Inpatient hospital complications and lengths of stay: a short report.

SHORT REPORT Open Access
Inpatient hospital complications and lengths of
stay: a short report
Ronald J Lagoe1*, Pamela E Johnson2 and Mark P Murphy3
Abstract
Background: Increasingly, efforts are being made to link health care outcomes with more efficient use of
resources. The current difficult economic times and health care reform efforts provide incentives for specific efforts
in this area.
Findings: This study defined relationships between inpatient complications for urinary tract infection and
pneumonia and hospital lengths of stay in three general hospitals in the metropolitan area of Syracuse, New York.
It employed the Potentially Preventable Complications (PPC) software developed by 3M™ Health Information
Services to identify lengths of stay for patients with and without urinary tract infection and pneumonia. The
patient populations included individuals assigned to the same All Patients Refined Diagnosis Related Groups and
severity of illness. The comparisons involved two nine month periods in 2008 and 2009.
The study demonstrated that patients who experienced the complications had substantially longer inpatient
hospital stays than those who did not. Patients with a PPC of urinary tract infection stayed a mean of 8.9 - 11.9
days or 161 - 216 percent longer than those who did not for the two time periods. This increased stay produced
2,020 - 2,427 additional patient days.
The study demonstrated that patients who experienced the complications had substantially longer inpatient
hospital stays than those who did not. Patients with a PPC of pneumonia stayed a mean of 13.0 - 16.3 days or 232
- 281 percent longer than those who did not for the two time periods. This increased stay produced 2,626 - 3,456
additional patient days. Similar differences were generated for median lengths of stay.
Conclusions: The differences in hospital stays for patients in the same APR DRGs and severity of illness with and
without urinary tract infection and pneumonia in the Syracuse hospitals were substantial. The additional utilization
for these complications was valued at between $2,000,000 - $3,000,000 for a three month period. These differences
in the use of hospital resources have important implications for reduction of health care costs among providers
and payors of care.
Findings
In recent years, interest in the improvement of quality
within the United States health care industry has
increased. One of the most important aspects of this
development is recognition that better health care out-
comes are related to more efficient use of resources [1,2].
This movement should stimulate much needed change in
an industry which historically has voiced support for
improving quality but has sometimes experienced diffi-
culty bringing this about.
Research concerning the connection between improved
outcomes and more efficient resource use is increasing
interest in this topic among the leadership of this sector.
Such research is helping individual hospitals reduce costs
during difficult economic times, as well as preparing
them for financial disincentives related to complications
and readmissions developed by government and private
payors [3,4].
This study concerned the relationship between inpati-
ent complications and lengths of stay for urinary tract
infection and pneumonia in the general hospitals of the
metropolitan area of Syracuse, New York. These acute
care facilities (2010 discharges excluding newborns in
parentheses) include Community General Hospital of
* Correspondence: hospexcl@cnymail.com
1Hospital Executive Council, PO Box 35089, Syracuse, New York, 13235, USA
Full list of author information is available at the end of the article
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© 2011 Lagoe et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

Greater Syracuse (7,373), Crouse Hospital (20,338), and
St. Joseph’s Hospital Health Center (22,421). The area
also includes University Hospital of the State University
of New York Upstate Medical University (19,655), which
did not participate in the program.
Historically, these hospitals have worked cooperatively
to develop programs to improve efficiency and out-
comes through the Hospital Executive Council [5,6]. As
an extension of previous efforts to improve the effi-
ciency of care, the Syracuse hospitals and the Hospital
Executive Council became involved in an evaluation of
the Potentially Preventable Complications (PPC) soft-
ware developed by 3M™ Health Information Systems.
Method
Potentially Preventable Complications is a system for
categorizing and evaluating inpatient hospital complica-
tions. The complications included in the system were
identified through a review of existing literature, the
diagnostic codes used in the Complications Screening
Protocol, and the Patient Safety Indicators developed by
the Agency for Health Care Research and Quality by the
3M™ Corporation [7,8].
Under the Potentially Preventable Complications Sys-
tem a number of diagnoses are excludes as non preven-
table. These include complications directly related to
malignant diseases, multiple trauma, organ transplants,
specific burns, HIV related disorders, and neonates.
Additional diagnoses are excluded only when accompa-
nied by another specific diagnosis [9].
Candidate diagnoses that are not excluded are identi-
fied as present or not present on hospital admission.
The Present on Admission Indicator is applied to each
secondary diagnosis of each hospital inpatient. Second-
ary diagnoses identified as not present on admission are
candidates for complications [10,9].
Studies completed by 3M™ Health Information
Systems using administrative data bases have suggested
that patients who experience inpatient complications
use considerably more resources on average than those
who do not These studies were based on estimated
hospital charges, rather than actual utilization [11].
This case study employed actual utilization data for
selected Potentially Preventable Complications in the Syra-
cuse hospitals to identify the impact of diagnoses on inpati-
ent utilization in the Syracuse hospitals, especially inpatient
discharges and lengths of stay. The study involved data for
Potentially Preventable Complications for urinary tract
infection and pneumonia generated by inpatients at Com-
munity-General Hospital of Greater Syracuse, Crouse Hos-
pital, and St. Joseph’s Hospital Health Center.
This study was related to a project involving the devel-
opment of interventions to prevent inpatient complica-
tions in hospitals. The interventions were implemented in
October 2008. In order to control for the impact of the
demonstration program in Syracuse, the data concerned
inpatients during the periods January - September 2008
and 2009, the nine months preceding and following imple-
mentation of the program interventions.
The study employed a simple design comparing hospital
inpatient lengths of stay and discharges for patients experi-
encing each of the two complications with stays and dis-
charges for those who did not. The comparison involved
PPC patients and patients who did not experience each
PPC assigned to the same All Patients Refined Diagnosis
Related Groups and Severity of Illness Categories.
The All Patients Refined Diagnosis Related Groups
were developed by 3M™ Health Information Systems to
describe and evaluate the utilization and outcomes of a
full range of hospital inpatients including all ages and
payor statuses. The All Patients Refined Diagnosis
Related Groups are driven by the principal diagnosis or
procedure of each patient.
The Potentially Preventable Complications System
employs principal diagnoses, secondary diagnoses, age,
and other factors to determine Severity of Illness. The
use of these variables makes it possible to identify Sever-
ity of Illness based on the condition of the whole patient,
rather than the principal diagnosis only.
In this study of hospital of hospital stays and dis-
charges, inpatient discharges were assigned to compari-
son groups based on the same All Patients Refined
Diagnosis Related Groups and Severity of Illness. This
design did not account for every clinical and demo-
graphic variable that could have involved these popula-
tions. At the same time, it controlled for the impact of
diagnoses which could have caused differences in stays
without regard to inpatient complications.
Results
Data for urinary tract infection, the PPC with the high-
est frequency in the Syracuse hospitals, are summarized
in Table 1. This information demonstrated that between
January and September 2008, 227 discharges in the
three hospitals experienced urinary tract infections,
compared with 5,877 discharges in the same APR DRGs
and severity of illness levels who did not experience this
complication. This amounted to a 3.9 percent complica-
tion rate. Between January and September 2009, there
were 204 discharges with the PPC and 5,182 patients at
risk, also resulting in a complication rate of 3.9 percent.
The data identified substantial differences in mean
lengths of stay between patients identified with urinary
tract infection as a potentially preventable complication
and those without it. These differences within individual
hospitals were significant at the .05 level. Compared with
patients in the same APR DRGs and severity of illness
levels, discharges with the complication in the three
Lagoe et al. BMC Research Notes 2011, 4:135
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hospitals combined in January - September 2008 stayed
an average of 8.9 days or 161.8 percent longer, while dis-
charges with the PPC in January - September 2009 stayed
11.9 days or 216.4 percent longer. Individual hospital dif-
ferences ranged from 145.4 to 293.2 percent longer in
2008 and from 194.2 to 240.8 percent longer in 2009.
The data in Table 1 also demonstrated that, between
January and September 2008, the PPC population pro-
duced 2,020 additional patient days, or an excess aver-
age daily census of 7.4 patients. Between January and
September 2009, the PPC population generated 2,427
additional days, or an excess average daily census of 8.9
patients. At a conservative late stay rate of $500 per day,
this excess hospitalization was valued at between
$1,010,000 and $1,213,500 for the nine month period.
The reduction of even a portion of the inpatient compli-
cations responsible for this excess hospitalization could
result in significant savings.
Median stay data for urinary tract infection for the
two study periods are summarized in Table 1. Between
January and September 2008, median length of stay for
patients with this complication was 6.0 days, or 136.4
percent longer for the discharges with complications,
while between January and September 2009, the median
stay was 9.2 days, or 191.7 percent longer than the stay
for uncomplicated discharges.
The same comparisons of utilization for patients with
and without complications was applied to community
acquired pneumonia. Data concerning general utilization
and mean lengths of stay are summarized in Table 2.
As in the case of urinary tract infections, the data for
pneumonia as a Potentially Preventable Complications
identified relatively low complication rates among the
Syracuse hospitals. Between January and September
2008, total of 212 inpatient discharges involved the
pneumonia PPC at the combined hospitals compared
with 4,418 discharges for patients with the same APR
DRGs and severity of illness levels, resulting in a com-
plication rate of 4.8 percent.
Between January and September 2009, there were 202
discharges and 4,505 patients at risk, resulting in a com-
plication rate of 4.5 percent.
Table 1 Hospital lengths of stay and complications medical/surgical patients by APR DRG and severity of illness major
PPC 16 - urinary tract infection Syracuse Hospitals January - September 2008 - 2009
Patients with PPC Patients at Risk without PPC Excess Days
for PPC
Patients
Number of
Discharges
Patient
Days
Mean LOS
Per
Discharge
Median LOS
Per Discharge
Number of
Discharges
Patient
Days
Mean LOS
Per
Discharge
Median LOS
Per Discharge
January -
September 2008
Community
General
52 564 10.8 10.0 1,359 5,938 4.4 3.6 332.8
Hospital
Crouse
Hospital
67 1,158 17.3 11.2 1,414 7,659 4.4 5.3 864.3
St. Joseph’s
Hospital
108 1,548 14.3 12.0 3,104 18,514 6.0 4.8 896.4
Health
Center
Total 227 3,270 14.4 10.4 5,877 32,111 5.5 4.4 2,020.3
January -
September 2009
Community
General
29 485 16.7 15.0 664 3,260 4.9 3.8 342.2
Hospital
Crouse
Hospital
80 1,224 15.3 9.5 1,486 7,733 5.2 4.7 808.0
St. Joseph’s
Hospital
95 1,837 19.3 17.0 3,032 17,672 5.8 5.1 1,282.5
Health
Center
Total 204 3,546 17.4 14.0 5,182 28,665 5.5 4.8 2,427.6
For mean lengths of stay comparisons within individual hospitals p = .05.
Medical/Surgical exclude rehabilitation.
Sources: Hospital Executive Council; 3M Health Information Systems.
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The data identified substantial differences between
inpatient hospital lengths of stay for patients with and
without the pneumonia Potentially Preventable Compli-
cation in the Syracuse hospitals. These differences
within individual hospitals were significant at the .05
level. During the period of the study, an analysis focused
on discharges in the same APR DRGs and severity of ill-
ness levels. The population that experienced the compli-
cation between January and September 2008 generated
mean lengths of stay 16.3 days, or 281.0 percent longer
than the one that did not, while discharges with the
PPC between January and September 2009 stayed an
average of 13.0 days, or 232.1 days longer. Individual
hospital stays for the population with the complication
ranged from 130.6 to 339.0 percent longer in 2008 and
208.2 to 249.1 percent longer in 2009.
The number of additional days associated with pneu-
monia between January and September 2008 was
3,455.6, or an excess average daily census of 12.7
patients. Between January and September 2009, the
number of additional days was 2,626, or an excess
average daily census of 9.6 patients. At a late stay rate
of $500 per day, this excess utilization was valued at
between $1,313,000 and $1,727,500 for the nine month
period. The reduction of even a portion of the inpatient
complications responsible for this excess hospitalization
could result in significant savings.
Median stay data for pneumonia in the two study per-
iods are summarized in Table 2. Between January and
September 2008, the median length of stay for patients
with this complication was 10.9 days, or 213.7 percent
longer than those who did not. Between January and
September 2009, the median stay for patients with the
PPC was 8.9 days or 174.5 percent longer than those
who did not.
Discussion
In the United States, the health care reform movement
and other factors are generating greater interest in the
relationship between health care outcomes and effi-
ciency. This study addressed a limited aspect of this
subject, the relationship between inpatient hospital
Table 2 Hospital lengths of stay and complications medical/surgical patients by APR DRG and severity of illness major
PPC 04 - pneumonia & other lung infections Syracuse Hospitals January - September 2008 - 2009
Patients with PPC Patients at Risk without PPC Excess Days
for PPC
Patients
Number of
Discharges
Patient
Days
Mean LOS
Per
Discharge
Median LOS
Per Discharge
Number of
Discharges
Patient
Days
Mean LOS
Per
Discharge
Median LOS
Per Discharge
January -
September 2008
Community
General
33 372 11.3 10.7 728 3,598 4.9 4.7 211.2
Hospital
Crouse
Hospital
31 481 15.5 9.5 617 3,568 5.8 4.8 300.7
St. Joseph’s
Hospital
148 3,827 25.9 24.0 3,073 18,279 5.9 5.4 2,960.0
Health
Center
Total 212 4,680 22.1 16.0 4,418 25,445 5.8 5.1 3,455.6
January -
September 2009
Community
General
34 515 15.1 12.5 679 3,347 4.9 3.9 346.8
Hospital
Crouse
Hospital
53 982 18.5 16.5 1,076 5,679 5.3 5.2 699.6
St. Joseph’s
Hospital
115 2,256 19.6 15.5 2,750 16,015 5.8 5.5 1,587.0
Health
Center
Total 202 3,753 18.6 14.0 4,505 25,041 5.6 5.1 2,626.0
University Hospital data not included because of coding problems identified in 2008 data.
Medical/Surgical exclude rehabilitation.
Sources: Hospital Executive Council; 3M Health Information Systems.
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complications and lengths of stay. Through evaluation of
this issue for the two most frequent inpatient complica-
tions, urinary tract infection and pneumonia, in the
hospitals of Syracuse, New York, it identified large dif-
ferences in lengths of stay between patients who experi-
enced the complications and those who did not. The
actual differences in stays were considerable, with
patients who experienced complications usually staying
two to three times as long as those without complica-
tions. The analysis of these data, based on patients
assigned to the same All Patients Refined Diagnosis
Related Groups and Severity of Illness categories, did
not exclude all extraneous variables, however, it did
control for most aspects of clinical conditions.
The analysis included data for nine month periods in
2008 and 2009, before and after a series of interventions
was implemented in the fourth quarter of 2008. It was
notable that, while the numbers of patients experiencing
complications decreased after the implementation of
interventions, the differences between lengths of stay for
patients with and without complications actually
increased. It may be that, after the interventions, remain-
ing patients experienced higher severity of illness and
stayed longer.
The interventions used to address urinary tract infec-
tion included protocols for the removal of urinary cathe-
ters and frequent monitoring of potential infection sites
and laboratory data. For pneumonia, the interventions
included early ambulation of patients, elevation of head
of patient bed, and hourly use of spirometry.
The differences in hospital stays were reflected in the
use of resources in the participating hospitals. For this
part of the analysis, the study used actual cost data for
the hospitals, rather than estimated charges. This was
possible because the study directly involved the adminis-
trations of the participating hospitals. The study sug-
gested that an average daily census of 16 to 21 patients
was generated by these complications alone in the same
hospitals. The additional utilization for both PPCs was
valued at between $2,000,000 and $3,000,000 for a nine
month period.
It should be emphasized that the primary purpose of
the reduction of inpatient complications is to improve
the health and treatment of individuals treated in hospi-
tals. Avoiding these adverse events contributes signifi-
cantly to the quality of life of these individuals.
Reductions in hospital stays brought about by lower
complication rates could also eliminate large expendi-
tures for pharmaceuticals and testing. The impact of
such reductions on nursing, a major component of hos-
pital costs, would depend on the staffing programs of
individual hospitals. For hospitals using traveling nurses,
shorter stays could reduce the number of these positions
that are required. For other hospitals, shorter stays
could contribute to greater efficiency or permit reassign-
ment of staff nurses. All of these reductions could gen-
erate substantial savings for hospitals and bring about
decreases in health care costs. Reduction of inpatient
hospital complications is a useful cost saving approach
because these outcome are within the control of hospital
staffs.
Author details
1Hospital Executive Council, PO Box 35089, Syracuse, New York, 13235, USA.
2Community General Hospital, Broad Road, Syracuse, New York, 13215, USA.
3St. Joseph’s Hospital Health Center, 301 Prospect Avenue, Syracuse, New
York, 13203, USA.
Authors’ contributions
RL was responsible for the design of the study and development of the
data. MM was responsible for development of the data for St. Joseph’s
Hospital Health Center. PJ was responsible for development of the data for
Community-General Hospital. All authors have read and approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 29 July 2010 Accepted: 5 May 2011 Published: 5 May 2011
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doi:10.1186/1756-0500-4-135
Cite this article as: Lagoe et al.: Inpatient hospital complications and
lengths of stay: a short report. BMC Research Notes 2011 4:135.
Lagoe et al. BMC Research Notes 2011, 4:135
http://www.biomedcentral.com/1756-0500/4/135
Page 5 of 5