Ensuring that patients don’t stay in hospital for any longer than is clinically necessary frees up capacity in the system but also improves quality of care. Across the UK there are wide variations in length of stay, even for patients with similar conditions. This suggests that improvements can be made to the way that care is organised and delivered, particularly to ensure that patients are discharged as soon as they no longer need acute care.
As well as easing pressure on the emergency department, Ipswich Hospital NHS Trust knew that finding ways to reduce length of stay would also have a positive impact on quality of care and patient experience. The team wanted to ensure discharge planning was happening in parallel to the medical plan of care, rather than waiting until patients were medically safe for discharge before considering what else needed to be in place.
The principles were that patients who were no longer in need of acute hospital care would be moved to a home or community setting to receive their care. This resulted in better patient experience and a more cost-effective use of resources for the trust.
“As with many organisations, we were struggling with our ED (Emergency Department) performance. While some of our focus was obviously on the ED, we knew we also needed to look at issues further downstream. Patients de-condition in hospital. If they stay longer than they need to we’re wasting their time and valuable days. For us when we talk about reducing length of stay, we’re thinking as much about improving the patient’s experience and journey, as we are about cost saving and performance. If we get the quality of care right for our patients, we achieve financial and target performance because we’re not building in delays that shouldn’t be there.”
Viv Barker, Lead Nurse for Patient Flow and Complex Discharge, Ipswich Hospital
The team carried out a point prevalence study of adult patients within the medical division over a five day period. This looked at estimated and actual dates of discharge and identified a few problem areas for further investigation. Following this, the hospital invited the NHS Emergency Care Intensive Support Team (ECIST) to help them look at improving patient flow. ECIST produced a set of recommendations, including the roll out of their improvement intervention, the ‘safer patient flow’ bundle, adapted slightly to fit the local demographic.
The patient flow bundle draws together six main initiatives, which when delivered together, support the smooth management of a patient’s care and timely discharge:
- All patients are given an expected date of discharge set within 24 hrs of admission to their base ward which is regularly reviewed. This helps the hospital to plan and understand its capacity at all times. All wards undertake a daily board round before 10.30AM led by either the matron or ward sister. These are a chance to communicate clinical plans so that all services can work in parallel towards the estimated date of discharge, and identify any blocks in the system. In areas of high turnover these rounds may take place twice daily.
- Medical ward rounds follow the board round each morning ensuring care is coordinated appropriately, relevant diagnostics are requested and medication is prescribed. Patients are seen in order of clinical priority with the most sick patients seen first, followed by those potentially ready for discharge.
- A protocol for criteria led discharge allows nurses to discharge patients as long as certain defined criteria (set out by the medical team) are met.
- Red and green days have been implemented for every patient. A green day indicates that something positive has happened to contribute to discharge planning. A red day means that nothing has changed and the patient’s care needs to be flagged for review.
- Length of stay reviews ensure that the team can proactively respond to identified delays to discharge through appropriate action planning.
- Expected date of discharge
- Board rounds
- Ward rounds
- Criteria led discharge
- Red and green days
Positive communication about the project was really important. Patients, their carers and families were told that planning for their discharge started on admission. Asking ward staff to discuss the expected length of stay with their patients led to greater engagement with the project and between nursing teams and their patients.
Implementing the bundle was as much about encouraging behaviour change as it was about introducing new processes. Teams had to learn it was ok to ask questions and challenge each other in order to make sure everything was working in a patient’s interest.
In addition to the patient flow bundle, the hospital has also created three new discharge coordinator posts. These colleagues note all the information from the board rounds and can follow up on anything blocking discharge, such as missing scans or specialty referrals.
The inclusion of community nurses and local authority social care teams in multi-disciplinary team meetings has also ensured that any external influences preventing discharge (such as the need for home adjustments or additional social care) could be flagged on admission and successfully managed prior to discharge. This collaborative approach has been really successful and has led to much better relationships with primary and community health providers and the voluntary sector.
The trust has succeeded in reducing the average length of stay. Data for July 2014 showed a length of stay for non-elective patients of over one day less than the same time in 2013 (6.07 days in July 2014 compared with 7.3 in August 2013). Since then the downward trend has continued, with an average length of stay of 5.3 in August 2015 and further decreases to 5 days in December. This is releasing capacity and allowing the trust to provide care to more patients within the same budget.
As predicted, this improved length of stay has supported the emergency department to regularly achieve 95% performance of the required quality standard of four hours to treat and discharge, or admit to a base ward.
With more accurate information now available in the trust’s delayed discharge database, and the development of an additional tracking system for patients receiving continuing healthcare, operational managers, matrons and CCG colleagues all now have a greater awareness of the progress of the patient pathway and any blocks to discharge. Better ‘real time’ reporting across the hospital and to local commissioners will also help predict future demand and set budgets.
The team are also developing a range of other projects in the community which will speed up discharge by ensuring appropriate support is available at home, while also preventing unnecessary admissions. This includes the admissions prevention service and a new crisis assessment team. A team of therapists and nurses can now coordinate 24 hour care in somebody’s home in order to provide additional short term support and avoid an unnecessary admission or prolonged hospital stay.
A pilot project is also testing ways that intravenous (IV) drugs can be provided in the community, which will also help to allow patients to be discharged as soon as they are well enough and continue to receive IV drugs at home.
The care bundle is now being rolled out across other wards and areas of the trust, including the local community hospitals. Trusts across the region and further afield have also been visiting to learn from the team.
The team are continuing to look at new ways to improve how they work. They are currently introducing new electronic whiteboards, which will help deliver real-time bed management.
‘Nothing ever stops. We’ve moved from initiating the patient flow bundles to looking at how we manage our capacity meetings, how we manage red and green days, how it’s escalated, how it’s dealt with… It’s a constantly evolving project really, you’re never at the end of it.’
Viv Barker, Lead Nurse for Patient Flow and Complex Discharge, Ipswich Hospital