 Short informative title

Accepted Article
A Multidisciplinary Approach to Decreasing Length of Stay in Acute Care Surgery Patients

 Short running title

Decreasing LOS in ACS Patients

 List of all authors

Christopher D. DEPESA, RN, MS1; Majed W. EL HECHI, MD1; Rachael MCKENZIE, RN, MSN, CCM2; Karen WAAK
PT, DPT, CCS3; Leslie MCLAUGHLIN, MS, OTR/L4; Yuchiao CHANG, PhD5; Alice GERVASINI, PhD, RN, NE-C1,6;
George C. VELMAHOS, MD, PhD, MEd1,6; Haytham M.A. KAAFARANI, MD, MPH1,6

1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care,
Massachusetts General Hospital
2 Case Management, Massachusetts General Hospital
3 Physical Therapy, Massachusetts General Hospital
4 Occupational Therapy, Massachusetts General Hospital
5 Division of General Internal Medicine, Massachusetts General Hospital
6 Harvard Medical School

 Author contributions

Study conception and design: DEPESA, EL HECHI, MCKENZIE, WAAK, MCLAUGHLIN, CHANG, GERVASINI,
VELMAHOS, KAAFARANI

Acquisition of data: DEPESA, MCKENZIE, WAAK, MCLAUGHLIN, CHANG, GERVASINI, KAAFARANI

Analysis and interpretation of data: DEPESA, EL HECHI, MCKENZIE, CHANG, GERVASINI, VELMAHOS,
KAAFARANI

Drafting of manuscript: DEPESA, EL HECHI, KAAFARANI

Critical revision: DEPESA, EL HECHI, MCKENZIE, WAAK, MCLAUGHLIN, CHANG, GERVASINI, VELMAHOS,
KAAFARANI

This article has been accepted for publication and undergone full peer review (not applicable for
Editorials) but has not been through the copyediting, typesetting, pagination and proofreading
process, which may lead to differences between this version and the Version of Record. Please cite
this article as doi: 10.1111/JAN.14335
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  Acknowledgments
Accepted Article
The authors would like to thank the case managers, physical therapists, occupational therapists, nurses, and
other clinical staff that care for this complex patient population at Massachusetts General Hospital. We
would like to further acknowledge the efforts of the surgical ICU and floor case managers for their ongoing
work and collaboration.

 Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit
sectors.

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Accepted Article
DR MAJED W EL HECHI (Orcid ID : 0000-0001-8960-764X)

Article type : Original Research: Empirical research - quantitative

Corresponding author mail id : hkaafarani@mgh.harvard.edu

Abstract

Aim: To decrease hospital length of stay in acute care surgery patients.

Design: An observational cohort quality improvement project at a single tertiary referral center.

Methods: A multidisciplinary team of physicians, nurses, case managers and physical and
occupational therapists was created to identify patients at risk for prolonged length of stay and
implement weekly multidisciplinary rounding, with a systematic method of tracking progress in
real-time. The main outcome measure was hospital length of stay. The observed/expected ratios
for length of stay two years before (2012-2014) and after (2014-2016) the intervention were
compared.

Results: A total of 6120 patients were analyzed. Early identification and action on barriers to
discharge created a significant decrease in risk-adjusted acute care surgery patient days per year
(96 days) with limited added cost (1-2 hours per week). Patients discharged to home with or
without services benefited most.

Conclusion: Decreasing length of stay in acute care surgery patients is possible without adding a
significant burden to healthcare providers.

Impact: We describe a comprehensive, multidisciplinary initiative to decrease the length of stay

of acute care surgery patients. Institutions can use existing resources in a sustainable manner to
create a significant decrease in patient days per year with limited added cost.

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Accepted Article
Registration: https://osf.io/zfc3t

Keywords: length of stay, multidisciplinary, acute care surgery, quality improvement, health
resources, nurse, nursing

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Accepted Article Introduction

Hospital length of stay (LOS) has been proposed as a key indicator of appropriate
resource use in the North American healthcare system (Brasel, Lim, Nirula, & Weigelt, 2007).
Prolonged LOS is associated with poor clinical outcomes (Rosman, Rachminov, Segal, & Segal,
2015) and increased cost to patients, healthcare facilities and state and federal governments
(Brasel, Rasmussen, Cauley, & Weigelt, 2002; Ciesla, Sava, Kennedy, Levinson, & Jordan,
2008). Brasel et al. (2002) noted that there was a 60% increase in cost to the trauma patient
when disposition is delayed (Brasel et al., 2002). Additionally, it has been reported that only 6%
of trauma patients occupy nearly half of all inpatient bed-days (Ciesla et al., 2008). Thus,
healthcare providers have a responsibility to effectively and efficiently address a patient’s
discharge needs by deploying appropriate but not unnecessary resources (Clarke & Rosen, 2011).

Background

The acute care surgery (ACS) patient population, which includes those presenting
emergently after a traumatic event or surgical emergency, has unique characteristics that make
their discharge from the hospital challenging. These characteristics often include: complex injury
patterns necessitating extensive rehabilitation, inconsistent insurance coverage and home
addresses in states other than the treating hospital. These factors all have an impact on the
providers’ ability to match the patient with an appropriate discharge destination. Interestingly, it
has been demonstrated that the root cause of prolonged LOS in the trauma patient is often not
related to the severity of the injury or clinical needs, but to system-related issues (Fakhry,
Couillard, Liddy, Adams, & Norcross, 2010; Hwabejire et al., 2013; Jacobs et al., 2009; Kurtz,
Cookson, & Mattie, 2008). Because prolonged LOS in this patient population is so often closely
associated with statewide rather than hospital-specific system-related factors, it has been debated
whether LOS should be used as a measure of quality (MacKenzie et al., 2012; Oyetunji et al.,
2013). However, hospitals acknowledge that a prolonged LOS has an adverse impact on their
performance both clinically and financially and thus decreasing LOS became a de facto priority
for many institutions interested in maintaining a high-level of care quality (Simorov, Bills,
Shostrom, Boilesen, & Oleynikov, 2014; Stock & McDermott, 2011).

In a study previously published by our group, we affirmed that system-related issues were
often the cause of prolonged hospital LOS for ACS patients and recommended specifically

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Accepted Article
targeting operational bottlenecks of patient transfer from acute to post-acute care to reduce LOS
(Hwabejire et al., 2013). This project follows that study and aims to address system-related
obstacles.

Methods

Aims

In this study, we sought to: 1) design and implement a multidisciplinary quality

improvement (QI) initiative for LOS reduction; 2) measure the impact of our QI initiative; and 3)
synthesize the lessons we learned from our efforts. We hypothesized that a multidisciplinary
approach to address barriers to discharge early in the hospitalization period would lead to a
reduction in the LOS of ACS patients.

Initiative Design

The quality improvement effort was done at an urban, academic, Level I trauma center
with approximately 1000 patient beds. In May of 2014, decreasing LOS became a priority QI
goal. A period of two years before the intervention (pre-QI: 7/1/2012 – 6/30/2014) was
compared with the period of two years after the intervention (post-QI: 7/1/2014 – 6/30/2016).

Most ACS patients at our institution are admitted to either of two main surgical floors or
two surgical ICUs. Thus, these locations were targeted for our multidisciplinary intervention.
Patients discharged from the two surgical floors were identified as “Surgical Floor”, patients
discharged from the two surgical ICUs were identified as “Surgical ICU,” and patients
discharged from any other unit than the four targeted units were identified as “Other.” The top
five discharge status assignments at our hospital were used as discharge endpoints. The
assignments were “Home,” “Home with Services,” “Skilled Nursing Facility (SNF),”
“Rehabilitation,” and “Long Term Acute Care (LTAC)”. Starting May 2014, taskforce members
convened and rounded weekly on the surgical floors and in the ICUs with a focus on predicting
and mitigating barriers to patient discharge as early as possible. The rounds included a weekly-
generated list of ACS patients who remained in the targeted units after ten hospitalization days.
The group would run the list on each unit to identify and act on reasons that precluded patients
from discharge.

Participants

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Accepted Article The task force consists of the nursing team, acute care surgery team, Case Management
(CM), Physical Therapy (PT) and Occupational Therapy (OT).

Validity, Reliability and Rigour (Measurement of the impact of the initiative)

Recognizing the need to risk-adjust for the level of complexity of patients and their
clinical needs, we opted not to use crude LOS measures. As such, we used the University
HealthSystem Consortium (UHC), now Vizient, Inc, data and risk-adjustment models to derive
real-time expected length of stay (eLOS) and observed LOS (oLOS) for any subset of our patient
population. This permitted us to compare the “observed over expected” (O/E) ratio trends as a
primary marker for progress throughout the project. The O/E ratio is particularly important for
the acute care patient population, which has inherent heterogeneity in severity of illness, trauma
burden and medical comorbidities.

Data Collection

In addition, using Tableau software, we created an interactive database and dashboard of

our ACS patients that can be updated in real-time. The database was comprised of multiple
variables (e.g. age, comorbidities, admit/discharge date/diagnosis/destination), including the
UHC benchmarked eLOS, which could be used to identify the causes of prolonged O/E LOS.
The data dashboard allowed concurrent monitoring of the initiative’s status and progress.

The pre-QI period was compared with the post-QI period. The primary outcome, O/E
LOS ratios, were generated and compared across two time periods. At the end of the two-year
period after the intervention, the multidisciplinary group met and reviewed the data to determine
what lessons could be learned from the effort. The results were presented and discussed with all
the task force services and the results of that discussion were summarized.

Ethical Oversight

The intention of the project was QI. The Institutional Review Board at our institution
waived our application for review as the project reports findings of QI work and not constitute
human subject research.

Statistical Analysis

Analysis was done on all ACS patients, stratified by discharge units (Surgical Floor,
Surgical ICU, or Other) and by discharge status (Home, Home with Services, SNF, Rehab and

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Accepted Article
LTAC). The eLOS, oLOS and the O/E ratio were compared using the Wilcoxon signed-rank test.
All analysis was done using SAS version 9.4. Statistical significance is defined as two-sided p <
0.05.

Results

Initiative Implementation

Weekly, a list of targeted patients was created (approximately 5-10 minutes) by the acute
care surgery service, specifically nursing. Then, multidisciplinary rounds on the ICU and floor
(approximately 30-40 minutes per week) were performed, while identifying, discussing and
addressing barriers (approximately 20-30 minutes per week). If the reasons were within the
purview of the nurse or physician on rounds, they would be addressed before leaving the unit or
shortly thereafter. Figure 1 outlines the weekly multidisciplinary rounding process and Table 1
presents examples of each type of intervention. If the reasons precluding discharge were beyond
the multidisciplinary team’s ability to intervene, a dialogue between team members was initiated
to understand what factors could have been addressed before the patient’s status reached that
point. From the discussions, we then began suggesting earlier intervention of patient financial
services, the guardianship team and physical medicine and rehabilitation consults to the
clinicians taking care of the patient.

Impact of the Initiative

A total of 6120 patients were included in the analysis, with 2932 pre-QI and 3188 post-
QI. Using the Wilcoxon signed-rank test, there was an overall decrease in the oLOS for all
patients from 7.53 days to 7.43 days (p = 0.01) as well as a decrease in the O/E ratio from 1.15 to
1.09 (p = < 0.001) [Table 2], which translated into 95.6 patient days per year saved [Figure 2].
The O/E ratio decreased in patients discharged from the Surgical Floor from 1.19 – 1.14 (p =
0.02) as well as those discharged from Other units from 1.16 – 1.01 (p < 0.001). Similarly, there
was a decrease in oLOS in ACS patients discharged to Home from 4.04 – 3.97 days (p < 0.001).
The O/E ratio decreased for patients discharged to Home and Home with Services from 0.93 –
0.85 (p < 0.001) and 1.31 – 1.18 (p = 0.048), respectively [Table 3].

Lessons Learned

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Accepted Article Throughout the planning, execution and analysis of this effort, the authors learned lessons
that could prove valuable to other teams attempting similar efforts.

Lesson 1: The importance of communication between clinical teams

Prior to the intervention, a real disconnect existed between the ACS physicians and
nurses and the role of CM, PT and OT in the disposition of ACS patients. In the meetings leading
up to the intervention, a good deal of clarity was gained by opening the channels of
communication among these services and a higher level of appreciation regarding the focus and
role of each discipline was achieved.

Lesson 2: Tangible impact is the sum of small and consistently repeated efforts

We learned that incremental changes lead to larger impacts. During the implementation
of the intervention, there would be periods when team members would be discouraged that there
is no impact on LOS on a greater scale. It was only in looking at the data that we came to
understand that a slight change (0.06 O/E Ratio difference), when spread over a large number of
patients, creates the significant impact in LOS, patient days and hospital resources that we were
hoping to create.

Lesson 3: Feedback early better than feedback late

Crucial to the success of this project was our ability to give ongoing and timely feedback
to all the team members with the Tableau dashboard. This feedback encouraged our team to keep
moving with our efforts when the LOS was trending down and to think creatively about solutions
when the LOS was trending up.

Discussion

By targeting a select group of ACS patients and addressing their barriers for discharge
through a multidisciplinary approach, a cost-effective QI initiative resulted in a significant
decrease in LOS. In 2001, Johnson described how recruiting clinical care coordinators, to direct
attention at patients at risk for increased LOS has been a successful way to shorten hospital
stay(Johnson, 2001). However, given financial constraints, hospitals, including our own, are
increasingly encouraged to use their own existing resources to make an impact.

The success of our initiative comes largely from its sustainability. By highlighting only
patients with a prolonged LOS, rounding once weekly and using the Tableau dashboard, the

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Accepted Article
burden on the involved teams was minimized. The taskforce members report that daily
responsibilities were minimally affected, and that the initiative added more attention to patients
that most required their services.

The O/E Ratio decreased across those discharged from the Surgical Floor, from Other
units and those discharged to Home or to Home with Services. While we would not necessarily
anticipate quicker discharges from the Surgical ICU, the changes observed outside of the
Surgical ICU likely represent the downstream effects of our intervention during the patients’ stay
in the Surgical ICU. Also, while we did not deliberately target units other than the two Surgical
ICUs and two Surgical Floors, the case managers, PTs and OTs involved in this intervention do
cover the ‘Other’ units and perhaps brought the same sense of urgency to addressing the same
LOS issues on those units.

In a 2006 study, de Jong et al. demonstrated that decisions regarding patient length of stay
are influenced by culture of the hospital environment, whereby physicians adjust their practice
according to the behavior of colleagues in the hospital they practice in (de Jong, Westert, Lagoe,
& Groenewegen, 2006). Our intervention demonstrated that those patients going Home or Home
with Services, whose discharge was not reliant on bed availability or other administrative
barriers, had a decrease in LOS, which is suggestive of a change in the way decisions are made
in our own institution. While we expected to observe changes regarding patients discharged to
places other than their own homes, the difficulties encountered in obtaining placement at a post-
hospital care facility are consistent with the same systematic and administrative issues that have
been previously identified in the literature.

Furthermore, consistent with the findings of previous studies on trauma-only patient

populations, the main delays were observed with patients being discharged to post-hospital care
facilities, where the O/E LOS ratios were consistently higher than one. In 2010, Kahn et al found
that post-discharge facilities, specifically LTACs, are being used at a higher rate nationwide
(Kahn, Benson, Appleby, Carson, & Iwashyna, 2010). This translates into a greater likelihood of
bed occupancy at post-discharge facilities, thus increasing hospital LOS for patients requiring
these beds. In our study, this might serve as an explanation as to why our intervention had no
impact of the LOS of those patients. Having a favourable impact on the LOS of patients

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Accepted Article
requiring post-discharge facility care remains difficult without changing the number or
availability of these beds.

Future studies should look further into the factors associated with discharge disposition
and discharge unit and even specific floors. By identifying patterns in disposition, future projects
could focus their efforts on improving throughput by identifying what certain units (and
providers) are doing well and applying those lessons to other units. Although it was not the focus
of our project, these analyses could identify further lessons to be learned to improve efficiency in
the acute care patient population and possibly have application to all patients.

Limitations

There were several limitations associated with this project. First, as this is a retrospective
analysis of a broad patient phenomenon, we cannot ascertain details of how the intervention
decreased LOS. Second, during the four-year study period, there were significant changes to the
healthcare landscape in our state, including the closure of four facilities that included SNF,
Rehab and LTAC beds (“Massachusetts Health and Hospital Association,” n.d.). This decreased
the availability of these beds for our patients and most likely decreased the potential impact of
our intervention. Third, these results were specific to our hospital and patient population, which
may not translate to non-ACS patients who would have different discharge needs. Finally, the
focus of this initiative was to decrease LOS and we did not examine the rates of readmission,
which has previously been studied regarding its relationship to LOS (Kaboli et al., 2016).

Despite its limitations, this intervention demonstrates that by creating a list of targeted
patients, rounding with a small, multidisciplinary group with influence on discharge decisions
and early identification and action on barriers to discharge, an institution can use existing
resources to create a significant decrease in ACS patient days per year with limited added cost
(1-2 hours per week).

Conclusions

We describe a comprehensive, multidisciplinary quality initiative to decrease the length

of stay of complex, acute care surgery patients. Our two-year experience suggests that the
initiative is impactful, cost-effective and sustainable.

Conflict of Interest Statement: “No conflict of interest has been declared by the author(s).”

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Accepted Article References

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Accepted Article
Table 1

Examples of Interventions Identified During Rounding

Issue Action

Consult needed for acceptance to discharge During rounds, consult ordered.

facility.

IV antipsychotic medication not appropriate During rounds, change medication to oral

for discharge facility. equivalent.

Patient lacks capacity due to traumatic brain During rounds, PM&R consulted.
injury.
After rounding, guardianship team contacted,
social work engaged, and healthcare proxy
clarified.

Patient has inadequate insurance status for During rounds, PT and OT reorganized their
discharge needs. therapy schedules in anticipation of a
prolonged hospitalization.

After rounding, patient financial services

contacted early in hospitalization in
anticipation for discharge needs.

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Accepted Article
Table 2

Pre- and Post-QI Means (with Standard Deviations) for Length of Stay of Acute Care Surgery
Patients by Discharge Unit

Pre-QI Post-QI p-Value†

Surgical Number of Patients 2074 2143
Floor oLOS mean 7.73 (10.50) 7.55 (10.63) 0.27
eLOS 6.65 (6.02) 6.71 (5.88) 0.12
O/E Ratio 1.19 (1.20) 1.14 (1.03) 0.019*

Surgical ICU Number of Patients 291 346

oLOS 7.36 (8.94) 8.59 (10.28) 0.14
eLOS 9.05 (6.76) 9.72 (7.52) 0.26
O/E Ratio 0.87 (0.92) 0.93 (0.90) 0.38

Other Number of Patients 567 699

oLOS 6.88 (10.00) 6.48 (11.13) <0.0001*
eLOS 5.83 (5.51) 5.85 (6.15) 0.27
O/E Ratio 1.16 (0.95) 1.01 (0.89) <0.0001*
†
Wilcoxon Signed-Rank Test

*p <0.05

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Accepted Article
Table 3

Pre- and Post-QI Means (with Standard Deviations) for Length of Stay of Acute Care Surgery
Patients by Discharge Status Assignments

Pre-QI Post-QI p-Value†

Total Number of Patients 2932 3188
oLOS 7.53 7.43 0.01*
(10.26) (10.72)
eLOS 6.73 6.85 0.24
(6.06) (6.23)
O/E Ratio 1.15 1.09 <0.001*
(1.14) (0.99)

Home Number of Patients 1417 1497

oLOS 4.04 3.97 <0.001*
(4.31) (6.21)
eLOS 4.56 4.64 0.60
(2.71) (3.25)
O/E Ratio 0.93 0.85 <0.001*
(0.74) (0.69)

Home with Number of Patients 546 664

Services
oLOS 7.74 7.37 0.25
(8.72) (8.80)
eLOS 6.34 6.57 0.32
(3.92) (4.34)
O/E Ratio 1.31 1.18 0.048*
(1.61) (0.94)

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Accepted Article SNF Number of Patients 300 327
oLOS 9.52 9.70 0.91
(9.09) (8.94)
eLOS 8.80 9.44 0.30
(8.43) (8.46)
O/E Ratio 1.30 1.19 0.29
(0.91) (0.76)

Rehab Number of Patients 277 267

oLOS 15.01 13.27 0.18
(15.79) (14.82)
eLOS 9.72 9.00 0.18
(6.65) (6.30)
O/E Ratio 1.70 1.69 0.62
(1.38) (1.57)

LTAC Number of Patients 121 132

oLOS 24.60 24.95 0.65
(21.70) (19.86)
eLOS 17.79 16.9 0.52
(12.38) (12.35)
O/E Ratio 1.73 1.81 0.44
(1.50) (1.46)
†
Wilcoxon Signed-Rank Test

*p <0.05

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 jan_14335_f1-2.docx

Accepted Article
Figure 1

Structure of Weekly Multidisciplinary Rounding

List created in the electronic medical record of all ACS patients in surgical ICUs and
surgical floors with a LOS of ≥10 days. List is reviewed by ACS nurse, with clinical
updates obtained from responding ACS physicians and nurse practitioners during
sign-out rounds.

Standing meeting with case managers and unit nurses on surgical floors/units.

Physical therapist, occupational therapist, ACS nurse and physician meet with case
managers and unit nurses and present the patients to the case managers. Discussion is
focused on barriers preventing discharge from the hospital.

Time on each unit is approximately 5-10 minutes.

Any interventions that can be done during rounds are done. Otherwise, notes are
taken for further issues that require resolution.

Physical therapist, occupational therapist, and the ACS nurse and physician then move
to the next floor/unit and repeat the process.

Total time of rounding is 20-30 minutes.

After rounding, notes are reviewed. Further contact made with providers that aid in
the resolution of outstanding issues.

Total extra time is 15-30 minutes.

1
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Accepted Article
Figure 2

Estimating Patient Days Saved After Intervention

1.15 (O/E Ratio pre-QI) – 1.09 (O/E Ratio post-QI) = 0.06

0.06 X 3188 (number of patients in post-QI) = 191.3 patient days saved

191.3 patient days / 2 years (Post-QI period) = 95.6 patient days saved per year

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