Achieving Hospital Length of Stay and Patient Throughput Goals: A Comprehensive Approach
As hospitals approach the end of their calendar or fiscal years, many are working towards ambitious performance goals such as improving access to care, impacting more lives, or focusing on population health and health equity. Achieving these goals hinges on effectively managing patient throughput and optimizing length of stay (LOS). Whether a hospital is in financial recovery or working toward strategic growth, patient flow plays a critical role in meeting these objectives. A comprehensive strategy to manage hospital beds should be a key priority in every hospital’s three-to-five-year plan.
The Importance of Effective Throughput and LOS
Patient throughput and LOS are fundamental to hospital operations. They directly affect bed capacity, patient safety, quality of care, and financial health. Hospitals that do manage operational flow with intention often face overcrowded emergency departments (ED), delayed care, and poor patient satisfaction, all of which are serious patient safety risks and add to episodes of workplace violence for caregivers.
Strategic Bed Management: Creating a Three to Five Year Plan
The first step in addressing throughput issues is ensuring a robust plan for how hospital beds will be used, a strategic bed management plan. This plan should be grounded in data, including admission projections, historical trends, and a clear understanding of both predictable and unpredictable patient volumes. It should ensure that the elective surgery schedule (controllable) is level-loaded and accounts for the emergency and transfer volume (predictable/not controllable) that is expected to need the same beds throughout the week. Ensure whenever possible that these two admission sources are not competing for the bed resources on the same days. Clear communication is vital and should include expectations so that each person and team know what they need to do to be successful. Taking the time to ensure that all stakeholders including lab, imaging and procedural areas as well as nursing units, physicians, and administrative teams—are aligned in their understanding of the goals and tactics to meet those goals. They also need to ensure that their goals do not create conflict such as driving outpatient imaging exams to the point of not having appointment times needed for inpatients to achieve inpatient throughput.
A successful plan also requires an annual review with adjustments. Hospitals should regularly assess their current performance against year-over-year trends and adjust as necessary to accommodate growth, especially for high-demand service lines and strategic growth areas.
Forecasting for Smooth Operations
Operationally using the forecasting data weekly and daily allows hospitals to predict the number of beds needed and prepare accordingly. For example, every day hospitals know what percentage of f the patients that are seen in their emergency department will be admitted to the hospital, which has a direct number correlation. Hospitals need to plan for those patients first thing in the morning every day, even though they have not arrived, because they are coming. We don’t know their names yet, but we do know approximately when they arrive and what units the historical data include the admission units. By proactively planning for them in the morning, just the same as we do for our surgical volume hospitals will create a smooth flow for patients and caregivers.
Comparing the staffing schedule and the bed management plan on a weekly basis to look ahead, and then daily to create the plan for the day to guide decisions is very important. By planning for what will happen 80% of the time, the team can effectively manage the 20% daily and weekly before it becomes a crisis. Paired with a tactical surge plan that builds upon the bed management plan with interventions to prevent the surge from escalating to the next highest level create allow the team to manage the 20% in a standardized way. Further, ensuring that 80% of the time operations are smooth will allow caregivers and leaders to manage their workday effectively rather than continuously having to put out fires or manage a crisis. This reduces stress for everyone in the organization, allowing optimal performance and increasing joy at work and an improved sense of wellbeing.
Discharge Planning and Specialized Care Pathways
One of the most significant obstacles to effective discharge planning is the availability of post-acute care services, such as skilled nursing facilities (SNFs), assisted living facilities, rehabilitation centers, and dialysis resources. Delays in transferring patients to these services can result in avoidable days, clogging the system with patients who are medically ready for discharge. Providing a separate work stream for complex discharges will allow ongoing operational and strategic improvement work related to these barriers.
Hospitals also need to have work teams focused on the other 70-90% of patients who will discharge home or home with home care or durable medical equipment. By focusing most of the effort on this group of patients, hospitals will create streamlined processes that can efficiently drive throughput. Many of the delays and barriers to discharging this population can be managed and mitigated operationally to ensure that goals are met, and patients and families know what to expect in terms of when they will be discharged. Trending operational delays and discharge barriers inform the teams what work needs to be highlighted for ongoing improvement and coordination efforts to strive to meet the goals.
Managing Boarding Patients: Ensuring the Right Care at the Right Time
Placing the right patient in the right bed at the right time is essential to preventing unnecessary delays in care. Emergency department boarding—the practice of holding admitted patients in the ED until an inpatient bed is available—poses a serious risk to patient safety. According to The Joint Commission, ED boarding is associated with delayed or missed care, medication errors, delirium, higher morbidity and mortality, and prolonged hospital LOS. Words matter and can be powerful tools. By changing the use of the term ED Boarders to Inpatients holding in the Emergency Department or IP Boarders, hospitals can begin to change the perspective of the hospital in terms of responsibility for these patients.
Delays in placing patients into the appropriate bed often result from waiting for a bed assignment due to delays in inpatient discharges. It can also be due to waiting for a consulting service to see the patient, especially in larger more complex hospitals, to determine which service will be the admitting team versus the consulting team. Having service line agreements can help facilitate this and can be part of the strategic planning for the hospital. In some instances, which service admits the patient can drive patient placement, and therefore bed assignments are delayed further. Hospitals should partner with providers to ensure that the patient is kept at the center of these decisions and navigate these decisions prior to patient care being delayed. In hospitals where the decision to admit is based on when the admission order is entered, the technical “start” of boarding is also significantly delayed, however, the patient experiences a very prolonged ED stay, and the practice ignores the research that has demonstrated that the increased morbidity, mortality, and length of stay begin at the point that the ED provider makes the decision that the patient needs to be admitted. Once the level of care required to safely manage the patient’s care is known, and there are primary and secondary differential diagnoses, the inpatient bed should be requested and assigned as quickly as possible. Creating a mitigation plan to decrease the risks of a prolonged ED stay, includes managing boarded patients as inpatients as early as possible and aligning staffing with the required level of care.
The Joint Commission advises that ED boarding should not exceed four hours from the decision to admit. And, while some hospitals use this to define boarding as the hours exceeding four hours, this is not a best practice and negates recognizing the impact in terms of safety and experience of patients and families. The care of these patients should mirror the care they should be receiving once on their inpatient units as closely as possible to mitigate the increased morbidity and mortality as well as the added length of stay. The Centers for Medicare and Medicaid Services requires hospitals that hospitals manage inpatients boarding outside of inpatient units as inpatients starting four hours after a decision to admit the patient, further recognition of the incremental risk that begins to accrue starting at hour two for these patients. While hospitals understand the regulatory impact, too often I see hospitals manipulating this in ways that are not meaningful from a patient experience perspective. Anything that is done to mitigate this risk should be obvious to the patients and families who are experiencing the delays, or they are superficial and meant to manage the metric alone. By aligning staffing, care models, and revenue stream in order to demonstrate what care is needed and provided to care for these patients, hospitals can create transparency in the efforts to mitigate these risks and ensure that the entire hospitals is aware and working together to care for them, just as they would on any inpatient unit. This should include any team or individual who would “touch” the patient on their inpatient unit, including social work and care management teams.
Quality Programs to Reduce LOS and Hospital-Acquired Conditions
Prolonged LOS increases the likelihood of hospital-acquired conditions (HACs) such as infections, falls, and pressure injuries. Reducing LOS through better patient flow directly reduces the opportunity for these adverse events, creating a safer environment for patients and improving overall hospital performance.
Effective quality programs should be tightly integrated with patient flow initiatives. By driving towards zero harm and minimizing the occurrence of HACs, hospitals can break the cycle of poor throughput and capacity management that results from extended patient stays.
Aligning Staffing and Capacity with Demand: A Dynamic Approach
An effective throughput strategy must include a dynamic staffing plan that aligns with patient demand. Too often, staffing decisions are based on historical averages of patients on inpatient units at a specific time of day, often midnight. Staffing plans should have flexibility to expand and contract based on real-time capacity, or even 24-hour planning. This is especially true in tertiary and quaternary care units, where patients may board in the ED due to a lack of available staffed beds on the appropriate unit. For most tertiary and quaternary hospitals, there should be a plan to open every bed on an inpatient unit to avoid inpatients boarding outside of an inpatient unit.
To address this, hospitals must include all patients boarding in non-inpatient units when calculating the midnight census, ensuring accurate capture of bed and staffing demands. Additionally, nursing hours worked should be correlated with the care required for these patients, whether they are boarding in the ED or being cared for in alternate areas.
Emergency Departments typically align staffing to patient arrivals, which means the ongoing care for inpatients boarding in the ED is built into their staffing plan. To have nurses to care for inpatients who are boarding in the ED, many emergency departments show a decreased productivity because their unit budgets are patient visit based, not hours of care based like an inpatient unit. This can be managed by separating boarding patients into a separate cost center where the revenue will connect with the staffing needs based on where the patient is physically located at midnight. Other options include averaging the number of hours that patient hold monthly in order to build a buffer into the ED HPPU budget, or converting holding hours into a modified ED volume to demonstrate the equivalent number of patients that could have been seen in the care that was required for the holding patients. In a best-case scenario, inpatients are cared for by nurses who are experts at inpatient care and have competencies to show they are proficient at the level of care that the patient requires. These nurses should be supported by the inpatient charge nurse on the unit where the patients will be assigned, this has also been shown to increase the number of discharges from those units earlier in the day. I This ensures that staffing is aligned with the level of care provided, improving both patient outcomes and operational efficiency.
Conclusion
Achieving LOS and patient throughput goals requires a comprehensive, hospital-wide approach. By aligning bed management, discharge planning, mitigation plans for inpatients boarding in the ED, and quality improvement efforts, hospitals can ensure that care is delivered efficiently and effectively. By not addressing each of these components, each of them compounds the others and can create a snowball effect. Ultimately, success depends on data-driven planning, coordinated teamwork, and a commitment to continuous improvement. When each department and team understand their role in managing patient flow, hospitals are better equipped to meet their strategic goals and provide timely, high-quality care to their communities.
