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Background: Delayed discharge, captured as alternate-level-of-care days, represents inefficient use of high-demand acute care resources and results in potentially poorer patient outcomes. We performed a study to determine the extent of alternate-level-of-care days among patients who survived hypoxic--ischemic brain injury in inpatient hospital care in Ontario and to identify predictors of alternate-level-of-care use in this population. Methods: A population-based cohort of acute care survivors of hypoxic--ischemic brain injury aged 20 years or more from 2002/03 through 2011/12 was identified. We used 2 case definitions, the more specific identifying patients with a most responsible diagnosis of "anoxic brain damage," and the more sensitive capturing additional likely causative conditions as the most responsible diagnosis. Multivariable zero-inflated negative binomial regression was used to estimate independent effects on the relative incidence of alternatelevel- of-care days. Results: We identified 491 patients using the specific case definition and 669 patients using the extended case definition. After deaths were excluded, 232 patients (47.2%) and 278 patients (41.6%), respectively, had at least 1 alternate-level-of-care day (median 20 and 19 d, respectively). In both cohorts, decreasing age, no special care unit hours and acute care episode earlier in the study period were predictive of increased alternate-level-of-care days relative to length of stay. Discharge disposition and psychiatric/ behavioural comorbidity were most predictive of having any alternate-level-of-care days. Interpretation: Patients with hypoxic--ischemic brain injury had a greater proportion of alternate-level-of-care days than has been reported for patients with other types of acquired brain injury. This finding suggests that substantial barriers to appropriate discharge exist for this population. Predictors of increased alternate-level-of-care days were also shown to be unique. Further study of care deficits among patients with hypoxic--ischemic brain injury is warranted. [ABSTRACT FROM AUTHOR]