Date of Award

January 2022

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Gretchen Berland

Abstract

Increasingly, patients experience prolonged lengths of stay (PLOS) beyond medical necessity on general medicine wards in the United States, staying up to hundreds of days in beds originally meant for acute care. Factors such as multiple facility rejections, need for guardianship, and lack of home support – commonly classified as “non-medical” barriers to discharge – are thought to contribute to PLOS. However, few studies in recent years have examined the prevalence and impact of such barriers on patients, healthcare staff, and healthcare systems. We performed a two-part study with the aim of investigating the impact of so-called “non-medical” barriers to discharge leading to PLOS, defined as ≥30 days. We then designed a multifaceted intervention in an effort to address the root causes of PLOS identified in our study. First, we conducted a retrospective chart review of PLOS patients on a general medicine floor at an academic teaching hospital over a two-year period to better characterize PLOS patient barriers to discharge and outcomes. Next, we conducted semi-structured key informant interviews with 23 healthcare staff from four organizations in order to understand their perspectives on caring for PLOS patients beyond medical necessity. Transcripts of interviews were analyzed using grounded theory methodology. In the first part of the study, we found 101 hospitalizations (3.5%) were prolonged (median: 44.4 days, interquartile range: 38.2 days), accounting for 6518 (27.2%) of total inpatient days. At day 30 of admission, 36.6% faced only non-medical barriers to discharge, the most common barrier being lack of facility placement options. Over half of all PLOS patients were eventually discharged to a facility, and 90-day mortality post-discharge was 17.8%. Results from the qualitative portion of the study further revealed that participants identified the source of barriers to discharge as structural inadequacies for vulnerable populations that are under-recognized in our society. Further themes included the substantial burden of non-medical barriers on individuals and systems, effect of barriers on perceived impaired communication between healthcare teams and patients/families, mixed emotional valence when interacting with PLOS patients, and perceptions of healthcare’s societal role. Based on our findings, we then: (1) hosted a multi-institutional meeting of researchers and leadership from both within and outside of Connecticut in order to compare and share experiences and solutions across different regions of the US; (2) designed a student driven volunteer art group in order to improve the inpatient experience of PLOS patients. In conclusion, our work highlights the manifold impacts of PLOS beyond medical necessity at various levels and establishes the basis for future partnerships across institutions to support this patient population and the staff caring for them.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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