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Readmissions May be Triggered by 'Post-Hospital Syndrome'

 |  By cclark@healthleadersmedia.com  
   January 15, 2013

As hospital teams zealously work to prevent 30-day readmissions, they may not realize that sometimes what brings patients back into their hospitals is not what brought them there in the first place.

Something else is going on. Writing in the New England Journal of Medicine, Harlan Krumholz, MD, calls it "post-hospital syndrome, an acquired transient condition of generalized risk."

The syndrome, he said, is making patients sick with a variety of other conditions after their primary illnesses are resolved, although it's unclear why.

In fact, hospital officials are aware that 20% of Medicare patients discharged from a hospital have a medical problem within the next 30 days that is so serious, they must be re-hospitalized.

Typical readmitting diagnoses include mental illness, gastrointestinal conditions, metabolic derangements, and trauma, as well as heart failure, pneumonia, and chronic obstructive pulmonary disease.

Krumholz postulates that readmissions not related to the index admission might be due as much to otherwise unexplained "allostatic and physiological stress that patients experience in the hospital just as they do from the lingering effects of the original acute illness."

And hospital teams need to work harder to explore "new approaches to making hospitalization less toxic."

For readmitted patients whose index admission was for treatment of heart failure, pneumonia, or chronic obstructive pulmonary disease, the reason for readmission was not the same as the reason for their first admission for 63%, 71% and 64% of the time, respectively, he wrote.

But why, Krumholz asked. "How might the post-hospital syndrome emerge?"

Substantial stress during the experience of being a patient, he suggested.

"During hospitalization, patients are commonly deprived of sleep, experience disruption of normal circadian rhythms, are nourished poorly, have pain and discomfort, confront a baffling array of mentally challenging situations, receive medications that can alter cognition and physical function and become deconditioned by bed rest or inactivity," he wrote.

"Each of these perturbations can adversely affect health and contribute to substantial impairments during the early recovery period, an inability to fend off disease, and susceptibility to mental error."

Krumholz stresses that it's important for hospital transition teams to "ensure that the condition for which a patient was initially admitted is successfully treated," but that teams also need to focus on the early recovery period, during which discharged patients are most vulnerable.

He has given readmission prevention a lot of thought. His group has been contracted with the Centers for Medicare & Medicaid Services to examine certain algorithms and risk adjustments in the 30-day readmission penalty provisions of the Patient Protection and Affordable Care Act.

Take sleep deprivation stemming from a patient being in a noisy, unfamiliar surrounding, he suggested.

"This disruption can have debilitating behavioral and physiological effects: sleep deprivation adversely affects metabolism, cognitive performance, physical functioning and coordination, immune function, coagulation cascade, and cardiac risk," Krumholz wrote.

And then there is the issue of the patient's diet and nutrition, "which often receive limited attention."

In one study of Medicare-eligible patients, 20% had an average intake of fewer than 50% of their energy requirements, which could be because their procedures require they eat nothing for certain periods, which are prolonged when the tests or procedures need to be rescheduled.

"These deficits, rarely addressed at discharge, can lead to protein-energy malnutrition," Krumholz wrote. And that can lead to loss of weight and decreased blood albumen levels that are "strong predictors of readmission within 30 day," he wrote.

Malnutrition can impair wound healing, raise risk of infection, exacerbate pressure ulcers, decrease respiratory and cardiac function and result in poorer outcomes for lung disease.

Krumholz gives special consideration to the cognitive deficits and information overload that can result from the confusion of hospitalization, and sometimes result in delirium.

Medications such as sedatives can be overprescribed, causing a dulling of the senses and impair judgment, or under prescribed, causing pain hypercatabolism, immunosuppression, hypercoagulability and increased nervous system activity.

He called on hospitals and doctors to "solicit details far beyond those related to the initial illness" and be aware of "functional disabilities, both cognitive and physical," to appropriately align care and support after hospitalization.

A good place to start, he suggests, is for hospital teams to reduce the causes of these disruptions where they occur, such as helping patients get better sleep and minimize pain and stress while they are hospitalized, and promote better nutrition.

They should also "optimize 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."

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