In today’s times a crucial issue facing hospitals is patients’ average length of stay (ALOS). A longer ALOS implies a higher risk to the patient of developing a healthcare acquired infection (HAI).
Higher LOS has also been associated with higher mortality rates in the hospital. In addition, for the hospital, it means lower patient capacities and increased costs
So how do you define average length of stay or ALOS?
The ALOS is the average number of days that patients spend in hospital.
Use simple division to divide the total number of days stayed by all inpatients during a year by the number of admissions or discharges, and you have a figure for your ALOS.
Now why should ALOS be considered important enough to warrant attention?
Healthcare CEOs have ALOS reduction as their top priority because LOS is directly related to patient satisfaction and profitability, and has therefore become a much looked at indicator of overall management effectiveness.
ALOS in a hospital is used to gauge the efficiency of a healthcare facility.
As per a study from The University of Texas at Dallas, an adequate length of stay during hospitalization is a critical factor in quality of care and a predictor of future readmission risk.
That apart, hospitals benefit from a shorter LOS, not having to worry about covering expenses for healthcare acquired infection (HAI) and they free up beds for new patients.
How even a small reduction in ALOS implies huge benefits?
Even a small reduction in ALOS can be quite significant because patient access is inversely proportional to LOS. Let’s take an example.
A hospital with a 300-bed capacity, which has an ALOS of 4 days is able to cut the ALOS by 5%, that is, by 5 hours. This could enable them to treat over 1,350 more patients each year.
That’s a huge jump in patient access and huge income increment in money terms from the same fixed capacity.
It also typically improves the patient and provider experience; the wait times in the emergency room come down and there is an overall ‘more pleasant’ experience for everyone involved.
What can you do to reduce ALOS?
There are some factors beyond the control of hospital—such as their patient’s medical condition and age—but there are other factors which the hospital management can influence to reduce ALOS.
Let’s take a look at the three drivers for reduced ALOS
As per a Danish group there are primarily three drivers for reducing ALOS
- Overall information to the patient about what is going on and what is expected of them;
- Information to and training for health care staff
- Pain treatment. Keeping these in mind, you can employ the following method
1. Have the Right-Size Unit Capacity
An incorrect assessment of the required unit size would invariably lead to a higher percentage of patients not being placed into their target unit.
What follows is longer wait times to get patients out of the emergency department.
What you need to do is analyze historical patient volumes by service to arrive at the correct number of required beds.
Usually medicine units mix patients accepting general medicine patients in addition to the specialty patients for whom the unit is intended.
To remedy this, reduce the size of your specialty units and open a larger general medicine unit. This may not be located in one single unit or floor, but can comprise several subunits.
For example, you could have a sub-unit as Acute Care for the Elderly (ACE) unit.
How would this help?
This enables you to have a simpler patient placement thus making it easier for a clinical team to co-locate patients assigned to them. It would expedite the right treatment as interdisciplinary teams focus on specific populations with similar clinical needs.
2. Get the Right Patient to the Right Unit
If you place patients in the wrong units, they end up being at the wrong level of care. They may even be treated by clinical staff who do not specialize in the ailment for which the patient has been admitted.
This causes slower recovery times and even clinical complications. Getting the right patient to the right bed is crucial to reduce ALOS.
To balance the numbers across units, use an algorithmic approach to patient placement. This would enable you to minimize the number of patients not being placed in their target units.
You may already have a rule of thumb for your patient placement system and moving to a more dynamic algorithmic approach will not interrupt the workflow much.
Follow the five guidelines--right level of care, right service, right nursing unit, right bed and right time period.
3. Estimate and Predict Your In-patient Census and Manage It
The in-patient census is usually quite fluid and keeps changing dramatically in most hospitals. The problems in capacity management, staffing and patient placement get spiked soon as there is a rise in this census.
For daily unit management, devising a system to accurately predict patient numbers, is imperative. Being able to predict future spikes in the census will help you to balance elective admissions when your ED volumes rise.
An accurate and granular forecast can be made using multiple data sources and sophisticated machine learning techniques.
For better tactical planning, break the day into useful segments.
You will need to review Census forecasts multiple times a day, which will involve a quick huddle and will be only a minor change to the workflow.
4. Cut Down on Delays in Admission from the ED
Delays are caused mostly because the process of admitting patients from the ED is time-intensive and highly variable.
The two main bottlenecks in the admission from ED are communication difficulties between ED providers and hospital physicians, coupled with the time taken to get the right bed ready on time.
Even though there is a cultural change required to correct this by monitoring a mobile visibility system, it could be well worth the effort.
You shall have to increase visibility into the ED and the inpatient units. With a summary view of ED, you can quickly determine how many patients are waiting for a bed.
Your inpatient unit view will let you know how many beds are occupied, dirty or available.
Both would help you cut down on delays in admissions from ED.
5. Address Provider Workflow
At most hospitals, the physicians’ rounding follows a general approach usually happening in the late morning or early afternoon.
This could at times imply an opportunity missed to discharge patients early in the morning.
This is easy to tackle.
Maintain a chart of those patients who can be discharged in the early morning and tell your team to follow up on this the next morning.
This means that you may have to change to the daily schedule for clinical teams, which may invite the introduction of additional incentives.
6. Initiate daily multidisciplinary rounding and daily bed huddles:
This would significantly reduce delays in completing ancillary tasks on time, such as teaching, patient evaluations, payer authorizations, post-acute service setup and rides home.
7. Identify Impact Areas by Checking On the Hours of Operation
Certain procedures such as imaging and labs may be taking longer hours and impacting ALOS.
Someone admitted on Friday afternoon may have to stay longer in the hospital simply because his test results were not available with the lab being closed on weekends.
Find out which areas are causing such delays and keep them open for a half day or even a full day on Saturdays. This will lead to increase in working hours and you may need to hire additional staff.
8. Plan the discharge in advance
Issues such as documentation or availability of transport can cause delays in patient discharge. You could obviate these delays if the team in charge is alerted to these delays much earlier during the patient’s stay.
A possible difficulty in discharge can be identified by using a machine learning framework to identify key patient attributes. This works as an early warning signal for those in charge of at-risk patients. Address the factors causing delays in discharge early in the patient’s stay and you can greatly reduce the risk.
9. Prioritize Patients to Be Discharged for Labs/Clinical Procedures
Clinically urgent cases are usually pushed forward in the lab queue while first come first serve treatment is meted out to less urgent cases. You can move a patient up in the queue if he is close to discharge.
Have a prioritized list for labs and clinical procedures for patients who would be discharged soon.
10. Transition Some Procedures to Outpatient
Identify procedures that can be tackled at the OPD rather than inpatient. Not only would it be cost effective in some cases, it would also nullify the need for admission.
It would work superbly for local patients. Even for those coming from out of city, they could stay a night in a local hotel and come back in the morning for an outpatient procedure.
However, this would require approval from an expert, since it is unlikely for an analytic system to be able to identify such cases.
11. Improve Communication with staff and patients
Communications delays are a key factor causing longer-than-necessary hospital stays.
Communications barriers could exist between treating physicians and nurses or in transmission of clinical information from labs to physicians, between case managers and other care team members, or in the reporting of diagnostic study results from interpreting physician to decision makers.
There may be ineffective communication of policies and procedures from managers to staff. Also team and individual communications performance metrics may not be aligned well with each other.
So what can you do?
Revisit your communication workflows and identify delays. Have a single communication platform to connect all physicians, nurses and support staff within and outside.
Delivery of critical labs, consultation requests and radiology reports to the physician should be automated.
Collect, respond to and track key communication performance analytics.
Streamline communications between patients and hospital staff which shall help ensure that that patients progress as quickly as possible through care milestones.
12. Real time dashboards and recording of patient information
The old fashioned way of having a scribe can ease reform within hospitals. When complete patient and care information is recorded in real time, it is much easier to share them with other providers and facilities. Creating trackable metrics becomes easy as you can extract data from these thorough records. This would again help you in minimizing delays in your documentation.
Have real time dashboards across the hospital so that doctors, nurses, administrators, shift coordinators and managers are able to optimize the flow of patients. The clinicians can see where there are bottlenecks and act quickly to eliminate them.
You can streamline your clinical workflow by embracing technology. This can help you in the following areas.
Asset management – automate PAR-level management to ensure equipment distribution is optimized. This would mean patients wouldn’t have to wait while staff search for equipment.
Nurse call automation – you can automate call cancellations and facilitate staff rounding.
Patient workflow – automatically record and analyze operational data and document patient milestones.
14. Create a discharge educator position
There can be inordinate delays in discharge if the patient is difficult and wants more than the regular care instructions that you hand out at the time of discharge.
It would do well for you to create a discharge educator position so that these documented concepts with patients and caregivers can be orally reinforced.
This not only makes the written documentation more effective, it also helps expedite discharge as you are able to answer all the FAQs, without the patient having to ask them.
15. Educating patients on pain management
What is the relationship between postoperative pain management and reduced length of stay? Well patients are psychologically more prepared in their ability to withstand pain when they know that their pain can be treated.
For example, a Danish doctor, Dr. Kjaersgaard-Andersen was attempting to reduce morphine usage in his surgery unit.
He says that when patients were made to understand that with morphine (used to alleviate pain after surgery) the saturation of blood is reduced and there is a higher risk of infection all over the body, they learned better to work with the pain management team and support the effects.
They coped better with the pain despite reduced dosage of morphine.
This allowed a faster return to mobility, which was essential in returning them home. So educating your patients on pain management can help in quicker recovery and therefore reduced ALOS.
In most cases it is poor communication and lack of co-ordination which leads to an increase in ALOS.
While there are some detractors who say that if you discharge patients too early, there is a likelihood of them being readmitted, a number of studies have indicated that such is not the case.
The hospital, all by itself cannot manage to reduce the ALOS, all on its own. It needs help from ancillary services and other providers and every member of the care team plays an important role in achieving timely discharge.
In a well-oiled system various components perform different functions that determine the ALOS.
Nurses and managers prepare patients for discharge, physicians see patients early in the day, and the radiology department processes reports in a few hours.
Each works as a vital link in the chain and with even one link malfunctioning, patients may be stuck for hours, waiting for test results or necessary documentation.
Therefore it is necessary that at both macro and micro levels the glitches in the system are weeded out to reduce the ALOS at your hospital.
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