This week the New England Journal of Medicine published an article by Dr. Harlan Krumholz that introduces the Post Hospital Syndrome. It turns out that in the United States nearly one fifth of people older than 65 (Medicare patients) who are released from an acute care hospital “have an acute medical problem within the subsequent 30 days that necessitates another hospitalization.†They are frequently readmitted for conditions that have little to do with the original diagnosis, but have a lot to do with the hospital experience itself. For example patients who are admitted with heart problems can be readmitted with gastrointestinal problems like impacted stool from extreme constipation. Patients who arrive with acute pneumonia can be readmitted for heart failure or “metabolic derangements,†says the article.
What quickly emerges is that often acute care hospitals are so focused on treating the presenting problem that they neglect other aspects of patient health, and can deprive them of sleep, food, or sanitation to the extent that they can become acutely ill within a short time after discharge. The article points to studies that show that typical patients over 65 “had an average nutrition intake of less than 50% of their calculated maintenance energy requirements.†This can lead to “increased risk of infections, pressure ulcers, cardiovascular and gastrointestinal disorders.†Similar studies show shortfalls in other areas which put increased stress on healthy bodily functions of older people.
It is particularly interesting that the most obvious solution to the problem is the last one mentioned - to ensure that hospitals are organized so that older patients eat enough, sleep enough, and get to go to the bathroom at regular intervals.
The first suggested solution is to pass the problem on to the community by identifying the deficits caused by the hospital stay:
We should assess a patient's condition at discharge by soliciting details far beyond those related to the initial illness. As we determine readiness for transition from the inpatient setting, we should be aware of functional disabilities, both cognitive and physical, and align care and support appropriately.
Here we have a clear example of where the hospital clearly does harm, but declares that the minimum response is to pass the responsibility for dealing with it to others. Later he agrees that a more comprehensive strategy should begin in hospital:
We should more assertively apply interventions aimed at reducing disruptions in sleep, minimizing pain and stress, promoting good nutrition and addressing nutritional deficiencies, optimizing the use of sedatives, promoting practices that reduce the risk of delirium and confusion, emphasizing physical activity and strength maintenance or improvement, and enhancing cognitive and physical function.
And finally he agrees that:
We must ensure that we are doing no harm in the course of assisting patients who are acutely ill. We will need to expand our efforts to reduce readmissions during this high-risk period, exploring new approaches to making hospitalization less toxic and promoting the safe passage of patients from acute care settings.
Here is yet another recognition that in their present configuration as rapid transit “factories†hospitals can themselves be “toxic.†We need to find ways to make them less toxic, not only by improving the necessary health conditions for their patients, but improving the health care experience as a whole. This can only be done with the collaboration of patients and those close to them.