Speeding up admission and smoothing discharge has reaped rewards in reducing length of stay. Mark Eaton explains.

Substantial amounts of managerial and clinical time are spent balancing the need for beds with ensuring that discharges occur safely. This can be complicated by unplanned admissions and delays in the transfer of care.

High pressure need for additional beds increases stress levels and lowers productivity, raising the risk of mistakes occurring. Rising to these challenges is not easy.

Sue Stanley, director of service improvement at Northampton General Hospital, says: “Success in reducing length of stay is achieved when we understand the pathway from the patient’s perspective and then remove all the delays and duplication that occurs.”

In using regional innovation funding to address these issues, the hospital has developed the Think Home First programme. The programme brings together acute and community care clinicians with a task force including transport, re-ablement and social care to effect faster discharges.

The project has reduced the time from referral to assessment to around 24 hours in most cases and has already saved more than 800 bed days, as well as winning two health and social care awards for partnership working.

The focus hasn’t stopped there. Ms Stanley’s team has reduced the time to dispense medications by 57 per cent, itself leading to an average 0.25 day reduction in length of stay.

A proactive approach to improving patient care and reducing length of stay can also be seen at University College London Hospitals Foundation Trust, which launched its quality, efficiency and productivity programme in 2010. To improve ward efficiency, the programme brought together various strands of activity including enhanced recovery, increasing morning discharges and lean methodology to improve patient pathways. HSJ judges commended the work when UCLH was shortlisted for the acute hospital of the year award.


Bed days saved in neurology at UCLH

Lisa Hollins, deputy director of service transformation for UCLH, says: “In 2009, our patients described delays in discharge as one of their key concerns for NHS services and we have worked hard to improve our systems and processes and build new services with local partners.”

This work has involved redesigning pathways so patients are seen by experienced clinicians as soon as possible and providing specialist chronic obstructive pulmonary disease and elderly care input in A&E and on admission.

The results at UCLH have been impressive. Length of stay reduced in elderly care and neurology by 2,307 and 1,112 bed days respectively from 2009-10.

Smaller gains in high volume areas, such as maternity, have reduced average length of stay by 0.2 days, which has reduced bed days by 2,933, a large impact due to the high volume of admissions.

Overall, length of stay reductions across all specialties have released 10,360 bed days, enabling the trust to place a hyper-acute stroke centre on the site. The reductions in length of stay have also helped to reduce the impact of winter pressures with fewer delays in pathways and continuing to ensure that over 98 per cent of patients are treated within a four hour A&E timescale.

Ms Hollins says: “The work we have done has improved our patient feedback scores and we are delighted that changes to our processes are being felt by patients. At a local level, clinical teams have worked together to deliver fantastic improvements and every week we showcase our ‘ward of the week’, an initiative that has helped with staff engagement and created a competition for improvement.” 

Morning glory

Coupled with this work, both Northampton and UCLH have taken steps to tackle indirect activities that also increase stay length. For example, Northampton has run a highly successful lean programme in pathology that has reduced turnaround times by as much as 93 per cent and increased productivity by 20 per cent, while UCLH has focused on a “pre-11am” peak for discharges that has tripled the number of patients discharged before lunchtime and brought the availability of beds much more in line with demand.


Bed days released across all specialties at UCLH

Effective teamworking across several organisations is often vital. Judith Kay, adult services manager at community services provider Hounslow and Richmond Community Healthcare Trust, explains: “Proactive support from community and social care teams is often the conduit to reducing excess bed days.”

Using CQUIN funding, Hounslow provides a seven day a week inreach service to its two local acute trusts. This involves on-site input into discharge planning activities and active support from community respiratory and stroke teams working in the acute setting to shorten referral times and create community capacity.

This service has removed almost all patients with more than 80 excess bed days and reduced significantly those with greater than 20 days. It is also increasing community bed use and providing acute care teams with faster access to a variety of out of hospital solutions to patient needs.

Such examples of good practice are balanced by the knowledge that reducing length of stay is not all plain sailing. Elsewhere, there are instances of community commissioners using a 24/7 inreach service to work with organisations that only discharged patients from Monday to Friday and a healthcare economy that resisted establishing a geriatrician led community team to speed up discharge for elderly patients, because they couldn’t agree on how the service would be funded.

These aside, the examples here demonstrate that reducing length of stay can be achieved through a practical service improvement mentality by:

  • treating every step from admission to discharge as key steps in the process of reducing length of stay and not just discharge activities themselves;
  • getting to grips with the difficult, controversial and non-value adding activities that increase the workload for staff and delay discharge by redesigning pathways, minimising delays between steps and ensuring greater levels of consistency in the way discharges are managed within and between departments;
  • increasing multidisciplinary working and breaking down funding barriers that prevent the effective transfer of care.

Other strategies involve starting the discharge planning process as early as possible and keeping a twin focus on both areas with exceptionally long stays and those with high volume, but plans should tackle short duration stays as well.

Reflecting on the Northampton experience, Ms Stanley says: “Without the commitment to working on the difficult issues surrounding length of stay and refining what we did until we got it right, we could not have achieved what we have.”