Delayed discharge after major surgical procedures in Ontario, Canada: a population-based cohort study

Dr. Heckman et al. raise the importance of frailty and delirium as possible contributing factors for delays in hospital discharge and need for continuing care. We support the inclusion of frailty measures in hospital-level national databases to standardize this assessment. Dr. Heckman alludes to a lack of standardized national hospital-level acute care data on frailty. While instruments have been developed to study frailty using administrative data, the tools measure frailty indirectly as a function of age, comorbidity, and pre-hospital residence.1 Hence, some elements within existing frailty indices are captured in our methods although we accept that addition of a frailty index could provide further information on the risk of delayed discharge.2 Hospital databases do not include standardized frailty measures such as the Clinical Frailty Scale or Fried Frailty Index, and are inaccurate sources for studying postoperative delirium.3

Alternate level of care is an endemic issue within public healthcare systems that impacts patient flow in acute hospitals and wait times. Closer inspection of the scale of alternate level of care for Canadian surgical patients who may have personal care needs and specific post-surgical rehabilitation needs (i.e., physiotherapy after joint replacement) has not been performed. This paper provided the first high-level assessment of alternate level of care use in complex surgical patients.4 Like any early evaluation, we focused on global epidemiological features such as incidence, trends and predictors rather than targeted areas like frailty. Given our paper showed that older adults are at greater risk of alternate level of care, next steps in this line of research includes evaluating why they are at higher risk - with frailty being an important potential explanation.

We respectfully disagree that all interventions to mitigate risks for delayed hospital discharge should occur before surgery. Upstream rigorously assessed interventions are important, but are by no means the only solution. Timely discharge planning and access to community care are invaluable for safe discharge. Indeed, our paper showed wide variation in alternate level of care status between surgeries. Cardiac surgery likely provides some key lessons for programmatic discharge planning because this patient subgroup is typically older with high levels of frailty yet showed low rates of alternate level of care. Another promising avenue is use of bundled care packages, which are available to Ontario patients having elective hip and knee replacement. Bundled programs link acute hospital to post-acute care, and have lowered hospital lengths of stay and alternate level of care.5

There is no single magic bullet for resolving alternate level of care. A sequential perioperative team-based approach, where healthcare providers pass on care carefully to the next provider, is needed to optimize recovery at the right times along the patients’ surgical journey.