Every year, approximately 1.7 million people in the U.S. acquire an infection from being in the hospital. What’s becoming an even more ominous outcome of that experience is post-hospital syndrome – a condition of extreme vulnerability to a variety of health threats to which recently discharged patients are subject.
A case study of the syndrome was described early this month by Dr. David Newman in the New York Times. A woman struggling to breathe was brought into a hospital emergency department by paramedics. Her husband said her respiratory problems began when she was a inpatient a few weeks earlier with pneumonia.
When her oxygen levels improved after five days, she was discharged, but once she got home, she could barely get out of bed, and in Newman’s ER, her breathing was increasingly labored and her heartbeat was rapid. Although her lungs sounded clear, her arms bore bruises from the multiple blood tests she underwent in the hospital. Her face was gaunt, her lips were dry, she barely slept or ate, and she was losing weight.
Newman recognized it as post-hospital syndrome, a disorder described by Dr. Harlan Krumholz, a professor of medicine and public health at Yale School of Medicine, that presents in the days and weeks after a hospital stay: “Physiologic systems are impaired, reserves are depleted, and the body cannot effectively avoid or mitigate health threats,” Krumholz wrote in 2013.
The syndrome emerged as a distinct disorder after Medicare imposed standards hospitals must meet to avoid readmitting patients within 30 days of discharge or be financially penalized. Scrutiny of why so many patients are readmitted so soon led to the discovery of two things, Newman says: The problems people experience at home, as his ER patient did, occur in about 1 in 5 hospitalized Medicare patients on Medicare. And, in most cases, these problems represent an illness distinct from what put them in the hospital in the first place.
“Post-hospital syndrome is therefore not a relapse,” Newman writes, “it is a state of susceptibility that most often leads to a new affliction. Infections, for instance, which are known complications of a hospital stay, were just one small category of post-hospital illnesses tracked in a large study of Medicare admissions. Others included heart failure, gastrointestinal conditions, mental illness, nutrition-related problems, electrolyte imbalances and trauma (probably from falls and weakness).”
That pretty well describes the woman he saw that day in ER. Her body’s defenses were weak, and made worse by dehydration and lack of sufficient nutrition. But her pneumonia had resolved.
As Newman puts it, post-hospital syndrome “suggests that patients can be the victims of friendly fire.”
A few weeks ago, writing in JAMA, Krumholz and Dr. Allan Detsky, from the University of Toronto, wrote a prescription for fixing post-hospital syndrome: Fix the hospital.
The hospital, they said, causes the problem, thanks to noisy machines, frequent needle sticks, unpredictable waits to see the doctor, unappetizing food and sleep deprivation. All of those things undermine a person’s ability to muster resources and heal.
They proposed sweeping changes in hospital care ranging from the aesthetic – more cheerful décor – and the personal – let patients wear their own clothing – to the clinical – reduce the number of routine procedures, including needle sticks, and minimize machine alarms, unnecessary sleep disruptions and room traffic.
They even dissed hospitals for their routinely poor food, referring to a commonly “draconian unsavory diet” when eating well is critical for healing.
Some of these recommendations have been embraced by some hospitals. Pediatric hospitals are known for brighter décor and a sensitivity to painful procedures that results in minimizing their use. Many hospitals have an upgraded food plan (that is, more expensive), and more creature comforts to address individual patients’ interests and need.
It’s all about creating a healing environment, which seems more like common sense than institutional infrastructure, doesn’t it?
It worked for Newman’s patient. Her breathing eased after she got intravenous fluids, and, during her second hospital stay her husband brought her favorite foods each day. He protected her from sleep interruptions. Her primary care doctor ordered that needles and procedures not be used if not absolutely necessary. Physical therapists helped her regain mobility.
Within three days she was back home, functioning and recovering.