If you’re a hospitalist, no doubt you’re familiar with length of stay (LOS) as a performance measure. In a McKinsey survey of academic medical centers across the country, only four out of 100 said they weren’t pursuing decreased LOS as an operational initiative. After all, tracking patients’ time in the hospital, from admission to discharge, is a relatively easy —though sometimes misleading — metric to consider.

A shorter stay makes sense for most patients. Unless they’re in dire condition, who wouldn’t rather be in more comfortable surroundings? Earlier discharge frees up beds and hospital resources, which makes care more accessible for others. Moreover, it reduces the risks for hospital-acquired conditions (HACs), which only prolong hospitalization. A recent systematic review looked at the most common HACs and found they increased LOS by nearly 5 days for falls up to 22 days for central line-associated bloodstream infections.

And let’s not forget the benefit to you. Your organization may offer a financial incentive to keep your average LOS low, or you may simply find it helps fend off burnout.

“Clinicians are people,” said Shannon Davila, RN, executive director of Total Systems Safety at ECRI, a healthcare safety nonprofit headquartered in Philadelphia. “It does take a toll when you’re caring for patients who aren’t getting better, who are suffering increased acuity in hospital longer.”

There’s No Magic Bullet

Unfortunately, bringing down your average LOS isn’t a question of trying harder. Many of the issues that lead to extended stays are systemic, like staffing problems, delays in testing and analysis, or the lack of availability at rehab facilities.

“Generally, it’s a combination of things we see in high-performing organizations,” Davila said. “[It’s about] how they’ve designed their systems — not the physical healthcare system but clinically and operationally: how they deliver care, engage with patients, [and] support team members to be successful [and] how they evaluate technology before they bring it in.”

Research on reducing LOS tends towards the systemic, too. But effectiveness varies widely. A systematic review of interventions to reduce LOS among high-risk patients compiled data from 19 previous systematic reviews. It identified eight different approaches backed by significant amounts of research, but none safely and consistently reduced LOS across high-risk populations.

“There has to be a consideration of tradeoffs,” said study co-author Kelley Tipton, associate director of clinical evidence services at ECRI. “One intervention may be promising to reduce length of stay for a given patient population, but how does it impact readmission risk, and how does it impact adverse events that can happen outside the hospital setting?”

Practical Tips on Reducing LOS

OK, so many, if not most, of the issues that may prolong a patient’s hospital stay are beyond your control as an individual clinician. But there are adjustments you can make that may help:

• Focus on the individual patient. Often, that means prioritizing the tests and procedures related to what brought them to your hospital. It also means assessing each patient’s reality. Research shows that social determinants of health — the nonmedical factors like their living situation, community support, and food security — play a significant role in LOS. Your perceptiveness and expertise matter here.

  “That’s the thing about hospital medicine: We see every type of patient, no matter what they’re admitted for,” said Ruby Sahoo, MD, hospitalist and hospital performance director at TeamHealth in Austin, Texas. “It’s why we go through so much training. It takes a lot of experience to be comfortable with knowing when a patient is ready for discharge.”

• Maintain effective communication. Sharing necessary information quickly can keep care moving smoothly. For instance, consultations with specialists play a huge role in patient care, but if you haven’t established a good rapport, it can cause delays.

  “If I’m the hospitalist seeing a patient and I identify the need for a cardiology evaluation, I call or text the cardiologist immediately and discuss the case,” Sahoo said. “They can do what they need to do, let me know, and then I can do what I need to do to get this patient home safely.” It may seem basic, but it matters. “This kind of communication is incredibly important,” she said.

  Keeping the patient’s family or healthcare proxy in the loop can also reduce delays — they may have key information to factor in. If you can, establish who will be your main contact during your initial interaction, and tell them what to expect in terms of daily communication. Let that person disseminate information with the rest of the family. When your contact isn’t on the premises, try to communicate while you’re in the patient’s room. Use the speakerphone or a video call to have one inclusive conversation.

• Start discharge planning as soon as possible — on the day of admission, if possible. This includes looking at the relevant social determinants of health to see if there are potential barriers to discharge. The sooner these are addressed, the sooner your patient can go home safely — and the more likely they are to avoid readmission or complications.

  “This isn’t just giving a discharge instruction,” Davila said. “It’s actually taking the time to work with the family, to work with the patient or the caregiver, and to understand ‘where are you truly going back to?’ Let’s talk about what post-discharge is going to look like to you. What are your goals of care? What do you hope to achieve in the next month, 3 months, 6 months? It’s a collaboration.”

• Adjust your end-of-shift routine. Try to set aside time to reassess and consider which patients may be ready for discharge the next day. Are you still waiting for test results or a consultation? On the flip side, has the patient shown marked improvement over the course of the day? If things are looking good, get a leap on the discharge papers.

• Embrace new technologies. Before the pandemic, how often did you use a tablet for anything other than notes on the job? Now, telehealth is the new normal. Some research suggests that hospitalist-performed telehealth evaluations done before scheduled hospitalizations can shorten LOS.

  “Telehealth and remote monitoring, which scaled out of necessity during COVID, are now core tools for managing patients safely outside the hospital and supporting earlier discharges,” said Dan Samarov, PhD, chief artificial intelligence (AI) officer at Health Catalyst, a healthcare data and analytics company, in an email.

  And don’t discount the ways AI may be used to lighten your load, which can help reduce LOS and prevent clinician burnout.

  “AI has a lot of different uses within the hospitals,” Davila said. “Dictation, medical record review — it can help the providers do their jobs more efficiently, which allows them to spend more time at the bedside with the patient, which is, of course, why people go into medicine and nursing.”