Unnecessarily prolonged stays in hospital are bad for patients. This is due to the risk of unnecessary waiting, sleep deprivation, increased risk of falls and fracture, prolonging episodes of acute confusion (delirium) and catching healthcare-associated infections. All can cause an avoidable loss of muscle strength leading to greater physical dependency (commonly referred to as deconditioning).
Tackling long stays in hospital will reduce risks of patient harm, disability and unwarranted cost, particularly for those who are intrinsically vulnerable because they have mild or moderate frailty and/or cognitive disorder, and for whom a different, more positive outcome can be achieved if the right steps are taken very early in their admission.
Hospital-related functional decline in older patients and the subsequent harm has dreadful consequences for many patients, and is something we should not tolerate.
- 35% of 70-year-old patients experience functional decline during hospital admission in comparison with their pre-illness baseline; for people over 90 this increases to 65%
- Extensive use of audit tools has shown 20% to 25% of admissions and 50% of bed days do not require an ‘acute’ hospital bed as these patients’ medical needs could be met at a more appropriate, usually lower, level of care
- 39% of people delayed in hospital could have been discharged using different, usually lower dependency, pathways and services more suited to meeting their assessed needs
- Typically these audits show that up to half the reasons why patients are not discharged earlier are under the direct control of the hospital itself and often relate to ineffective internal assessment processes, lack of decision-making and poor organisation of care management
Every day in hospital is a precious day away from home. We want to embed a ‘home first’ mindset across our health and social care systems and do everything we can so our patients, particularly older people, can enjoy their lives in their own home environments or, for the few who cannot go straight home from hospital, in a care location most suited to meeting their needs.
The benefits of reducing the time a patient occupies a hospital bed are clear, but achieving it has proven difficult, particularly during winter. This guide explains what can be done to implement the approaches proven to reduce LoS (see Figure 1). We go beyond principles, describing the practical steps and suggesting tactics to employ. This is a ‘how to’ guide, not high-level guidance. It is primarily aimed at acute and community trusts, but refers to how system partners, social services, the voluntary/third sector, independent care providers and unpaid carers can play a supporting role.
These tactics must of course be carefully considered and implemented with an eye to local circumstances. One size does not fit all. We stress the need to use effective improvement approaches and in particular plan, do, study, act (PDSA) cycles to ensure that new approaches are implemented in a way that works locally.
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