A pair of chief clinical officers share their strategies for managing length of stay.
Managing length of stay in hospitals is a primary concern for chief medical officers and chief clinical officers.
Reducing length of stay cuts costs by decreasing the labor associated with caring for patients. Reducing length of stay also decreases the risk of a patient suffering an adverse event in the hospital such as a hospital-acquired infection or fall. In addition, length of stay reflects the efficiency of processes and clinical care in the hospital setting.
Length of stay is ultimately a key metric for how well hospitals care for patients, says Marjorie Bessel, MD, chief clinical officer of Banner Health. "When your length of stay is appropriate, it means that everything that sits under that—how well you take care of patients, how well you work them up, how well you treat patients once you understand what disease process they have, and how well you anticipate the patient's needs post-discharge—is functioning well. From a chief clinical officer's perspective, having the hospital function well is ultimately our responsibility."
Weak management of length of stay is a driver of emergency department boarding of patients, says Peter Charvat, MD, MBA, chief clinical officer of the Bon Secours Richmond market. Bon Secours is part of Bon Secours Mercy Health, and the Bon Secours Richmond market features seven hospitals.
"Oftentimes, we find that some of the initial testing and treatment for patients may not be started when they are boarded in the ED. Boarding can also overwhelm an ED. As we discharge patients appropriately out of the hospital, we can free up inpatient beds and pull patients from the EDs to start their inpatient care," he says.
Reducing length of stay
Bessel and Charvat say there are six primary strategies for reducing length of stay.
1. Preventive care: Health systems should encourage their patients to receive preventive care. During the coronavirus pandemic and in the post-pandemic period, many patients did not receive routine preventive care, which has led to sicker patients in hospitals and longer lengths of stay. "During the pandemic, there was concern that people were not getting preventive care and in the post-pandemic era people would have late presentation of disease. We are seeing some of this effect," Bessel says.
2. Operational efficiency: Hospitals need to focus on the efficiency of their internal operations, Bessel says. "How fast can you get things moving? How fast can you get a patient worked up to get a diagnosis? How fast can you get the right treatment for the patient? And how quickly can you help the patient recuperate so they are stable enough to be discharged to the next level of care?" she says.
3. Manage transitions to post-acute care: Sometimes, length of stay is extended because of limited access to post-acute care services such as skilled nursing or home health. "Post-acute placement such as with skilled nursing, inpatient rehab, and home health care can be problematic if our post-acute partners are not able to provide services on a timely basis," Charvat says. Hospitals need to start their discharge planning early and hold conversations with post-acute care partners as soon as possible, he says.
4. Managing high-demand services: Hospitals need to coordinate high-demand services such as MRI exams or move high-demand services to the outpatient setting when possible after a patient is discharged, Charvat says. "Is there an evidence-based best practice for determining which patients need to be admitted and which patients need testing such as high-tech imaging? If you can standardize your approach, you may be able to decrease the demand for some inpatient services. The other consideration is looking for opportunities to shift to outpatient services. So, if a patient does not need a test during the inpatient stay, you can schedule that test in the outpatient setting after discharge," he says.
5. Embrace a team approach to discharge: Hospitals can use daily rounding on patients in the morning to identify barriers to discharge and work through those barriers, Charvat says. "We have the hospitalists, nurses, care management team, and other members of the care team going through each patient every day. The team looks at the goals for discharge, the expected discharge date, how the patient is tracking toward discharge, the tests and treatment needed, and successfully transitioning the patient from the inpatient setting. We work through the barriers and often follow-up with an afternoon huddle to go through any last-minute issues," he says.
6. Establish mobility: One of the more recent efforts to reduce length of stay at Bon Secours has been to establish early mobility of patients, Charvat says. "The sooner that a patient who is admitted can get up and start having mobility, we can identify a safe disposition for the patient and whether the patient needs any ongoing therapy or special services at home or in the post-acute setting."
Related: Increase in Length of Stay Adds to Hospitals' Financial Strain
Christopher Cheney is the CMO editor at HealthLeaders.
KEY TAKEAWAYS
Length of stay is a key hospital metric because it is associated with labor costs, risk of adverse events such a falls, efficiency of internal processes, and emergency department boarding.
Promoting preventive care is one strategy to reduce length of stay because it can reduce patient acuity in the hospital setting.
To avoid a bottleneck in post-acute care placements of patients, hospitals should start discharge planning early and communicate with post-acute care partners as soon as possible before a patient is discharged.