Harlan Krumholz (Yale) is a cardiologist who focuses his research on the impact of health services on health outcomes (Center for Outcomes Research and Evaluation - CORE), and on "Post-Hospital Syndrome. An Acquired, Transient Condition of Generalized Risk" focused its attention on readmissions, a problem that affects 20% of people who are discharged in the US. In this context, Krumholz's most prominent finding in the article was that of Jenks and colleagues (with 12 million Medicare discharge records), which enabled them to conclude that patients who had been admitted with decompensations of the most common chronic pathologies: heart failure, pneumonia, COPD or gastrointestinal disorders, if they were readmitted before 30 days, they did so in two-thirds of the time, for reasons other than the diagnosis of the previous admission.
With this data, according to Krumholz post-hospitalization syndrome is a clinical decompensation that often forces the patient to have to re-enter due to unfavourable circumstances acquired during their stay in the hospital. To understand the problem it may be useful to schematically review the processes and ways of working of today's hospitals. Imagine that an elderly person, living alone, affected by heart failure without a referral nurse, suddenly feels worse. She calls an ambulance and goes to the emergency room. There, between corridors and observation rooms, she can spend between 12 to 24 hours (if not more) and end up entering Internal Medicine or Cardiology, where the doctor responsible will focus all clinical efforts to reduce the symptoms that caused the visit. Having achieved the goal, perhaps 10 or 12 days later, the doctor will prepare to discharge of the patient. The point is that during her stay, no one will have taken care of the overall needs of the person because the clinical focus will have been exclusively on improving the symptoms therefore, upon returning home the person can easily be in a situation of greater cognitive, functional and physical impairment.
An unfriendly environment for vulnerable people
- The traditional deprivation of sleep that patients suffer when admitted, affects their metabolism and induces disorientation and loss of functional level, among other negative effects for their health.
- Inpatients may experience circadian rhythm disorders, beyond sleep loss, especially when they spend many hours with artificial light in the emergency room.
- During hospitalizations, malnutrition can also be a problem. Krumholz says that one in five elderly hospitalized patients eat less than half of the needed nutrients. This happens especially in people who have been intubated or who have been kept fasting for tests or other circumstances. Malnutrition results in delays in wound healing, in the risk of nosocomial infections, or in the ability to produce decubitus ulcers, in addition to other functional impairments.
- One of the greatest risks for hospitalized elderly people is the deterioration of their cognitive level, influenced by sleep deprivation, circadian rhythm disorders, the lack of referring professionals in an environment with a lot of contact from a lot of people who often say different or even contradictory things, in addition to the usual improvisations in the daily work of hospitals. All this ends up generating confusion and the induction of delirium situations.
- Resting due to poorly planned postoperative periods, poorly justified sedation, or other circumstances of pain or inadequate maintenance of catheters, probes or monitoring, inevitably worsen the frailty of the elderly and result in an increased risk of falls.
Four recommendations to reduce post-hospitalization syndrome
The data says: Hospitals are a trap for vulnerable people. So what to do, since avoiding hospitalizations is not always possible? The answer is clear, modern hospitals must be prepared to care for frail people:
- Training emergency doctors and nurses to evaluate older people from a general perspective and rigorously apply the entry criteria.
- Reforming emergency services with units planned specifically for the most vulnerable people.
- Entering all frail patients into specific units (some call them acute geriatric units), where all clinical staff should be trained to prevent the factors causing the post-hospitalization syndrome.
- Working with the family and community from entry until discharge.
Due to the appearance of respirators in the 1950's, hospitals realized that it was not reasonable to train all nurses to use the equipment; this is why the first ICU was created. The "care" criterion had passed the "main diagnosis" concept. Now two meta-analyzes (1, 2) warn that grouping all vulnerable patients into a single unit managed by trained professionals would allow them to be more closely tailored to their needs, which would reduce the post-hospitalization syndrome.