Tips to help get patients out the door faster.
Dear Director,
My chair posts our individual length of stay data and I’m tired of being the slowest in the group. What tips do you have to help me reduce patient’s length of stay?
Discharged length of stay (LOS) is a key metric for hospitals. It’s publicly reported on the CMS website, contributes to a hospital’s CMS Star Rating, is related to quality of care, and has financial impact to hospitals as longer lengths of stay may require more nursing FTEs.
The responsibility for length of stay is split between the ED leadership (medical and nursing directors) who are responsible for staffing and designing a good flow system and the individual providers who need to be attentive to the things they can control. I’ve written on the system issues before so this article will address issues that are within the control of the individual physician.
In a recent article on LOS, the authors found evidence that different patient characteristics (age, acuity, etc) significantly impacted LOS and that LOS should be viewed through a more balanced lens.[1] This is an interesting concept as the article was based on a large, urban, academic ED that assigned patients to pods and did not have a dedicated Fast Track area.
In other words, you saw the patient you were assigned. This model clearly can have differences in acuity as you could see many low acuity patients or have a pod full of 80-year-olds. Many of us assume that each doc sees a similar patient population at their site. This may or may not be true.
One way to easily balance this is to look at individual LOS by ESI level. At my site, we’ve started looking at what percentage of our ESI 3 patients are discharged within a certain time period. While this doesn’t account for all age and acuity differences, it’s a far better comparison than when I looked at discharge LOS (dcLOS) and a couple of docs were phenomenally better than everyone else but they had also worked more Fast Track shifts. If I got really into it, I could also balance it by comparing individual docs to each other by age groups and ESI level.
Part of understanding how to reduce LOS is to better understand the metric. LOS is generally considered door to door time for the discharged patients. Most hospitals use a median time, which negates the impact of the outliers. Otherwise, docs might avoid the intoxicated patient or we might try to discharge them too quickly if we were really worried about metrics. Because it’s arrival to out the door time, we can break it up to door to provider, provider to disposition and disposition to out the door.
When I sit with docs to discuss their metrics and coach on LOS, I try to get into the weeds of all of these numbers. One of the things that we often can control is how long someone waits before we go see them. Door to doc remains a key hospital metric and sometimes we need to decide if we’re going to see the next patient, discharge the patient who is ready to go or pick up the phone to track down the radiologist about a CT.
All of these actions impact each patient’s length of stay, but picking up that chart, and at least doing a brief intro with the patient, allows you to get your whole team working on them, which has downstream benefit.
Some places track room to provider time and not the time from arrival, leaving it up to nursing to get the patient into a room. That’s an interesting managerial data point but removes the physician incentive to get patient into rooms more quickly, use hallway spots effectively, or see patients in the waiting room. After all, the metric is arrival to out the door so it’s beneficial if we’re all focused on the entire metric.
While there is no secret sauce that will reduce LOS by 30 minutes, the good news is that there are many techniques the slower docs can use to move the needle on this key metric. And it doesn’t generally take compromising on your approach to patient care.
Keep in mind, we all have non-productive time during our shifts. It might be texting your spouse or kids, checking your email or talking to the nurses about a new restaurant. All of these things are important, but should not come at the expense of delays in patient care.
Make sure you win the easy wins.
- Every day, each of us gets a few patients that we should be able to turn them around pretty fast, such as asymptomatic hypertensive patients, most head injuries and patients presenting with hyperglycemia to name a few. Once you know you’re going to see these patients, you want to do everything you can to make sure their care moves swiftly. That means minimizing door to doc time, checking in with the nurses to make sure there’s no hang ups in the work up and then getting them out the door quickly once the disposition is made. I lose whatever hair I have left on my head when I find my asymptomatic hypertensive patient waiting a long time for creatinine level. On the flip side, I don’t sweat it if my really intoxicated patient has a bit of a delay before he gets his labs drawn as he’s not going anywhere quickly either.
Chart Review before seeing the patient
- For stable patients, take a minute to look at their chart before you see them. You’ll be surprised how many patients come in for something that they recently had an extensive work up on, such as recent abdominal/pelvic CTs or even a cardiac cath. Tell them what you’ve already reviewed so they don’t have to explain to you at great length things you can read very quickly in the chart.
Patient Communication
- Be clear with patients upfront about what will and won’t be accomplished during the ED visit and the anticipated disposition. When relevant, ask the patient up front how they’re getting home if the workup is negative.
- Set reasonable expectations at the beginning of the visit. With a chronic pain patient you might say: “I will order one dose of pain medications but not more. Your discharge instructions will be ready after that dose is administered.” Or for someone with 10 complaints, “That would be an appropriate X-ray for your primary care doctor to order as an outpatient.”
Nurse Communication
- As soon as you see the patient, let the nurses know the big-picture plan and what’s the most urgent or key rate-limiting step for the patient. It helps with LOS but more so empowers them to be part of the clinical management.
- I’ve found that I sometimes spend countless time wandering around looking for nurses. Take advantage of your EMR’s Secure Chat function (if available) to communicate with the nurses about the patient’s progress.
Testing
- For elderly patients who need a UA, consider ordering a straight cath early on.
- Just like nurses don’t like to be “nickeled and dimed” with orders, don’t do that to yourself as you interpret results. Wait until a critical mass has returned before reviewing and then put all of your attention on interpreting the full picture so you can decide discharge vs. home vs. more testing. Then immediately move forward with this decision so you don’t expend the mental energy to interpret the results multiple times each time something new results.
- Don’t order imaging without a clear question in place. If you can avoid imaging through a soundly reasoned MDM note, then save the patient the radiation and yourself the time and don’t order it. There’s plenty of ways to reduce utilization through the use of evidenced based decision rules that reduce the need for additional testing, such as PECARN head injury rule, PERC rule and HEART Score. Build phrases that can assist your MDM note.
- Cancel triage orders (like urine) that are not needed. I’ll never understand why patients become anuric as soon as we tell them we need urine for a test and waiting on a test you don’t need just adds to the LOS.
- If someone needs a CT, they need a CT, but if they have been to the ED 10x in the past six months and have had six negative scans, you should be hard pressed to order another. Along with that, for chronic pain issues, check your local/state prescription monitoring plan and/or any other records available to you.
- Act on the information you have available. Ignoring the data is just delaying the disposition and means more time the patient will spend in the ED.
Discharging
- Law #5 of the House of God: Placement comes first. Get case management involved early for patients who might need it.
- At my shop, registration sometimes occurs long after the patient has been evaluated. Give registration a heads up when you’re going to be discharging a patient who hasn’t been registered yet. For patients you know you’ll discharge quickly, do this as soon as you’ve seen the patient so they can register them and enter the pharmacy info. Registration is critical but don’t let it hold up a discharge more than a few minutes.
- For those sending e-prescriptions, confirm the pharmacy with the patient when you’re having your discharge talk with them, so you’re not asked to re-do the prescription afterwards.
- When you have your discharge talk with the patient, let the nurses know that you’re about to put the patient up for discharge. This tunes them in to help reduce the dispo to out the door time.
- Make discharging patients your top priority. If a patient is ready for discharge, do it. Clear out some brain space so you’re in better shape to then pick up another patient. I once heard someone lecture that patient priority is emergency/critically ill, then discharge, then new patients. Everything competes for your time and the space in the ED. But be careful of creating a mass exodus and spending an hour discharging several patients. If patients are waiting on you, then it’s an hour before the first patient is seen and that’s valuable time lost.
- Use as many scripted phrases as possible for the discharge instructions. I think discharge instructions are critically important and should be customized to the patients needs. With that said, time spent developing your key phrases will help you hit the mark for thorough and individual discharge instructions that you can knock out in seconds.
Take advantage of your EMR/Tracker. Not everyone is on Epic, but about half of us are and there are a large percentage of people who are on equally savvy EMRs. Let technology be your friend and your assistant.
- Click the bell icon on the key result you’re waiting for to determine the dispo. That way, as soon as the key result is back, you’ll know it either via the tracker or your phone. You can even get results to display on your Apple Watch.
- Each time you sit down at your computer, scan your tracking board and ask yourself, “Can anyone be discharged?” If so, do that immediately. Don’t get distracted and wait for a more convenient time.
- Organize your tracker by the Total Time in the department so you can scan your board and more easily keep track of people whose LOS is nearing the 2-2.5 hour mark
- I try to review the board every time I sit back down to see if anyone is ready to be dispositioned.
Other tips
- What’s worse than a fecal impaction patient? Having it diagnosed on CT because you didn’t do the rectal exam. You just added hours to their visit. Perform any specialty exam (such as pelvic or rectal) during the initial H&P and exam. Bring all the equipment with you on your first meeting.
- In many busy community EDs, the reality is that you may not be able to chart until a lull in the action or at the end of your shift. Delaying charting will provide some additional time to get to the next patient quicker though it comes with trading off a possible reduction in the thoroughness of the chart and certainly time after your shift. With that said, a compromise may include writing (or dictating) the critical medical decision making component right after you see the patient since your thinking will be the most clear and it will help you remember aspects of the case when you complete the chart later. Sometimes, it becomes necessary to not complete the chart until there is nothing else to do, the patient is getting admitted, or it’s the end of your shift.
- Know your disposition from the beginning. What’s the threshold for amount of IV fluids and meds for thinks like renal colic, gastroenteritis and asthma?
- Place phone calls early. If patients need a consultant, give the consultant the heads up. If you know you’ll want to talk to the PMD or specialist to facilitate follow up, lab results probably won’t change much if you anticipate the patient leaving.
Conclusion
Length of stay is important to your hospital. Therefore it’s important to your medical director and should be important to you. There are no magic potions that can make a slow, very methodical provider faster, but there’s a variety of techniques you can apply to help reduce your dcLOS. It’s important to remember that it’s a median so there’s huge impact in reducing your “typical” patient by about 10-20 minutes. With some additional focus on the total time in the department, you can reassess some of your priorities and get the patients who should be discharged out the door.
I want to acknowledge and thank many of the docs at my site who contributed their own strategies that are listed above.
Reference
Chang CY et al: Association Between Emergency Physician Length of Stay Rankings and Patient Characteristics. Acad Emerg Med. 2020 Oct;27(10):1002-1012
