title: Root causes for delayed hospital discharge in patients with ST-segment Myocardial Infarction (STEMI): a qualitative analysis.
abstract: BACKGROUND
  The majority of patients who suffer a ST-segment myocardial infarction (STEMI) are hospitalized for longer than 48 h. With the advent of reperfusion therapy, the benefits of such extended hospitalization has been questioned. The goal of this qualitative study was to identify the root causes for prolonged hospitalization in STEMI patients in order to refine future interventions to optimize the length of hospitalization.
  
  
  METHODS
  Practitioners involved in the discharge process for STEMI patients at a single tertiary care STEMI center underwent semi-structured interviews focused on three fictional patient cases. Data were transcribed and analyzed for key themes by thematic analysis.
  
  
  RESULTS
  Interviews were conducted with 17 practitioners (5 Attending Physicians, 4 Internal Medicine Residents, 4 Cardiology Residents, 4 Nursing Staff). The key themes were patient factors, provider factors, and transitions to outpatient care. Patient factors included concerns that early discharge would limit dose titration of medications, the educational experience of the patient, and prevent monitoring for complications. Provider factors included past clinical experience with STEMI complications, in turn impacting discharging behaviour. Transitions of care factors were difficulty in establishing reliable follow-up plans and home care services.
  
  
  CONCLUSIONS
  Several themes were identified that influence the timing of discharge post STEMI. The majority of these issues are not incorporated into currently available post STEMI risk stratification tools. Future quality improvement interventions to reduce STEMI length of stay should focus on in-patient and out-patient strategies to address these unique clinical situations.
authors.affiliation: Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Suite A202, Toronto, ON, M4N3M5, Canada. jeremy.adams@sunnybrook.ca.|Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada. jeremy.adams@sunnybrook.ca.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Adams
authors.affiliation: Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada. BrianM.Wong@sunnybrook.ca.|Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada. BrianM.Wong@sunnybrook.ca.
authors.forename: Brian
authors.initials: B
authors.lastname: Wong
authors.affiliation: Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Suite A202, Toronto, ON, M4N3M5, Canada. harindra.wijeysundera@sunnybrook.ca.|Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada. harindra.wijeysundera@sunnybrook.ca.|Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. harindra.wijeysundera@sunnybrook.ca.|Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada. harindra.wijeysundera@sunnybrook.ca.|Li Ka Shing Knowledge Institute of St. Michael Hospital, University of Toronto, Toronto, ON, Canada. harindra.wijeysundera@sunnybrook.ca.
authors.forename: Harindra C
authors.initials: HC
authors.lastname: Wijeysundera
mesh_terms: D000367:Age Factors; D002170:Canada; D006801:Humans; D007902:Length of Stay; D009203:Myocardial Infarction / Q000150:complications / Q000628:therapy*; D010351:Patient Discharge; D010353:Patient Education as Topic; D036301:Qualitative Research; D058996:Quality Improvement; D012307:Risk Factors; D062606:Tertiary Care Centers / Q000592:standards*