When Is a Hospital Delay Okay?

There are few perfect things in this world, and hospital operations are not one of them. While multitudes of individuals – clinical and non-clinical – work diligently to carry out the most efficient and effective processes to provide patient care, often, their efforts fall short.

Many of these shortcomings are related to staffing and the availability of services on weekends and evenings. “Differentials” in pay for these time periods often apply to employees needed to carry out these services across the spectrum, from environmental service technicians to surgical nurses. This can lead to decisions by hospital leadership to cut back on testing, imaging, procedures, and surgeries outside of “banker’s hours.”

These kinds of delays should be a focus of your utilization management team’s assessment of avoidable days. While different from the patient who is medically ready for discharge but still waiting for a skilled nursing facility bed to open up, they are still delays. A patient might medically require a cardiac catheterization before he can be safely cleared to discharge home, but the delay in procedure on a Saturday and Sunday until it can be performed on Monday has nothing to do with the patient’s condition. The delay is due to the hospital’s lack of resources over the weekend. 

These avoidable days should not only be captured by reason – for example, EEG, PICC line placement, upper endoscopy, etc. – but also include the average financial impact. What cost did the hospital incur by caring for that patient an additional two days while waiting for a nuclear stress test? Or, in the case of a patient in outpatient status, how many observation hours were erroneously billed or written off because the hospital doesn’t perform MRIs after 4 p.m.? In order to present a strong case supporting increased availability of services, you must have data showing the impacts to length of stay, bed availability, and cost.

Are there any delays in imaging, testing, or procedure that can be medically justified? Absolutely! Examples include a brittle diabetic who’s quick to develop significant hypoglycemia during bowel prep before a colonoscopy, leading to a slower cleanout with close titration of IV fluids with dextrose – or an anticoagulated patient who requires time off their medication before proceeding with a surgical procedure to avoid excessive bleeding. Both of these instances are medically justified, and as such, should be documented in detail by the clinician to clearly support the medical need of the delay. Without such documentation, there is a risk auditors will assume a capacity or timing delay instead. 

As with other scenarios involving documentation, it’s incredibly easy for a physician to overlook these specifics involving medically necessary delays, because at face value, they seem to be obvious and relatively inconsequential. Case and utilization review nurses should keep an eye out for these potential omissions as they review patient charts and inquire either the attending physician or physician advisor when clarification is required. Similarly, physician advisors should track commonly missed documentation related to specific situations and create standardized education for hospitalist, cardiology, GI, and surgical groups.

Finally, an insidious factor contributing to avoidable days related to service delays involves testing, imaging, and procedures that are not required. While grossly unnecessary services are likely uncommon, if you look closely, you’ll probably find quite a few situations where the services did not have to take place during the hospitalization, and instead could have been scheduled in the outpatient setting following discharge. Convenience for the patient or patient’s caregiver is often a major factor, but poor accessibility and availability of outpatient services is another. These issues should also be investigated when found to be leading to avoidable days, as outpatient solutions could positively impact inpatient lengths of stay.

Programming note: Listen live today when Dr. Juliet Ugarte Hopkins is the special guest on Talk Ten Tuesday with Chuck Buck and Angela Comfort at 10 Eastern.