Background
In 2018, there were 36.4 million inpatient hospital stays in the United States.1 The average length of stay (LOS) for a hospitalization is 5½ days.2 Unnecessary days in hospital may lead to increased hospital-acquired patient complications (e.g., healthcare-associated infections, falls) and increased costs for patients and healthcare systems. In addition, prolonged LOS may negatively affect both patient and staff experience.3 Delays in hospital discharge may be related to unnecessary waiting, poor organization of care, delays in decision-making, or difficulties related to discharge planning.3,4
A broad array of interventions have been developed to reduce hospital LOS, and they differ in design, intent, and focal point. While some interventions primarily aim at improving clinical care (enhanced recovery programs,5–7 clinical pathways,8 and early patient mobility programs9), other approaches address logistical factors (care coordination, transition and discharge planning,10–12 case management,13 medication management,14 or specialized units for high-risk populations15,16). Other interventions target the workforce, such as multidisciplinary care teams17 or redesigned staffing models.18
Interventions have the potential to create trade-offs between outcomes. Reducing LOS might increase concerns for readmission risk or shifting costs of care to the outpatient setting.3 Conversely, interventions might be ineffective in reducing LOS but yield significant improvements in other patient-centered outcomes, such as patient satisfaction. Further, interventions to reduce LOS may differ for those needing treatment for exacerbation of a complex chronic condition and those needing treatment for an acute illness or undergoing an elective surgical procedure.
Particular patient populations, such as patients who are socioeconomically vulnerable, affected by healthcare disparities, or with medically complex needs, may be at increased risk for unnecessary delays in discharge.19–21 These patients are typically at greater risk for adverse events during and after hospitalization.22 Interventions that address the distinctive challenges of LOS reduction in these populations might increase efficiency of patient throughput, reduce health inequities, and improve the delivery of safe and effective care.
Successful hospital-based interventions may significantly depend on environmental factors, including the unique resources, personnel, leadership, and infrastructure specific to each setting. A hospital or health system-based approach could therefore address the multiple factors (e.g., admission process, discharge disposition) contributing to unnecessary delays in hospital discharge.3 We categorized and evaluated current knowledge regarding the many strategies to reduce LOS; examined contextual factors (e.g., resources, costs, staffing, technology) that may affect implementation of LOS-focused interventions; identified emerging concepts or initiatives that merit future research; and developed a series of evidence maps to inform health systems’ strategic efforts.
