Sunday, January 13, 2013

A Hospital is a Dangerous Place

The latest New England Journal of Medicine includes the description by Dr. Harlan Krumholz of a new disease: Post Hospital Syndrome.  In the article entitled, “Post-HospitalSyndrome – An Acquired, Transient Condition of Generalized Risk”, he notes clearly and concisely what most people in medicine have always believed but never voiced in this manner.  Just being in the hospital makes you sick. 

As he states it, “Patients who were recently hospitalized are not only recovering from their acute illness; they also experience a period of generalized risk for a range of adverse health events.”  To put it simply, the experience of being in the hospital puts you at risk for a virtual cornucopia of illnesses that often are totally unrelated to the reason you were admitted to the hospital in the first place.  He backs up this contention by reviewing the reasons that people are readmitted after Heart Failure, Pneumonia, COPD and Gastrointestinal problems.  It turns out that most of the time readmission is for causes other than those diagnoses that drove the need for hospitalization in the first place.  This chart from Dr. Krunholz’s article makes that vividly clear. 

When people are in the hospital, we, that is the health professionals who care for them, deprive them of sleep, disrupt their sleep and wake rhythms, often do not feed them in preparation for tests and procedures, create pain by poking them and prodding them, confuse them, give them medications which all have side effects, and keep them in bed which results in deconditioning their muscles.  Then we send them home saying “You are better”.  Numerous studies have shown that people who lose weight in the hospital are more likely to be readmitted.  At least part of that weight loss is related to the poor nutrition and the muscle depletion that comes from lying in bed. 

When we send them home, it is often with little coordination between the care givers in the hospital and those in the community, such as the primary care physician.  “Improvements” in health care delivery, such as the use of hospitalists, has fragmented care and impaired our ability to help peole through the transition from hospital to home.  The old saying that people are sent home “sicker and quicker” is often true and contributes to this “Post-Hospital Syndrome”. 

They are also sent home confused as the sleep disorders beget sleeping pills and the pain begets pain pills.  We then send people home either on the pills, some of which may be unnecessary when they are in their own beds without IVs sticking out of their arms, or on too few pills so they are racked with pain and fear despite having been “fixed” in the hospital.  Then we wonder why they have to be readmitted for the confusion and for mental status changes.
So what is my advice for patients and their families?

  • Be a demanding patient in the hospital.  Do not meekly accept being awoken in the middle of the night, or being in a room in which there is noise and distraction.  Ask why being disturbed while asleep is necessary and what alternative plan can the doctors and nurses devise. 
  • Do not meekly accept being starved.  If you are made NPO (nothing by mouth) prior to some test, specifically ask why and how long before you can eat.  After a test demand being brought food even if it is not the scheduled time for the floor. 
  • Question everything.  What are these medications for, what is the blood test for, and why is that CT scan being done must be questions to ask constantly.
  • If you are strong enough, get up and walk.  If you are not strong enough, aks a nurse to get you into a chair and to help you walk.
  • If you are well enough, get dressed.  (Staff in the hospital will see you with more respect and as more “human” rather than the patient in room 3.)
  • Have a bodyguard.  Have someone you know and trust, like a family member, stay with you as much as possible to help you and to advocate for you.  They should be coached beforehand so that they are assertive on your behalf. 
  • Have an assistant or an advocate available by telephone.  This should be someone who understands the health care system and can help you be assertive and help you know the right questions to ask at the right times.  Your on-site “bodyguard” (see the previous bullet point) may not be enough of an expert to fill that role.
  • When you go home, insist that the nurses and doctors call and report to the doctor who will be caring for you as an outpatient.  It is even better if you can be part of the call and listen in.  The transfer of the knowledge of your hospital stay is critical to your health. 
  • Insist on taking copies of your records home with you.  Even in this day of electronic medical records, the staff can print out records for you to take with you. 

Finally the best way to avoid Post-Hospital Syndrome is to avoid going into the hospital in the first place.  While a hospital stay is sometimes unavoidable and can be lifesaving, it is also risky and can leave you sick in ways that are totally different than your reason for going in.