Addressing Barriers to Efficient LOS: Overcoming Challenges for Nurses

This article is for bedside nurses, nurse managers, and CNOs who aim to identify and address the barriers impacting Length of Stay (LOS). Nursing professionals can improve patient outcomes and operational efficiency by tackling challenges such as delayed diagnostics and social determinants of health (SDOH).

Why Tackling LOS Barriers Matters

Welcome to Day 5 of our 10-day series on reducing LOS. Barriers like delayed tests, staffing gaps, and patient-specific factors are common culprits behind extended hospital stays. Understanding these barriers and implementing solutions can streamline workflows and enhance care quality.

Barriers to Efficient LOS

Delayed Diagnostics: A Common Roadblock

Diagnostic delays, such as waiting for imaging results or lab processing, significantly contribute to prolonged Length of Stay (LOS). These delays can unnecessarily consume resources, increase costs, and reduce hospital efficiency.

• Example: A patient admitted with abdominal pain experienced a 48-hour delay in receiving CT imaging due to high demand in the radiology department. During this time, their condition remained stable but undiagnosed, delaying definitive treatment and prolonging their hospital stay by two days.

Solutions for Nurses:

1. Flagging Priorities During Rounds: During multidisciplinary rounds, a bedside nurse ensures that the need for imaging is discussed as a high-priority task. This proactive communication streamlines the patient’s care plan, enabling the care team to prioritize diagnostic tests earlier in the hospital stay.
2. Using EHR Alerts for Timely Follow-Up: Nurses can leverage electronic health record (EHR) alerts to track the status of pending diagnostic tests. Regularly monitoring these alerts ensures that results are reviewed promptly and escalated to the care team if delays occur (Kutz et al., 2022).
3. Coordinating Diagnostic Scheduling: Nurse managers work with radiology and lab teams to identify recurring bottlenecks in diagnostic workflows. For example, a manager might observe that imaging delays commonly occur during weekends and adjust staffing or scheduling practices to improve access during peak times.

Social Determinants of Health (SDOH): Beyond the Hospital Walls

Social determinants of health (SDOH) such as housing instability, lack of transportation, or inadequate caregiver support—often create significant barriers to discharge readiness. Addressing these issues is critical for ensuring safe and timely transitions from hospital to home.

• Example: A patient recovering from hip replacement surgery is medically ready for discharge but remains hospitalized because they lack access to a stable and safe home environment. The patient’s single-story home was damaged in a flood, and temporary accommodations were not wheelchair-accessible. This delay in discharge extended the patient’s hospital stay by three additional days while solutions were coordinated.

Solutions for Nurses:

1. Involve Case Management Early in Admission: During admission, a bedside nurse identifies that the patient may lack adequate post-discharge accommodations. The nurse immediately informs the case management team, which begins exploring transitional housing options. Example: In the case of the patient with the flooded home, the nurse worked with case managers to arrange a short-term stay in a rehabilitation facility, allowing the patient to leave the hospital sooner.
2. Partner with Social Services for Resources: Nurse managers collaborate with social workers to address transportation or temporary housing challenges. Proactively involving these teams ensures that patients with SDOH-related barriers are supported. For example,?a patient lacking reliable transportation for follow-up care was provided with a ride-share service voucher, coordinated by the hospital’s social services team, ensuring timely discharge.
3. Leverage Community Outreach Programs: Nurses connect patients with local organizations offering post-discharge support, such as meal delivery, in-home care, or mental health services. For example,?a patient without a caregiver was linked to a volunteer home-care program through a community partnership. This support reduced the risk of readmission and facilitated their discharge (Walsh et al., 2022).

Nurses’ Role in Overcoming LOS Barriers:

Nurses are at the forefront of identifying and addressing these challenges. Their unique position allows them to act as advocates, coordinators, and problem-solvers.

1.????? Proactive Discharge Planning

Starting discharge planning at admission helps anticipate and resolve potential delays.

• Example: A bedside nurse identifies that a stroke patient will require home therapy. The nurse ensures smooth discharge by initiating therapy scheduling and caregiver coordination early (Konicek & Blevins, 2023).

2.????? Interdisciplinary Collaboration

Many LOS barriers require input from various disciplines. Nurses can bridge communication gaps and foster teamwork to address these challenges effectively.

• Example: During rounds, a nurse highlights a patient’s mobility limitations that could delay discharge. The team prioritizes physical therapy, preventing an extended stay (Friel et al., 2021).

Tools to Address LOS Barriers:

1.????? LOS Dashboards:

Dashboards highlight delays in real-time, helping teams track trends and intervene promptly.

• Example: A nurse manager uses a dashboard to identify frequent delays in physical therapy for post-surgical patients and adjusts staffing to meet demand.

2.????? Standardized Protocols:

Tools like the SMART Framework or IDEAL Discharge Planning Checklist ensure that all steps are addressed systematically, preventing last-minute surprises (AHRQ, n.d.).

3.????? Community Resource Directories:

Linking patients to external support services—such as transportation or home health care—can resolve common SDOH challenges and expedite discharge readiness.

Real-Life Applications for Nurses, Managers, and CNOs:

1. Bedside Nurses: Proactively Coordinating Care. A bedside nurse identifies a diabetic patient who lacks a refrigerator for insulin storage. By working with case management to secure a cooling solution, the nurse ensures the patient can be discharged safely.
2. Nurse Managers: Addressing Systemic Issues. A nurse manager observes a recurring issue: delays in weekend discharges due to the limited availability of social workers and case managers. This results in patients staying longer than necessary, increasing the average LOS. Recognizing the need for change, the nurse manager collaborates with the Chief Nursing Officer (CNO), Chief Financial Officer (CFO), and Chief Executive Officer (CEO) to address the resource gap. Together, they develop a plan to reallocate work hours strategically. After implementing the changes, the average LOS is reduced by 0.5 days per patient. Patients benefit from timely discharges, and the hospital improves resource utilization and patient flow.
3. CNOs: Leading Institutional Change. A CNO identifies recurring delays in diagnostic imaging as a primary contributor to LOS extensions. The CNO collects hospital-wide data showing that delays in diagnostic imaging extend LOS by an average of 1.2 days per affected patient. This data is presented to the CFO and CEO, highlighting the financial implications of extended stays, including increased operational costs and reduced bed availability. The CNO proposes restructuring radiology schedules to prioritize inpatient imaging requests during peak hours. Diagnostic backlogs are reduced without additional costs by reallocating staffing from less busy times (e.g., late evenings) to high-demand periods. The CNO collaborates with nurse managers and radiology leads to establish a communication protocol where inpatient imaging requests are flagged as a high priority. Nurses use this protocol to ensure that radiology teams are immediately alerted to urgent tests, minimizing delays. With these adjustments, delays in imaging are reduced within weeks. As a result, average LOS decreases by 8% hospital-wide, improving patient flow and allowing more timely admissions from the emergency department. Also, by investing in additional imaging equipment and expanding radiology hours, LOS is reduced hospital-wide by 12% (Manoukian et al., 2021).

The Financial and Operational Impact of LOS Barriers

Increased Costs:

Prolonged stays result in higher operational expenses, including extended staffing and resource use (Friel et al., 2021).

Lower Patient Satisfaction:

Patients often express dissatisfaction when delays prolong their hospital experience. Efficient LOS management improves satisfaction scores and overall care quality (Walsh et al., 2022).

5 Steps to Overcome LOS Barriers

1. Identify Common Delays: Use LOS dashboards to analyze trends and pinpoint recurring bottlenecks.
2. Collaborate During Rounds: Discuss barriers with interdisciplinary teams to find immediate solutions.
3. Implement Standardized Protocols: Use checklists like SAMRT Framework or IDEAL to ensure consistent discharge readiness assessments.
4. Engage Case Managers and Social Services Early: Address SDOH challenges at the start of hospitalization to prevent last-minute delays.
5. Advocate for Resources: To address frequent barriers, request support, such as a weekend case manager, social work coverage, or additional diagnostic team personnel or equipment.

Act on Barriers Today

Reflect on the most common LOS barriers in your practice. Are delays related to diagnostics or patient-specific factors? Identify one actionable step to mitigate these barriers and collaborate with your team to implement it this week.

Vision for the Future

Imagine a hospital where barriers to discharge are resolved before they impact LOS. Nurses are vital in this transformation, shaping a healthcare system and prioritizing efficiency, patient outcomes, and seamless care transitions.

Stay tuned for Day 6, where we will explore the connection between LOS and value-based metrics, including the reimbursement implications and alignment with quality improvement initiatives.

References

1. Agency for Healthcare Research and Quality. (n.d.). IDEAL discharge planning overview, process, and checklist.
2. Friel, K. M., McCauley, C., McCann, M., O'Kane, M., Delaney, G., & Coates, V. (2021). The efficacy of hospital-based interventions in reducing hospital length of stay for the inpatient with diabetes: A systematic review. Diabetic Medicine.
3. Konicek, S., & Blevins, T. (2023). Optimizing multidisciplinary rounds: Improving outcomes through collaboration. Indiana University Health Bloomington Hospital.
4. Kutz, A., Koch, D., Haubitz, S., Conca, A., Baechli, C., Regez, K., Gregoriano, C., et al. (2022). Association of interprofessional discharge planning using an electronic health record tool with hospital length of stay among patients with multimorbidity. JAMA Network Open, 5(9), e2233667.
5. Manoukian, S., Stewart, S., Graves, N., Mason, H., Robertson, C., Kennedy, S., & Dancer, S. J. (2021). Bed-days and costs associated with the inpatient burden of healthcare-associated infection in the UK. Journal of Hospital Infection, 114, 43–50.