Monday, 21 January 2019

The post-hospitalization syndrome

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
  1. 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.
  2. Inpatients may experience circadian rhythm disorders, beyond sleep loss, especially when they spend many hours with artificial light in the emergency room.
  3. 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.
  4. 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.
  5. 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:
  1. Training emergency doctors and nurses to evaluate older people from a general perspective and rigorously apply the entry criteria.
  2. Reforming emergency services with units planned specifically for the most vulnerable people.
  3. 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.
  4. 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.

Jordi Varela

Monday, 14 January 2019

Could the American Health System Become the Best in the World?

Josep M. Picas

The title of this paper is the same as one recently published in the "Perspective" section of The New England Journal of Medicine (NEJM), "From Last to First. Could the U.S. Health Care System Become Best in the World?" This article seemed to me to be an interesting example of introspection and critical analysis, and at the same time an excellent formulation of future challenges. I must confess that I feel admiration and envy for these types of approaches and advances that we frequently observe in the Anglo-Saxon environment.

Monday, 7 January 2019

Focusing on the daily life of frail people

The PACE (Program for All-Inclusive Care for the Elderly) model was born in 1971 when a dentist and a social worker working for the San Francisco Department of Public Health in Chinatown-North Beach realized that older people were reluctant to move to a social residence when, instead, with some complementary services, they could continue to live in their own homes, in a more friendly and stimulating environment. Nearly fifty years later, PACE enjoys good health and "The Commonwealth Fund" has published a "Case Study" analysing its operation and results.

Monday, 31 December 2018

Who’ll talk about us when we’re dead?

Antoni Peris

First of all, allow me to recommend that you rush out to see A ghost story (D. Lowery, 2017). It's not a ghost movie. It's a movie with ghosts. It's not a movie about grief. It’s a film about permanence, about memory, about the permanence of memory and our will to endure as human beings. We are asked, what will remain of the Ninth Symphony of Beethoven when a thousand years have passed. And what will remain of us? Who will remember our passing through this world? The presence of A ghost story (ironically presented as one of those phantasms of children's stories, with a bed sheet and holes to see through) is something that refuses to disappear, perhaps the boy that appears at the beginning of the movie, perhaps the ghost of the house, or of the place, or perhaps the accumulation of experiences that take form whilst trying to continue their existence; It’s a beautiful and serene film exploring whether our existence and memory make any sense.

Monday, 24 December 2018

On the subject of continuity of care in hospitals

Last week we debated how the longitudinal continuity of primary care affects the comings and goings of chronic patients to emergency services. Along this line, I would like to explore the difficulties that hospitals have in guaranteeing ongoing health care services especially at night and at weekends, and how this problem weighs on services when taking care of the most vulnerable groups.

Imagine that a frail person enters a hospital due to acute decom-pensation, according to the known evidence, a global geriatric eva-luation and an individualized therapeutic plan should be deve-loped in agreement with the primary care team, if the desired outcome is to have a reasonable chance of returning home as soon as possible and in the best possible condition. The problem originates in that the hospitals, not even the best of them, are able to give a continuous response to patients as described, since the usual medical equipment usually offers a continuous coverage of only 27% (From a 5 day week of 8 to 5). What happens in the remaining 73% of time (evenings, nights and weekends)? As our imaginary patient, although you would enjoy medical coverage on duty, the service you will receive is very likely far from guaranteeing the continuity necessary for the fulfilment of your personalized plan.

Monday, 17 December 2018

Dysphagia and "minimal mass interventions": ethics, management and value

Marco Inzitari

In recent times there is an increased risk that the relevant becomes unseen. I understand that readers are mainly from the world of health but did you know that in Barcelona, ​​at the end of September 2017, the European and world congress on swallowing disorders was organized? And that the current president of the European Society of Swallowing Disorders is very close to us because he’s Dr. Pere Clavé, gastroenterologist and academic director, teaching and innovation at the Hospital de Mataró?

I was fortunate to be invited to talk about Dysphagia in older people in this meeting, with the opportunity to review the advances in this area. I don’t aim to venture into any clinical treatise on Dysphagia, but I think it’s useful to disseminate some aspects that are in line with the "value practices" advocated by this blog.

Monday, 10 December 2018

Innovation or decadence. There’s no middle ground

Josep Maria Monguet

Innovation is not a fad; it’s a structural phenomenon of the future, largely a product of the acceleration in the production of new knowledge. Innovation was always part of our world, but there are two new factors nowadays:
  1. Accelerated innovation: more novelty in products and services are observed more frequently.
  2. It's everyone's business: each one of us are protagonists of innovation.