One of the most common statistics kept in a hospital, nursing home, or any other

One of the most common statistics kept in a hospital, nursing home, or any other facility in which patients stay overnight, is the average length of stay. In 70s, the average length of stay (ALOS) for Medicare patients (with medical diagnoses, not surgery) was 9.7 days1. By 1985 that had dropped to 7.5 days2 (for the same population of patients). The reason for the decline? First, prior to the early 1980’s physicians and hospitals weren’t held accountable for admissions – it wasn’t unusual for patients to be admitted for “any little ache or pain.” Hospitals were paid well by Medicare (and by commercial insurance companies) as were physicians. There was no accountability as to whether patients needed hospital care. But then the prospective payment system came along in the early 1980’s as well as Quality Improvement Organizations, so physicians and healthcare facilities were held accountable for the care patients received. Medical care was much better in the 1980s and 90s and subsequent years – new, safer pharmaceuticals were available, there was an increase in the availability of outpatient care, and nurses could visit patients at home (referred to as Home Health Agencies) at a much less expensive rate than the patient being kept in the hospital. Medicine in general had improved greatly. Within hospitals, Utilization Management (previously called Utilization Review) staffed by nursing personnel, reviewed all elective admissions (admissions that were planned and that did not come through the Emergency Department) to ensure the admission met certain admission criteria. If a patient could be safely cared for as an outpatient, then the physician was told that the patient did not meet the criteria and could not be admitted. Needless to say, that did not go down well with physicians. If a patient was admitted through the Emergency Department (ED), a Utilization Management nurse would review the case within 24 hours of admission. If the patient didn’t meet admission criteria, the attending physician would be notified that the patient needed to be discharged or improve his/her documentation in the patient’s medical record to show the need for inpatient hospitalization. If the case was “iffy” or if the attending physician disagreed, then a physician currently serving on the Utilization Management Committee would review the case and make the final decision. This is called peer to peer review (physician-to-physician), nurse to physician review is not peer to peer, since a nurse does not have the same educational background as a physician. Medicare can deny payment even if a patient stayed in the hospital as an outpatient, but a retrospective (after the fact) review of the patient’s record didn’t prove that the patient needed inpatient hospitalization. In that case, the hospital isn’t paid, but the attending physician may be paid. The patient is not responsible for paying the hospital or the physician (if he/she wasn’t paid) because it wasn’t his/her fault. Obviously, that’s not good for the “bottom line” of the hospital or the physician. Thus, hospitals had pretty tight Utilization Management programs! Some insurance companies (also called third-party payers) also had Utilization Management programs as well. On the other hand, if a physician writes a discharge order, and a patient doesn’t think they’re ready to leave or refuses to leave, then the patient is responsible for paying their hospital bill from that point forward! The patient (or their representative) can appeal the discharge, and that appeal is reviewed by the Utilization Management Committee of the hospital. If the UM committee agrees with the attending physician that the patient no longer requires acute care services, then the discharge order stands, and the patient needs to leave, and the method of payment from that point forward changes to “private pay” meaning the patient is paying “out-of-pocket,” or “patient-pay.” If the UM committee feels that the patient does still meet acute care continued stay criteria, then that is documented, and the patient continues their stay in the hospital. That does not mean that the hospitalization for that patient may not be reviewed by Medicare and all or part of it will not be denied by Medicare, meaning the hospital may not be paid for all or part of it. The patient will not be charged; the hospital will lose money for that hospitalization. Being in the hospital when one doesn’t need to be isn’t a good thing. Why? Because there are sick people in the hospital. If a patient doesn’t need to be in the hospital, they shouldn’t be in the hospital. Back to length of stay…..length of stay is counted by starting with the day the patient is admitted, even if it is 15 minutes before midnight, and ends on the day before the patient leaves (alive or deceased). So, if Joan Jett is admitted on February 4th and is discharged on February 9th, you would count the 4th, 5th, 6th, 7th, and 8th, for a length of stay (LOS) of 5 days. It doesn’t matter what time the patient was admitted on the 4th, you count that day. But, even if the patient left at 8 p.m. on the 9th, you do not count the discharge day. If the admission and discharge occur in the same month, you can subtract the admission date from the discharge date and get the correct number. BUT, if the admission spanned one month into another, that’s not as easy. My preference for these cases, is to determine the number of days in each month – BUT, make sure you know how many days are in each month – remember, February only has 28 (except in a leap year); other months have 30 or 31 days! Look at your book in Chapter 5 for methods of calculating LOS when a length of stay spans two (or more) months. Table 5.1 has an excellent example. Outpatients don’t stay overnight so there’s no length of stay, right? Well, yes………and no. Observation patients (which started as a Medicare designation) may stay overnight. These are not “inpatients” but they do occupy a bed and they stay for a number of hours (usually just up to 23 hours), and you may need to calculate the number of hours). There are several examples of tracking the time of outpatient visits (not just observation patients) in your text in Chapter 5. Not only do we track LOS for individual patients, we track the average length of stay (ALOS) as well. To do that you would add the lengths of stay of all patients discharged in a given time period and divide that by the number of patients discharged. Adults and children are calculated separately from newborns. So, if 32 adults and children were discharged yesterday from Memorial Hospital and the total length of stay for those 32 patients was 103 days, you would divide that number by 32 (discharges) and therefore your ALOS for those 32 adults and children is 3.22 days (you would round 3.21875 to 3.22) Finally, your text talks about “leave of absence days” -in an acute care hospital, these rarely happen because if a patient can leave the hospital on a leave of absence, does the patient really need to be in the hospital in the first place? Probably not. They do happen in nursing homes, chronic care hospitals, and rehabilitation facilities, however. Answer the following questions 2. Based on a brief overview of LOS changes and the accompanying article, explain why LOS is changing. (Up to 10 points, if you describe at least three reasons with a short explanation for each.)

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