In the process of giving life-saving therapies, healthcare providers are often unaware that the dehydration, malnutrition, deconditioning, and information overload that happen during hospital stays may have long-term consequences to the cognitive function of vulnerable patients.
Harlan Krumholz, MD, director of the Center for Outcomes Research and Evaluation at Yale School of Medicine, says that while patients get their diagnosed illnesses treated during their hospital stays, some can leave the hospital a lot worse off than than how they came in.
He's calling this scenario "the hospitalization toxic." In a paper in the New England Journal of Medicine earlier this year, he called it "post-hospital syndrome."
See Also: ICU Delirium Linked to Post-Discharge Cognitive Decline
'Regardless of what it's called, the result is that these patients are weaker, more prone to infections, cognitively impaired, and seem more vulnerable, more susceptible to adverse events such as falls. "Nothing's quite working right. They're not thinking straight."
But hospital teams don't think about this. Case managers, clinicians, nurses, discharge planners, and physicians all tell the patients what to do next to keep them from being readmitted and to speed their recovery:
- Here's how to take your medication.
- See this doctor next Tuesday.
- Eat less salt.
But patients don't hear a word and can't recall any of it the next day. "Their brains aren't working like they used to," Krumholz says.
Misplaced Focus
A few years ago, Krumholz would describe this paradox to medical groups and get blank stares. But these days, it's "starting to be met with universal head-nodding," he says. "People embrace the idea as if a light has gone off, and they sort of recognize what they've been seeing in front of them all this time, but haven't been able to describe well."
That's because doctors' clinical perception has been clouded by the patient's history, and the focus has been on what led the patient to the initial hospitalization, and trying to get the acute symptoms resolved. Providers forget about this other thing that's been hovering right there in front of them. The elephant in the room—the "hospitalization toxic."
"When I call this the 'hospitalization toxic,' I don't mean that we're purposefully harming people or exposing people to anything, of course," he says.
"It's just that when we're in the process of trying to provide life-saving therapies, we're indifferent to the aggregate of what we cause the patient, which we consider minor inconveniences: Dehydration, malnutrition, deconditioning, information overload, dislocation, and chaotic scheduling." Then there are the medications and their cumulative effects.
"The aggregate of all that," he says, "is what causes patients to lose their equilibrium."
And that leads to patients getting readmitted. And of course hospitals and the physicians who treat their patients are increasingly concerned about preventing those.
Validation
In Thursday's New England Journal of Medicine, Krumholz's theory got a boost from researchers at Vanderbilt University. Praktik Pandharipande, MD, and colleagues conducted a multi-center clinical trial of patients treated for respiratory failure or shock in intensive care units.
They found that delirium developed in 74% after their hospital stay. At three months after discharge, 40% had cognition scores 1.5 standard deviations below the mean scores for their age and educational levels, and similar to patients with a traumatic brain injury.
The big variable was the duration of delirium that the patients endured in the ICU, a not-infrequent occurrence in patients with long ICU episodes.
The longer the delirium persisted, Pandharipande says, the more likely the patient would suffer cognitive impairment, manifested by an inability to plan, or think, or organize, which clinicians refer to as "executive function." The effect was seen as long as one year after discharge.
Better Transitions Are Possible
The good news is that Pandharipande and Krumholz think that delirium is preventable to some extent. Instead of overusing sedatives, patients can be kept awake to keep them oriented and engaged with their surroundings so they aren't confused to the point of psychosis. Caregivers can use lighter sedatives. They haven't proven it yet, but it makes sense.
And extremely important and do-able is that hospital teams can avoid waking people up in the middle of the night for tests or bathing or vital signs if they can be reasonably performed during waking hours.
What person who has spent any time as an inpatient, only to be discharged dazed and confused, like they haven't slept in weeks after being poked and prodded at all hours of the night, wouldn't appreciate that?
Smart hospitals are starting to do just that, to see what impact "sleep protocols" might have, Krumholz and Pandharipande tell me. I'm anxious to hear.
Krumholz thinks hospitals and policy experts, including himself, have not spent enough time working to understand how to make these transitions better for their patients who can't be expected to do what they're told when the hospital experience has disoriented their lives to this extent.
Hospitals, of course, are unhappy with being blamed for readmissions. They're now in a performance period for reimbursement cuts of up to 3% of their Medicare base DRG payments if their readmission rates are significantly higher than expected. Many hospital leaders don't think they can control, nor should they control, what happens to a patient once he or she leaves the hospital grounds.
"I feel bad for hospitals," Krumholz says. "For once they're going to have to really focus on making the transition easier for patients, and maybe create a healing environment that's more supportive. I know that's a hardship.
Quit Playing the Blame Game
But there's so much more we can do, Krumholz says. First, physicians and other members of a patient's whole caregiver team, inpatient and outpatient, need to stop blaming the patient for going home and forgetting what they were told to do. It might not be their fault.
"In my experience, as a patient, I don't think of this as an inpatient episode of care and an outpatient episode. I am suffering from an illness and I am going home. But I haven't finished one thing and started another; I'm dealing with the same thing.
"And I wonder why my doctors can't talk with each other. Why are people talking with me like they're educating me in the hospital instead of realizing that I'm cognitively impaired? I can't hear a word you're saying. I see your mouth moving but I don't understand a word you're saying."
"It's up to us to deal with this rather than just complain that the patients never listen."
What Pandharipande and Krumholz are opening us to is a whole new field of research and measurement. It will require a serious evaluation of remedies to see the extent to which the "hospitalization toxic" is affecting their patients, and how much of that can be prevented.
Then maybe we can all get a good night's sleep.