Length of stay: Timing it right

Strategies for achieving efficient, high-quality care.

A hospitalist makes many decisions that influence the cost of an inpatient stay—from ordering blood tests and radiology scans to calling for specialist consults—but probably none has more impact than “Should this patient go home today or tomorrow?”

“As we understand the cost of care in the hospital setting, probably the most important decision a clinician can make is whether a patient stays past midnight,” said Bradley Sharpe, MD, FACP, acting chief of the division of hospital medicine at the University of California San Francisco Medical Center. “With health care reform and the increasing focus on high-value care, the implications around length of stay (LOS) are profound for the health care system.”

Image from Thinkstock
Image from Thinkstock.

Under the Affordable Care Act, it is still in hospitals' financial interest to discharge patients as soon as possible, but also to facilitate post-discharge care and prevent 30-day readmissions. Rather than just lowering LOS, hospitals now aim to optimize it at the intersection of quality and cost.

That's the goal of Medicare's initiatives to penalize hospitals for excess 30-day readmissions and pay for bundled care, said James S. Goodwin, MD, professor in the department of internal medicine at the University of Texas Medical Branch in Galveston, who has researched variations in LOS. Under the ongoing Medicare Bundled Payments for Care Improvement Initiative, episodic payments can encompass the initial inpatient stay plus any readmissions within 30 days of discharge.

“By bundling payments, Medicare is ameliorating the financial incentive of hospitals to reduce LOS, but also offering huge incentives to reduce costs post-discharge,” said Dr. Goodwin. “The financial incentive will become achieving the lowest cost for the entire episode of care, not just during hospitalization.”

Creating efficient systems

Recent research suggests that improvements in efficiency during the inpatient stay can lower LOS without increasing unnecessary readmissions. In an adjusted analysis of 129 VA hospitals over 14 years, published in Annals of Internal Medicine in December 2012, researchers found that an intense focus on efficiency led to decreases in both LOS (down 27%) and 30-day readmissions (down 16%) as well as fewer deaths from any cause at 30 and 90 days after admission. Over the 14-year period, the risk-adjusted LOS for all diagnoses fell from 5.44 to 3.98 days.

A length of stay that was longer or shorter than average was associated with increased risk of readmission, the researchers found. However, LOS had to be 1 full day below the average before it had a negative impact on readmissions, suggesting that there is still room for improvement.

“It's tempting to believe that if you discharge too early, those patients are likely to be readmitted, but that's not what a number of studies have found,” said Arun Mohan, MD, chief medical officer of hospital medicine for Atlanta-based ApolloMD, which partners with hospitals to provide hospitalist services.

In many cases, poor communication and coordination—not lack of time—are keeping LOS numbers higher than necessary, said Dr. Sharpe. Every member of the care team plays an important role in achieving timely discharge.

“Hospitalists need help from ancillary services and other providers to discharge patients in a timely and safe manner,” he said. “You need an infrastructure where everything happens efficiently so the patient can go home that day.”

In a well-functioning system, nurses and case managers help prepare patients for discharge, consultants see patients early in the day, and the radiology department processes orders in a few hours, he said. If there is a missing link in that chain, patients may be stuck waiting around for test results or paperwork instead of leaving when they're ready to go home.

“A lot of the time that patients are in the hospital is spent waiting for things to happen,” said Dr. Mohan. “In order to avoid increasing LOS, hospitalists have to plan very carefully and take a team-based approach.”

Strategies for timely discharge

Goals for discharge can help manage LOS but shouldn't be viewed as hard-and-fast rules, hospitalists said. Trying to discharge patients by noon, for example, can shorten or add to LOS, depending on the circumstances.

“Admissions typically start coming in the afternoon from the ED and ICU, so if you can get most discharges done by noon, you can have fewer nurses, fewer beds, and be more operationally efficient,” said Benjamin A. Hohmuth, MD, chief of hospital medicine at Geisinger Medical Center in Danville, Pa. “Hypothetically, if you have 100 patients in the morning and are anticipating 20 admissions and 20 discharges, you will need capacity to manage a maximum census of between 100 and 140 that day. If you get most of your discharges out early you will have less overlap and will stay much closer to 100.”

Aiming for discharge by noon often works with patients scheduled for elective surgery, because their stay is usually predictable, he said. But it doesn't always work for patients admitted through the ED.

“If a patient comes in at 2 a.m. with an upper GI bleed, then an endoscopy the next afternoon shows it's a clean-based ulcer and he can go home, he should not wait until the next day,” said Dr. Hohmuth. “If you're managing LOS aggressively, patients should be going home in the evening, too.”

Focusing on teamwork and continuity of care, rather than time of discharge, is often a better way to manage LOS, said Dr. Mohan. One way to do that is by creating specialized units, such as Acute Care for the Elderly (ACE) units, where interdisciplinary teams focus on specific populations with similar clinical needs. For example, patients cared for in an ACE unit had shorter LOS than those who received usual care (7.3 vs. 6.7 days) and did not have higher readmission rates, according to a study published in Health Affairs in June 2012.

Similarly, assigning hospitalist-led care teams to home units has been shown to reduce LOS. Emory University Hospital in Atlanta, for example, introduced accountable care units (ACUs), where multidisciplinary teams composed of physicians, nurses and others, such as social workers and pharmacists, round on patients every morning to discuss the plan of care.

After the first year of the initiative, average LOS dropped from 5 to 4.5 days and in-hospital mortality fell from 2.3 to 1.1 deaths per 100 encounters, according to results published last year in the Harvard Business Review.

“You need to develop schedules and models designed to minimize fragmentation,” said Dr. Mohan. “Multiple handoffs over the course of a hospitalization can have a negative impact on LOS.”

At Johns Hopkins Bayview Medical Center in Baltimore, LOS went down after the hospital began scheduling hospitalists in 4-day blocks, aligning them with the number of days most patients spend in the hospital. The idea was for physicians to admit patients on the first day and follow them through to discharge on day 4.

The schedule allowed physicians to focus on admissions and discharges—typically the most labor intensive part of the stay—on the first and last days of the cycle, said hospitalist Eric Howell, MD, FACP. “If you try to mix them together on the same day, discharges will often get postponed or held over to next day.”

The initiative, called “Creating Incentives and Continuity Leading to Efficiency” (CICLE), reduced LOS by 7.5% and lowered costs due to less duplication of tests, said Dr. Howell, who co-authored a paper on the results in Mayo Clinic Proceedings in April 2012. Thirty-day readmission rates remained steady.

By the numbers

Hospital administrators focus on overall LOS data, but hospitalist leaders may benefit from looking at the discharge patterns of individual physicians in order to spot potential problem areas on their team, said Dr. Hohmuth.

To do that, Dr. Hohmuth calculates each physician's “charge ratio” by dividing total number of encounters (admissions, follow-up, and discharges) by total number of discharges, rather than attributing a patient's entire LOS to the discharging physician. That way, physicians get credit for discharges regardless of whether they admitted the patient.

“If I pick up a patient who has been here 10 days and I discharge them tomorrow, I inherit that 12-day LOS,” he said. “Whereas using charge ratio methodology, that would still be a discharge for me. It helps tease out what we sort of know already, which is that some physicians are much more able or capable at discharging.”

Another key measurement is the LOS index, or the ratio of observed length of stay to expected (the average LOS based on diagnosis), said Dr. Sharpe. The LOS index depends both on the actual length of stay as well as the calculated “expected” LOS. If you are documenting appropriately and discharging promptly, the observed should be lower than the expected so that the ratio is less than 1.

“If your index is 0.3, you're likely doing a very good job of documenting the degree of illness,” he said. “One way to lower the LOS index is to accurately and appropriately document the medical illnesses and comorbidities that increase reimbursement to the hospital.”

It's also important to understand how your hospital measures LOS, he said, especially whether or not outliers are included in the averages for each unit. For example, if a patient who has been in the hospital for 58 days (an outlier) is transferred to your unit from another service, then discharged to hospice after 2 days, the entire 60-day stay could be included in your unit's average.

You may be able to prevent that from happening by managing that patient on a consultant basis, said Dr. Hohmuth. And you can only make that choice if you know what you're being held accountable for.

“You have to educate providers about how things are being measured,” he said. “If we have great operational efficiencies to reduce LOS, but we're routinely taking transfers from other services with long LOS and our hospital does not exclude outliers, then all our hard work is going to be washed out by the effect of the transfers.”

To assess a unit's performance on LOS, hospitalist groups should define their patient population and look for patterns that may be affecting the average, said Dr. Howell. For example, a subanalysis of different business groups in a division may help you zero in on specific areas that are driving up LOS.

Often, administrators look at risk-adjusted LOS, which accounts for age, diagnosis, and comorbidities and excludes outliers, said Dr. Mohan. It can also be helpful to stratify LOS by discharge diagnosis, he said, so that you understand performance across the higher-volume diagnoses, like pneumonia.

However, the data will be meaningless to hospitalists unless they understand how managing LOS fits into the larger picture of practicing medicine, noted Dr. Hohmuth.

“Controlling LOS allows us to justify a lower census, which allows us to practice medicine in a way that is pleasurable and of higher quality,” he said. “That's the hook for physicians.”