Impact of accurate initial discharge planning and in-patient transfers of care on discharge delays: a retrospective cohort study

Objective To investigate the association between initial discharge planning and transfers of in-patient care with discharge delay. To identify operational changes which could expedite discharge within the Discharge to Assess (D2A) model. Design Retrospective cohort study. Setting University Hospital Southampton NHS Foundation Trust (UHSFT). Participants All adults (≥18 years) who registered a hospital spell in UHSFT between 1 January 2021 and 31 December 2022 (n = 258,051 spells). Individuals were followed from hospital admission through to discharge. Data includes demographics, comorbidities, operational information (ward changes, handovers) and discharge information (estimated discharge date, D2A pathway). Main outcome measures The primary outcome was discharge delay, defined as the number of days between the final estimated discharge date and the actual discharge date. Odds ratio analysis was used to assess the impact of initial discharge planning accuracy (D2A pathway), number of ward moves, and number of in-speciality handovers on the outcome, adjusting for demographic and patient complexity factors. Results Out of 65,491 spells, 10,619 had an initial planned pathway that did not match the final discharge pathway, with 7,790 of these spells (75.1%) recording a discharge delay. Conversely, 10,216 of 54,872 spells (18.6%) where the initial pathway matched the final pathway recorded a discharge delay (adjusted odds ratio 2.72 (95% CI 2.55 – 2.91)). Ward moves and in-specialty handovers were also associated with increased likelihood of discharge delay, with adjusted odds ratio 1.25 (1.23 – 1.28) per ward move and 1.17 (1.14 – 1.20) per in-specialty handover. Conclusions This study finds a strong association between inaccurate initial discharge plans and in-patient transfers of care with discharge delay, after controlling for patient complexity and acuity. This highlights the need to consider how initial plans, and in-patient transfers affect discharge planning. Given the lead-times for organising onward care, operational inefficiencies are most impactful for patients eventually discharged on pathways with higher planning complexity. Key messages What is already known on this topic Several factors are known to influence discharge delay including age, whether the spell was elective, and patient complexity. Discharge planning has been historically difficult to characterise. What this study adds A robust measurement of the accuracy of discharge planning. Highlights the importance of considering the impact of initial discharge plans on the planning process. How this study might affect research, practice or policy Encourage a higher level of consideration when suggesting an initial Discharge to Assess pathway to reduce errors in planning down the line. Ensure that relevant discharge information is communicated when patients are transferred between wards and care teams.