Remember, “do no harm.”
We are all aware of efforts in the healthcare system devoted toward reducing length of stay, but when does that metric interfere with quality of patient care and subsequent results? There are several areas where we see this phenomenon.
Let’s start with the beginning, and that is in the emergency room, often referred to as “throughput.” The goal is to get the patient’s disposition set and completed in as little time as possible, door-to-door, if you will.
The goal behind this most times is to improve patient satisfaction or experience, which is a measurement in value-based purchasing (VBP) and influences hospital-based incentives. This is gauged by HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems), a survey.
Sometimes, in order to improve results, ED physicians are incentivized by making this a metric for bonuses. We have all seen how this may actually adversely affect patient quality of care.
There are other areas where reducing length of stay can have an adverse effect on the quality of care provided, but the focus remains on getting patients out of the hospital. There is a fine line between reducing length of stay and not increasing readmissions.
Also, other metrics are measured in value-based purchasing, scrutinized by Medicare and other variations in the commercial payor world. Most of the time, it all works well, but the fallout of those times when it doesn’t can have grave consequences on patients’ morbidity and even mortality – which ironically can become another negative metric, along with readmission rates, mortality rates, hospital-acquired conditions, conditions present on admission, “never events,” and more.
What inspired this report is a true experience of a family member of mine that is not unique, but exemplifies the problem. This family member was recuperating from a rather severe episode of COVID, resulting in fatigue and deconditioning in someone already challenged with diabetes, walking issues, knee and back problems, and osteoporosis.
At home, physical therapy was helping until she fell and suffered an angulated lower leg fracture of the tibia and fibula. Here is where it all started. She underwent surgery, with pinning and casting of the fractures and she was discharged on the second day with a temperature of undetermined etiology to a facility for rehabilitation.
The temperature elevation continued, leading to altered mental status within less than 24 hours of arrival, requiring sending her back to the hospital – reluctantly, on the part of the rehab hospital. In addition, the hospital did not want to admit her even to observation until strongly encouraged by a family member (who by the way is an ED, and previously an ICU nurse).
The reasons behind the reluctance on their part is unclear, but one wonders if it had anything to do with a rather quick readmission for a patient who should have never been discharged so quickly when unstable.
In summary, we have a couple of scenarios that are reflections of decreasing length of stay resulting in significant quality issues:
- Inappropriate early discharge; and
- Reluctance to appropriately readmit a patient.
In conclusion, metric-driven incentives may not have the best results. What happened to “first, do no harm?”
Programming note: Listen to Dr. Zelem’s ongoing series called, “Journaling John MD,” Tuesdays on Talk Ten Tuesdays at 10 a.m. Eastern.
