Friday, 3 August 2018

The Illness Is Bad Enough. The Hospital May

The Illness Is Bad Enough
The Illness Is Bad Enough. The Hospital could also be Even Worse.

Bernadine Lewandowski left, makes pasta sauce together with her daughter, Dona Jones. Ms. Lewandowski lived independently until recent hospitalizations.

When she moved from Michigan to be near her daughter in Cary, N.C., Bernadine Lewandowski insisted on renting an apartment five minutes away.

Her daughter, Dona Jones, would have welcomed her mother into her house, but “she’s always been very independent,” Ms. Jones said.

Like most of the people in their 80s, Ms. Lewandowski contended with several chronic illnesses and took medication for osteoporosis, coronary failure, and pulmonary disease.

Increasingly forgetful, she had been diagnosed with mild cognitive impairment.

She used a cane for support as she walked around her apartment complex.

Still, “she was trucking along just fine,” said her geriatrician, Dr. Maureen Dale.

“Minor health issues here and there, but she was taking excellent care of herself.”

But last September, Ms. Lewandowski entered a hospital after a fracture of her vertebra caused pain too intense to be managed reception.

Over four days, she used nasal oxygen to assist her to breathe and received intravenous morphine for pain relief, later graduating to oxycodone tablets.

Even after her discharge, the strain and disruptions of hospitalization — interrupted sleep, weight loss, mild delirium, deconditioning caused by days in bed — left her disoriented and weakened, a vulnerable state some researchers call “post-hospital syndrome.”

They believe it underlies the stubbornly high rate of hospital readmissions among older patients.

In 2016, about 18 percent of discharged Medicare beneficiaries returned to the hospital within 30 days, consistent with the federal Centers for Medicare and Medicaid Services.

Ms. Lewandowski, for instance, was back within three weeks. She had developed an embolism, a grume in her lungs, probably resulting from inactivity.

The clot exacerbated her coronary failure, causing fluid buildup in her lungs and increased swelling in her legs. She also suffered another fracture.

“These hospitalizations can cause big life changes,” Dr. Dale said. Having grown too frail to measure alone, Ms. Lewandowski, now 84, moved in together with her daughter.

Dr. Harlan Krumholz, a cardiologist at Yale University, coined the phrase “post-hospital syndrome” during a New England Journal of drugs article in 2013.

As Medicare began penalizing hospitals for 30-day readmissions under the Affordable Care Act, he checked out the national data and noticed that the majority of readmissions involved conditions seemingly unrelated to the initial diagnoses.

Patients came in with coronary failure or pneumonia, were treated and discharged, then returned with internal bleeding or injuries from a fall.

“Our general approach during a hospital is, all hands-on deck to affect the matter people are available with,” Dr. Krumholz said.

“All the opposite discomforts are seen as a minor inconvenience.”

He has argued instead that discharge marks the beginning of a 60- to 90-day period of increased vulnerability to a variety of other health problems, stemming from the strain of hospitalization itself.

“This is quite an inconvenience,” he said. “This is toxic. It’s detrimental to people’s recovery.”

Any hospital patient or hovering loved one, knows those stresses: Disrupted sleep, as staff draw blood and take vital signs at 4 a.m. A distorted sense of day and night.

Unappetizing meals often served at inopportune times.

Reduced muscle mass and poor balance following even a couple of days in bed.

New prescriptions with unpredictable consequences. Shared rooms. Delirium. Pain.

“It affects your hormones, your metabolism, your system,” Dr. Krumholz said.

“All this stuff have widespread effects,” leaving people depleted and fewer ready to debar other health threats.

The ripple effects vary considerably.

Researchers at Yale followed discharged Medicare patients after hospitalizations for coronary failure, heart attacks, and pneumonia.

Readmissions for gastrointestinal bleeding and anemia, they found, peaked four to 10 days after discharge.

The danger of trauma from falls or other accidents, on the opposite hand, remained elevated for 3 to 5 weeks.

While post-hospital syndrome remains a hypothesis for now, research on several fronts may help establish its validity.

Donald Edmondson, a behavioral medicine researcher at Columbia University center has acknowledged links between the strain levels that attack victims report and their likelihood of readmission.

In a meta-analysis, he and his colleagues found that 12 to 16 percent of attack patients, most of them older adults, actually develop post-traumatic stress syndrome.

As Dr. Edmondson acknowledged, people, experiencing heart attacks have multiple sources of stress, from fear of death to financial worries.

But he and his colleagues even have measured the impact of the hospital environment itself.

They compared patients (average age: 63) who came to the NewYork-Presbyterian Hospital ER when it had been crowded and chaotic (median time during a crowded ER: 11 hours) to those that arrived when it had been calmer.

“The more crowded it's once you are available, the more PTSD symptoms you’ll have a month later,” he concluded.

Now the Columbia researchers are following 1,000 E.R. patients with heart attacks, tracking their weight and stress levels, and giving each a wearable device to live physical activity and sleep.

The results may help substantiate the consequences of post-hospital syndrome.

“We’ve gotten better and better at treating disorders, but we haven’t gotten to the purpose where we avoid a number of the fatal accident to the patient,” Dr. Edmondson said.

Making hospitals less destabilizing, more conducive to healing seems an achievable goal. Hospitals roll in the hay for youngsters, Dr. Krumholz has acknowledged.

They could enable older patients, too, to wear their own clothes, get out of bed for walks (even with IV poles), eat enough to take care of their weight.

They might assess what percentage of lab tests patients really need and whether blood must be drawn before dawn.

“We should never wake a sleeping patient unless there’s a compelling reason, which reason shouldn’t be our own convenience,” Dr. Krumholz said.

But while we’re expecting hospitals to adopt such policies, we could try a D.I.Y. approach.

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