In our last article, we reviewed precisely why length of stay is so important for hospitals, looking at the clinical, financial, strategic, operational and experiential impact resulting from patients spending more time in the hospital than necessary. When analyzing each of those outcomes, it becomes evident that avoidable days are something health systems leaders should strive to reduce as often as possible.
But to do that, it’s important to gain a better understanding of what, exactly, keeps a patient in a hospital bed longer than clinically necessary. The reasons are varied, but they tend to fall in one of seven categories that contribute to avoidable days.
Two of the biggest hindrances to reducing length of stay go hand in hand: phones and fax machines.
Let’s put these both under the umbrella of “manual processes.” Fax machines and phones require team members to spend time overseeing communications that would be better left to a digital, automated system.
In the case of the fax machine, even if your own health system uses Electronic Health Records, that doesn’t necessarily mean the patient’s prospective post-acute care (PAC) providers are going to. So either a member of the hospital staff has to physically sit by the fax machine to transmit all relevant Patient Health Information (PHI), or, if you have a solution that can E-fax, that same staff member will have to initiate the E-fax process again and again.
This isn’t efficient from either a resource, staffing or time perspective, and it can add many avoidable hours to the patient’s stay.
Similarly, any step in your workflow that hinges on calling facilities on the phone is another potential roadblock to a speedy discharge. Once the prospective PAC facilities have been chosen, it can take potentially hours of phone tag to actually coordinate the successful transfer of the patient. During that time, the staff member is checking on beds and clinical capabilities, taking the information back to the patient, and acting as a go-between. If your team member has to leave a voicemail and await a call, your patient stays in the bed until there’s a response.
We’re not exaggerating when we say that reliance on phones and faxes can add days to the patient’s stay, particularly if that individual has high-acuity clinical needs, which can severely limit who’s able to even take on the patient.
One easily overlooked aspect of the patient discharge experience seems straight-forward on the surface: contact information for your post-acute partners.
Do you have a system in place that automatically updates when post-acute facilities open, close or move? Or that tracks points of contact for those same facilities? Or, taking the next step, that actually disperses these details to the entirety of your health system?
It’s only recently that health systems have really even begun to acknowledge how important this information is, and how much revenue can be re-captured, by improving this process. The truth is, there’s a dearth of information about the post-acute facilities available in a given geographic area. And not having access to this information is causing critical delays that leave a patient in an acute-care bed for longer than necessary.
Who’s responsible for discharging your patients? This is another potential roadblock to an efficient discharge experience.
Why? Because the patient discharge process shouldn’t take up the workday of individuals whose time would be better spent on the actual provision of care. If hours of a nurse’s day are spent on coordinating a post-acute bed for a patient, you’re paying for a highly skilled professional to conduct administrative work. Any hours where the nurse or other clinically capable staff member is unable to work top of license are a drain on your labor budget.
This metric is typically hard to measure. But once health systems take a closer look at just how much time their clinical teams spend on administrative labor, they’re usually shocked at the results (a quarter or even half a day isn’t uncommon).
Once you see the numbers, you start to realize it’s actually better from a revenue perspective to invest in full-time, non-clinical employees than it is to saddle this task on nurses or other clinical team members.
Another factor complicating the discharge of patients is transportation availability.
A patient may need transportation to get them to the next level of care, be that a PAC facility or the home setting depending on their care needs. But an ambulance isn’t always the most efficient solution because it’s typically better suited to emergencies.
Coordinating the transportation of the patient is a step that can take up just as much time as the actual placement of that individual. You need to know what transportation companies are available, what’s covered by the patient’s insurance and which transport can attend to the individual’s needs.
This takes yet more phone calls and steps in the process, and it can add time to the patient’s stay even after a post-acute bed has been secured.
There’s another issue that has reared its head recently, particularly in regard to the pandemic: supply.
Recovering COVID patients have been forced to remain in acute beds longer than necessary because there was a shocking lack of supply in Long Term Acute Care (LTAC) providers and Skilled Nursing Facilities (SNF). At the beginning of the pandemic, post-acute providers were understandably hesitant to accept a patient who could spark an outbreak, but even as those fears were assuaged by quarantine best practices and improvements to care provision, supply hasn’t always followed suit.
This isn’t a problem unique to COVID patients. It’s something all hospitals must contend with when targeting PACs based on the parameters of clinical needs, geography, insurance and more. Inadequate supply of post-acute beds holds back the successful and timely discharge of patients.
As part of the IMPACT Act of 2014, hospitals are now required by law to share the CMS ratings of PAC facilities with patients.
This requires documentation, via signature, that the patient has been presented with their post-acute choices and the attendant ratings of each facility. Where the delay comes is when the patient’s initial PAC selection is unable to accept that patient. Because then your team member has to repeat the process all over again: present the patient with potential post-acute choices, have the patient review the information and make their selections, then go about actually contacting facilities.
When this process goes numerous rounds, it can add hours and even days to the patient’s stay. And it’s not like you can get around this hurdle, as presenting the patient with their choices and documenting their selections is now legally mandated.
We’ve spent the entirety of this article addressing issues that occur at the backend of the patient’s stay at your hospital. But it should be noted that problems at the front end of the stay can also add avoidable time.
If a patient delays preventive care for minor issues, they may wind up seeking emergent care, adding days onto a stay that originally may not have even required admission. Or, if you receive a patient within a part of your health system that doesn’t have the capacity, you may have to transfer that individual before they can even seek appropriate acute care, costing valuable time and money, not to mention delaying the critical care they may need.
When a patient is inappropriately admitted to the incorrect department, all the issues mentioned above (minus patient choice documentation) rear their heads again. But this time, you’re also dealing with a condensed timetable and the need to provide acute care, complicating things further.
These are some of the main factors extending patient length of stay at a hospital or health system. So now you’re probably asking yourself: well, how do I take care of these problems?
That’s precisely what we’ll examine in part 3 of our series on Length of Stay… [Part 1: Why Is Length of Stay Important? Five Key Reasons]