The #last1000days from #red2green


Time is the most important currency in healthcare. It manifests in patients waiting, duplication, staff running around looking for things and needless harm being caused. Patient time as the key metric of performance and quality is best measured from the perspective of the person.

The Last 1,000 Days emerged from the construct of patient time. It’s a metaphor that stems from the recognition that in most developed nations, if you’re a white woman, you can expect to live to the age of 83 and if you’re a white man, you can expect to live to the age of 79. But supposing you’re an 80 year-old woman or a 76 year-old man, what have you got left?

What you have left is 1,000 days. 1000-days

Once you survive childhood life expectancy goes up, the longer you live, the longer you can expect to live. But, if you had 1,000 days left to live, how many would you choose to spend in hospital?

This is where Red2Green comes in.

A Red Day is when a patient receives little or no value-adding acute care, such as investigations, assessments, procedures or therapeutic intervention. Or a patient is receiving care that does not require them to be in an acute hospital bed.
  • A Red Day is a day of no value to the patient.
  • A Green Day is when a patient gets acute care that can only be provided in hospital that actively progresses them towards discharge.
  • A Green Day is a day of value to a patient.
Red and Green Bed Days operationalises the #last1000days to get patients closer to the place they call home. It respects patients’ time as sacred and the days they spend at home as both an outcome and a goal.


Another way to bring the #Last1000days and #Red2Green to life would be to #EndPJparalysis

Healthcare was born in the church and raised in the army, and the uniform the patients are expected to wear is a gown or pyjamas, often right up to the hour of their discharge. Being in bed when not clinically necessary is really bad for patients and being in pyjamas reinforces the ‘sick role’ that, although enabled out of compassion and kindness, leads to unintentional harm.

For every 10 days of bed-rest in hospital, the equivalent of 10 years of muscle ageing occurs in people over 80-years old, and reconditioning takes twice as long as this de-conditioning. One week of bedrest equates to 10% loss in strength, and for an older person who is at threshold strength for climbing the stairs at home, getting out of bed or even standing up from the toilet, a 10% loss of strength may make the difference between dependence and independence; it is one of several reasons why, to use the memorable phrase of Dunedin NZ-based geriatrician Dr Nigel Millar (@nigelmillarnz), the person stays in hospital as, ‘a stranded patient’.

While in hospital – let’s keep patients in their own clothes as much as possible

Enabling patients to get into their own clothes would build system capacity by improving patient flow, enabling more timely discharges, reduced length of stay, and more timely admissions for other patients. In addition, it would likely lead to enhanced mental wellbeing of people as they are encouraged to take greater responsibility for their own health and become active participants in their personal health journey. Many more of their red days would be green days and in the last 1,000 days, each and every day counts.

Where are we likely to see improvements? Measures of success

The likely measures of success include:
  • Enhanced patient safety
  • Improved reports of patient satisfaction
  • More timely discharges
  • Reduced LOS
  • More timely admissions for other patients
  • Reduced laundry costs where hospital gowns/pyjamas are used
Compelling stories and burning ambition

#red2green Days, the #last1000days and more recently #EndPJparalysis (an idea co-created with Irish nurse leader @AvileneCasey) are all compelling stories  that enable us to win hearts and minds of colleagues with whom we work each day. They move us from constant burning platforms lit by organisational pyromaniacs into a burning ambition to make it better that comes from within.

For in our own last 1,000 days, we’d like every day to be green and, if in hospital, we can wear our own clothes unless it’s for reasons of clinical appropriateness rather than organisational culture. We’d know that while staff time is busy and important, there would be a recognition that patients’ time is sacred and there needs to be no needless waiting, no needless harm, and no needless suffering. We would know that in valuing patient time, staff time was valued too. It’s what we’d want for our patients, our loved ones, and ourselves.

You can find useful #red2green information and resources here.

Professor Brian Dolan is Director of Service Improvement, Canterbury District Health Board, New Zealand (@brianwdolan). Here's a brief video of Brian presenting to multidisciplinary teams in Nottingham University Hospitals NHS Trust about the #Last1000days.


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