Originally published in the AAHAM Summer Journal
Research and real-world experience continue to show that reducing patient length-of-stay (LOS) offers multiple benefits for providers and patients alike.
For providers, reducing LOS can increase capacity by freeing up already stretched resources, minimize the risk of denied claims and uncompensated care, increase patient satisfaction ratings, and improve throughput allowing for more patients to be treated. For patients, a reduced LOS usually saves money, reduces the risk of hospital acquired infections (HIA), gets them back to their normal routine more quickly (which has numerous psychological and economic benefits), and results in improved treatment outcomes.
Given these proven benefits and considering that providers are under constant pressure to achieve the dual goals of maintaining quality-of-care while lowering operating costs, it would be easy to believe that reducing LOS should be a sine qua non in provider operations management. The problem, and risk, of adopting this philosophy, however, is that while shortened LOS does, for the most part, benefit providers and patients alike, this is not always the case. There also is no universal agreement on exactly what LOS targets should be for different in-patient procedures nor of the corresponding risk/benefit. The situation is further complicated by contradicting results from different research studies on this very important aspect of provider operations.
Consider, for example, a recent study from Norway conducted by St. Olavs Hospital and the Norwegian University of Science and Technology. In this study, researchers were looking specifically at the relation between LOS of hip fracture patients and survivability after discharge. What they found was these patients have a higher risk of dying if they are discharged from the hospital too early (primary due to capacity issues). In their sample of 60,000 patients over 70 years of age who were discharged early, approximately 13 percent died within the first 60 days following surgery. During the first year, some 27 percent died. To give these data context, according to the researchers, the difference in 60-day mortality rates for these patients and others is approximately four percentage points.
Contrasting, and contradicting the Norwegian study, is one from Virginia Commonwealth School of Medicine in the United States. In this study, researchers found the opposite to be true – specifically that the longer a hip fracture patient stays in the hospital, the more likely that patient will die within 30 days of discharge. Here, researchers studied a sample of more than 188,000 patients admitted to hospitals for hip fracture in the state of New York. In comparison to the Norway study, they found that hospital stays of from 11 to 14 days were associated with a 32 percent increased odds of death 30 days after discharge compared to stays of five or fewer days.
The lead researcher explained the difference in results by opining the “the shorter you stayed in the hospital in the United States, the better.” He went on to say that this may be due to the care received after leaving the hospital since, in the U.S., more than 90 percent of patients go from the hospital to a SNF for continued care and rehabilitation. This is not necessarily the case in other countries where patients may just be sent home after a hip fracture hospital stay.
There are other research data that could easily lead hospital administrators to rethink what has become conventional wisdom about LOS and even reexamine their existing discharge protocols and procedures. Some, for example correlate shorter LOS with a significantly higher risk of readmission. This can create a financial risk for providers from Medicare readmission penalties. Other studies also suggest that the cost of readmitting patients (aside from possible Medicare penalties which recently totaled more than $563 million) can often be more than cost related to keeping a patient under the hospital’s care for a little longer. This is not surprising given that unplanned readmissions cost U.S. providers between $15 billon and $20 billion annually.
For the patient, accelerated or premature discharge may also pose risks to their physical and financial health. A recent study of over 32,000 people discharged from the University of Texas Southwestern Medical Center showed that approximately 20 percent of them were discharged too early. An analysis of the outcomes for those patients discharged too early revealed that many had abnormalities or instabilities in temperature, heart rate, blood pressure, respiratory rate and oxygen saturation within 24 hours of discharge. The outcome was that while 12.8 percent of patients discharged with no instabilities in their vital signs at discharge either were readmitted or died, 16.9 percent of those with one instability died or were readmitted; 21.2 percent with two instabilities died or were readmitted; and 26.0 percent with three or more died or were readmitted.
Steps Providers can Take
Hospital in-patient acute care and critical care capacities will most likely continue to shrink over the short and medium term given hospital closures and cost-cutting measures. This is happening at a time when demand for these resources most likely will continue to increase as a function of population growth and the ongoing Covid-19 pandemic. This creates a very delicate balancing act for providers since both discharging patients prematurely and keeping them in the hospital too long carries risks for both.
Given that finding the best LOS for any given situation has ramifications for provider and patient health, this would be a good time for providers to take a second look at their current discharge protocols and procedures, including post-discharge patient after-care and follow-up. Key elements to review include:
- Where will patient be discharged to? Sending a patient home to family members who can care for him/her has different implications than sending an older patient who live to a home where no one is there to support or care for them. Also is the home suitable for the patient’s condition?
- How functional is the patient? Will he/she be able to adequately self-care once discharged? Or will they require some sort of life-skills support for feeding, toileting and general daily activities?
- Will there be any challenges in getting medications, follow-up services or other elements of the post-discharge plan?
- At what time during the day is the discharge planned? In general, it is better to discharge patients during the day, if possible, to facilitate transportation and ease operational bottlenecks.
- Does the patient have a history of readmissions? If so, the most prudent thing for them and for the provider is to consider extending LOS.
- How is the patient’s cognitive status? Is she/he fully aware and able to understand discharge and post-care instructions?
There are a variety of screening tools that providers can use to determine the readiness of any given patient for discharge. These include the LACE Index and Hospital score as well the 8Ps Risk Assessment tool.
The overriding guiding principle should be that reduced LOS due to better treatment is in the interests of the patient and the provider. But reducing LOS primarily because of capacity or financial pressures creates unnecessary risks for both.