Inpatient Practice Medical Economics

What Machiavelli Would Say About Hospital Length Of Stay

Machiavelli famously said to the prince: “It is better to be both loved and feared but if you can only be one, be feared”. I’ve been wondering what Machiavelli would say about time of hospital discharge versus length of stay?

Hospital length of stay is measured by the length of stay index. This adjusts the length of stay (in days) for the patient’s diagnosis. Because sicker patients are expected to be in the hospital for more days than less sick patients, the length of stay index makes more sense than just the plain length of stay. A patient who was in the hospital for the expected number of days for that patient’s diagnosis would have a length of stay index of 1.00. A patient who was in the hospital more days than would be expected would have an index of greater than 1.00. And if that patient was in the hospital for fewer days than expected, the index would be less than 1.00.  We benchmark our hospital’s length of stay to Vizient, which is composed of most of the academic medical centers nationwide. Our medical center’s goal is a length of stay index of 0.95; we have been proud that our hospital’s length of stay index last year was only 0.88.

But here is the problem with length of stay. If you are going to get a patient out of the hospital a day earlier than expected, that usually means you have to cram a lot of testing, consults, treatments, and case management into that last hospital day. That means that the patient is going to get out of the hospital later because you are waiting for that test result, or that last antibiotic infusion, or the discharge arrangements to a nursing facility.

In addition to the length of stay, the other metric that we watch carefully is the time of day that patients are discharged. Ideally, you like to get  your patients out of the hospital early in the day so you can have a bed available when the next patient needs to be admitted. Think about hotels – they usually want you to check-out by 11:00 AM so they can get the room cleaned and ready for the next guest arriving in the afternoon. The reality is that hospitals only have so many environmental services employees and so there is a limit to the number of rooms that can be cleaned at any one time. Therefore, what you like to see is an even distribution of patients being discharged over the course of the day so that rooms can be cleaned as soon as a patient leaves without having to leave the room dirty for hours waiting for environmental services.

Often, getting the patient out early in the day is in direct conflict with shortening the hospital length of stay. It is kind of like a game of Whack-A-Mole; if you get the patient out of the hospital a day early, that patient is more likely to leave later in the afternoon (or in the evening) rather than early in the morning. Therefore, shortening the length of stay will usually push back the time of discharge.

So, what is a hospital to do?

You have to be realistic. the goal is NOT to get all of the patients out by noon (like a hotel) but rather to get some of the patients out before noon so you can get those rooms cleaned and then get a few more patients out by 2 PM so you can then get those rooms cleaned, etc. Hospitals are not like hotels – in a hotel, most of the guests arrive between 4 PM and 8 PM but in a hospital, patients show up in the emergency room and are getting admitted 24 hours a day.

I think if Machiavelli was alive today, he would say: “It is better to have both a short length of stay and an early average hospital discharge time but if you can only have one, have the short length of stay”.

February 22, 2017

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital