The NHS could save up to £400m a year in length-of-stay costs with some simple measures, argues Andrew Webb
It has long been recognised that some hospitals have longer lengths of stay than others. The true extent of the variations becomes starkly apparent when trust-by-trust data is closely analysed.
According to information supplied by NHS trusts to data warehouse HES for 2005-06 (the most recent available), patients' hospital recovery time can vary by as much as seven weeks, depending on which trust treats them.
Looking at hip replacement and bowel surgery, two of the most common elective surgeries, the average length of hospital stay in English NHS trusts is 10.4 days and 17 days respectively. However, patients who have had a hip replaced in one South West trust are discharged after an average of just 4.4 days, while others in west London spend 26 days in hospital.
For bowel surgery, one London hospital discharges patients after 11 days, almost six days sooner than average, but patients in another trust a few miles away spend as long as 25.7 days in hospital.
One of the interesting aspects of this data is there are no clear patterns. Geographic location has little effect on a hospital's average length of stay and neither does the type of trust - both university hospitals and district general hospitals have below average lengths of stay in some areas, and above average in others.
The volume of surgery a hospital carries out might be expected to have an impact. However, although trusts performing fewer than 20 procedures were not included in the data, those that carried out more did not necessarily perform better or worse. It is, therefore, likely that a hospital's average length of stay is determined by the treatment each patient receives.
It is important to emphasise that effective reduction of a hospital's average length of stay is not a question of simply discharging patients earlier; rather, we must ensure patients recover more quickly to reach the point at which they are ready to leave hospital sooner. No two patients are the same. Nevertheless, there are many examples of best practice that can be shared for the benefit of all.
Steeped in dogma
A number of trusts around the country have made significant reductions in their length of stay by implementing a range of procedures aimed at improving surgical outcome while improving length of hospital stay.
The problems of retraining staff, investing in new technology and altering long-held practices steeped in dogma rather than evidence can deter hospitals from making inroads into reducing the length of stay.
The investment in reducing length of stay can reap financial as well as clinical rewards. The cost of extra days in hospital is expensive. The average cost of a 24-hour stay in a surgical bed is up to£400. The hospital with the longest length of stay for hip replacements could save up to£8,500 per patient in bed costs alone if it was able to discharge patients as quickly as the hospital with the shortest length of stay.
The Improving Surgical Outcomes Group is concerned with the best ways to improve surgical outcomes and, through evidence-based approaches, identify ways to ensure patients leave hospital faster and fitter. Its latest report, Modernising Care for Patients Undergoing Major Surgery, looks at examples of a number of hospitals that have been able to reduce their average length of stay.
A study at the Freeman Hospital in Newcastle showed that patients who were fluid optimised during major bowel surgery were less likely to suffer major post-operative complications and were discharged after an average of seven days, a week and a half below the national average.
At University College London Hospitals we have radically altered the way we approach colorectal surgery and the early indicators are very positive. We introduced an enhanced surgical treatment and recovery programme early in 2007 and reduced the length of stay from approximately nine to 10 days per patient to just six.
The programme builds on the fast-track surgery work pioneered by Danish surgeon Henrik Kehlet. He demonstrated dramatic reductions in hospital length of stay by bringing together a raft of separate measures in the pre, peri- and post-operative periods. By combining these with keyhole surgery and fluid optimisation during the operation, we have seen real improvements in the outcomes of our patients.
The programme has reduced post-operative morbidity, allowing a rapid recovery period. The criteria for discharge are the same, so the burden of care has not been shifted to primary care staff. Patients reach the discharge criteria earlier. It is cost-effective; by freeing beds earlier we can treat more patients and generate more income for the trust.
The success of the colorectal programme is such that we are implementing the programme in hepatobiliary, pancreatic and vascular surgery. The principles behind the programme are well established and are used, to varying degrees, in other parts of the NHS. The surgical outcomes group report notes trusts up and down the country that have adopted components of the programme and made significant reductions in their average length of stay.
While this kind of patient care overhaul takes time, there is no reason why it cannot be rolled out across the NHS. If the programme were implemented across the health service, the NHS could save as much as£400m a year to invest in further improvements to healthcare.
How to cut colorectal surgery stays
Comprehensive multidisciplinary preparation of the patient before admission, including:
a package of education to better inform them about their surgery and expected post-operative recovery process;
an assessment of fitness using cardio-pulmonary exercise testing;
optimisation of their circulation.
During the operation
Anaesthetic techniques to minimise the stress response to surgery and avoid nausea and vomiting;
minimally invasive surgical techniques;
specialist cardiac and fluid monitoring - oesophageal Doppler monitoring - during and immediately after the operation.
Effective pain relief;
early return to eating and drinking.