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Post-hospital Syndrome and the Readmissions Quandary

Posted on October 28, 2015   |   
4 Comments   |   
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Post-hospital syndrome

Post-hospital syndrome is a term coined only within the last three years, yet many might recognize the construct as one old as hospitals themselves. In a 2013 Perspective piece for the New England Journal of Medicine, Dr. Harlan Krumholz introduced post-hospital syndrome as “an acquired, transient period of vulnerability” precipitated by the physical and psychological stressors associated with the period of hospitalization itself. The syndrome compromises the physical and mental health of patients leading to poorer health outcomes.

Krumholz asserts that evidence for the existence of the phenomenon can be found in current rehospitalization data. Given that the vast majority of hospital readmissions are for a cause other than that which led to the index hospitalization, Krumholz believes additional factors must be at play (only 36% of patients first admitted for issues related to a COPD diagnosis of are readmitted within 30 days for that same diagnosis). Bolstering his theory, he claims, is the fact that severity of the index condition does not reliably predict rehospitalization; that is, the severity of the illness that first brought a patient to the hospital does not seem to determine the likelihood that he will return.

Krumholz briefly outlines five distinct elements of hospitalization syndrome: sleep disturbance and deprivation; nutritional inadequacy; confusion as well as a general state of being overwhelmed without adequate resources to cope; pain and discomfort; and deconditioning due to decreased activity. He offers that health systems might address these vulnerabilities by not only ensuring each is attended to prior to discharge, but by proactively addressing each while a patient is under a hospital’s care.

In a recent Forbes article, Dr. Robert Pearl outlines the ways in which multi-disciplinary teams might do this in a standardized way:

  • Increasing awareness among staff about post-hospitalization syndrome and delirium.
  • Identifying those patients most at risk.
  • Maximizing caloric intake and minimizing delays for those procedures requiring fasting.
  • Limiting blood draws to only what is necessary.
  • Encouraging support system visitation.
  • Lighting patient rooms in keeping with outside lighting and minimizing noise and waking during sleeping hours.
  • Ensuring any functional aids (e.g., glasses, hearing aids) are working and in use.
  • Encouraging ambulation as frequently as possible.
  • Addressing patient pain, if possible, through medications with minimal cognitive side effects.

While more data are needed to establish this as a valid construct, Krumholz believes the field need not wait for research to improve patient care. Quoted in an ACP Hospitalist cover story, he asks, “’What if we really did start to monitor how much sleep people got and how good their nutrition was and got them ambulating as soon as possible and we tried not to disturb their circadian rhythm? Could we do all that and still treat their acute illness and would they be doing better at the end? I would love to have places say, We'll try this and see what happens.’”

Let’s hear from the PRAXIS community: do you think “post-hospital syndrome” exists? Is your organization taking steps to address it?

Additional information and other perspectives can be found here:

New York Times blog

JAMA 

Geripal blog

Join the ongoing conversation with colleagues in the PRAXIS social group: https://www.copdfoundation.org/Praxis/Community/Discussions.aspx

4 Comments



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  • I do believe this syndrome exists - I am glad to know there is a name for it and that there is a pretty clear list of things that providers can do to minimize the impact or prevent the occurrence altogether. We have all had to wake patients up in the middle of the night for medication/treatment/labs and feel horrible for doing so, but we don't always realize the impact of the disruption. Perhaps this is a 'wake up call' for us (Pardon the pun) to create more appropriate protocols especially as the patient condition returns more to their baseline.
    Reply
  • Great article, thank you. I am particularly interested in the nutrition piece - I think one of the must inpatient interventions for all COPD patients ( if not all inpatients) is a consult with the nutritionist. I also believe part of the psycho-social assessments should include asking about how meals will be prepared and food bought in the first two weeks following discharge. This can help to ensure clear plans can be developed with family, friends and community resources to ensure good nutrition and supplements to sustain healthy nutrition.
    I know some organizations are being innovative in how they support this- would love to here them.
    Reply
  • Last year, I was in the hospital (w/Sepsis) from Thanksgiving Eve until 12/4/2014. At this time, I was moved to a Rehab facility. On 12/21/2014, I awoke with an oxygen saturation of 70% which did not improve no matter how many liters my O2 was raised. I was sent back to the hospital (ICU) and put on a Bi-Pad (?). I stayed in the hospital, at least 1/2 in ICU, until 01/02/2015. I was again moved back to the Rehab facility where I stayed until release to home on 02/04/2015. All together I was institutionalized for over 70 days. The infectious disease doctor has told me there is a 1 week recovery period for each day in the hosp/rehab. I believe this to be true. My health has improved markedly since April, but I am permanently on O2...but I am still not back 100% and probably won't be. I push myself daily to get up, get dressed...and to go out many days. I go to Pulmonary Rehab 2-3 times per week. Fortunately, I have not had any health relapses.
    Reply
  • A continuation of this conversation via new article from FierceHealthcare -- pleased to see that the discussion continues. It seems logical to combat post-hospital syndrome from admission on. More proactive care at work!

    http://www.fiercehealthcare.com/story/battle-against-post-hospital-syndrome-must-begin-hospital/2016-02-18

    Reply

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