Analysis of long-stay patients in the hospice palliative ward of a medical center

Background: The Pilot Project on Per-diem Payment for Inpatient Hospice Services of Taiwan's National Health Insurance Program was begun in July 2000. The project monitors hospices to control for a median length of stay (LOS) of not longer than 16 days to prevent inappropriate stasis in hospices. To determine the best utilization of palliative care, patients remaining in the hospice for more than 28 days were analyzed to discover their characteristics and reasons for not being discharged. Methods: The study sample included 1,670 hospice patients who were admitted to the Hospice Palliative Unit in Taipei Veterans General Hospital between July 16, 1997 and December 31, 2002. Two hundred and sixty admissions (21.5%) with LOS > 28 days were identified. Further instrument survey of selected items was performed by 2 trained staff via chart review independently. The basic data were analyzed and comparison between long-stay patients and non-long-stay patients was made. Results: The mean LOS of 1,670 hospice patients was 16.0 +/- 14.9 days. Two hundred and sixty-eight patients (16.1%) admitted for longer than 28 days were surveyed. Those who had longer mean survival time, a diagnosis of prostate cancer, a metastatic site in the bone, and readmitted patients were associated with long stay. The study also revealed a significant difference in LOS between fee-for-service (FFS) patients and per-diem payment (PDP) patients (mean LOS, 17.5 +/- 16.4 vs. 14.3 +/- 13.4, p < 0.001). Conditions of major physical distress on Day 29 were delirium (41.9%), depression and/or anxiety (20.4%), and severe dyspnea (21.2%). The main reasons for being unable to be discharged on Day 29 after admission included "prolonged terminal phase" (34.2%), "difficult symptom control" (25.8%), "placement problem" (16.9%), and "need of parenteral medication" (15.0%). Conclusion: Better understanding of the factors related to LOS can help staff in the palliative ward of medical centers to identify patients who are apt to have long stay, and shorten their LOS by successfully dealing with their problems.