Reducing Avoidable Hospital Inpatient Days

Hospitals working to improve efficiency by rightsizing length of stay and reducing avoidable hospital inpatient days must implement a process that begins prior to admission and extends beyond discharge. Extended hospital stays beyond what is needed for high quality care and avoidable readmissions, can be associated with an increased potential for complications such as hospital acquired infections and patient safety events. Reducing extended stays relies on a coordinated, multi-facetted process to reach the desired outcomes.

Hospitals should consider nine factors in building an improved system to promote optimal length of stay and decrease inpatient days and admissions while increasing efficiency. Those best practices for rightsizing LOS are based on improvements in emergency room flow, census and bed management, operating room schedules, assessing patient needs and risk factors, discharge planning, expanding hours of operation for certain procedures and tests, prioritizing tests and procedures for discharges, transitioning non-urgent tests and procedures to outpatient, and preventing readmission. The following expounds upon each of these steps.

Best Practices for Reducing Length of Stay to an Optimal Size

Emergency Room Flow

The sooner and more efficiently a patient gets admitted from the ER, if appropriate, in the proper type of bed, the quicker they can get treated and discharged.

Actions:

• Early in an emergency room visit, assess whether a patient needs and meets criteria for admission using InterQual, MCG or other admission tools, as well as what type of bed/level of care they will need.
• Maintain excellent communication with admitting clinicians and bed board to smooth the process and avoid delays.

Census and Bed Management*

Actions:

• Analyze historical patient volume and admission data to predict the number and distribution of beds you will need for smooth and correct level of patient care.
• Put algorithms in place to triage patients to appropriate and integrate surge history to adjust numbers.

 Adjust Operating Room Schedule*

Optimizing the elective surgery schedule with respect to recovery time yields a flatter inpatient census.

Actions:

• Forecast the volume and case mix of surgeries together with the associated recovery time per case and apply lean manufacturing techniques combined with an optimization engine to build surgery templates that avoid spikes in the downstream census.

Assess Patient Needs and Risk Factors Early

Like Emergency Room Flow, assessing needs and risk factors early – even before admission – can improve the overall process of admission.

Actions:

• Starting at the time of admission, consider factors such as age, prior independence, preexisting medical conditions, medication complexity, and behavioral health status including cognitive functioning, social, or financial situations.
• Based on these factors listed above, the team should identify and escalate the discussion of barriers to discharge and work to address each one.
• Institute complex care rounds engaging care managers and social workers to assist in addressing patients’ unique discharge needs.

Discharge Planning

Discharge planning starts at the time of admission.

Actions:

• Assessment of expected clinical course, clinical and psychosocial factors that impact post discharge needs begin also on day one.
• Identification, documentation, and communication of the expected date of discharge is essential. Care plan should be orchestrated to progress the patient condition to meet the desired date of discharge.
• Setting discharge expectations and understanding the needs of the patient and the designated support system (caretakers) are critical. Eliminating eleventh-hour notifications of discharge is essential.
• Strategies such as active and early mobilization ensure readiness for safe discharge.
• Proactive daily care including:
  1. Team huddles around care needs
  2. Interdisciplinary rounds to discuss patient’s expected date of discharge, needs as identified on admission as well as those evolving during hospitalization
  3. Tangible actions plans to remove barriers to discharge

• Daily discharge assessment should include:
  1. Target discharge day
  2. Current medical condition and stability: Is the patient on target or is an adjustment needed (use InterQual, MCG etc.)?
  3. A realistic disposition plan that considers prior condition and support systems to help determine disposition needs:
     • Where is the patient going post hospitalization?
     • Will an extended care facility (ECF) or 24-hour caregiver be needed?
     • If ECF is needed, determine payment eligibility early as well as family preferences and resources.
  4. Discharge needs such as equipment and services, home health nurse, aide, caretaker, therapy, oxygen, walkers, wheelchairs etc.
  5. Schedule follow up appointments.
• If next day discharge is likely or possible, make sure all needed measures are in place the day before: home health, equipment, transportation, medication reconciliation, prescriptions, patient instruction (preferably discussed with patient), transfer forms for ECF, and follow up appointments.
• Work with providers for early morning rounding and/or verbal discharge orders if appropriate.
• NOTE: For more information, see UpToDate’s helpful article on discharge and readmission.

Expand hours of operation for certain procedures and tests*

 Actions:

• Testing may need to be expanded into evenings and weekend to speed discharge.
• Stress testing, GI lab, radiology, non-urgent procedures such as lines, peg etc. may need to be done during nontraditional work hours.

Prioritize tests and procedures for patients ready to be discharged*

Patients ready for discharge pending one final test or procedure should be considered for priority, if clinically feasible, without impacting quality of care for other patients.

Transition non-urgent tests and procedures from inpatient to outpatient setting*

Test and procedures that can be deferred to post discharge without a negative clinical impact should be considered for scheduling as outpatient.

Prevent readmission

Readmissions add to avoidable days.

Actions:

• Use tools such as the lace score to identify readmission risk and address them.
• Discharge appointment should be set up prior to leaving the hospital.
• Medication adverse events are key causes of readmission.
  1. Providing clear medication reconciliation document and reviewing with patient and caretakers is critical.
  2. Involve pharmacist, if available, in discussion of potential adverse effects of medications.
  3. Check for drug interactions.
  4. Home medication administration tools -- pill boxes, reminders, checking home to remove discontinued drugs -- are key.
• Clear instruction of what to look out for and what to do if any undesirable event or symptoms occur.
• Explain diagnosis, what happened in the hospital and follow-up plan to patient and their caretakers avoiding medical jargon and using teach back.
• Discharge summary sent with a good hand off to primary care provider.
• Assign case managers for complex patients going directly home or to oversee care in ECF as appropriate for complex cases.
• Post discharge, follow up phone calls to check on status.

*Ideas adapted in part from: 10 Ways Hospitals Can Reduce Length of Stay for Their Patient Published on March 13, 2017 – Linked - Sanjeev Agrawal

SUMMARY

In summary, hospitals working to reduce inefficiencies and unnecessary inpatient days need to review each of these steps to look for opportunities for improvements in their own facility. Hospital length of stay, just like hospital medical care, is something that needs to be in the forefront of everyone’s minds. Every hospital is unique and will require a unique approach to each step from managing emergency room flow effectively to determining appropriate level of care to careful discharge planning. We believe that this list of nine factors is a solid starting point in the journey toward providing patients a more healthy, optimized, and efficient hospital experience.

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