Increasing Length of Stay
Patients in our hospital have been experiencing increasing lengths of stay. The longer stay does not improve patient outcomes, and it contributes high occupancy and lower financial efficiency for our hospital. How can we improve efficiency around the discharge process so patients are staying the right amount of time?
Patients in our hospital have been experiencing increasing lengths of stay. Even when we control for acuity of illness, patients are staying at the hospital for longer today than they were two years ago. This does not improve patient outcomes, and it contributes high occupancy and lower financial efficiency. Some factors we believe may be contributing to the increasing length of stay include:
- We are experiencing growth in patient volumes and workloads are increasing across the hospital
- Accountability for discharge and discharge planning is unclear
- Discharge planning involves many different disciplines including nurses, physicians, therapies, and often social workers
- We have few performance indicators besides “length of stay” that allow us to drill down further to this problem
Can you suggest strategies or tools we can use to improve our efficiency around the discharge process so patients are staying the right amount of time?
Participant comments on Increasing Length of Stay
Our organization has had some success in reducing LOS over the past few years, and it has led to significant cost reductions at our hospitals. The most important piece of moving LOS is being vigilant, understanding the drivers, and having senior leadership engaged. When we started the process, our utilization management team would connect with our COO every morning to review the overnight change in LOS- if there was an uptick, was it due to an outlier patient being discharged, or was it more of an overall throughput issue? Here are some strategies we used:
• Push LOS data out to physicians on a monthly basis so they can see their numbers. As possible, compare to an applicable benchmark (we use Crimson).
• Engage physician leaders for each service line (or at least the high volume ones) that can own or at least help drive LOS for their service line.
• Look at the % of patients that are discharged before 11AM, and set a loftier target. This will free up beds for afternoon/evening admissions.
• Resource environmental services to when most of the discharges are occurring. Longer waits to be bedded from the ED will lead to longer LOS.
• Review the time between when a discharge order is written and when the patient physically leaves, and identify improvement opportunities. We isolated by nursing unit and found significant variance between units.
• Review time that the discharge order is written trends by physician, and look for opportunities for earlier orders.
• Look for trends- by service line, by disposition, by physician, etc. We found that we got patients out quickly when they were going home, but were experiencing delays for patients going to SNF or Home Health. We worked on identifying patients that needed these services earlier in the stay, getting screeners in earlier, working on quicker insurance authorizations, as strategies. We reviewed results with key stakeholders monthly.
• Hold a weekly outlier meeting. Our sites have a multidisciplinary team review all inhouse cases with LOS of 20 days or greater, and review and address barriers to discharge.
• For surgical patients, look at how long the patient is inhouse before the procedure. We found, especially in cardiac, that surgeons were bringing patient in for days in advance of the procedure unnecessarily.
• Ensure adequate resourcing of discharge planning over the weekend. We found that many patients were staying unnecessarily not for medical necessity, but due to discharge planning resources.
• Send the message that discharge planning starts on the day of admission, not when the patient is close to being ready to go home.
• Set the expectation with the patient- let them know that typical stays for their condition are X days. This helps them to arrange transportation resources in advance.
We have used almost all of the same strategies successfully that Brian mentions above. In addition, we have also rented beds in a SNF for our uninsured patients who simply need a place to wait while pursuing Medicaid, guardianship, etc. This has helped free up beds for patients who truly need an acute level of care and has helped throughput.
My only other thought to the excellent suggestion above: if it is clear that patient is gong home the next day (or very close to clear), incentivise MD/APPs to write pre discharge orders the evening before. May use RVUs for discharge orders written prior to 9 am.
We have had some great success in reducing length of stay for elective surgical patients.
The most effective method has undoubtedly been setting very clear expectations with the patient, in advance of surgery. At pre-assessment, they are told specifically which day to arrange transport home, and everything from the day of admission is geared towards this discharge date. All documentation is clear, the nursing staff are briefed, the consultant plans accordingly.
Of course if there are clinical issues, or if the pathway changes, the patient would always be kept in. But we have found that when the patient is aware so far in advance, they are very keen to stick to the discharge date, and we don’t get many who request to stay longer.
One issue we’ve had is insurance companies when pre-authorising surgery, writing to the patient saying they are authorised for a set number of days, which is often more than clinically required. Changing patient mind set to something lower than what has been approved is tough!
The National Emergency Access Target (NEAT) has meant there has been a sustained focus on discharge before 10am across WA hospitals. Many of the strategies outlined by Brian have been implemented and providing national benchmark data to Heads of Dept has been effective in engaging medical teams and developing a shared understanding about hospital priorities and drivers. The strategies that have made the biggest difference on a day to day basis however have been
1. Implementation of a Nursing Coordinator: Patient flow role. This person leads daily bed meetings at 10am and 3pm with Heads of Dept, Nurse Unit Managers of wards, ED and allied health. Information from the morning and afternoon ward round underpins a shared understanding of planned discharges for the day and ensures the MDT is focused on tasks required to safely achieve the discharge.
2. Implementation of Care Coordination team: comprised of 3 allied health and 1 nurse, the CC team is responsible for implementing and coordinating care plans for frequent presenters to the hospital and receives referrals for discharge coordination for complex cases on day 1 of their admission.
3. Long Stay patient committee – Chaired by the Director of Nursing and meets weekly to oversee care coordination of patients whose LOS is above the national benchmark target. The Director of Clinical Services and Director of Allied Health also attend this meeting to ensure decisions regarding a patients care can be made in a timely fashion.
I actually really liked Nicola s comment on setting very clear expectations with the patient. In fact, this gives me an idea of transforming the lenght of stay as a measure of performance to share with the patient. Indeed, many patients see our willingness to send them home as an economical pressure only. By setting the expectation in advance with the patient we can transform it as a common goal. Thanks for sharing the post and potential solutions.
Great suggestions and I concur that planning for discharge to the degree possible, prior to patient admission has been of tremendous assistance in reducing our length of stay, particularly with pre-planning home health visits, post-discharge follow-up visits and discharge prescriptions. Many organizations also use a dry erase board in each patient’s room which identifies the plan for progression of care for the day with discharge goals identified and an anticipated discharge date assigned at the time of admission.
A novel concept that was in place in a previous market that I worked was for a staffing agency to provide a non-licensed, bonded, insured staff member to meet the patient at the time of hospital discharge, drive them home, and assist in ensuring they were set up in their home and perhaps assist with a meal preparation, pick-up medications from the pharmacy or run other short errands. A nominal fee was charged for this, which included the transportation and a maximum of two hours of assistance. This helped to alleviate the delays we often experienced with patients needing to wait for a ride to get home.
Hi, some comments from my department
Managing expectation from patients is very important. So all patients are coming in on the day of surgery and they all know if they are going to be discharged the same day, or the next morning and so on.
The day before discharge, I speak with them at the end of the day to explain everything they want to know, so they do not see a doctor in the morning. So no waiting for docters or prescriptions, only for the nurse. If patients know this, they are happy with it.
Aside this, we also do value based health care project with other hospital eg breastcancer with 6 other hospitals. We compare also length of stay and that really helps doctors to change their protocols if they see that the same patients are released one or two days earlier in a comparable hospital. We help eachother in these 7 hospitals to eventually have the best care in all the 7 hospitals
good luck, Viviane
I thought Brian response was excellent. We also have case management review on Day 1 with the patient or family members a clear expectation on outcomes. We go over with them the discharge setting to make sure everyone knows what is happening after. We want to know if they have a support system in place to help when they are discharged.
In our publically funded health care system, our hospital sends Emergency Department patient flow statistics to the entire Senior Management Team 3 times as day, 7 days a week. Being aware of the demand for beds from patients admitted through the Emergency Department is a strong incentive for physician and administrative leads to focus on more timely discharges.
I suggest you to creat a multidisciplinary team to take care of this issue. Have a white board on patients room, ask doctor to write the expected date of discharge and which criteria (no fever, end of antibiotics, etc) would be necessary in order to the discharge happen. Nurses will follow that expected date everyday, and circulating the signs or symptons that were achieved one by one. Patients will be engaged on discharge date as much the staff. Families will pay attention and plan to be there early on the day to bring the patient home. 24 hours before the expected date, the multidisciplinary team contacts the doctors and if its confirmed, social service, pharmacists, nurses, family, and start to work on discharge to guarantee that before 10 am next day the bed is free.
If you have Eletronic Medical Records you can do it eletronically. Having a TV screen at the nurse area can help follow step by step, patient by patient who is approaching the expected discharge date. If doctors alter the expected date they have to justify and restard the list of signs and symptoms list again.
Follow the doctors that can predict the lenght of stay precisely and recognize them publically.
I concur with Brian’s comments and many of the responses above. Creating a dedicated team to break down the barriers to discharge is a key to decreasing LOS. This has to be an organizational initiative that engages all of the stake holders. For example, we are a mix of community and employed providers. Our community partners often would round late in evenings vs early AM, causing delays in discharges and a backlog in the ED. This issue had to be addressed at the medical staff level to get fixed. There are a number of good strategies in the above posts. The key ingredient in my opinion is buy in from all stake holders and “esuite” pressure on all parties to effect change.
I would suggest an initial gap analysis to ascertain the reasons of the increased LOS. Measuring and managing ALOS is multifaceted because of several variables and impacts of other metrics; disease process, patients seeking early treatment, complexity in diagnosis among others. However, understanding the underlying factors, and identifying the bottleneck in patient flow requires tracking and understanding of the variables through a streamlined data collection process and analyzing the data to develop strategies to mitigate them.
One of the important widely used tool is the clinical pathways in the inpatient care process, the discharge plan process, and establishing an estimated date of discharge as early as possible. It is also important to involve Utilization Management (UM) tools to minimize wastage of resources and to develop tailored measures to address the gaps.