Length of Stay

There is an obsession within healthcare about Length of Stay – usually shortened to LoS.

In general terms, the shorter the LoS the better, although in some situations, if the LoS is too short, that can be a problem too.

For every disease, condition, treatment or ailment that requires a person to spend a period of time in hospital there is an associated LoS. Elective hip operation 48 hours, fractured hip, 7 days, pneumonia three days, stroke seven, and so on.

You name it and there is a corresponding LoS.

There are complicated calculations that sit alongside these numbers – for example, the LoS for a one-legged man who breaks their hip is likely to be longer than an otherwise able-bodied person (for obvious reasons). These sums tend to translate to complex payment system calculated both in the NHS and around the world.

If we keep things simple, imagine two people, both similar ages, with not too many other health conditions, both of whom contract pneumonia.

If person A, let’s call him Marcus is admitted to hospital F, let’s call it Farflung, and stays four days before returning home with whatever additional support might be needed in the community then the LoS if four days. Everyone goes home happy.

If however, person B, let’s call her Gloria is admitted to hospital O, let’s call this one Outskirts, and stays eight days before she is released home, the LoS at eight days, double Marcus’, suggests that either Gloria was more unwell than Marcus or the systems and processes at Outskirts are not as good as at Farflung, which has managed to address delays and obstacles to care potentially encountered at the other hospital.

At Farflung, they may have consultants working seven-days a week, they may have rapid access to diagnostics, their safety profile might be better, there are endless possibilities.

Gloria might fall on her first day in hospital, she might receive the wrong medicines, her x-ray might be misinterpreted. She might be infected with an unusual bacterium that doesn’t respond to the initial antibiotics and requires two courses; the possibilities are endless.

Yet, in the eyes of the system four is good, eight, less so.

Four is even better as that means you can treat Marcus twice for the time you treat Gloria.

In terms of system efficiency, Farflung is 2x as efficient as Outskirts. The treatment cost half as much, or double, depending on who you are looking at.

The systems used by hospitals are however far from adequately sophisticated to analyse at this level of detail.

One might assume that on average, all things being equal, if Farflung and Outskirts are both equivalent in quality, effectiveness and care, the average LoS for 100 people like Marcus and Gloria would balance at four days – with Gloria being an outlier, or, perhaps six days, as Marcus was actually a miraculous super-healer.

Equally, Farflung might be in a prosperous area where there are many affluent patients who present early, don’t smoke, look after themselves, and, have good support networks to facilitate early discharge, whereas Outskirts is less so, with folk less aware of health issues, smoking more, presenting later, and so on.

You could probably write an entire Tale of Two Hospitals about Farflung and Outskirts, demonstrating the similarities and differences of the two.

When it comes down to it however, these subtleties I have described are often lost in the system and regardless whether one is better than another, more efficient or effective, the staff more dedicated and caring, whether a week after going home Marcus is back again because he had the same infection as Gloria but did not receive the same appropriate mixture of medicines, we don’t know (this, we call, readmission – again, something for another day.)

Humans tend to be as unsophisticated in their analyses of systems as the systems themselves are complex.

We see a number, fixate on that, generalise and imagine, ‘Four good, eight bad,’ or, the inverse, again, it depends on your point of view, or, it could be that when Marcus returns to hospital, in a worse state than he originally presented, he stays for two weeks; yet, the Four sticks; the 14 of the second admission become lost in the arithmetic of the accountant’s ledger.

And what is my point?

Is there a point?

My point is essentially, that the sledgehammer used within the NHS to measure good vs bad, with LoS sitting at the head of the tree is inadequate. It is blunt, amenable to manipulation and confabulation. It can be embedded within a myriad of other factors which are either unavailable or unknowable.

LoS, LoS, discharge, discharge…

Like a crazy mantra that takes you to the same place as Nam Myoho Renge Kyo – in other words, in circles.

The repetition creates tension that does no one any good.

My message – consider LoS to be important although no more or less than the other measures, the other means by which we determine effectiveness. Just because something can be translated into a number ‘21’ doesn’t mean good or bad; it is quantity and quality; one without the other is a weakened structure that does no one any good.

When in doubt, go to the people, listen, hear, feel.

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