May 05, 2014

About Time

Just over a year ago, physician-researcher Harlan Krumholz created a stir by describing the “post-hospital syndrome.” Some patients, he argued, were so traumatized by hospitalization that they went home in some ways sicker than when they entered the hospital. They were confused (delirious) or they had a new “hospital-acquired infection” (so common that it has its own acronym, HAI) or they suffered a side-effect from a new medication, perhaps one that was no better (and evidently in some ways considerably worse) than the medicine they had taken previously. Readmissions to the hospital, the number one bugaboo of Medicare these days, result from the illnesses induced by a previous hospitalization, Krumholz argued. Now, writing together with health economist and policy maven Allan Detsky, Krumholz recommends a few practical steps that might alleviate the problem. 

The authors suggest 7 commonsense, seemingly simple changes that could make the hospital a less toxic environment for older people (particularly frail older people although they don’t specifically identify this subgroup as especially prone to developing problems in the hospital). Hospitals should personalize their care to make patients feel like individuals (for example, allowing them to wear their own clothes); they should ensure that patients get enough rest and nourishment (abandoning the practice of waking the patient up to check vital signs every few hours and of supplying unappetizing meals adhering to draconian dietary restrictions); hospitals should reduce stress by providing privacy and decreasing uncertainty (giving patients a schedule of their daily activities and a list of the names of those taking care of them); they should eliminate unnecessary tests and procedures (that unwarranted urine test that shows bacteria may lead to unwarranted antibiotics that in turn result in diarrhea—along with promoting the development of resistant bacteria); hospitals should avoid abrupt changes in medication regimens (introducing new medicines in the middle of the night, for example, in response to a transient increase in blood pressure or heart rate, medications that are then continued, only to produce dangerously low blood pressure or heart rate); they should encourage physical activity to avoid the rapid deconditioning that occurs with even a few days of bed-rest; and hospitals should provide a post-discharge “safety net” by scheduling follow-up appointments.

Harlan and Detsky are absolutely right: we should do everything they advise. The only problem is that most of these solutions were proposed 30 years ago as a way to avoid adverse consequences of hospitalization. Many of them were instituted, at least on a limited scale, through the introduction of Acute Care for the Elderly (ACE) units. ACE units have spread through many US hospitals and they have been studied extensively. They do seem to help—a little. But a recent review article and meta-analysis found that the risk of falls, delirium, pressure ulcers, and decline in independence remain stubbornly high. While the focus of this analysis was on problems that arise during the hospitalization, it is equally applicable to what happens after discharge since these “new” problems are in fact generated by events occurring during the hospital stay.

So yes, we should redouble our efforts to make the principles of the ACE unit a reality in all American hospitals. And we should update the list of ACE unit practices to include those that recent work suggests are important along with those clearly identified in the early 1980s as important (for example, attention to diet and supplying patients with the names of their hospital clinicians). But these measures alone will not fix the problem of frequent readmissions to the hospital, any more than better “transitional care” (doing a better job of passing the baton from hospital staff to outpatient primary care clinicians) has solved the problem. It is a step and an important step. The next step will be to keep frail, older patients—the ones most likely to develop adverse consequences of hospitalization or “post-hospitalization syndrome”—out of the hospital in the first place.

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