In the era of “bed crunch,” hospitals have begun a push for expedited discharge to decrease the costs to patients and third-party insurers and to increase the throughput of patients. Discharging patients requires significant teamwork and efficient discharge planning. Previously, it has been demonstrated that a lack of communication between physicians and nurses often delays discharge.1,2 Therefore, many hospitals describe developing a “discharge team” with staff working aggressively from the time of admission to plan for discharge.3–8 In one hospital, the simple addition of advanced care nurse practitioners assigned to assist in care management and discharge planning for trauma patients was shown to decrease the average length of stay by 0.8 days, resulting in savings of $9111.50 and a reduction of hospital charges by $27.8 million in 1 year.4
At the authors' institution, there is a similar team consisting of an orthopedic nurse practitioner, a hospitalist, physical therapists, a pain management consultant, and a case manager. However, these ancillary services are not always available or are available on a reduced basis on weekends. Multiple studies have demonstrated a difference in care during the week as compared with on the weekend. Significantly more patients are discharged on Monday. Furthermore, patients who are discharged on Monday have a significantly longer length of stay as compared with patients discharged on other days of the week. This indicates that many of these patients could have been discharged sooner if their potential discharge day had not fallen on a weekend.9 Care on weekends has been shown to result in increased delays and poorer performance on quality of care metrics.10–16 Also, extended hospital stays lead to increased costs, increased risk of hospital-acquired infection, loss of physical conditioning, time away from family and friends, and decreased quality of care.17
This study examined a homogeneous patient population undergoing posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis at a level 1 pediatric tertiary care center to determine if day of the week of admission affects length of stay. The authors hypothesized that an admission later in the week would result in an increased length of stay. Following this initial analysis, a quality, safety, value initiative (QSVI) was implemented in an attempt to expedite patient care and subsequently decrease overall length of stay. Prior to July 1, 2017, patients received one guaranteed physical therapy session on Saturday and received physical therapy on Sunday only if they were pending discharge that day. After July 1, 2017, the authors' institution implemented a policy requiring physical therapy for all orthopedic patients, not just those pending discharge, 7 days a week. The authors' secondary hypothesis was that by providing increased care during the weekend, length of stay would decrease for the patients who had surgery later in the week and would approach that of the patients who had surgery earlier in the week after the July 1 mark.
Materials and Methods
This study received internal review board approval. Data were obtained and stored on an encrypted device. During data analysis, all protected health information was redacted.
All patients undergoing PSIF for adolescent idiopathic scoliosis between 2001 and 2018 were identified and retrospectively reviewed. Patients were classified as having had surgery either “early” in the week (Monday or Tuesday) or “late” in the week (Thursday, Friday, or Saturday). All surgeons included in the analysis performed surgeries both early and late in the week. Patients were also classified as “prior to QSVI” or “after QSVI” based on the date of their surgery, with the date of implementation of the QSVI being July 1, 2017.
Patients were excluded if they had non-idiopathic scoliosis, underwent anterior spinal fusion, did not have a modern pedicle screw dual rod construct, or had surgery performed outside of the designated days of the week.
All statistical analyses were performed using RStudio version 1.1.456 software (RStudio, Boston, Massachusetts), with a two-sided level of significance of alpha=0.05. Differences in patient characteristics between the early and the late groups were analyzed to establish that the groups were similar, using either a chi-square test for categorical variables or a Mann–Whitney U test for continuous variables. To analyze the difference in length of stay between the early and the late groups, a Mann–Whitney U test was used. A multivariable generalized linear model was used to assess whether time of the week and any covariates (possibly influential variables) affected length of stay. The covariates included sex, age at surgery, number of levels fused, and number of osteotomies performed at the time of surgery.
A total of 271 adolescents underwent PSIF between 2001 and 2018. Prior to the QSVI, 228 adolescents underwent PSIF between 2001 and July 1, 2017 (Table 1). Regarding timing of surgery, 104 underwent surgery early in the week and 124 underwent surgery late in the week. Females accounted for 194 patients (85.1%), and males accounted for 34 patients (14.9%). Patients had a mean age of 15.1 years and a mean of 9.52 levels fused. After July 1, 2017, 38 adolescents underwent PSIF. Of these, 29 were classified as early in the week and 9 were classified as late in the week. Also, 28 patients (73.7%) were female and 10 patients (26.3%) were male. Patients had a mean age of 15.1 years and a mean of 10.1 levels fused. Five patients from the original surgical cohort had surgery on a Wednesday and were therefore excluded from further analysis.
Patient Characteristics Before and After the Quality, Safety, Value Initiative
Prior to the QSVI, mean length of hospital stay for patients having surgery early in the week was 4.9 days. For patients having surgery later in the week, mean length of stay was significantly longer at 5.5 days (P=.003) (Figure 1). There were no significant differences among experimental groups in terms of number of levels fused, age at which surgery was performed, or race. However, sex was found to be a contributing factor for length of stay, with male patients having a more rapid discharge (mean of 0.66 days shorter compared with female patients). After adjusting for sex, patients in the late group had an increased mean length of stay of 0.49 days.
Length of stay before and after implementation of the quality, safety, value initiative (QSVI) for patients undergoing surgery “early” and “late” in the week. Error bars represent 95% confidence interval.
Per the authors' financial counseling department, the cost of a 24-hour admission on their medical surgical ward averages $15,624 (excluding medication charges, consult charges, and so on). This increase in length of stay therefore results in an increase in the overall cost to families and insurance companies of $7749.50.
After implementation of the daily physical therapy QSVI, the mean length of stay for patients having surgery later in the week decreased to 3.8 days, a difference of 1.7 days (P=.002). The early surgical group also had a decreased length of stay of 3.7 days (P<.001). There was no longer a significant difference between early and late day of surgery as it related to length of stay (P=.840) (Figure 1). Following an increase in staffing, the cost of admission decreased by at least $26,560.80 for children having surgery later in the week.
Prior studies have found 10% to 30% of hospital days to be unnecessary.1,5,18,19 Nearly 1 in 4 patients at a tertiary care children's hospital experienced a medically unnecessary prolonged stay of at least 1 day, with a mean delay of 2.1 days.18 This alteration in length of stay can be highly dependent on date of admission, likely due to restricted weekend services.20 Delay in care progression results in a higher risk of negative outcomes, including increased costs, exposure to iatrogenic illness, and an overburdened hospital occupancy system.18,21–23
Patients undergoing orthopedic surgical procedures have a significantly higher likelihood of delayed discharge.24 This could be due to the need to coordinate multiple services such as physical therapy, case management, and pain management with the primary team prior to discharge. With a decreased staffing model on the weekend, there is an overall lower relative rate of discharge of patients on the weekend and a disproportionate number of discharges early in the week, indicating that weekends may be a factor contributing to lack of bed access and wasting of resources.25
The authors were able to increase the availability of physical therapists on the weekend by first examining the normal weekly patient physical therapy requirements. They discovered that several days during the week had lighter patient care loads. The authors subsequently decreased physical therapist staffing on these lighter weekdays, freeing up therapists for treatments on the weekend. The physical therapists were given several months' notice of this transition so that they could appropriately adjust their schedules.
Several prior studies in orthopedic surgery have examined a relatively heterogeneous patient population when evaluating the causes of delayed discharge among adult trauma patients.4,10,26–28 This study has the benefit of having examined a homogeneous set of patients, all of whom underwent the same procedure. Because the 2 senior surgeons (L.A.R., M.N.I.) perform this surgical procedure in a similar fashion and have the same requirements for discharge, variables due to the primary team were nearly eliminated. Similarly, patients undergoing a posterior spinal fusion for adolescent idiopathic scoliosis generally do not require durable medical equipment that might delay discharge.
A potential confounding factor for this study was the large number of patients included prior to the implementation of the QSVI and the small number of patients included following implementation simply due to the number of years available for follow-up for each group. Despite these low numbers, the authors were able to demonstrate a significant decrease in overall length of stay of more than a day and a half for patients having surgery late in the week.
Another limitation of this study was that the authors were unable to parse out the exact difference in charges to patients and billing from their physical therapy department following the QSVI. Therefore, they do not know what the specific overall cost savings of this QSVI was to the system. However, the initiative did not require an increase in staffing.
In addition, prior to this study, the authors implemented several other initiatives for expediting care for their postoperative adolescent idiopathic scoliosis patients, including daily multidisciplinary rounds and a dedicated pain service. Because these initiatives were in effect throughout all days of the week, they should have improved length of stay for all patients regardless of whether they had surgery early or late in the week. This could account for the decreased mean length of stay for all patients over time.
Finally, this was a retrospective study. Although this can lead to challenges with accurate data collection, the retrospective nature of this study actually avoided a potential confounding variable of biasing the care team toward more rapid discharges. As the initial data analysis demonstrating that patients having surgery later in the week had longer stays had not yet been performed, this finding could not have biased the team.
For this specific QSVI, there was a single intervention that was implemented during this 1-year period that affected one group of patients (the late group) disproportionally compared with the other (the early group). Because there was a specific initiative that was implemented during this 1-year period, the authors have demonstrated that by simply increasing the availability of just the physical therapy staff on the weekend without altering any other care patterns for the patients, they were able to significantly expedite the care of patients and decrease their length of stay.
For the US health care system to survive, it is imperative that care be timely and efficient and avoid waste.29 By simply increasing the availability of services on the weekend, New York University, Tisch School of Medicine, demonstrated that weekend discharges increased and the overall length of stay decreased by 13%.9 Other hospitals have been able to decrease the average length of stay by 30% and to decrease admissions to outside nursing departments by 76% in a single year through stepwise, simple interventions that mainly increased the team's attention to discharge planning.5
This study demonstrated that in a homogeneous orthopedic patient population, simply being admitted later in the week previously adversely affected the timing of discharge, resulting in a significantly longer and more costly hospital course. However, by increasing the availability of ancillary staff on the weekend, the authors were able to have a similar hospital course and subsequently similar length of stay for all patients regardless of date of admission. This resulted in a significant reduction in cost of admission for patients and families and decreased their exposure to the risks of a prolonged hospital admission.
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Patient Characteristics Before and After the Quality, Safety, Value Initiative
|Time/Characteristic||Early in the Week Patients||Late in the Week Patients||P|
| Age at surgery, y|
| Early group||104||15.35||2.20||NS|
| Late group||124||14.88||2.00|
| Early group||104||9.61||1.56||NS|
| Late group||124||9.44||1.53|
| Early group||103||0.72||1.42||NS|
| Late group||116||0.60||1.21|
| Age at surgery, y|
| Early group||29||14.90||2.07||NS|
| Late group||9||15.62||1.01|
| Early group||29||10.21||1.76||NS|
| Late group||9||9.78||1.09|
| Early group||29||0.59||0.98||NS|
| Late group||9||1.00||1.58|