Avoidable Discharge Delays: Children Waiting in Hospitals Deserve More Attention

The first issue is the lack of standard nomenclature. Delayed discharge, prolonged hospitalization, inpatient boarding, and unnecessary hospital days are variably used to describe days patients spend in the hospital beyond the point of medical clearance.

The American Case Management Association defines an “avoidable delay” in the hospital as “any barrier to facilitating effective, efficient, timely and safe care…that causes an extension in the patient’s length of stay…of four hours or more.”¹  Under this definition, there are many types of delays, including short delays related to the provision of medical care, such as patients admitted over the weekend awaiting specialist consultation, those awaiting elective surgery, or even those awaiting test results.

Although these delays are important, they are qualitatively different problems with different primary drivers than the prolonged delays we highlight in the above cases. Compared with the delayed delivery of in-hospital services, certain prolonged delays are less practically avoidable in current practice because they stem from complex coordination and delivery of limited out-of-hospital services, like home nursing, behavioral health care, and social services.

Delay types have been characterized by the “Delay Tool,” which was introduced in 1987 to track “unnecessary hospital days.” Relevant subcategories include delays due to (1) discharge planning or scheduling and (2) availability of outside care and resources.²  In contrast to other subcategories of delay, these prolonged delays occur after the point of medical clearance.

To help hospitals and health systems capture the prevalence and duration of these subcategories of avoidable delay using existing and accepted definitions, we propose modified terminology that highlights this nuance: “avoidable delay after medical clearance.” To operationalize such a definition, organizations must establish criteria for medical clearance, note subcategories of delay, and document them in the electronic medical record. Establishing criteria for medical clearance can be challenging, particularly for children with complexity. Fortunately, existing literature reveals that criteria can be established for common diagnoses by expert consensus,³  and that reducing variation via clinical pathways can be a path toward timely and effective discharge.⁴  Expanding consensus-based discharge criteria for common reasons for admission among children with medical complexity may be a useful strategy for establishing medical clearance, particularly as this population grows.

Although implementing avoidable delay tracking is challenging, it has been done. The case management team at our large, urban children’s hospital developed a dashboard to track patients experiencing avoidable delays by using the date of medical clearance as documented in the medical record and specifying the subcategory of delay, when possible. According to this dashboard, in 2021, patients awaiting facility placement or private duty home nursing had an average delay of 30 days.

Although any patient can experience avoidable hospital days, our review of the literature and clinical experiences suggest there are several groups of patients at higher risk. These populations include children with (1) behavioral health needs, (2) complex medical conditions, and (3) child welfare system involvement. Although these pediatric populations differ in terms of their specific discharge needs, they each require robust and well-coordinated out-of-hospital services after discharge.

Children admitted with behavioral health needs who require psychiatric services at discharge are at risk for avoidable delays after medical clearance. The pandemic exacerbated the existing pediatric mental health crisis, with more children requiring admission, in part due to the sudden lack of available inpatient and outpatient psychiatric placement options.⁵  In the first year of the coronavirus disease 2019 pandemic, potentially avoidable days more than doubled for behavioral health patients,⁶  a challenge that has not abated.

Children with medical complexity are also at increased risk of avoidable delays after medical clearance because of the need for home nursing care, skilled facility services, and uncommon medical equipment or devices. In a 2019 single institution study, children with medical complexity who were approved for at least 8 hours of home nursing were admitted, on average, for 52 days beyond the point of medical clearance.⁷  Home nursing challenges contributed to 57% of discharge delays and 92% of avoidable days, and avoidable hospital days comprised 10% of the cost of the total stay.⁸  These challenges have been exacerbated by staffing and supply chain challenges associated with the pandemic.

Finally, children involved in the child welfare system are likely to experience avoidable delays after medical clearance because of the challenges of ensuring a safe home environment. In a 2021 study, inpatient providers noted significant delays (>7 days) for children in foster care due to the complexity of discharge planning, procedural delays, or lack of appropriate placement options.⁹ 

Avoidable delays after medical clearance are important to address for numerous reasons, including their negative impacts on child and family health and wellbeing, hospital care, and health care costs.

Prolonged hospitalizations adversely impact infants’ and toddlers’ progression toward milestones.¹⁰  Acute care environments, no matter how well-resourced, are not designed to provide substantial behavioral support, educational offerings, or social interaction with peers and support networks. Additionally, when children are hospitalized, families can experience financial strain. Low-income families and families of children with medical complexity may be more impacted by these costs.¹¹ 

Avoidable delays have impacts on patient care and safety. Because of the frequent changes in bedside providers, ordering clinicians, and consulting teams, the inpatient environment places children at ongoing risk of medical errors. The risk of errors is higher among children with medical complexity, who are already at risk for iatrogenic errors (5.3 errors per 100 discharges compared with 1.3 per 100).¹² 

Avoidable delays have impacts on hospital flow and health care costs. When medically cleared patients occupy beds for days, weeks, or months, it limits acute care hospitals from delivering care to patients most matched to their capabilities. This contributes to hospital crowding, which is associated with increased mortality and worse health outcomes.¹³  Although costs of avoidable delays have been calculated in only a few pediatric studies, they are likely substantial given the duration of delays and estimated per diem costs of thousands of dollars to the insurer or hospital.

More work needs to be done to characterize the burden of avoidable delays after medical clearance, the patient populations most impacted, and key drivers.

Starting with nomenclature, hospitals should update information systems to indicate avoidable days after medical clearance. Such a tool would allow local data to be aggregated and shared with physician, nursing, and administrative leadership, as well as patient advocacy groups and other key stakeholders, such as local and state behavioral health and child welfare agencies. Standard definitions will allow data to be pooled and compared across institutions to assess local, regional, and national needs and trends in data sources like the Pediatric Health Information System.

As we implement medical clearance definitions and gather more representative data, we suggest an interim focus on children with behavioral health conditions, complex medical conditions, and involvement in the child welfare system. Although the specific needs of these populations are different, they each require more integrated care to safely leave the hospital in a timely manner.

Effective solutions will require stakeholders to innovate in this area. Organizations could innovate by investing in inpatient and outpatient psychiatric services, helping train a cadre of home nursing staff, forging stronger partnerships with long-term care facilities or transitional facilities,¹⁴  and/or building new facilities. Organizations may also use their own child development and behavioral health expertise to bolster in-home support for families with child welfare involvement to maximize reunification or support foster families.

Ultimately, how care for these vulnerable populations is financed will need to evolve. Models are being developed and evaluated through Integrated Care for Kids, a CMS Innovation program that incentivizes local agencies to identify children with physical and behavioral health needs through population-level risk stratification, integrate care, and develop alternative payment models that align payment with care quality and health outcomes. Alternative payment models are forthcoming, with the current goal to launch in January 2023.

Greater focus on unraveling the issue of avoidable delays after medical clearance is crucial to creating a safe, high-value, integrated pediatric health care system that meets the needs of the children and families it serves.