Discharge Delay in Patients with Community-acquired Pneumonia Managed on a Critical Pathway

Introduction: It has previously been reported that a critical pathway for community-acquired pneumonia (CAP) significantly reduces bed days per patient managed but results in no difference in average length of stay, suggesting that discharge criteria were not successfully implemented. The present study sought to identify factors in the timing of discharge not taken into account by discharge criteria.

Methods: Patients admitted with CAP and placed on a pneumonia critical pathway were studied. Patients' functional and cognitive status were evaluated using the Barthel Index, Hierarchical Assessment of Balance and Mobility (HABAM) and the Mini-Mental Status Examination. Once discharge criteria were met, the patient, a family member and the treating physician were interviewed to identify other factors contributing to length of stay.

Results: Thirty-one patients were enrolled in the study; 12 were discharged when they met discharge criteria and 19 stayed in hospital longer. There were no differences between patients discharged at stability versus those with an increased length of stay in terms of demographics, pneumonia severity score, functional or cognitive status at discharge using the Barthel Index (87.3+/-11.1 versus 83.8+/-8.6, respectively; P=0.46) and MMSE (27.1+/-1.1 versus 27.3+/-1.1, respectively; P=0.64); however, there was a significant difference in HABAM score at the time clinical stability was reached (22.6+/-1.3 versus 17.4+/-3.5, respectively; P=0.03), which correlated with physician and family assessments of patients' readiness for discharge.

Conclusions: HABAM may be a useful tool to identify patients at risk of remaining in hospital after objective discharge criteria are met. Additional resources may be targeted at these patients to reduce length of stay in CAP.