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Causas de atraso na alta hospitalar no cliente adulto: scoping review

Causas de retraso en el alta hospitalaria en el cliente adulto: scoping review

Resumo

OBJETIVO

Mapear a evidência existente sobre as causas de atraso na alta hospitalar no cliente adulto.

MÉTODOS

Efetuada revisão da literatura do tipo scoping review. Pesquisou-se na plataforma informática da Ebscohost, na PubMed e na literatura cinzenta, consultando-se as referências bibliográficas desses documentos.

RESULTADOS

Dos 22 artigos analisados verificou-se que o atraso na alta hospitalar se deve a causas relacionadas com os recursos da comunidade, designadamente a falta de vagas em unidades de saúde e motivos sociais; a causas organizacionais relacionadas com os cuidados de saúde; a causas individuais, destacando-se as questões familiares e financeiras; culminando nas causas organizacionais relacionadas com a gestão hospitalar.

CONCLUSÃO

O atraso na alta hospitalar é multifatorial, tornando-se necessário monitorizar o processo de internação, apostando-se num planejamento de alta antecipado.

PALAVRAS Chave:
Alta do paciente; Cuidados de enfermagem; Tempo de internação

Resumen

OBJETIVO

Mapear la evidencia existente sobre las causas de retraso en el alta hospitalaria en el cliente adulto.

MÉTODOS

Se realizó una revisión de la literatura del tipo scoping review. Se investigó en la plataforma informática de Ebscohost, en la PubMed y literatura gris, consultando las referencias bibliográficas de estos documentos.

RESULTADOS

De los 22 artículos analizados se verificó que el retraso en el alta hospitalaria se debe a causas relacionadas con los recursos de la comunidad, en particular la falta de vacantes en unidades de salud y motivos sociales; a causas organizacionales relacionadas con la asistencia sanitaria; a causas individuales, destacándose las cuestiones familiares y financieras; culminando en las causas organizacionales relacionadas con la gestión hospitalaria.

CONCLUSIÓN

El retraso en el alta hospitalaria es multifactorial. Es necesario controlar el proceso de internación, centrándose en una planificación de alta anticipada.

PALABRAS Clave:
Alta del paciente; Atención de enfermería; Tiempo de internación

Abstract

OBJECTIVE

To map the existing evidence on the causes of hospital discharge delays among adult clients.

METHODS

A scoping review was conducted. We searched in the Ebscohost’ plataform, in PubMed, and in grey literature, consulting the bibliographic references of the documents found.

RESULTS

From the 22 articles analyzed it was verified that the delay in hospital discharge is due to causes related to community resources, namely the lack of vacancies in health units, and social reasons; to organizational causes related to health care; to individual causes, standing out family and financial issues; culminating in organizational causes related to hospital management.

CONCLUSION

The delay in hospital discharge is multifactorial. It’s necessary to monitor the hospitalization process, focusing on early discharge planning.

KEYWORDS:
Patient discharge; Nursing care; Length of stay

INTRODUÇÃO

A Organização para a Cooperação e Desenvolvimento Econômico (OCDE)11. Organisation for Economic Co-operation and Development (FR) [Internet]. Paris: OECD; c2017 [cited 2017 Jul 13]. Length of hospital stay [indicator]; [about 2 screens]. doi: https://doi.org/10.1787/8dda6b7a-en.
https://doi.org/10.1787/8dda6b7a-en...
define tempo de internação como o número médio de dias que o cliente passa no hospital, excluindo-se os casos de admissão e saída no mesmo dia. Designa-se por atraso na alta a permanência da pessoa no hospital após ser dada alta clínica. O tempo de atraso consiste no intervalo de tempo entre o momento em que a pessoa se apresenta em condições de ter alta e sai efetivamente do hospital22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
. Este atraso na alta com retardo do regresso a casa apresenta consequências para a saúde e bem-estar do cliente e para a instituição ao nível dos custos associados33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
) e da rentabilidade, dificultando uma prestação de cuidados eficaz e eficiente44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
.

Identificar os obstáculos que dificultam uma alta no prazo adequado pode ajudar a instituição a direcionar esforços para reduzir tempos de internação desnecessários44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
. O enfermeiro tem um papel fundamental no processo de alta do cliente, visto encontrar-se numa relação mais próxima com este, sendo da sua responsabilidade a avaliação das necessidades da pessoa. O planejamento da alta deve ser iniciado o mais cedo possível, no sentido de prevenir problemas quando da alta e depois desta, providenciando-se cuidados de qualidade55. Pirani A. Prevention of delay in the patient discharge process - an emphasis on nurses' role. J Nurses Staff Dev. 2010 [cited 2017 Jun 15];26(4):E1-E5. doi: https://doi.org/10.1097/NND.0b013e3181b1ba74.
https://doi.org/10.1097/NND.0b013e3181b1...
.

Face a problemática exposta decidiu-se realizar uma revisão de literatura do tipo scoping review com o objetivo geral de descrever a evidência atual disponível sobre as causas de atraso na alta hospitalar no cliente adulto, com consequente aumento do tempo de internação hospitalar.

A relevância deste estudo está no fato de se abordar uma problemática pertinente e relevante, digna de atenção no contexto atual, dado o crescente aumento dos custos associados à saúde, parte destes devido a internações prolongadas evitáveis, sendo esta realidade uma preocupação diária do governo e da sociedade em geral.

Esta revisão urge pela necessidade de análise das diferentes causas, não se tendo encontrado nenhuma revisão que se foque na ação de enfermagem. Apoiar o processo da alta hospitalar é uma das dimensões do papel do enfermeiro, de forma a promover-se a continuidade dos cuidados, um cuidado integrado e comprometido66. Silva RV, Ramos FR. [The nurse work in the discharge of hospitalized children: articulation of basic hospital attention]. Rev Gaúcha Enferm. 2011 [cited 2017 Dec 13];32(2):309-15. Portuguese. doi: https://doi.org/10.1590/S1983-14472011000200014.
https://doi.org/10.1590/S1983-1447201100...
. Ao se identificarem as causas de atraso na alta hospitalar consegue-se definir medidas que podem contribuir para a diminuição do tempo de internação, otimizando-se o processo de internação do cliente, resultando em benefícios para a sua saúde e bem-estar e vantagens econômico-financeiras para a instituição.

MÉTODOS

Realizou-se uma revisão de literatura do tipo scoping por forma a analisar de forma ampla e abrangente estudos focados nesta problemática. Utilizando a metodologia de Joanna Briggs Institute, definiu-se a seguinte questão de revisão, tendo por base a mnemónica população - conceito - contexto (PCC): quais as causas de atraso na alta hospitalar do cliente adulto internado na enfermaria?

Definiram-se como questões secundárias de revisão: Quais as diferentes tipologias de causas de atraso na alta hospitalar do cliente adulto internado na enfermaria? Em que contextos clínicos se verificam os atrasos na alta hospitalar? E em que populações se verificam os atrasos na alta hospitalar?

No que diz respeito aos critérios de inclusão analisaram-se estudos que abordavam causas de atraso na alta hospitalar, fatores esses que podem estar relacionados com a própria pessoa, a instituição de saúde ou a comunidade. Incluíram-se clientes adultos e idosos internados em contexto hospitalar com atraso na alta, em situação aguda e/ou crónica, das diferentes especialidades médicas: cardiologia, cirurgia, dermatologia, estomatologia, gastrenterologia, ginecologia e obstetrícia, infecciologia, medicina, nefrologia, neurologia, oftalmologia, oncologia médica, ortopedia, otorrinolaringologia, pneumologia, endocrinologia e urologia; de forma a se efetuar uma análise geral sobre as diferentes causas para o retardo da alta. O contexto do estudo abrangeu os serviços de internação dos hospitais. Para a pesquisa efetuada definiu-se como limite inferior no universo temporal o ano de 2001, com a intenção de determinar causas decorrentes no século XXI, resultados relevantes para o sistema de saúde atual, correspondendo a estudos realizados na União Europeia, de forma a ser possível comparar realidades semelhantes. O limite superior data a julho de 2017. Respeitante às fontes de dados incluíram-se estudos que abordavam causas de atraso na alta hospitalar, podendo o tipo de estudo ser primário qualitativo e quantitativo, incluindo revisões da literatura, no sentido de complementar o máximo de evidência existente; com resumo e texto integral disponíveis e nos idiomas português, espanhol e inglês.

Como critério de exclusão definiu-se todo o artigo do gênero artigo de opinião, anúncios publicitários, editoriais ou cartas ao editor.

Respeitante à estratégia de pesquisa, numa primeira fase pesquisou-se nas bases de dados eletrônicas Medline with full text, Cinahl with full text e na PubMed, assim como na plataforma Descritores em Ciências da Saúde, efetuando-se uma pesquisa flutuante sobre o assunto, no sentido de identificar as palavras-chave mais comuns usadas nos artigos relacionados com o atraso na alta hospitalar, adaptando-os para termos MeSH, Headings e Descritores. Posteriormente, identificados os descritores a usar na pesquisa de artigos construiu-se a equação de pesquisa e investigou-se nas seguintes bases de dados da plataforma eletrônica da Ebscohost: Medline with full text, Cinahl with full text, MedicLatina, Cochrane Data Base of Systematic Reviews; e na PubMed.

No sentido de complementar esta análise por estudos primários e revisões pesquisou-se na literatura cinzenta, consultando-se os sites The Grey Literature Report, Open Grey, Repositório Científico de Acesso Aberto de Portugal, Veritati - Repositório Institucional da Universidade Católica Portuguesa, MedNar Search; e WorldWideScience.org - The Global Science Gateway.

Consultaram-se as referências bibliográficas dos documentos selecionados, averiguando-se se existiam mais estudos que fossem importantes de analisar. A pesquisa na literatura decorreu durante o mês de agosto de 2017.

Na base de dados PubMed resultou a seguinte sintaxe de pesquisa:

((((delay) OR length of delay)) AND (((("Patient Discharge"[Mesh]) OR "Patient Discharge Summaries"[Mesh]) OR Transfer, Discharge) OR Hospital Discharge)) AND "Length of Stay"[Mesh]

Sintaxes semelhantes foram adotadas para as restantes bases de dados.

Identificados os estudos iniciou-se o processo de seleção, eliminando os que se encontravam repetidos. Os restantes foram selecionados de acordo com os critérios de inclusão, sendo o processo de seleção efetuado inicialmente através do título, depois pelo resumo, seguido da leitura integral do artigo, verificando-se se este respondia à questão de investigação. O processo de seleção dos artigos deve ser conduzido de forma criteriosa e transparente, pelo que esta pesquisa foi efetuada por dois revisores de forma independente.

Decorrido este processo constituiu-se o corpus da análise, procedendo-se à colheita de dados para posterior comparação de evidência científica. A informação recolhida englobou: identificação do artigo, título, autor, ano de publicação, país, objetivo, participantes, população, tamanho da amostra, características metodológicas, desenho do estudo, resultados obtidos e principais conclusões relevantes para a scoping review. No que diz respeito à apresentação dos resultados as causas foram subdivididas em grupos, tendo-se realizado uma análise descritiva e comparativa dos resultados com uma síntese narrativa.

RESULTADOS

Da totalidade dos artigos obtidos, após a remoção dos seus duplicados, obtiveram-se 381 artigos para seleção inicial pela leitura do título. Desta primeira análise selecionaram-se 58 artigos, eliminando-se assim, 323 documentos. Posteriormente, eliminaram-se 25 artigos pela leitura do resumo, dado não responderem aos critérios de inclusão, visto 13 artigos apresentarem estudos realizados fora da União Europeia, 1 incluir clientes pediátricos no estudo e 11 não se focarem nas causas de atraso na alta hospitalar. Dos 33 artigos selecionados procedeu-se à leitura integral dos documentos, selecionando-se 17 para análise. Consultando as referências bibliográficas dos 17 artigos finais obtiveram-se mais 5 artigos para se adicionar à análise, visto responderem à questão de pesquisa. Deste modo, resultaram 22 artigos para analisar e incluir na revisão.

Figura 1
Prisma do processo de seleção dos artigos

Analisando os resultados obtidos, a maioria dos estudos sugere a existência de múltiplos fatores contribuintes para o atraso na alta hospitalar, designadamente relacionados com os serviços sociais, os serviços hospitalares de cuidados agudos e da comunidade, incluindo questões pessoais e familiares. Dada esta linha orientadora designaram-se três tipos de causas ou fatores para o atraso na alta hospitalar relacionados com as características da instituição prestadora de cuidados, das pessoas e do sistema de saúde: causas organizacionais, ou intra-hospitalares; causas individuais, também denominadas por pessoais; e causas da comunidade, ou seja, relacionadas com os recursos existentes na comunidade ao serviço do cliente.

De uma forma sucinta, da análise efetuada verificou-se que o atraso na alta hospitalar se deve significativamente devido a causas relacionadas com os recursos da comunidade, especialmente com a falta de vagas em lares e unidades de cuidados de saúde, designadamente nos cuidados continuados22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
-33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...

8. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...

9. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...

10. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...

11. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...

12. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2015;27(2):737-45. doi: https://doi.org/10.1007/s00198-015-3293-9.
https://doi.org/10.1007/s00198-015-3293-...

13. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...

14. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...

15. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...

16. Worthington AD, Oldham JB. Delayed discharge from rehabilitation after brain injury. Clin Rehabil. 2006;20(1):79-82. doi: https://doi.org/10.1191/0269215506cr881oa.
https://doi.org/10.1191/0269215506cr881o...

17. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
-1818. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
e por motivos sociais33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
,1212. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2015;27(2):737-45. doi: https://doi.org/10.1007/s00198-015-3293-9.
https://doi.org/10.1007/s00198-015-3293-...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...

20. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...
-2121. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...
; a causas organizacionais relacionadas com os cuidados de saúde, com maior incidência na espera por avaliações de saúde, tratamentos ou resultados de exames44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
,77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
-1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
-1818. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
,2222. Jasinarachchi KH, Ibrahim IR, Keegan BC, Mathialagan R, McGourty JC, Phillips JRN, et al. Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over. BMC Geriatrics. 2009;9:4. doi: https://doi.org/10.1186/1471-2318-9-4.
https://doi.org/10.1186/1471-2318-9-4...
; a causas individuais, com destaque para as questões familiares77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
-1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
,2121. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...
) e financeiras77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
,1616. Worthington AD, Oldham JB. Delayed discharge from rehabilitation after brain injury. Clin Rehabil. 2006;20(1):79-82. doi: https://doi.org/10.1191/0269215506cr881oa.
https://doi.org/10.1191/0269215506cr881o...
; e a causas organizacionais relacionadas com a gestão hospitalar, onde se destaca a falta de recursos humanos77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
-1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,2323. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...
.

Quadro 1
Principais causas de atraso na alta hospitalar

DISCUSSÃO DOS RESULTADOS

O atraso na alta hospitalar e as suas repercussões ao nível do cliente, da própria instituição e dos sistemas de saúde são problemáticas vivenciadas e abordadas em vários países. Focando a União Europeia, da análise efetuada, o Reino Unido é o que tem dado mais importância e atenção a este assunto.

Os 22 artigos analisados foram publicados entre os anos 2001 e 2016, com especial destaque para os anos de 2006 e 2012, cada um com 3 publicações; e realizados especialmente no Reino Unido (n=14)33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
,77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...

10. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
-1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
,1313. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...
-1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
,1616. Worthington AD, Oldham JB. Delayed discharge from rehabilitation after brain injury. Clin Rehabil. 2006;20(1):79-82. doi: https://doi.org/10.1191/0269215506cr881oa.
https://doi.org/10.1191/0269215506cr881o...
,1818. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
,2020. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...
,2222. Jasinarachchi KH, Ibrahim IR, Keegan BC, Mathialagan R, McGourty JC, Phillips JRN, et al. Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over. BMC Geriatrics. 2009;9:4. doi: https://doi.org/10.1186/1471-2318-9-4.
https://doi.org/10.1186/1471-2318-9-4...
-2323. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...
,2525. Panteli M, Habeeb S, McRoberts J, Porteous MJ. Enhanced care for primary hip arthroplasty factors affecting length of hospital stay. Eur J Orthop Surg Traumatol. 2014;24(3):353-8. doi: https://doi.org/10.1007/s00590-013-1188-z.
https://doi.org/10.1007/s00590-013-1188-...
, em Espanha (n=3)1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
,2121. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...
, na Itália (n=2)88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
, em Portugal (n=1)1212. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2015;27(2):737-45. doi: https://doi.org/10.1007/s00198-015-3293-9.
https://doi.org/10.1007/s00198-015-3293-...
, na Noruega (n=1)22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
e na Dinamarca (n=1)2424. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82(6):679-84. doi: https://doi.org/10.3109/17453674.2011.636682.
https://doi.org/10.3109/17453674.2011.63...
.

Relativamente ao tipo de estudo, um estudo1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
corresponde a uma revisão da literatura realizada no Reino Unido que foca o cliente idoso; e 21 estudos correspondem a estudos observacionais, entre os quais transversais22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
,88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
,1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
,1818. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
, estudos de coorte prospetivos33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
,99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
,1212. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2015;27(2):737-45. doi: https://doi.org/10.1007/s00198-015-3293-9.
https://doi.org/10.1007/s00198-015-3293-...
-1313. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...
,1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...

20. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...

21. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...

22. Jasinarachchi KH, Ibrahim IR, Keegan BC, Mathialagan R, McGourty JC, Phillips JRN, et al. Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over. BMC Geriatrics. 2009;9:4. doi: https://doi.org/10.1186/1471-2318-9-4.
https://doi.org/10.1186/1471-2318-9-4...

23. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...

24. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82(6):679-84. doi: https://doi.org/10.3109/17453674.2011.636682.
https://doi.org/10.3109/17453674.2011.63...
-2525. Panteli M, Habeeb S, McRoberts J, Porteous MJ. Enhanced care for primary hip arthroplasty factors affecting length of hospital stay. Eur J Orthop Surg Traumatol. 2014;24(3):353-8. doi: https://doi.org/10.1007/s00590-013-1188-z.
https://doi.org/10.1007/s00590-013-1188-...
) e retrospetivos77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
,1616. Worthington AD, Oldham JB. Delayed discharge from rehabilitation after brain injury. Clin Rehabil. 2006;20(1):79-82. doi: https://doi.org/10.1191/0269215506cr881oa.
https://doi.org/10.1191/0269215506cr881o...
. Respeitante ao nível de evidência científica por tipo de estudo, seguindo Melnyk e Fineout-Overholt classifica-se a grande maioria dos estudos com nível IV33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
,77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
-1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
,1212. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2015;27(2):737-45. doi: https://doi.org/10.1007/s00198-015-3293-9.
https://doi.org/10.1007/s00198-015-3293-...
-1313. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...
,1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...

16. Worthington AD, Oldham JB. Delayed discharge from rehabilitation after brain injury. Clin Rehabil. 2006;20(1):79-82. doi: https://doi.org/10.1191/0269215506cr881oa.
https://doi.org/10.1191/0269215506cr881o...
-1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...

20. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...

21. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...

22. Jasinarachchi KH, Ibrahim IR, Keegan BC, Mathialagan R, McGourty JC, Phillips JRN, et al. Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over. BMC Geriatrics. 2009;9:4. doi: https://doi.org/10.1186/1471-2318-9-4.
https://doi.org/10.1186/1471-2318-9-4...

23. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...

24. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82(6):679-84. doi: https://doi.org/10.3109/17453674.2011.636682.
https://doi.org/10.3109/17453674.2011.63...
-2525. Panteli M, Habeeb S, McRoberts J, Porteous MJ. Enhanced care for primary hip arthroplasty factors affecting length of hospital stay. Eur J Orthop Surg Traumatol. 2014;24(3):353-8. doi: https://doi.org/10.1007/s00590-013-1188-z.
https://doi.org/10.1007/s00590-013-1188-...
, 4 estudos com nível VI22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
,88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
,1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
,1818. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
e um estudo com nível V1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
.

No que diz respeito à especialidade médica, 8 artigos incluem clientes cirúrgicos44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
,88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
,1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
,1313. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...
,1818. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
,2020. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...
,2424. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82(6):679-84. doi: https://doi.org/10.3109/17453674.2011.636682.
https://doi.org/10.3109/17453674.2011.63...
, 7 abrangem clientes de medicina88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...

9. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
-1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
,1313. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...
,1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
,2121. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...
, 6 analisam clientes da especialidade de ortopedia-traumatologia33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
,1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
,1212. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2015;27(2):737-45. doi: https://doi.org/10.1007/s00198-015-3293-9.
https://doi.org/10.1007/s00198-015-3293-...
,2424. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82(6):679-84. doi: https://doi.org/10.3109/17453674.2011.636682.
https://doi.org/10.3109/17453674.2011.63...
-2525. Panteli M, Habeeb S, McRoberts J, Porteous MJ. Enhanced care for primary hip arthroplasty factors affecting length of hospital stay. Eur J Orthop Surg Traumatol. 2014;24(3):353-8. doi: https://doi.org/10.1007/s00590-013-1188-z.
https://doi.org/10.1007/s00590-013-1188-...
, incluindo cirurgia ortopédica2424. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82(6):679-84. doi: https://doi.org/10.3109/17453674.2011.636682.
https://doi.org/10.3109/17453674.2011.63...
, 2 focam-se em clientes da especialidade de cardiologia1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
,2323. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...
, 2 em clientes da especialidade de gastroenterologia99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
-1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
, 2 em clientes de reabilitação88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
,1616. Worthington AD, Oldham JB. Delayed discharge from rehabilitation after brain injury. Clin Rehabil. 2006;20(1):79-82. doi: https://doi.org/10.1191/0269215506cr881oa.
https://doi.org/10.1191/0269215506cr881o...
, 1 em clientes do foro psiquiátrico1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
e 1 em clientes do serviço de geriatria88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
. Dos 22 artigos analisados, 422. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
,77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
,2222. Jasinarachchi KH, Ibrahim IR, Keegan BC, Mathialagan R, McGourty JC, Phillips JRN, et al. Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over. BMC Geriatrics. 2009;9:4. doi: https://doi.org/10.1186/1471-2318-9-4.
https://doi.org/10.1186/1471-2318-9-4...
não especificam especialidades médicas e 11414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
aborda diferentes especialidades.

Focando a faixa etária destes clientes verifica-se que a grande maioria se destaca no cliente idoso, ou seja, pessoa com idade igual ou superior a 65 anos (n= 16)22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
,33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...

8. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...

9. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...

10. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...

11. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
-1212. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2015;27(2):737-45. doi: https://doi.org/10.1007/s00198-015-3293-9.
https://doi.org/10.1007/s00198-015-3293-...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...

18. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
-1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
,2121. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...
-2222. Jasinarachchi KH, Ibrahim IR, Keegan BC, Mathialagan R, McGourty JC, Phillips JRN, et al. Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over. BMC Geriatrics. 2009;9:4. doi: https://doi.org/10.1186/1471-2318-9-4.
https://doi.org/10.1186/1471-2318-9-4...
,2424. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82(6):679-84. doi: https://doi.org/10.3109/17453674.2011.636682.
https://doi.org/10.3109/17453674.2011.63...
-2525. Panteli M, Habeeb S, McRoberts J, Porteous MJ. Enhanced care for primary hip arthroplasty factors affecting length of hospital stay. Eur J Orthop Surg Traumatol. 2014;24(3):353-8. doi: https://doi.org/10.1007/s00590-013-1188-z.
https://doi.org/10.1007/s00590-013-1188-...
, seguido de 4 estudos44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
,1313. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...
,1616. Worthington AD, Oldham JB. Delayed discharge from rehabilitation after brain injury. Clin Rehabil. 2006;20(1):79-82. doi: https://doi.org/10.1191/0269215506cr881oa.
https://doi.org/10.1191/0269215506cr881o...
,2020. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...
que se focam no cliente adulto. No entanto, 2 artigos1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,2323. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...
não referem a faixa etária dos clientes analisados.

No que concerne ao tamanho da amostra a sua dimensão varia desde 50 a 23.390 pessoas, sobressaindo o gênero feminino, excluindo-se 5 estudos22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...

3. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
-44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
,77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,2323. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...
que não diferenciam o gênero na contabilização dos clientes e 1 estudo1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
que não menciona o número de clientes dos diferentes estudos investigados.

A admissão e a alta hospitalar correspondem a momentos de estresse para o indivíduo, família, cuidadores e prestadores de cuidados1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
. Perante uma situação de doença a pessoa vê-se muitas vezes, mais dependente e vulnerável, requerendo mais apoio e suporte de ordem psicológica, física e social2626. Katikireddi SV, Cloud GC. Planning a patient's discharge from hospital. BMJ. 2008;337:a2694. doi: https://doi.org/10.1136/bmj.a2694.
https://doi.org/10.1136/bmj.a2694...
. A transferência do hospital para o domicílio com necessidade de cuidados corresponde também, a uma mudança de vida significativa, tanto para o próprio cliente, como para a sua família77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
.

O atraso na alta hospitalar aumenta a ocupação de leitos, ou seja, o leito está ocupado por uma pessoa que já não necessita de cuidados agudos, impossibilitando a entrada de novos clientes em situação aguda. Como consequência diminui o número de admissões e a rotatividade de clientes no serviço, mantendo-se os custos associados a uma internação.

Especificando às diferentes especialidades clínicas verificou-se que as especialidades de medicina e de ortopedia são as que apresentam maior número de causas para o atraso na alta hospitalar, seguidas dos clientes do foro cirúrgico, de gastrenterologia e de cardiologia. O tempo de atraso nos clientes cirúrgicos representou desde 9.48%88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
(valor igualmente idêntico nos clientes de ortopedia, de reabilitação e de geriatria), 19.2%44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
, 35%1818. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
a 41.9%1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
do tempo de internação total. No cliente ortopédico o intervalo variou entre 9.48%88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
e 11.49%1212. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2015;27(2):737-45. doi: https://doi.org/10.1007/s00198-015-3293-9.
https://doi.org/10.1007/s00198-015-3293-...
do tempo de internação total, ao passo que nos clientes de medicina interna e de gastrenterologia correspondeu a 20.7%99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
.

São diversos os fatores que podem ser apontados como causadores de atraso na alta hospitalar. É importante conhece-los, no sentido de melhorar o cuidado, diminuindo a ocupação de leitos2323. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...
. Analisando em detalhe as causas verifica-se que a grande maioria deve-se a causas da comunidade, por falta de vaga em unidades de cuidados continuados e de reabilitação22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
,77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...

8. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
-99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
,1212. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2015;27(2):737-45. doi: https://doi.org/10.1007/s00198-015-3293-9.
https://doi.org/10.1007/s00198-015-3293-...

13. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...

14. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...

15. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...

16. Worthington AD, Oldham JB. Delayed discharge from rehabilitation after brain injury. Clin Rehabil. 2006;20(1):79-82. doi: https://doi.org/10.1191/0269215506cr881oa.
https://doi.org/10.1191/0269215506cr881o...
-1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
, seguida da falta de vaga em lares22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
,33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...

9. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...

10. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
-1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
,1313. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
-1818. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
e por causas sociais. Estas causas sociais estão relacionadas com a falta de providência de apoio social77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
,2121. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...
, ou situações de fragilidade social33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
-2020. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...
, mencionando um estudo situações de isolamento social1212. Landeiro F, Leal J, Gray AM. The impact of social isolation on delayed hospital discharges of older hip fracture patients and associated costs. Osteoporos Int. 2015;27(2):737-45. doi: https://doi.org/10.1007/s00198-015-3293-9.
https://doi.org/10.1007/s00198-015-3293-...
, fortemente condicionadoras do regresso a casa.

Concretamente sobre a falta de vaga nos cuidados continuados e de reabilitação, esta situação tende a agravar, dado o aumento da esperança média de vida da população, associado a um maior nível de dependência e necessidade de cuidados de saúde2727. Watkins JR, Soto JR, Bankhead-Kendall B, Rappa PJ, Holland D, Truitt MS, et al. What's the hold up? factors contributing to delays in discharge of trauma patients after medical clearance. Am J Surg. 2014;208(6):969-73. doi: https://doi.org/10.1016/j.amjsurg.2014.07.002.
https://doi.org/10.1016/j.amjsurg.2014.0...
. Estes aspetos estão congruentes com o relatório da OCDE2828. Organisation for Economic Co-operation and Development (FR). OECD reviews of health care quality: Portugal 2015: raising standards. Paris: OECD Publishing; 2015. doi: https://doi.org/10.1787/9789264225985-en.
https://doi.org/10.1787/9789264225985-en...
que refere que Portugal deve continuar a expandir a capacidade de resposta de cuidados de saúde ao nível da comunidade, diminuindo a carga e pressão sobre os hospitais, promovendo a efetividade dos cuidados e segurança do cliente, melhorando a qualidade do cuidado prestado a nível nacional. Um estudo italiano abrangendo diferentes especialidades médicas, refletiu esta necessidade, constatando que os clientes internados nas unidades de cuidados de longa duração/reabilitação e ortopedia/traumatologia sofriam mais atrasos na alta. Comparando o serviço de cirurgia com o de medicina, os clientes deste último tinham mais atrasos88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
.

Ainda no âmbito das causas da comunidade, aguardar tratamentos na comunidade44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
,99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
,1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
,2222. Jasinarachchi KH, Ibrahim IR, Keegan BC, Mathialagan R, McGourty JC, Phillips JRN, et al. Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over. BMC Geriatrics. 2009;9:4. doi: https://doi.org/10.1186/1471-2318-9-4.
https://doi.org/10.1186/1471-2318-9-4...
, incluindo tratamentos de reabilitação99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
,1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
,1818. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
,2525. Panteli M, Habeeb S, McRoberts J, Porteous MJ. Enhanced care for primary hip arthroplasty factors affecting length of hospital stay. Eur J Orthop Surg Traumatol. 2014;24(3):353-8. doi: https://doi.org/10.1007/s00590-013-1188-z.
https://doi.org/10.1007/s00590-013-1188-...
ocupam ambos lugar de destaque nas causas para atraso na alta hospitalar, seguidos pela necessidade de cuidados no domicílio77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
,2222. Jasinarachchi KH, Ibrahim IR, Keegan BC, Mathialagan R, McGourty JC, Phillips JRN, et al. Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over. BMC Geriatrics. 2009;9:4. doi: https://doi.org/10.1186/1471-2318-9-4.
https://doi.org/10.1186/1471-2318-9-4...
e assegurar condições de segurança em casa33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
,1313. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...
para se proceder à transferência da pessoa para a sua residência. Face os dados apresentados pode-se concluir que a União Europeia ainda não possui suporte comunitário suficiente para o cliente com alta.

Relativamente às causas organizacionais estas podem ser subdivididas em relação aos cuidados de saúde e à gestão hospitalar, ou seja, atrasos na alta que estejam relacionados com a prestação de cuidados e resultados junto do cliente, ou segundo questões mais direcionadas para procedimentos de gestão e administração. Assim, relacionando com os cuidados de saúde há a salientar o atraso por aguardar avaliações do estado de saúde, tratamentos ou resultados de exames44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
,77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
-1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
-1818. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006;88(7):650-2. doi: https://doi.org/10.1308/003588406X149246.
https://doi.org/10.1308/003588406X149246...
,2222. Jasinarachchi KH, Ibrahim IR, Keegan BC, Mathialagan R, McGourty JC, Phillips JRN, et al. Delayed transfer of care from NHS secondary care to primary care in England: its determinants, effect on hospital bed days, prevalence of acute medical conditions and deaths during delay, in older adults aged 65 years and over. BMC Geriatrics. 2009;9:4. doi: https://doi.org/10.1186/1471-2318-9-4.
https://doi.org/10.1186/1471-2318-9-4...
, seguidos da má prática profissional44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
,1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
, da infecção associada aos cuidados de saúde33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
-2020. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...
e da necessidade de transfusões sanguíneas2020. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...
,2424. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82(6):679-84. doi: https://doi.org/10.3109/17453674.2011.636682.
https://doi.org/10.3109/17453674.2011.63...
-2525. Panteli M, Habeeb S, McRoberts J, Porteous MJ. Enhanced care for primary hip arthroplasty factors affecting length of hospital stay. Eur J Orthop Surg Traumatol. 2014;24(3):353-8. doi: https://doi.org/10.1007/s00590-013-1188-z.
https://doi.org/10.1007/s00590-013-1188-...
. Causas menos incidentes, mas igualmente importantes são a necessidade de cuidados de reabilitação intra-hospitalar1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
,2424. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82(6):679-84. doi: https://doi.org/10.3109/17453674.2011.636682.
https://doi.org/10.3109/17453674.2011.63...
, a necessidade de cateterização vesical2424. Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop. 2011;82(6):679-84. doi: https://doi.org/10.3109/17453674.2011.636682.
https://doi.org/10.3109/17453674.2011.63...
-2525. Panteli M, Habeeb S, McRoberts J, Porteous MJ. Enhanced care for primary hip arthroplasty factors affecting length of hospital stay. Eur J Orthop Surg Traumatol. 2014;24(3):353-8. doi: https://doi.org/10.1007/s00590-013-1188-z.
https://doi.org/10.1007/s00590-013-1188-...
, o atraso na referenciação por parte do enfermeiro33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
, as quedas1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
, a gestão da dor1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
, a necessidade de ventilação pós-operatória2020. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...
, o número de procedimentos realizados22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
, a utilização de analgesia controlada pelo paciente2525. Panteli M, Habeeb S, McRoberts J, Porteous MJ. Enhanced care for primary hip arthroplasty factors affecting length of hospital stay. Eur J Orthop Surg Traumatol. 2014;24(3):353-8. doi: https://doi.org/10.1007/s00590-013-1188-z.
https://doi.org/10.1007/s00590-013-1188-...
e a preparação da alta44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
. Estudo inglês sugere intervenções promotoras de internações mais curtas, através de melhorias na analgesia, na monitorização de perdas hemáticas e na diminuição do número de clientes que necessitam de transfusões ou cateterização vesical2525. Panteli M, Habeeb S, McRoberts J, Porteous MJ. Enhanced care for primary hip arthroplasty factors affecting length of hospital stay. Eur J Orthop Surg Traumatol. 2014;24(3):353-8. doi: https://doi.org/10.1007/s00590-013-1188-z.
https://doi.org/10.1007/s00590-013-1188-...
.

No que concerne às quedas, um estudo italiano com clientes de medicina foca este problema, verificando-se em 5% dos casos de atraso na alta hospitalar1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
. Nesta problemática o enfermeiro desenvolve um papel fundamental na identificação de clientes de risco de sofrerem quedas, providenciando as medidas preventivas de segurança necessárias.

Respeitante às infecções associadas aos cuidados de saúde, um estudo no Reino Unido verificou que em 28% da amostra a causa de atraso na alta foi devido a sepse. Destes 28% quase 50% tinham infecções associadas aos cuidados de saúde, com especial destaque para a infecção do trato urinário (12%) e a pneumonia (10%)33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
. Noutro estudo inglês com clientes cirúrgicos, situações relacionadas com a infecção da ferida cirúrgica geraram mais 11.7 dias de internação. Os autores sugerem que deve ser preocupação da equipe cirúrgica desenvolver medidas que previnam esta complicação, assim como complicações urinárias e de perdas hemáticas intraoperatóriamente2020. Reddy KM, Meyer CE, Palazzo FF, Conaghan P, Blunt MC, Stebbings WS, et al. Postoperative stay following colorectal surgery: a study of factors associated with prolonged hospital stay. Ann R Coll Surg Engl. 2003;85(2):111-4. doi: https://doi.org/10.1308/003588403321219894.
https://doi.org/10.1308/0035884033212198...
. Segundo dados da OCDE2828. Organisation for Economic Co-operation and Development (FR). OECD reviews of health care quality: Portugal 2015: raising standards. Paris: OECD Publishing; 2015. doi: https://doi.org/10.1787/9789264225985-en.
https://doi.org/10.1787/9789264225985-en...
estas infecções têm uma prevalência significativa em Portugal comparativamente com a média da União Europeia (prevalência relatada de 10,7% em 2011/12, em comparação com a média da União Europeia de 6,0%).

Focando o papel do enfermeiro, um estudo com clientes internados num serviço de medicina geral de gastrenterologia, constatou que 3.5% dos casos de atraso na alta hospitalar deviam-se a atrasos na referenciação por parte do enfermeiro, o que se traduziu num custo total adicional de 22.628,49€, que corresponde a 22,15€ por cliente. No sentido de resolver esta problemática, os autores sugerem soluções efetivas, como um plano de alta cuidado, o mais precoce possível, por forma a evitar atrasos na internação, poupando-se a nível financeiro, demonstrando-se também, que o cliente é prioritário99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
.

Relativamente à gestão hospitalar, o fator mais preocupante é a falta de recursos humanos77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
-1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,2323. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...
. Mais recursos humanos e materiais contribuem para uma redução do tempo de internação e de atraso22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
. Segundo a opinião de profissionais de saúde para as causas de atraso na alta hospitalar de clientes idosos, estas convergem para a falta de profissionais para o apoio no domicílio e para a prestação de cuidados, assim como a falta de apoio aos cuidadores informais; e limitações no financiamento77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
.

No que concerne às causas individuais, as questões familiares77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
-1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
,1717. García FS, Oterino de la Fuente D, Peiró S, Librero J, Raya CB, García de León NP, et al. Factores asociados con el uso y adecuación de la hospitalización en personas mayores de 64 años. Rev Esp Salud Publica. 2001 [cited 2017 Aug 5];75(3):237-48. Available from: http://scielo.isciii.es/pdf/resp/v75n3/a07v75n3.pdf.
http://scielo.isciii.es/pdf/resp/v75n3/a...
,2121. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...
) são as que sobressaem mais, seguidas das questões financeiras77. Bryan K, Gage H, Gilbert K. Delayed transfers of older people from hospital: causes and policy implications. Health Policy. 2006;76(2):194-201. doi: https://doi.org/10.1016/j.healthpol.2005.06.005.
https://doi.org/10.1016/j.healthpol.2005...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
,1616. Worthington AD, Oldham JB. Delayed discharge from rehabilitation after brain injury. Clin Rehabil. 2006;20(1):79-82. doi: https://doi.org/10.1191/0269215506cr881oa.
https://doi.org/10.1191/0269215506cr881o...
e do estado de saúde da pessoa, mais concretamente as patologias associadas22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
,1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
e o seu nível de dependência elevado1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
.

Analisando as questões familiares um estudo espanhol, com clientes de medicina, verificou que os casos de atraso na alta correspondiam a clientes tendencialmente mais idosos, com problemas de consumo de álcool e benzodiazepinas ou acidentes vasculares cerebrais. 51.8% destes atrasos eram devidos a sobrecarga e/ou incapacidade dos familiares para o cuidado, por impossibilidade de conciliar o trabalho com a prestação de cuidados; e 21.8% devido a carência de familiares disponíveis ou falta de apoio da rede social2121. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...
.

Particularizando ao cliente idoso, este tem maior probabilidade de vir a sofrer atraso na alta, não só pelas comorbilidades associadas e elevados níveis de dependência1010. Challis D, Hughes J, Xie C, Jolley D. An examination of factors influencing delayed discharge of older people from hospital. Int J Geriatr Psychiatry. 2014;29(2):160-8. doi: https://doi.org/10.1002/gps.3983.
https://doi.org/10.1002/gps.3983...
, presentes já antes da agudização da situação, como pela maior probabilidade de vir a necessitar de cuidados de reabilitação, de curta ou longa duração ou no domicílio, não sendo muitas vezes possível disponibilizá-los logo no momento da alta clínica88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
.

Através desta análise verificou-se que muitos fatores estão interrelacionados, no sentido em que com o avançar da idade, as comorbilidades tendem a ser em maior número, assim como o nível de dependência nas atividades de vida diárias, o que pode aumentar o risco de aumento do tempo de internação e de atraso. De igual forma, a necessidade de institucionalização implica estados de saúde com morbilidades associadas, o que depreende uma maior necessidade de consumo de serviços de saúde.

O atraso na alta hospitalar é evitável se estratégias adequadas forem implementadas no prazo adequado. É importante desenvolver programas que visem dar resposta às necessidades dos clientes, diminuindo o seu tempo de estadia no hospital, otimizando o processo de internação e de alta. É neste contexto que a cooperação entre serviços de saúde e de apoio social se demonstra crucial1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
,1414. Glasby J, Littlechild R, Pryce K. All dressed up but nowhere to go? delayed hospital discharges and older people. J Health Serv Res Policy. 2006;11(1):52-8. doi: https://doi.org/10.1258/135581906775094208.
https://doi.org/10.1258/1355819067750942...
, aperfeiçoando a articulação entre os diferentes profissionais para melhorar o percurso do cliente99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
,1919. Nardi R, Scanelli G, Tragnone A, Lolli A, Kalfus P, Baldini A, et al. Difficult hospital discharges in internal medicine wards. Intern Emerg Med. 2007;2(2):95-9. doi: https://doi.org/10.1007/s11739-007-0029-7.
https://doi.org/10.1007/s11739-007-0029-...
, devendo-se providenciar serviços completos 7 dias por semana para uma mais rápida avaliação2323. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...
. É importante reorganizar os serviços para serviços especializados, melhorando o cuidado e a eficiência do serviço de saúde1313. Carter ND, Wade DT. Delayed discharges from Oxford city hospitals: who and why? Clin Rehabil. 2002;16(3):315-20. doi: https://doi.org/10.1191/0269215502cr496oa.
https://doi.org/10.1191/0269215502cr496o...
,1515. Zambrana García JL, Delgado Fernández M, Cruz Caparrós G, Martín Escalante MD, Díez García F, Ruiz Bailén M. Factores predictivos de estancias no adecuadas en un servicio de medicina interna. Med Clin. 2001;117(3):90-2. doi: https://doi.org/10.1016/S0025-7753(01)72026-X.
https://doi.org/10.1016/S0025-7753(01)72...
.

É fundamental identificar logo no momento da admissão os clientes com risco de atraso na alta, que necessitem de um planejamento de alta complexo, monitorizando-se situações consideradas de risco2121. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...
,2323. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...
. Este planejamento de alta cuidado e o mais precoce possível deve ser realizado33. Rambani R, Okafor B. Evaluation of factors delaying discharge in acute orthopedic wards: a prospective study. Eur J Trauma Emerg Surg. 2008 [cited 2017 Aug 3];34(1):24-8. doi: https://doi.org/10.1007/s00068-007-6184-8.
https://doi.org/10.1007/s00068-007-6184-...
,88. Lenzi J, Mongardi M, Rucci P, Di Ruscio E, Vizioli M, Randazzo C, et al. Sociodemographic, clinical and organizational factors associated with delayed hospital discharges: a cross-sectional study. BMC Health Serv Res. 2014;14:128. doi: https://doi.org/10.1186/1472-6963-14-128.
https://doi.org/10.1186/1472-6963-14-128...
-99. Hendy P, Patel JH, Kordbacheh T, Laskar N, Harbord M. In-depth analysis of delays to patient discharge: a metropolitan teaching hospital experience. Clin Med [Lond]. 2012;12(4):320-3. doi: https://doi.org/10.7861/clinmedicine.12-4-320.
https://doi.org/10.7861/clinmedicine.12-...
,1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
,2121. Giraldo DM, Navarro A, Quijano AS, Villegas A, Marchante RA, Otero EL. Retraso del alta hospitalaria por motivos no medicos. Rev Clin Espanola. 2012;212(5):229-34. doi: https://doi.org/10.1016/j.rce.2011.12.009.
https://doi.org/10.1016/j.rce.2011.12.00...
,2323. Varnava AM, Sedgwick JEC, Deaner A, Ranjadayalan K, Timmis AD. Restricted weekend service inappropriately delays discharge after acute myocardial infarction. Heart. 2002 [cited 2017 Aug 5];87(3):216-9. Available from: https://heart.bmj.com/content/heartjnl/87/3/216.full.pdf.
https://heart.bmj.com/content/heartjnl/8...
, comunicando-se com a equipe de gestão de altas e rede de cuidados, implementando-se intervenções, no sentido de prevenir atrasos na alta hospitalar1111. Houghton JS, Rodriguez DU, Weale AR, Brooks MJ, Mitchell DC. Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward. BMJ Open. 2017;6(9):e011193. doi: https://doi.org/10.1136/bmjopen-2016-011193.
https://doi.org/10.1136/bmjopen-2016-011...
.

Um estudo da Noruega realça a importância da existência de mais recursos22. Holmås TH, Islam MK, Kjerstad E. Between two beds: inappropriately delayed discharges from hospitals. Int J Health Care Finance Econ. 2013 [cited 2017 Aug 5];13(3-4):201-17. doi: https://doi.org/10.1007/s10754-013-9135-4.
https://doi.org/10.1007/s10754-013-9135-...
. Focando os recursos humanos um estudo inglês destaca a relevância do enfermeiro na orientação do processo de alta do cliente44. Majeed UM, Williams DT, Pollock R, Amir F, Liam M, Foong KS, et al. Delay in discharge and its impact on unnecessary hospital bed occupancy. BMC Health Serv Res. 2012 [cited 2017 Aug 4];12:410. doi: https://doi.org/10.1186/1472-6963-12-410.
https://doi.org/10.1186/1472-6963-12-410...
. Deve ser preocupação deste profissional de saúde a preparação da pessoa e sua família para a alta e para os cuidados pós-alta, cumprindo-se o papel de educador e orientador2929. Glanzner CH, Zini LW, Lautert L. Programa de atendimento de enfermagem na admissão e alta hospitalar. Rev Gaúcha Enferm. 2006 [cited 2017 Dec 12];27(1):92-9. Available from: http://seer.ufrgs.br/index.php/RevistaGauchadeEnfermagem/article/view/4590/2544.
http://seer.ufrgs.br/index.php/RevistaGa...
.

CONCLUSÃO

O estado da arte mostra que o atraso na alta hospitalar é multifatorial. Pode resultar devido a fatores hospitalares internos, fatores externos e pessoais, causas estas muitas vezes interdependentes e previsíveis. As principais causas de atraso são semelhantes entre os vários estudos dos diversos países, assim como as características clínicas dos clientes, maioritariamente idosos, com acentuada fragilidade e nível de dependência aumentada por deterioração da capacidade funcional.

São várias as limitações a apresentar decorrentes desta análise, das quais temos consciência. Antes de mais, estamos cientes do risco de omissão de estudos relevantes não abrangidos pelos descritores e palavras-chave empregados na pesquisa inicial. Contudo, no sentido de diminuir este risco optou-se por consultar as referências bibliográficas dos estudos obtidos na pesquisa, de forma a complementar este processo de análise. Também a limitação linguística é uma realidade, excluindo-se estudos noutros idiomas que não o Português, o Inglês e o Espanhol, possivelmente importantes de incluir nesta revisão.

Depois, as diferentes definições adotadas para considerar atraso na alta hospitalar, com base na decisão clínica ou na definição do próprio autor, podem influenciar esta análise, o que pode subjetivar os resultados e a possibilidade de comparação entre estes. Isto, porque o tempo estipulado pelo autor como limite para se considerar atraso diverge em alguns estudos.

Esta scoping review permite concluir que é necessário investir em metodologias resolutivas do atraso na alta hospitalar. Deve-se investir no planejamento da alta, criando-se modelos e protocolos para implementação nas práticas de enfermagem, logo no momento da admissão do cliente, que permitam identificar potenciais casos do atraso na alta.

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Datas de Publicação

  • Publicação nesta coleção
    10 Jun 2019
  • Data do Fascículo
    2019

Histórico

  • Recebido
    29 Jun 2018
  • Aceito
    16 Nov 2018
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