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Reducing length length of hospital stay for hip replacement patients

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How one hospital trust streamlined it's discharge process with simple system of reminders based on predicted discharge dates

Brief outline of context

With a high turnover of patients discharge planning is particularly relevant (Salter, 2001) within the general political climate of the modern NHS. This article serves to share good practice of a new discharge innovation that has been created and led by nursing staff in an elective orthopaedic department.

Cardiff and vale NHS trust is one of the largest in the UK, providing health services for over 500,000 people living in the Cardiff and the vale of Glamorgan.Orthopaedic nurses on ward west 3, at Llandough University Hospital, identified a need to reduce the length of stay (LOS) of their elective patients. The process was nurse led with collaborative input from the multi-disciplinary team, and aimed to reduce the LOS for elective orthopaedic patients by focusing on predicted discharge date (PDD).

Brief outline of problem

The average LOS for total hip replacements on the ward was identified as 6.2 days; the nursing team considered that they could improve on this.

The clinical area already had robust systems and processes in place to ensure prompt discharge - pre-operative assessment, patient education classes, and discharge board, but it was felt that the discharge process could be further facilitated.

Assessment of problem and analysis of its causes

Nursing clinical leaders using a brainstorming approach identified that increasing the patients and the team's awareness of the (PDD) could improve the patients flow through the system and reduce the length of stay within the client group. An action approach to change was adopted by the clinical leaders and the ticket home system designed. Evaluation of the system ran parallel with the implementation of the ticket home to ensure rapid feedback on usability and potential improvements.

Strategy for change

The ticket home system became operational on 1.8.08 following 48 hours of assessment, design, and implementation.The ticket home quite simply is an A4 laminated card placed on the patients' bedside lockers.The ticket home is placed on the patient's locker as this is visual and accessible to all.

On admission the ticket home is explained to the patient and their PDD added to the ticket. From that point all members of the multi-disciplinary team with full patient and carer involvement engage towards the same PDD. As the patient meets the multi-disciplinary discharge goals further information is added to the ticket until all discharge goals are achieved. Then the patient is identified as being fit for discharge and they are discharged.

Measurement of improvement

Figures produced within the trust data warehouse system were used comparatively to measure the impact of the ticket home system. Before the ticket home implementation the average LOS for total hip replacement patients was 6.2 days, 2 months following the implementation of the process the average LOS for total hip replacements had fallen by 19% to 5 days.

As a bi-product of the ticket home it was discovered that discharges of patients before 12.00hrs across orthopaedics had also increased. It is well recognised that discharging patients before 12.00hrs is effective and efficient bed management. Clearly the team work and improved communication around discharge enabled this to occur.

Data is still being collected on the impact on ticket home via Cardiff and Vale trust central information warehouse, but ward level data collection identifies that the trend is still continuing. Data collected at ward level has identified that in the clinical area September 2008 56% of patients achieved their PDD, followed by 70% in October, and 65% in November.

Some clinical areas due to their caseload and clinical speciality will be able to achieve higher patient achievement of their PDD, and some would achieve lower but surely any tool that assists to improve discharge efficiency to whatever degree is of benefit to clinicians and patients alike.

Effects of changes

Click here for progress charts from the project in Microsoft Word

The ticket home has reduced the average LOS for total hip replacements by 19% and patients flow through the discharge process far more smoothly. The patients and their carers are able to start their patient journey with the end in mind.

Setting PDD's and ensuring that they are shared enables focus and clarity in the team work. The improvement in team work between all members of the multi-disciplinary team has been noticeable. The ticket home empowers the patients and carers to take part in the discharge process, and as each discharge goal is achieved the relevant section on the ticket home is completed.

Patient feedback:

'I only need to tick those two boxes and I can go home'

'I will beat that ticket and go home earlier'

'Oh that's great I'll be home for the weekend'

'My daughter will take Thursday off work to collect me.'

'Last time I came in I didn't know what was happening - now I do'

'It gives us confidence to go home'

Lessons learnt

During the whole ticket home system and the parallel evaluation process not one single thing was changed. The implementation was nurse led and run smoothly due to the effective team work from all members of the team. The system was created and implemented in 48 hours and an action approach to change can be as effective as lengthy approaches to change management.

Visual systems of work are far simpler to implement than non visual systems, the accessibility of the ticket home ensured that the cultural change became quickly embedded in the clinical area.

Message for others

Ticket home has proved to be a simple efficient and effective method of providing PDD's for patients. It is interactive, relevant and has not become just another paper exercise.

The ticket home has worked for 5 reasons;

  • Simple idea
  • Visual and accessible
  • Full engagement
  • Strong clinical leadership
  • Team work


Melanie Webber-Maybank, ward manager west 3 Llandough University Hospital, Cardiff and Vale NHS

Helen Luton, deputy ward manager west 3 Llandough University Hospital, Cardiff and Vale NHS Trust.

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