SUBMITTED 27 JAN 22 1

REVISIONS REQ. 17 MAR & 22 MAY 22; REVISIONS RECD. 20 APR & 3 JUN 22 2

ACCEPTED 16 JUN 22 3

ONLINE-FIRST: JUNE 2022 4

DOI: https://doi.org/10.18295/squmj.6.2022.045 5

Inappropriate Hospital Stay of Patients Admitted Under Care of 7

General Medicine Units 8

A retrospective study 9

Ahmed Al-Yarabi,1,2 Huriya Al Balushi,2 Khaloud Al Hatmi,2 Reem Al Yahyaie,2 11

*Abdullah M. Al Alawi,1,3 Khalfan Al Zeedy,1,3 Hatem Al Farhan1,3 12

1Oman Medical Specialty Board, Muscat, Oman; 2National Cardiology Center, Muscat, Oman; 14

3Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman. 15

*Corresponding Author’s e-mail: dr.abdullahalalawi@gmail.com 16

Abstract 18

Objective: This study aims to assess the incidence of inappropriate hospital stay and to identify 19

reasons behind inappropriate hospitalisation. Methods: The study was a retrospective cohort 20

study included patients admitted under the care of General Internal Medicine. First, we 21

calculated the average length of hospital stay for all included patients, and then we used 22

Appropriateness Evaluation Protocol to examine admissions that exceeded the average length of 23

hospital stay and then identify reasons for the inappropriate hospital stay. Results: There were 24

854 admissions during the study period. In this cohort, 53.1% were men, and the median age was 25

64 (IQR:44-75) years. There was a total of 6785.4 hospitalization days, and the average length of 26

hospital stay was 5 (IQR:3-9) days. 31.9% of admissions (n=272 admissions) included 27

inappropriate hospitalization days. 9.9 % (n=674 days) of hospitalization days were classified as 28

inappropriate. Delay in complementary tests (29.0%), and unavailability of extra-hospital 29

resources (21.7%) were the most common reasons associated with inappropriate hospital stay. 30

mailto:dr.abdullahalalawi@gmail.com

Old Age was associated with increased inappropriate hospital stay. Conclusion: A significant 31

proportion of hospitalisation days were inappropriate due to hospital related factors. Therefore, 32

auditing hospital services, and investing in home-based care are among the top strategies which 33

are likely to improve early discharge and minimize inappropriate hospital bed occupancy. 34

Keywords: Hospital Stay; Hospitalization, patient discharge; General Internal Medicine 35

Advances in Knowledge: 37

 A significant proportion of hospital stay is inappropriate primarily due to hospital-related 38

factors. 39

Application to Patient Care: 41

 Auditing healthcare services, implementing programs to lean process of tests and 42

procedures execution, and investing in subacute health services and home-based care 43

programs are essential steps to improve early discharges and minimize inappropriate 44

hospital stay. 45

Introduction 47

Inappropriate hospital stay has been used widely in the medical literature to describe any hospital 48

stay with no clinical indication resulting from the suboptimal use of health care services.1, 2 The 49

inappropriate days of hospitalization may undermine the effort to improve medical health care 50

quality due to the increased risk of iatrogenic complications such as healthcare-associated 51

infection, deep vein thrombosis, depression, and loss of physical dependence. In addition, 52

inappropriate length of hospital stay is associated with a substantial increase in morbidity and 53

mortality.2, 3 54

Reducing healthcare costs and optimizing the utilization of the current healthcare facilities, 56

including hospital beds, are among the best ways to increase the efficiency of healthcare 57

resources. Nevertheless, studies showed that more than 20% of hospital beds are used 58

inappropriately, resulting in a waste of resources, and increased iatrogenic risks for patients.4, 5 59

Previous studies have shown that between 20-and 40% of hospital days were inappropriate 61

stays.1, 6-8 Delay in performing and reporting diagnostic tests, delay in consultation, delay in 62

performing procedures are among the most common causes of inappropriate hospital stay.1, 7, 9, 10 63

old age, prolonged length of hospital stay, and medical admissions were associated with an 64

increased inappropriate hospital stay.8, 11, 12 In general, implementing quality improvement 65

projects including routine auditing hospital services, multidisciplinary team approach, 66

engagement of discharge planners early on admission, and improving home-based services have 67

been shown to reduce inappropriate hospital stay.6, 13 68

Studies assessing factors associated with inappropriate hospital stay in the Middle Eastern 70

Region are sparse. The study's findings will assess the extent of inappropriate hospital stay and 71

identify reasons for the inappropriate hospital stay. Also, it will guide hospital managers, and 72

stakeholders to put strategies and implement measures to optimize health care resources 73

utilization without the need for additional financial investment. 74

Methods 76

Study setting 77

Oman's population is rising at more than 9% per year, making it one of the most growing 78

populations globally. According to the latest United Nations figures, Oman’s current population 79

is around 5 million people, and more than 1.4 million live in Muscat governorate.14, 15 80

Socioeconomic growth coupled with a remarkable improvement in the health care system in 81

Oman has resulted in an increased birth rate and decreased mortality rate, hence causing an 82

accelerated population expansion which continues to put a tremendous strain on the healthcare 83

system resources.16 84

One of the indicators of the quality of health service delivery is the number of hospital beds. 86

According to the Ministry of Health's annual report in 2020, there were 15.6 hospital beds 87

available for every 10,000 individuals in Oman.17 Similarly, hospital beds available for every 88

10,000 individuals range from 12.5 to 22 beds in the Gulf Cooperation Countries (GCC). While 89

in the United States, there are 28.7 beds for every 10,000 of the population.16, 18 90

The study was a retrospective cohort study conducted at Sultan Qaboos University Hospital 92

(SQUH), a 500-bed multispecialty tertiary referral hospital with several unique services and 93

certain specialized medical facilities. In addition, it is a major teaching hospital for medical and 94

nursing students at the College of Medicine and Health Sciences and College of Nursing. Also, it 95

is a major training centre for medical interns, general foundation program trainees and residents 96

of the Oman Medical Speciality Board. 97

The General Internal Medicine Unit receives around 70-80% of medical patients admitted 99

through the Emergency Department. The range of patients varies between patients with single 100

organ system disease -e.g. pneumonia-and patients with complex diseases or undifferentiated 101

illnesses. Besides medical admissions, the General Internal Medicine Unit provides admission 102

services to patients with immunological, genetic, and metabolic diseases due to the lack of 103

admission services for these specialities. 104

105

There are two main medical wards with a total bed capacity of 45 beds and ten beds in the high 106

dependency unit. In addition, general medical patients may be admitted to other non-medical 107

wards during busy periods. 108

109

Data sources 110

We included patients admitted under the care of the General Internal Medicine Unit from the 1 of 111

January 2020 until the 30 of June 2020. Patients admitted with COVID-19 infection were 112

excluded from the study. Trained medical doctors collected relevant demographic and clinical 113

data from patients' electronic records. Length of hospital stay counted as difference between the 114

time and date of admission and the time and date of discharge Primary diagnoses were coded 115

and classified according to the 10th revision of the International Statistical Classification of 116

Diseases and Related Health Problems (ICD-10). 117

118

Hospital Stay Appropriateness measurement tool and procedure 119

The Appropriateness Evaluation Protocol (AEP) is the most widely used instrument for 120

evaluating the appropriateness of hospitalizations in various countries. Gertman and Restuccia 121

developed AEP in 1981, and the original version contains 27 criteria for use in internal medicine 122

and surgical departments to evaluate the appropriateness of hospital admission and 123

hospitalization days.19 Reasons for inappropriate hospital stay-according to AEP- include 124

inappropriate date of discharge, delay related to awaiting complementary tests, delay related to 125

awaiting the results of complementary tests, awaiting surgical procedures, delay related to 126

awaiting consultations, delays related to poor planning for discharge, delay related to unavailable 127

extra-hospital resources (e.g. palliative care, and rehabilitation services), delay related to 128

unavailable intensive care bed, or delay related to inadequate family support.20 129

130

AEP has been used across many countries, and it was modified many times to adapt to various 131

health care settings.21 In addition, previous studies have proven that AEP is highly reliable and 132

valid modality to provide an objective assessment for inappropriate hospital stay.21, 22 133

134

We have used a modified version of AEP that includes 27 objective criteria items related to 135

medical and nursing services, extra-hospital resources, and patient-related factors. If one of the 136

criterion is fulfilled, the hospital days are considered appropriate, and if none are met, then the 137

days are considered inappropriate.20, 23 138

139

A team of four trained medical doctors who were not involved directly in patient care reviewed 140

all included patient medical records – patient electronic medical records- in detail. Each 141

admission was assessed independently by at least two medical doctors to assess the 142

appropriateness of hospital stay. The previously reported average length of hospital stay for 143

patients admitted under the care of the General Internal Medicine Unit at SQUH and the 144

calculated average length of hospital stay for our cohort was five days. Hence, any admission 145

that exceeded five days was reviewed to assess the appropriateness of the hospital stay. 146

Uncertainty regarding the appropriateness of hospital stay was discussed among team members 147

until consensus was achieved. 148

149

Statistical analysis 150

Categorical variables (e.g. sex) were reported as numbers and percentages, and differences 151

between groups were assessed using the Chi-square test or Fisher's exact as appropriate. We 152

report continuous variables (e.g. age) as mean ± SD for normally distributed values or median 153

(IQR) for non-normally distributed values. In addition, differences between groups (3 or more) 154

were assessed using one-way ANOVA for normally distributed continuous variables or Kruskal–155

Wallis rank test for non-normally distributed continuous variables. Finally, we conducted a 156

regression analysis to identify patient-related factors associated with an increased risk of the 157

inappropriate hospital. Stata v. 17.0 software package (StataCorp LLC, USA) was utilized to 158

perform statistical calculations, and P-values <0.05 were considered statistically significant. 159

160

Ethical approval 161

The study was approved by the Medical Research Ethics Committee (MREC) of the College of 162

Medicine and Health Sciences at our institution. 163

164

Results 165

There were 855 admissions under the care General Internal Medicine Unit during the study 166

period. In this cohort, 53.1% were men, and the median age was 64 (IQR:44-75) years. There 167

were 6785.4 hospitalization days, and the average length of hospital stay was 5 (IQR:3-9) days. 168

31.8% of admissions (n=272 admissions) included inappropriate hospitalization days. 9.9 % 169

(n=674 days) of hospitalization days were classified as inappropriate. There were 29 mortalities 170

during the study period (Table 1). 171

172

Diseases of the circulatory system (22.4%) and respiratory systems (22.0%) were the most 173

common class of primary diagnoses for patients admitted under the care of the General Internal 174

Medicine Unit. In addition, neoplasms and diseases of the skin and subcutaneous tissue had a 175

longer hospital stay than other classes of primary diagnoses-i.e. 8 and 7, respectively (Table 2). 176

177

Pneumonia (14.0%), heart failure (3.8%), transient ischemic attack (TIA) and stroke (8.0%), 178

exacerbations of chronic lung diseases (6.3%), sepsis (4.6%), admissions related to drug and 179

alcohol (4.2%), and urinary tract infection (4.1%) were the most common primary diagnoses. 180

Drug and alcohol-related admissions occurred mainly in young and male patients. Admission 181

due to TIA and stroke (42.7%), exacerbations of chronic lung disease (42.6%) and urinary tract 182

infections (42.9%) were likely to result in an inappropriate hospital stay. Also, TIA and stroke 183

diagnoses (3 {1-3} days) were associated with prolonged length of inappropriate hospital stay. 184

Sepsis was associated with an increased inpatient mortality rate (12.8%) (Table 3). 185

186

Delay in complementary tests (29.0%), unavailability of extra-hospital resources (21.7%), and 187

delay in the results of the complementary tests (18.8%) were the most common reasons 188

associated with inappropriate hospital stay (Table 4). 189

190

In terms of patient’s related factors, a regression analysis showed that old age was associated 191

with an increased risk of inappropriate stay (p= 0.007; odds ratio [OR]: 0.020 per 10-year 192

increase in age, 95% confidence interval CI: 0.006-0.036). 193

194

Discussion 195

This study assessed inappropriate hospital stay in a region with a rapidly expanding population 196

that overstrained health care system resources. It showed that around 10% of hospital bed-day 197

were wasted. Waiting for complementary tests, awaiting results of complementary tests and lack 198

of extra-hospital resources were the most common causes of inappropriate hospital stay. In 199

addition, old age and specific diagnoses such as stroke and chronic respiratory diseases are more 200

likely to result in an inappropriate hospital stay. 201

202

In this study, the overall average length of hospital stay for patients admitted to the General 203

Internal medicine unit was five days which is higher than the average length of stay (3.9 days) in 204

a similar health care setting in Oman,17 but is below the average length of stay reported in 205

different Asian & European countries (6.4-7.8 days).24 A study from Thailand reported a length 206

of hospital stay of 25.9 days for patients admitted under the care of the general medicine 207

department.25 This probably is due to the inclusion of subacute admissions (e.g. palliative care, 208

rehabilitation services) under the internal medicine department. In contrast, a study from 209

Australia has shown the length of hospital stay of patients admitted under the care of general 210

medicine was 3.7 days.26 The variations in the reported length of hospital stay could be explained 211

by multiple factors, including accessibility to diagnostic and therapeutic services, availability of 212

subacute medical services and home-based services. 213

214

According to Appropriateness Evaluation Protocol criteria, 31.9% of hospitalization (n=272) 215

included inappropriate hospital days, causing a waste of around 9.9% of total hospital bed-days 216

(n=674). The rate of inappropriateness has been reported in various international studies with 217

significant variation across countries, hospitals, and clinical departments. However, studies 218

conducted to assess the utilization of beds in internal medicine departments over the past 20 219

years concluded the rate of inappropriateness ranges between 20 to 41%. 27-30 A study from 220

Netherland showed that more than 20% of hospital stay was inappropriate and old age, lack of 221

home-based care and specialized medical services were associated with an increased risk of 222

inappropriate hospital stay.28 223

224

The disparity in the rate of inappropriate hospitalization between these studies is significant, 225

which could be due to differences in admission and discharge protocols, geographic areas, or bed 226

occupancy rates of different hospitals. In addition, differences in methodology, including 227

sampling methods, AEP modifications, options used to justify hospitalization days, and the 228

quality of medical records are important factors that might have contributed to the differences in 229

the previously reported rate of inappropriate hospital stay.28, 31 Our rate is lower than the reported 230

rate in a similar setting, probably because we have only included admissions that exceeded the 231

calculated average length of hospital stay (i.e. five days). 232

233

The most common reasons for the inappropriate hospital stay in the current study mainly were 234

related to the hospital system factors, including delay of complementary tests or awaiting its 235

results. In our institution, a routine imaging request is usually carried out in 1-3 days, and the 236

official report may require up to 2 days following the procedure. As a tertiary and university 237

hospital receiving many undiagnosed cases from different regional hospitals for expert opinion, 238

diagnostic workup represents a significant part of patient's hospitalization period. Hence, 239

institutional arrangements should be initiated, including the execution of a program for request 240

justification, scheduling and reporting procedures.9 241

242

In addition, extra-hospital care, including the availability of long-term or palliative care beds and 243

rehabilitation services, accounted for around 21% of inappropriate hospital stay. This result 244

highlights the lack of adequate rehabilitation services, home-based care and nursing homes, 245

resulting in inappropriate hospitalization and utilization of acute health resources in Oman. 246

247

Around 17% of inappropriate hospital stays were due to waiting for specialist consultation. 248

General Internal Medicine routinely admits patients with multiple complex issues; hence other 249

specialities consultation is vital. Creating an efficient consultation process and improving 250

communication between teams might decrease inappropriate hospital stays. 32, 33 251

252

In term of patients’ related factors, previous studies have shown that old age, patient with 253

multiple comorbidities including chronic heart failure, stroke, and soft tissue infection at 254

increased risk of prolonged length of hospital stay.34, 35 255

256

Our study has shown that the majority of patients were hospitalized with circulatory and 257

respiratory systems diseases. Pneumonia and exacerbations of chronic lung disease were among 258

the most common diagnoses, with a median length of hospital stay of 6 days, which is higher 259

than the reported length of hospital stay in similar health settings (i.e. five days).36 This could be 260

explained by the fact that our cohort of patients had advanced chronic pulmonary diseases, and 261

many were on long-term oxygen therapy and mechanical ventilatory support. 262

263

Acute decompensated heart failure was the second most common diagnosis in our study, with a 264

median length of hospital stay of 5.5 days (IQR: 4-9), consistent with international studies, 265

which reported a median of 6 days (IQR 4-9).34, 37 This is due to the nature and complexity of 266

managing heart failure leading to an increased rate of admission and readmission, the need for 267

intravenous diuretics and the possible development of complications like renal injury.38 Heart 268

failure was also associated with increased length of inappropriate hospital stay, which might be 269

due to the delay in performance of cardiac-specific imaging, the interpretation of these 270

investigations, and lack of multidisciplinary heart failure service. 271

272

Neoplasm’s class of diagnoses had the most extended length of hospital stay and the highest total 273

number of inappropriate hospitalization days, which is likely due to the time needed to perform 274

diagnostic investigations to confirm the diagnosis and arrange the appropriate transfer of care to 275

oncological specialities. Diseases of the skin and subcutaneous tissue had an increased length of 276

inappropriate hospital stay, possibly due to delay diagnosis and delayed specialist consultation. 277

278

Around 43% of admission due to stroke and TIA contains inappropriate hospital days. This was 279

mainly due to delays in performing relevant investigations such as Magnetic Resonance Imaging 280

(MRI), Holter monitoring, and echocardiography. In addition, the absence of a dedicated stroke 281

unit and inpatient rehabilitation service contributed to inappropriate hospitalization of patients 282

with acute stroke. 283

284

Logistic regression analysis demonstrated that old age was associated with an increased 285

inappropriate hospital stay. This could be explained by the increased burden of comorbidity and 286

high prevalence of geriatric syndromes in elderly patients.39 Dementia, poor pre-morbid 287

functional status were found to be associated with prolonged length of hospital stay in elderly 288

patients in previous studies.40 289

290

Many previous studies identified strategies and interventions to promote early discharge and 291

reduce inappropriate hospital stay. Auditing clinical and procedural services, physicians' 292

accountability, coordinating patient care early on admission, establishing a discharge planning 293

unit, investing in home-based care, nursing home and rehabilitation services were effective 294

strategies to minimize inappropriate hospital stay.5, 9, 41, 42 295

296

Also, geriatric assessment for old patients, implementing of clinical pathways for management of 297

common diagnoses such as heart failure, medications for patients with polypharmacy, and case 298

management may reduce length of hospital stay.34, 43 299

300

This study has many strengths. It is one of the few studies from the Middle East Region where 301

the expanding population puts extreme pressure on health care systems. The study identified 302

several hospital-related factors causing the prolongation of inappropriate hospital stay. Also, it 303

provides stakeholders and hospital managers with insights about the waste in acute hospital beds 304

and potential services to target to reduce inappropriate hospital stays. 305

306

The limitation of the study includes the retrospective nature of the study that reports data from a 307

single centre. Also, only we reviewed admissions that exceeded the average length of hospital 308

stay, which might underestimate the wasted hospital beds. Due to the study's retrospective nature 309

and lack of billing information -free of cost health care system for citizens- we could not 310

estimate the financial implication of inappropriate hospital stay. 311

312

Conclusion 313

A significant proportion of hospital stays are deemed inappropriate primarily due to hospital-314

related factors, including in-hospital delay procedures and the inability to discharge patients to 315

subacute hospital care settings. Therefore, auditing hospital services to minimize the time 316

between test request and completion of the test (performance and reporting), monitoring the 317

quality of consultation services, establishing rehabilitation services and investing in home-based 318

care are among the top strategies which are likely to improve early discharge and minimize 319

inappropriate hospital bed occupancy. 320

321

Conflicts of Interest 322

The authors declare no conflict of interests. 323

324

Funding 325

No funding was received for this study. 326

327

Author Contributions 328

Ahmed Al-Yarabi was involved in study conception and design, data collection, and draft 329

manuscript preparation. Huriya Al Balushi, Khaloud Al Hatmi and Reem Al Yahyaie were 330

involved in data collection, and draft manuscript preparation. Abdullah M. Al Alawi was 331

involved in study conception and design, analysis and interpretation of results, revision, and final 332

editing of the manuscript. Khalfan Al Zeedy and Hatem Al Farhan were involved in study 333

conception and design. 334

335

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462

Table 1: Patients' characteristics and admission data 463

Characteristic Total (n= 855)

Age (years)-Median (IQR) 64 (44-75)

Female-no (%) 401(46.9%)

Male -no (%) 454 (53.1%)

The average length of hospital stays (days)-median (IQR) 5 (3-9)

Total hospitalisation days (n) 6785.4

Admissions with appropriate date of discharge no (%) 583 (68.2%)

Admissions included inappropriate hospitalization days -no (%) 272 (31.9%)

Total number of inappropriate hospitalization days (days) 674

Mortality- no (%) 29 (3.4%)

464

Table 2: The length of hospital stay according to the primary diagnosis classified according to 465

ICD-10 466

The average length of

hospital stay; Median

(IQR)

Total (n= 855) Classification of primary diagnosis according to ICD-10

6 (3-10) 46 (5.4%) Infectious disease (A00-B99)

8 (5-14) 18 (2.1%) Neoplasms (C00-D48)

4 (3-7) 29 (3.4%) Haematological diseases (D50-D89)

4.5 (3-6) 70 (8.2%) Endocrine, nutritional, and metabolic diseases (E00-E90)

4 (2-6) 25 (2.9%) Mental and behavioural disorders (F00-F99)

5 (3.5-8) 44 (5.2%) Diseases of the nervous system (G00-G99)

3 (2-5) 7 (0.8%) Diseases of the ear and mastoid process (H60-95)

6 (4-10) 191 (22.4%) Diseases of the circulatory system (I00-I99)

6 (3-10) 188 (22.0%) Diseases of the respiratory system (J00-J99)

4 (3.5-7) 60 (7.0%) Diseases of the digestive system (K00-K93)

7 (3.5-11) 20 (2.3%) Diseases of the skin and subcutaneous tissue (L00-L99)

https://doi.org/10.1186/1472-6963-9-44

6 (3-16) 12 (1.4%) Diseases of the musculoskeletal system and connective tissue

(M00-M99)

6(5-8) 55(6.4%) Diseases of the genitourinary system (N00-N99)

6(4-8) 69 (8.1%) Symptoms, signs and abnormal clinical and laboratory findings

not elsewhere classified (R00-R99)

5 (2-13) 7 (0.8%) Injury, poisoning and certain other consequences of external

causes (S00-T98)

3 (2-5) 13 (1.5%) Factors influencing health status and contact with health

services (Z00-Z99)

ICD-10: the 10th revision of the International Statistical Classification of Diseases and Related Health

Problems

467

468

Table 3: Patients' characteristics and admission data of the most common diagnoses

Characteristic Pneumonia Heart

Failure

Stroke

& TIA

Exacerbation

of chronic

lung

diseases*

Sepsis Drugs &

alcohol

Urinary

Tract

Infection

Others P-value

Admissions

(Total n=855)

120

(14.0%)

118

(13.8)

(8.0%)

54 (6.3%) 39

(4.6%)

36 (4.2%) 35(4.1%) 385 (45.0%)

Age (years) 68 (43.5-

75)

70 (61-

77)

67 (56-

76)

67.5 (53-76) 75 (64-

84)

38 (29.5-

47.0)

71 (48-79) 57 (35-72) 0.0043*

Female (n) 49 (40.9%) 61

(51.7%)

(41.2%)

31 (57.4%) 17

(43.6%)

7(19.4%) 22(62.9%) 186 (48.3%) 0.0034**

Male (n) 71(59.2%) 57

(48.3%)

(58.8%)

23 (42.6%) 22

(56.4%)

(80.6%)

13(37.1%) 199(51.7%) 0.0034**

Average Length

of Hospital stay

(days)

6 (3-10) 5.5 (4-9) 5.5 (4-8) 6(3-8) 6 (4-10) 4 (3.0-6.5) 6 (5-8) 5 (3-8) 0.0751*

Admissions with

appropriate date

of discharge (n)

77 (64.2%) 72

(61.0%)

(57.4%)

31(57.4%) 31

(79.5%)

28(77.8%) 20

(57.1%)

285(74.0%) 0.0023**

Admissions with

inappropriate

hospital stay (n)

43 (35.8%) 46

(39.0%)

(42.7%)

23(42.6%) 8

(20.5%)

8 (22.2%) 15(42.9%) 11(26.0%) 0.0023**

Total number

unnecessary

hospital stay days

(n=674 days)

120

(17.8%)

103

(15.3%)

(10.7%)

49 (7.3%) 12

(1.8%)

21 (3.1%) 40 (5.9%) 257 (38.1%) 0.0411**

Average length of

inappropriate

hospitalization

(days)

2 (1-3) 2 (1-3) 3 (1-3) 2 (1-3) 1(1-2) 2 (1.5-4) 2 (2-3) 2 (1-3.5) 0.0043*

Mortality (n) 2 (1.7%) 1 (0.9%) 1(1.5%) 0 5

(12.8%)

0 0 20 (5.2%) 0.0016**

TIA: transient ischemic attack. *Chronic obstructive lung disease, interstitial lung disease, bronchiectasis, bronchial asthma.

*p-value for differences between continuous variables groups using Kruskal–Wallis rank test.

** p-value for differences between categorical variables groups using chi-square test.

Table 4: Reasons for the inappropriate hospital stay20

Reasons for the inappropriate hospital stay Total admissions

n=272

Awaiting complementary tests 79 (29.0%)

Awaiting the results of complementary tests 51(18.8%)

Awaiting surgical procedures 3 (1.1%)

Awaiting specialist consultations 48 (17.6%)

Awaiting extra-hospital care to be arranged & unavailable extra-hospital

resources, including the availability of long-term or palliative care beds or

rehabilitation

59 (21.7%)

Patients awaiting transfer to intensive care or admission to another program

or in-home care or awaiting transfer to other departments within the same

hospital

3 (1.1%)

Inadequate family support 29 (10.7%)