A study of patient flow through inpatient rehabilitation and potential for improvements

Problems with patient flow are well documented in Emergency Departments and acute hospitals but poorly studied in rehabilitation. Barriers to rehabilitation patient flow can have adverse consequences for patients and reduce access in acute hospitals and Emergency Departments. A literature review found that relatively little is known about problems with rehabilitation patient flow. There is no published system for classifying this or accepted benchmarks for its measurement. The extent of the problem is also poorly studied. These issues are important to address to facilitate research and because demand for rehabilitation services will increase significantly with population aging. In this thesis the development of a definition of barriers to discharge from inpatient rehabilitation is described along with a classification system for the main causes. In addition, key performance indicators for rehabilitation patient flow are proposed. A web-based survey of key stakeholders found that half the respondents (n=101) reported barriers to admission into subacute hospitals (including rehabilitation) as moderate, severe or extreme, and 81% reported a similar degree of severity for barriers to discharge. There was a much higher prevalence of problems reported among rehabilitation physicians. The most common barriers to admission were availability of beds (61%) and environment or equipment inadequacies (62%). The most common barriers to discharge were waiting for a more appropriate setting of care (76%) and funding for home modifications, equipment or carers (55%). A retrospective study was conducted of patients admitted into two rehabilitation units in Melbourne, Australia (n=360; females =51.7%; mean age = 58.4 years). There was a median of 7 (interquartile range [IQR] 4–13) days from acute hospital admission till rehabilitation referral and a median of 1 (IQR 0–3) day from been deemed ready for transfer till admission into rehabilitation, with 20% of patients waiting more than 3 days. Overall, patients spent 12.0% of their acute admission waiting for a rehabilitation bed. A prospective study of the above patients studied the occurrence of inpatient rehabilitation discharge barriers, their causes and duration of unnecessary hospitalisation. Fifty-nine (16.4%) patients had a discharge barrier. The most frequent causes were: non-weight bearing after lower limb fracture (5.6%), family deliberations about discharge planning (3.6%), waiting for suitable accommodation (2.5%) or home modifications (2.5%). Overall, 21.0% of all inpatient rehabilitation bed-days were occupied by patients with a discharge barrier. A computer model was developed to estimate potential improvements in acute and rehabilitation hospital length of stay for rehabilitation patients from hypothetical scenarios that address barriers to patient flow. Most scenarios resulted in significant improvements compared with baseline. The effect size for the changes was typically small to medium and was larger when multiple barriers were addressed simultaneously. It is suggested that health system modelling can inform reforms to models of care and assist with cost benefit analyses. Similar to other components of the hospital system – rehabilitation has numerous barriers to optimal patient flow. In this thesis the major barriers are identified, classified and measured. Potential solutions are identified and areas for further research proposed.