Ask a doc: Length of stay
Internal Communications recently spoke with Dr. Chadi Ibrahim, internal medicine hospitalist, chief of medicine at Beaumont, Troy and medical director of Care Management, about the importance of patient throughput and length of stay.
Throughput is about efficiency and providing valuable care. It is important to be efficient and nimble in caring for patients while being mindful of appropriate use of resources as they move through the continuum of care.
As a physician, how does patient throughput play a role in your workday today?
Physicians have to be mindful of what kind of care the patient needs to receive while in the hospital, versus care that could be deferred to the outpatient setting. It’s important to recognize that. It’s also important to recognize what resources are needed to help make care efficient, such as which consultants to involve, leveraging care management early in the course of treatment, partnering with patients and families, setting expectations early on and optimizing communication. The physician is the leader of the care team, and we need to have strong communication with all members of the patient’s team. Good communication leads to more reliable team function, helping us take better care of our patients while also involving families in the decision making.
So patient care is really a team sport, and we all have to be on the same page, is that accurate?
I frequently have discussions with physicians about length of stay. When discussing throughput and length of stay, it’s critical to point out the clinical perspective of why it’s important. I try to focus on the quality and safety aspect of it. When discussing hospital-based initiatives, physicians and nurses first and foremost want to know “how will this impact my patient’s care?” We know from the Quality and Safety Reports and other quality data we receive that patients who are waiting in the emergency room without an inpatient bed are an especially vulnerable population because the normal inpatient processes we have devised are not applied to them in a consistent way. We need to be mindful of these challenges and do our part to help our patients, serve our community and make sure that patients who need inpatient care are receiving it in the best way possible.
In internal medicine, we take care of very ill patients who are at increased risk for complications. Staying longer in the hospital could mean patients become weaker and develop more complications, resulting in staying in the hospital even longer. That longer period puts them at more risk. It’s a snowball effect, so physicians really need to understand that concept well. Sometimes, with elderly and ill patients, there’s a window of opportunity we need to take. That opportunity is when the patient is medically improving and no longer has to remain in the hospital. That’s when we need to transition them into the next stage of care so they can continue getting better outside the walls of the hospital. If we miss that window of opportunity, it puts the patient at risk of developing more complications, such as further functional decline, hospital acquired infections and other problems. The sooner we can safely get the patient discharged, the less we expose them to these complications.
Working together to accomplish the goal of quality and safety while keeping the patient’s best interests in mind and setting patient expectations of reaching their milestones is the key to improving length of stay. Length of stay is a crucial piece of the patient experience, yet not one that always gets the attention it deserves. It’s time to start thinking hard about this critical aspect of your clinical capabilities.
Best practices to help improve efficiency:
- Engage Care Management early in the hospitalization. Care coordinators can identify early obstacles to discharge and can help use available resources to efficiently coordinate discharge.
- Discuss discharge planning with the patient and family early in the admission so expectations can be set and potential issues identified sooner.
- Inform the patient and family that care continues after discharge and reassure them any non-acute issues will be properly addressed in the outpatient setting.
- Common delays and problems may result from overuse. The most common instances of overuse are with IV fluids, telemetry, foley catheters and daily lab testing. Limiting these when appropriate can help expedite care.
- Ensure that consultants’ recommendations are clear and all involved in the care are on the same page.
- Touch base with nurses when you round. Bedside nurses are often aware of details that can impact care and discharge recommendations.