatrogenic complications (e.g. falls and medication errors), and improve the flow of patients throughout the whole hospital system, including the emergency department. Policy makers and healthcare managers should consider allocating greater resources to addressing subacute patient flow inefficiencies and not just focus on the emergency department. This strategy is patient-centred, which patient wants to be in the wrong setting, and is likely to be more cost-effective.
1. Wise J. Royal college calls on hospitals to tackle emergency department “exit block” to hospital beds. BMJ. 2015;350:h849.
2. New PW, Cameron PA, Olver JH, Stoelwinder JU. Key stakeholders’ perception of barriers to admission and discharge from inpatient subacute care in Australia. Med J Aust. 2011;195:538-41.
3. New PW, Scivoletto G, Smith É, Townson A, Gupta A, Reeves RK, et al. International survey of perceived barriers to admission and discharge from spinal cord injury rehabilitation units. Spinal Cord. 2013;51:893-7.
4. New PW, Andrianopoulos N, Cameron PA, Olver JH, Stoelwinder JU. Reducing the length of stay for acute hospital patients needing admission into inpatient rehabilitation: a multicentre study of process barriers. Intern Med J. 2013;43:1005-11.
5. New PW. Reducing process barriers in acute hospital for spinal cord damage patients needing spinal rehabilitation unit admission. Spinal Cord. 2014;52:472–6.
6. New PW, Jolley DJ, Cameron PA, Olver JH, Stoelwinder JU. A prospective multicentre study of barriers to discharge from inpatient rehabilitation. Med J Aust. 2013;198:104-8.
7. New PW. Prospective study of barriers to discharge from a spinal rehabilitation unit. Spinal Cord. In press. Epub September 30, 2014. doi: 10.1038/sc.2014.166
Competing interests: No competing interests