This article describes an initiative to reduce length of stay on an orthopaedic ward by focusing on predicted discharge dates.
Webber-Maybank, M., Luton, H. (2009) Making effective use of predicted discharge dates to reduce the length of stay in hospital. Nursing Times; 105, 15, early online publication.
This article outlines an initiative by nursing staff in the elective orthopaedic department at Cardiff and Vale NHS Trust to improve discharge planning for all patients on the ward. It describes how renewed focus on the predicted discharge date among multidisciplinary teams and patients themselves increased the proportion of patients who went home by or before their target date and reduced the average length of stay.
Keywords: Discharge, Planning, Length of stay
Melanie Webber-Maybank, PGCE, BSc, DipN, RGN,is ward manager; Helen Luton,BSc, RGN, is ward sister; both at the West 3 elective orthopaedic ward at University Hospital Llandough, Cardiff and Vale NHS Trust, Wales.
The National Audit Office (2000) estimated that reducing length of stay by between two and six days per patient could save the NHS £15.5m- £46.5m a year.
At least 80% of patients discharged from hospital can be classified as simple discharges. Changing the discharge procedure for this large group could have a major impact on patient flow and effective use of bed capacity.
Ensuring that patients and their carers are aware of their predicted discharge date from the time of admission is recognised as good practice and improves patient experience.
There has been much work done on reducing hospital admissions and caring for people more appropriately outside hospital. However, when hospital care is needed, the NHS also needs to minimise the time spent as an inpatient, while not undermining patient safety or quality of care.
Limited NHS resources need to be spent wisely and productivity and efficiency are paramount. It costs up to £400 per day for an average patient on an NHS surgical ward and there are obvious financial benefits to reducing length of stay. Careful planning of patients’ predicted discharge date has a significant part to play in this.
It is estimated that a reduction in length of stay of between two and six days per patient could save NHS trusts £15.5m-£46.5m a year in total. Furthermore, shorter lengths of stay improve patient satisfaction and lower the risk of healthcare-associated infections (National Audit Office, 2000). In the Healthcare Commission’s 2004 national patient survey, patients identified delays in discharge as a key area for improvement (Department of Health, 2004).
At least 80% of patients discharged from hospital can be classified as simple discharges. Changing the discharge procedure for this large group could have a major impact on patient flow and effective use of bed capacity. The ideal system should be associated with minimum delay and with patients who are fully informed about when they will be able to leave hospital (DH, 2004). Managing the patient’s journey is crucial to improving patient experience and making the best use of beds (DH and RCN, 2003).
Predicted discharge date
Ensuring that patients and their carers are aware of their predicted discharge date from the time of admission is recognised as good practice and improves patient experience, helping them to feel more in control. It is patients’ right to know how long they are going to be in hospital and what time they will be discharged so that they and their families can plan accordingly.
Nobody wants to be in hospital longer than necessary and patients would rather recuperate in the more familiar and comfortable surroundings of their own home.
The Orthopaedic Plan 2004 pointed out that ensuring a sustainable orthopaedic service is about making better use of resources through improved management and innovative ways of working (Welsh Assembly Government, 2004).
Nursing staff on the elective orthopaedic ward at University Hospital Llandough identified a need to reduce patients’ length of stay. The aim was to improve the flow of patients through increased focus by multidisciplinary teams and patients on the predicted discharge date. The ‘ticket home’ initiative started in August 2008 and was implemented within 48 hours of planning.
Through a series of brainstorming sessions by clinical leaders,staff developed the ticket home, which is an A4 laminated card placed on patients’ bedside lockers, where it is easily visible.
The ticket home contains the patient’s name and consultant and there are sections for the physiotherapist and occupational therapist to fill out when the patient is discharged. It also contains information about whether the patient needs transport home, and whether their X-ray and take-home medication have been completed. The final and most important part is the section where the planned date for going home is written.
On admission, the ticket is explained to patients and their predicted discharge date added to the ticket. As they meet their multidisciplinary discharge goals, further information is added until all goals are achieved. Patients are then identified as fit for discharge.
The discharge process should be a multidisciplinary effort with consistently high standards for all patients (Tierney and Closs, 1993). The ticket-home system is a tool to ensure these high standards are achieved. The predicted discharge date is clearly visible to patients and staff and the ticket home identifies the goals that need to be achieved before discharge is possible, for example, physiotherapy and occupational therapy assessments, transport needs, prescriptions, X-rays, and so on. However, staff and patients are made aware that this is only a guide and is subject to change as safe discharge is paramount.
To aid nursing teams in accurately setting the predicted discharge date and to ensure standardisation, a list of appropriate lengths of stay for specific surgical procedures or clinical diagnoses was put together.
It was important to evaluate the ticket-home system and data from the trust was used to monitor its implementation. Before the ticket home system was introduced the average length of stay for total hip replacement patients was 6.2 days. Two months after implementation, the average length of stay for total hip replacements had fallen by 19% to five days. In addition, patient flow through the discharge process was far smoother.
It was also discovered that as a by-product of the ticket home, discharges of patients before 12pm had increased across orthopaedics. It is well recognised that discharging patients before 12pm is effective and efficient bed management (DH, 2004). It seems that improved communication about discharge in the team and better collaborative working enabled this to occur.
The system also increased the number of discharges over the weekend, which had previously been irregular and unplanned. Since the implementation of ticket home, discharges on a weekend are now part of the whole system and patient flow. A key recommendation for achieving timely simple discharge from hospital (DH, 2004) is establishing weekend discharge as standard to reduce fluctuations in numbers of beds needed.
Data is still being collected on the impact of ticket home via Cardiff and Vale NHS Trust’s central information warehouse, but ward-level data collection suggests the trend is continuing. This ward-level data shows that in September 2008, 56% of total hip replacement patients achieved their predicted discharge date, followed by 70% in October, 65% in November, and 86% in December (Fig 1).
The patient’s perspective
With the ticket-home system, patients and their carers are able to start their patient journey with the end in mind, and plan accordingly.
The ticket home empowers them to take part in the discharge process and, as each discharge goal is achieved, the relevant section on the ticket home is completed and patients can see this process happening visually.
‘I only need to tick those two boxes and I can go home.’
‘Last time I came in I didn’t know what was happening – now I do.’
‘I will beat that ticket and go home earlier.’
‘My daughter will take Thursday off work to collect me.’
‘It gives us confidence to go home.’
Setting and achieving predicted discharge dates gives patients goals to work towards and a sense of achievement when these are reached. Not all patients will meet their predicted discharge date due to surgical complications or complex social care arrangements but, even for those who miss the target, it ensures focus on discharge arrangements and accelerates the discharge date.
Some clinical areas are more suited to the ticket-home system than others, and elective care is an ideal clinical environment. Other areas such as emergency care will need different principles to ensure that the ticket meets their needs but the system is easily modifiable. Some specialities, due to their caseload and patient mix, will be able to achieve more predicted discharge dates and some fewer, but a tool that helps to improve discharge efficiency to whatever degree will benefit clinicians and patients.
Through strong clinical leadership and teamwork on the orthopaedic ward at University Hospital Llandough,there has been a recognisable culture change and patient discharge is now the focus of attention for all healthcare professionals, patients and relatives.
Since the initial implementation of the system, no modifications have been made. The visibility, accessibility and simplicity of the ticket home ensured that the cultural change became quickly embedded in the clinical area.
- Better planning and awareness of predicted discharge dates can shorten length of stay and improve bed management.
- Patients who spend less time in hospital are less likely to be exposed to healthcare-associated infections and cutting length of stay reduces NHS costs.
- The ticket-home system is visible, accessible and simple, and improves communication between patients and staff and between members of the multidisciplinary team.
- Although this system was implemented on an elective orthopaedic ward, the scheme is applicable and easily transferable to other clinical specialties.
Department of Health (2004) Achieving Timely ‘Simple’ Discharge From Hospital: A Toolkit For TheMultidisciplinary Team. London: DH.
Department of Health, RCN (2003) Freedom To Practise: Dispelling The Myths.London: DH.
National Audit Office (2000) Hip Replacements: Getting It Right First Time. London: NAO.
Tierney, A., Closs, J. (1993) An evaluation of hospital discharge. Nursing Times; 89: 11-12.
Welsh Assembly Government (2004) An Orthopaedic Plan – Getting Wales Moving. Cardiff: WAG.