Timing of Hospital Discharge a Predictor of Readmission

Patients and their families often do not want to be hospitalized over a weekend; Hospital staff does not want to keep patients over a weekend. But, could the push out the hospital door have serious implications for patient morbidity and mortality? Several studies have shown that the timing of hospital discharge is an indicator of death or readmission in many patients.

Several studies have found that patients discharged from intensive care units (ICU) at night or on weekends fare worse than those discharged during daytime hours. Many clinicians view off-hours discharges as “premature,” citing an insufficient number of ICU beds as a culprit. Patient care may also be inconsistent during night and weekend hours do to decreased hospital staffing and cross-coverage of physicians. Whether the patients are discharged home, or discharged to a medical ward in the hospital, studies consistently show an increased risk of mortality in patients discharged from ICUs during night and weekend hours.

Discharge day of the week also affects patient outcomes. Friday is the most common day for hospital discharge, but these patients also have an increased risk of death or hospital readmission within 30 days, compared to patients discharged in the middle of the week. Patients may be discharged too soon due to patient and family wishes, or physician and staffing concerns. One study showed that 7.1% of patients discharged on Friday either died or were readmitted to the hospital within 30 days, compared to 5.4% of patients discharged on Wednesday. The risk was independent of patient or hospital variables such as gender, age, length of stay, or procedures performed during the stay. With an increased number of discharges taking place on Friday, patients may not receive adequate discharge instructions from hospital staff or may not be able to take advantage of social services that might be needed until Monday, contributing to poor patient outcomes.

Few studies have examined readmission rates among children. Studies have primarily focused on neonatal admissions as a factor of maternal care and discharge. However, one study found no increased risk of readmission for children discharged from the hospital based on day of discharge. Children discharged on Fridays had no significant risk of morbidity or mortality compared to children discharged in the middle of the week. (The rate of readmission for Friday discharges was 3.6%, versus 3.4% for Wednesday discharges.) This could be due to the fact that children are discharged home with adult caregivers. Children were more likely to be readmitted to the hospital based on patient complexity, disease severity, and previous hospital admissions. Males were less likely to be readmitted than females, as were children who had an operative procedure while admitted to the hospital.

An additional study recently examined the rate of hospital readmission of patients discharged from a hospitalist-based service versus a resident-staffed teaching service. The rate of readmission within 30 days from the resident’s service was significantly higher than from the hospitalist’s service. The length of hospital stay was longer under the hospitalist’s care, and patients were more often discharged home with detailed self-care instructions.

Time and place of hospital interventions may be critical in predicting patient outcomes. While time, day, or location of discharge may not be the only factor in determining patient recovery or prognosis, physicians should be aware of the consequences of hospital discharge when attempting to move patients out of hospital beds. Many hospitals are understaffed and in need of more bed space, but discharging patients before they are stable and without proper after-care instructions is a dangerous practice.

References

Beck CE, Khambalia A, Parkin PC, Raina P, Macarthur C. Day of discharge and hospital readmission rates within 30 days in children: A population-based study. Paediatr Child Health. Sep 2006;11(7):409-412.

Melissa J. Frei-Jones, Joshua J. Field, Michael R. DeBaun (2008). Risk factors for hospital readmission within 30 days: A new quality measure for children with sickle cell disease Pediatric Blood & Cancer DOI: 10.1002/pbc.21854

K LAUPLAND, R SHAHPORI, A KIRKPATRICK, H STELFOX (2008). Hospital mortality among adults admitted to and discharged from intensive care on weekends and evenings? Journal of Critical Care, 23 (3), 317-324 DOI: 10.1016/j.jcrc.2007.09.001

Palacio C, Alexandraki I, House J, Mooradian AD. A Comparative Study of Unscheduled Hospital Readmissions in a Resident-staffed Teaching Service and a Hospitalist-Based Service. South Med J. Jan 9 2009.

Tobin AE, Santamaria JD. After-hours discharges from intensive care are associated with increased mortality. Med J Aust. Apr 3 2006;184(7):334-337.

van Walraven C, Bell CM. Risk of death or readmission among people discharged from hospital on Fridays. Cmaj. Jun 25 2002;166(13):1672-1673.

C GOLDFRAD, K ROWAN (2000). Consequences of discharges from intensive care at night The Lancet, 355 (9210), 1138-1142 DOI: 10.1016/S0140-6736(00)02062-6