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Length of Stay - Reducing Length of Stay


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Length of Stay - Reducing Length of Stay


What is it and how can it help me?

Hospitals usually experience far more variation in patterns of patient discharge than in patterns of admission. The main reason for this is the way we manage processes such as ward rounds, inpatient tests, pharmacy etc. This results in highly variable and unpredictable length of stay (LoS), even among patients admitted with similar conditions. Generally, discharges peak on Fridays with a trough over the weekend.  The situation is made worse by the fact that patients are admitted seven days a week (emergencies), but typically discharged five days a week. However, we can control the discharge process (and therefore variations in LoS).

Reducing the length of stay releases capacity in the system but requires proactive planning of the whole process of care, as well as active discharge planning. You can achieve this by having a clear pathway of care or flow model through the system for particular conditions. A good example of a high volume condition for such a pathway is total hip replacement. These pathways of care should also include an estimated date of discharge, which the patient must be aware of.

Many trusts have also found it helpful to focus on the time of day when discharges occur. Moving discharges to the morning before peak arrival times helps keep the flow through an organisation.

When does it work best?

Use this tool when you suspect that you have length of stay issues.

Reducing LoS will release capacity in the system, including beds and staff time. A greater focus on treating day surgery (rather than inpatient surgery) as the norm (see treat day surgery as the norm) could also release nearly half a million inpatient bed days each year.  This increase in capacity will help to minimise waiting times, maximise productivity and improve the patient experience. 

How to use it

Diagnosis: 

  • Map the process, identify bottlenecks and the main causes of delay (see process mapping)
  • Map the information flows and responsibility for direct patient care at all points in the patient journey  
  • Measure and analyse current patterns of discharge by day of week, hour of day, speciality etc. (See www.productivity.nhs.uk and select Acute Hospital Trust indicator 2.1: Reducing length of stay) 
  • Analyse all inpatient stays by LoS to identify where improvements in the discharge process will have the greatest impact.  The 80:20 rule will help here, (80 per cent of patients have a much shorter LoS than the remaining 20 per cent, therefore there is more to gain from addressing the 80 per cent of shorter waits. See Pareto)
  • Consider how long patients are spending in a bed before they have an operation (see www.productivity.nhs.uk Acute Hospital Trust indicator 2.3: Reducing pre-operative bed days)

Problem solving: 

  • Use predictive discharge methods to reduce variation and to help eliminate delays
  • Attempt to smooth demand from surgeons across the week (even the demand for HDU beds)
  • Set a planned date for discharge on the day of admission or at pre-admission, if possible, using protocols / pathways for common conditions
  • Involve patients and their families or carers in discharge planning so that they are prepared and can make their own arrangements
  • Use visual triggers, e.g. visible expected date of discharge
  • Involve social services early if required

Orchestrating discharge:

  • Establish regular discharge making ward rounds at least once a day
  • Consider nurse-led discharge (see protocol based care)
  • Identify the lead-in times required, e.g. test and test result availability, medicines, transport etc. Ensure that they don't hold up discharge
  • Plan around the lead-in times
  • Match the time of discharge with the time beds are required on an hourly basis
Examples

Enhanced Recovery Programme - South Devon Healthcare NHS Trust 
The Enhanced Recovery Programme is a structured, evidence based approach to prepare patients for surgery and reduce its physical impact. This means that patients recover more quickly, enabling early discharge. 

Focus on Cholecystecomy - Northumbria Healthcare NHS Foundation Trust
The average length of stay for laparoscopic cholecystectomy is 2.6 days (ranging from 1.2 to six days). If the average length of stay was reduced by one day, there would be an annual saving for the NHS of approximately 35,400 bed days (£8 million, based on a bed day cost of £225). Northumbria Healthcare NHS Foundation Trust changed to a system where day case cholecystectomy was the default unless there were good clinical or social reasons to admit a patient. The trust's day case rate rose from 20 per cent to 50 per cent, with consistently high patient satisfaction (see High volume care).

Managing the patient's journey proactively - North West London Hospital NHS Trust
The majority of patient care is proactively managed by agreed multidisciplinary protocols of care within this trust. This includes mapping out the processes, streamlining them, extending staff roles and agreeing and auditing length of stay. Over the last ten years, the predicted duration of stay for total knee replacement has been reduced from 13 days to five days.   

What next?

Concentrate on the high volume pathways. Identify these by using the Pareto Principle. (See Pareto).

Ensure a date for discharge is made at or before the point of admission and encourage your organisation to proactively manage care using agreed protocols or pathways. This will enable staff to address the key questions of what should be done, when, where and by whom at a local level and help to reduce LoS.

LoS can also be influenced by not admitting some patients at all. For example, using day surgery more appropriately: see British Association of Day Surgery (BADS) / Day Surgery UK .

Reducing LoS is about change and so it is crucial to get clinical engagement (see clinical engagement).

Other useful tools and techniques on this website

Key to reducing LoS is managing variation. A number of other tools on this site will help you achieve this. We suggest you look at:

Additional Resources
  • Reducing the length of stay website, www.reducinglengthofstay.org.uk contains some fantastic facts, figures and improvements for looking at hospital length of stays.
Background

If this high impact change was implemented across the NHS to existing best practice rates, you could expect that:

  • Ten per cent of total bed days would be released for other activity
  • Average length of stay would be the same regardless of admission
  • Patients would be given a predicted day of discharge at admission or pre-admission
  • A similar percentage of patients would be discharged every day

Acknowledgements / sources

High Impact Changes


 

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