Published: 05/02/2004, Volume II4, No. 5891 Page 23

Reducing bed stays rather than delayed discharge is the key to freeing up acute beds, says Roger Taylor

Many delayed discharges occur when an acute hospital is ready to discharge a patient but cannot do so because the patient needs to be transferred to somewhere with adequate nursing or residential care but no places can be found.

The frustration this causes is one reason why delayed discharge has been a focus of policy. Another reason is that, unsurprisingly, such delays reduce available hospital beds. Chart 1 shows that for patients who have a hipreplacement operation in England and then return home, the average time spent in hospital was 12 days. However patients who were transferred to another hospital spent an average of 17 days in hospital, while those who were discharged to 'other' destinations - principally nursing or residential care - spent an average of 19 days in hospital.

Chart 2 shows the average length of stay of transferred patients by trust alongside the length of stay of those discharged home. If beds were being used efficiently, one would expect to see patients discharged to a community bed leave hospital more quickly than those discharged home since they can be discharged at an earlier stage of recuperation. But in many cases the opposite is the case.

The explanation is often the lack of intermediate beds.

Only the sickest patients use them and they may often have to wait in an acute bed to be moved into them.But these figures disguise a more important issue. Both within trusts and between trusts there is enormous variation in the length of time patients spend in hospital. Again, comparing hip replacement patients, chart 2 shows the average length of stay ranked for each of 168 acute trusts. The figures range from eight to 18 days. Of these, 29 (18 per cent) had an average length of stay of 10 days or less while another 11 per cent had average stays of 14 days or more.

Chart 3 shows the bed days which could have been saved if no hip-replacement patient had remained longer than the average length of stay for patients of their age, sex or diagnosis. Such a perfect result could not be achieved in reality, but the exercise helps to clarify where the greatest potential lies for reducing demand on acute beds.

The answer is clear. Reducing the length of stay for patients discharged home has far greater potential to free up acute beds than any amount of clearing patients whose discharge is delayed because of a lack of care home beds.

By this calculation, the average trust could have saved 600 bed days on the patient discharged home, compared with less than 100 for patients transferred or discharged to other destinations.

There are steps that can be taken to address the length of stay of patients. Sometimes the problem is exacerbated by bureaucratic blockages. Improving levels of community nursing support to patients at home may also enable earlier discharge. Another approach is to improve availability of intermediate care beds in community hospitals.

Roger Taylor is a director of health information analyst Dr Foster (www. drfoster. co. uk/phone 020-7256 4900). The figures are calculated from hospital episode statistics for the year to March 2002 by the Dr Foster Unit at Imperial College London. This is the first of a fortnightly column from Dr Foster examining key data on waiting lists, access and demand.