It was over a quarter of a century ago that I first started talking about “the missing statistic”–those people who die from complications from their hospital visit, but not during the visit itself. If someone is treated for heart problems at a hospital, for example, and is sent home only to die later at home as a result of what happened in the hospital, it doesn’t count against the hospital’s record for treating the disease–even if the patient dies in the ambulance on their way back to the hospital, as long as they don’t actually die in the hospital itself. This means that there are many more people dying as a result of their hospital visits than tally in the statistical sheets.
Over the last few years, there’s been some attempt to address this issue, or at least a subset of it–those who are treated for a disease and sent home, only to be readmitted to the hospital at a later date as a result of their original visit, even if not for the original cause. If you die at home, you’re still among the great uncounted. But now at least, if you make it back in, it counts. It may not sound like much, but it actually is since it at least acknowledges the connection between the original visit and the readmission, even if the reason for readmission might seem initially unrelated. This is a big deal since it identifies yet another set of dangers related to hospital stays that was previous ignored–except by those who actually died as a result. A bit later we’ll explore the entire panoply of dangers typically found in hospitals, but for now, we’ll focus on this latest discovery, which is called post-hospital syndrome.
The essence of post-hospital syndrome is very simple. A hospital stay, especially if traumatic, can make some patients susceptible to new health problems, unrelated to the initial problem. For example, nearly one fifth of Medicare patients discharged from a hospital — approximately 2.6 million seniors — have an acute medical problem within the subsequent 30 days that necessitates another hospitalization.1 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418-1428. http://www.nejm.org/doi/full/10.1056/NEJMsa0803563#t=articleTop These recently discharged patients have heightened risks for a whole range of conditions, many of which, as mentioned a moment ago, appear to have little in common with the initial diagnosis. For example, among patients admitted for treatment of heart failure, pneumonia, or chronic obstructive pulmonary disease (COPD), the cause of readmission is the same for only 37%, 29%, and 36%, respectively. The causes of readmission, regardless of the original admitting diagnosis, commonly include heart failure, pneumonia, COPD (which are the same as the three original admitting conditions, although not always matched up)–but also, infection, gastrointestinal conditions, mental illness, metabolic derangements, and trauma. (As we will discuss later, the same principle applies not just to seniors but also to the very young and, most likely, all categories of patients to varying degrees.)
Professor Harlan Krumholz examined both this study and the concept of seemingly unrelated readmissions in a perspective article published in the New England Journal of Medicine in January of this year.2 Harlan M. Krumholz. “Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk.” N Engl J Med 2013; 368:100-102. http://www.nejm.org/doi/full/10.1056/NEJMp1212324 He was also part of a research team that published the results of their study of the same issue in the Journal of the American Medical Association that was released around the same time.3 Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia. JAMA. 2013;309(4):355-363. http://jama.jamanetwork.com/article.aspx?articleid=1558276 Professor Krumholz is a cardiologist and Professor of Medicine and Epidemiology and Public Health at the Yale University School of Medicine. The original intent of Professor Krumholz and his research team was to focus on the hospital admissions rate of patients with cardiovascular disease; but after looking at what was happening to patients after their release from the hospital, they began to see something unexpected. They named this phenomenon: post-hospital syndrome–a temporary period of increased vulnerability to all sorts of risks, from falls to heart attacks. According to Professor Krumholz, patients initially hospitalized for pneumonia, for example, might become so weakened after a hospital stay that when they were back home, they’d fall and fracture a bone. Historically, these would be recorded as two isolated, independent incidents, when in truth they are anything but.
As the research team stated, “They [the patients] come into the hospital with one thing, but they leave with another. Maybe what is going on is that people, through the hospitalization, are acquiring a new condition, something that makes them susceptible to a whole range of problems.” According to the researchers’ analysis of more than 3 million hospitalizations, among readmitted patients, 90% of those initially diagnosed with a heart attack came back with a different problem. So did 65% of the heart failure patients and 78% of the pneumonia patients. According to Krumholz and his fellow researchers, this period of risk is the result of the cumulative stressors on patients during hospitalization that can increase their susceptibility to adverse health events. These include:
- Sleep deprivation and the concomitant disruption of normal circadian rhythms. Have you ever tried to sleep in a hospital? They’re noisy; there’s always some level of light in the room (so you can forget melatonin production), and even if you manage to overcome all of that and fall asleep, there’s always some nurse or aide waking you up to take your blood pressure, draw blood, or give you some medication at all hours of the night. It should come as no surprise then that studies have revealed sleep abnormalities in hospitalized patients, including reductions in sleep time and stages R (rapid eye movement [REM]) and N3 (slow wave sleep) and an increase in stage N1 (non-REM sleep). This disruption can have debilitating behavioral and physiological effects. Specifically, sleep deprivation adversely affects metabolism, cognitive performance, physical functioning and coordination, immune function, normal blood clotting mechanisms, and cardiac risk. Disruptions of the sleep–wake cycle may cause disruptions in circadian rhythms and may have adverse effects even independently of sleep deprivation and abnormalities. These disturbances in hospitalized patients may confer jet-lag–type disabilities. Studies of people with jet lag have revealed increased incidence of dysphoric mood (feeling unwell and unhappy), diminished physical performance, cognitive impairment, and gastrointestinal disturbances.
- Poor nourishment. How many times have I talked about the inadequacy of hospital food when it comes to nourishing the body and giving it the building blocks it needs to repair and heal itself? Hospital food merely reflects a vague attempt by dieticians to provide sufficient calories presented in a reasonable ratio of protein to fats to carbohydrates. Forget enzymes, phytochemicals, antioxidants, or even a natural complement of vitamins and minerals. Hospital food is dead by any and all definitions understood in the natural health community. And that’s if patients are actually eating the food! Patients may not get enough to eat because of lack of appetite, the unappetizing nature of the food, and especially if doctors order patients to fast before procedures. In fact, one-fifth of hospitalized patients 65 years of age or older consume less than 50 percent of the nutrients recommended to maintain their energy requirements.
- Pain and discomfort. Isn’t this the essence of being in a hospital; need anything else be said? Actually yes! Pain and other discomforts, common among these patients, are often inadequately addressed. This can lead to sleep disorders, mood disturbances, and impaired cognitive functioning. Chronic low level pain is also known to negatively impact immune and metabolic function. In addition, pain medications can further compromise cognitive function. Patients often take sedating pain killers or other medications that can leave them confused, or even delirious, especially in the unfamiliar surroundings of a hospital.
- Dealing with a baffling array of mentally challenging situations. Hospitalized patients often meet a variety of health care professionals but have little time to learn their names or understand their roles. Schedules are often unpredictable, and in patients who are already under stress, information overload can be stressful in and of itself and may even provoke confusion. Moreover, these stressors of hospitalization can cause delirium, which is associated with increased risk after discharge. Patients in this state of mind are in no condition to understand discharge instructions, such as how to keep wounds clean or when to take medications. It’s easy to see how these patients can quickly deteriorate.
- Medications, as already mentioned, can alter cognition and physical function. But in addition, medications to treat symptoms can negatively affect the early recovery period. Sedatives, especially benzodiazepines, are commonly prescribed and may become part of the discharge regimen. Unfortunately, under-sedation can cause accelerated breakdown of body tissue, immunosuppression, a propensity to form blood clots, and increased sympathetic nervous system activity, which can lead to increases in blood pressure and heart rate and decreases in food digestion. Over-sedation, on the other hand, can dull the senses and impair cognitive function and judgment and may also lead to post-traumatic stress disorder.
- Financial stress. According to a study published in 2009 in the American Journal of Medicine, medical bills underlie 60 percent of U.S. bankruptcies.4 David U. Himmelstein, Deborah Thorne, Elizabeth Warren, Steffie Woolhandler. “Medical Bankruptcy in the United States, 2007: Results of a National Study.” The American Journal of Medicine – August 2009 (Vol. 122, Issue 8, Pages 741-746). http://download.journals.elsevierhealth.com/pdfs/journals/0002-9343/PIIS0002934310009915.pdf Even more frightening is the fact that 75 percent of these bankrupt families had health insurance…and still went bankrupt. And these numbers have only gotten worse since the recession fully kicked in, most of which took place subsequent to the study collecting its data. That kind of stress can negatively impact all kinds of physical and health problems.
- Lastly, extended bed rest can weaken patients’ muscles and bones. In effect, hospitalized patients commonly become “deconditioned,” so recently discharged patients often have impaired stamina, coordination, and strength, which place them at greater risk for accidents and falls. These limitations may also diminish their ability to comply with post-discharge instructions–not to mention the fact that the capacity to resume basic activities or attend a follow-up appointment can be affected.
The Study’s Recommendations
It’s important to understand that post-hospital syndrome is not about medical errors and hospital-acquired infections, both of which can jeopardize patients’ lives. Those are tallied separately–again assuming the patient doesn’t die outside of the hospital. What we’re talking about here is not poor hospital care or medical mistakes, but “the routine difficulties of being a patient,” says Krumholz.
Krumholz goes on to say that hospitals should try to address these issues, both before patients leave the hospital and in follow-up visits. In some cases, he says, it may be better for a patient to get a good block of sleep, rather than be awakened at 3 a.m. in order to administer a medication at the appropriate interval. In analyzing the reasons why patients are readmitted, he says, “we haven’t thought enough about the hospitalization, and how to make it less toxic, more healing and more soothing.” Professor Krumholz also recommends teaching patients about post-hospital syndrome and taking the time to warn them about the implications of the associated mental and physical impairment. Patients should be encouraged to find someone to help them with post-discharge instructions, to resume daily activities, and to be safe by recognizing their risk for falls and accidents.
30 Days Is Only the Tip of the Iceberg
The problem for the medical community is that the further away from the hospital discharge you go, the harder it is to connect the dots. That’s why Krumholz and his team stuck with 30 days. But that’s not to say there aren’t more drawn out connections.
For example: according to a study performed at Dana-Farber/Children’s Hospital Cancer Center (DF/CHCC) in Boston and just presented last month at the American Society of Pediatric Hematology Oncology in Miami, nearly two-thirds of children receiving stem cell transplants returned to the hospital within six months for treatment of unexplained fevers, infections, or other problems.5 “Majority of children readmitted to hospital following transplant.” Dana-Farber Cancer Institute 24 April 2013. (Accessed 21 May 2013.) http://www.dana-farber.org/Newsroom/News-Releases/Majority-of-children-readmitted-to-hospital-following-transplant.aspx Children who received donor cells were twice as likely to be readmitted as children who received their own stem cells. The key point, as Leslie E. Lehmann, MD, clinical director of pediatric stem cell transplantation at DF/CHCC, pointed out is that, “No one had ever looked at these data in children.”
In other words, until this study made the connection, the original treatment in the hospital and the subsequent readmission appeared to be unrelated. The dots were not connected.
And then there was the British Medical Journal, Quality & Safety observational study published last year that found a direct link between nursing staff ratios and hospital readmissions for children with common medical and surgical conditions.6 Heather L Tubbs-Cooley, Jeannie P Cimiotti, Jeffrey H Silber, et al. “An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions.”BMJ Qual Saf 7 May 2013. http://qualitysafety.bmj.com/content/early/2013/05/03/bmjqs-2012-001610.full Specifically, the study concluded that children with common conditions treated in hospitals in which nurses care for fewer patients each are significantly less likely to experience readmission between 15 and 30 days after discharge. How less likely? The study found that children who are treated in hospitals that meet the current California mandated staffing ratio of four or fewer pediatric patients per nurse have a 63% reduced risk of readmission.
Over the years, we have discussed many of the reasons you might want to avoid checking into a hospital. As it turns out, there are many dangers (dots) that exist in isolation and never get connected in terms of the total risk you face. It’s important to understand that the whole is greater than the sum of its parts. When looked at one at a time, the risk factors at first seem almost manageable. It’s not until you look at them in their totality that you realize how great a risk you face. Some of these risks that have not already been discussed include:
- Picking up a secondary infection.
- Lack of full disclosure by your medical team.
- The hospital harm factor.
- Sleep deprived, burnt out doctors making mistakes and bad decisions.
- Bad timing– the entire month of July and nights and weekends throughout the year are especially risky.
- Mistakes and errors by hospital staff.
- Doctors under the influence of alcohol and drugs.
- Cognitive decline
But these things we already knew. What the new studies tell us, though, is that it’s even worse than the medical community thought. It turns out that you can take all the numbers cited above and ramp them up because a lot of deaths have not been getting connected to what actually caused them–the original hospital stay. And, as I mentioned at the top of the newsletter, it’s even worse than the new studies suggest since they’re only talking about those people who are readmitted to the hospital and thus get included in the statistics. What about those who develop a problem as a result of their hospital stay and die at home? As I discussed previously, no one’s connecting their deaths to their hospital stays. How many are we talking about? It’s more than zero, and whatever the number is, it’s not included in the hospitals’ statistics.
What Can Be Done?
Well, the first and most obvious thing is to start correcting some of those things that now lead to post-hospital syndrome…and ultimately to hospital readmissions and death. You can start with the things Krumholz points out.
- Allow hospital patients to actually sleep.
- Provide tastier, fresher, more balanced meals. It’s not just about proteins, fats, and carbohydrates. Food needs to taste good so that patients eat it. And it needs to provide a full complement of vitamins, minerals, trace minerals, antioxidants, and phytochemicals. And the bulk of it needs to be alive–not heavily processed and kept in a plastic package for several months or even a food warmer for several hours.
- Provide more human care and help patients understand what’s happening to them. A series of 1-minute visits looking at a patient’s chart and saying “Hmm” by a dizzying array of doctors looking for billing opportunities and hospital personnel continually drawing blood, administering unexplained medications, and regularly testing blood pressure does not cut it. In fact, it does just the opposite. It’s dehumanizing and leaves patients feeling confused and powerless–a feeling they take with them when they leave.
- And let’s rethink the medications that are handed out like candy–medications that have serious side effects such as impaired cognition, hallucinations, and shattered immune systems. And speaking of immune systems, perhaps hospitals should rely a bit less on massive doses of antibiotics for patients and a bit more on natural antipathogens and, even more importantly, building patients’ immune systems–for the simple reason that the patient takes that stronger immune system with them when they leave the hospital. Oh, and as a side benefit, unlike pharmaceutical antibiotics and antivirals, natural antipathogens don’t breed drug resistant strains.
- On a related note, there needs to be a better process for reconciling medications against physician prescriptions as patients move between health care settings.
- In addition, all medications within hospital settings need to be bar-coded and scanned and matched against a patient barcode before every use to verify that the proper medication at the proper dose is being administered to the proper patient.
- And it’s probably a good idea to implement a similar procedure before surgeries so a doctor doesn’t accidentally remove a breast from the wrong patient. Oh, it happens.7 Sarah Boesveld. “Top surgeon performed mastectomy on patient who didn’t have cancer.” The Globe and Mail. 17 Feb 2010. (Accessed 25 may 2013.) http://www.theglobeandmail.com/news/national/top-surgeon-performed-mastectomy-on-patient-who-didnt-have-cancer/article4306509/
But it doesn’t stop there.
Hospitals need to adopt common reporting formats and definitions so that data is easily understood as patients enter different facilities. Surprisingly, that is not yet the case, which means doctors in one facility may not understand what has been done for a patient in a previous facility…and that can be deadly.
Patients need better guidance when being discharged and better follow up once they are home. You’re pretty much handing out a death sentence to a patient when you quickly give instructions to a drug addled, exhausted, confused patient just before you discharge them and don’t follow up with them shortly after they get home to see if they actually understood what they need to do. And seniors, if they do not have a family member working as an advocate for them, need special attention both when being discharged and when making sure they are following proper protocols once home. Many are fully capable of taking care of themselves, but many are not.
And hospitals need to adopt checklists for all procedures, especially surgical procedures–much like a pilot’s checklist before taking off in a plane–to make sure everything is A-OK before commencing.8 Sarah Boesveld.
Don’t be afraid of hospitals and don’t avoid them unnecessarily. On the other hand, recognize the dangers and think of hospitals as a last resort. If you can avoid checking into one, you avoid exposure to a huge amount of collateral risk. If you can be treated on an outpatient basis, in most cases, that’s a better way to go. If you can avoid taking pharmaceutical drugs and deal with your condition using natural remedies and dietary modifications and lifestyle changes, then you’re miles ahead of the game doing so. (Think Baseline of Health.) On the other hand, if you can’t control your condition using natural means, then don’t be a martyr. Use the pharmaceutical drugs, but:
- Talk them out with your doctor before doing anything. Know what you’re taking before you put even one pill in your mouth. Know the side effects. Look them up on the internet (you’d be surprised how many times your doctor doesn’t know). If you don’t like the side effects, explore alternatives with your doctor. Don’t head down the rabbit hole of taking an endless progression of pharmaceutical drugs–each one designed to deal with the side effects of the last–until you become a drooling, drugged out zombie mistakenly diagnosed as suffering from dementia. No joke: common prescription drugs such as sleep aids, anti-anxiety drugs, antidepressants, allergy drugs, and even cold remedies can cause dementia as a side effect.
- My mother-in-law was admitted to a hospital several years ago after fainting. Within 48 hours of her admission they had determined she was suffering from advanced dementia as she was seeing spider webs falling from the ceiling and flowers growing on the walls. Kristen was unable to convince the medical staff that no such hallucinations had existed before her mother had entered the hospital. She asked me to look at her medications to see if anything jumped out. It did. They were giving her Ambien to sleep, even though she had never requested it, or had trouble sleeping. It turns out it was just something they automatically gave to almost all the patients to keep them quiet at night. Fortunately, I had previously done a national radio show tour on the side effects of sleeping pills and knew that Ambien could trigger hallucinations. Kristen then told the nurses and doctors to take her mother off the Ambien. Surprise! They did not know that one of its side effects was hallucinations. In less than 24 hours of taking her mother off the drug, the hallucinations stopped. Oh, and they then decided that she wasn’t actually suffering from dementia.
- And make no mistake, dementia, real or drug induced, pretty much guarantees readmission to a medical facility and ultimately death–even if it’s a living death slumped over drooling in a wheelchair until, eventually, your body follows your brain and dies.
And if your doctor won’t work with you, find another doctor who will. Sometimes hospitals are necessary. If you’re in a major automobile accident, you want a hospital, not a chiropractor’s office (at least initially). But just because hospitals are sometimes necessary doesn’t mean that they are ever completely safe. Know the risks and protect yourself as best you can. Don’t become a hidden statistic.
|Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418-1428. http://www.nejm.org/doi/full/10.1056/NEJMsa0803563#t=articleTop
|Harlan M. Krumholz. “Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk.” N Engl J Med 2013; 368:100-102. http://www.nejm.org/doi/full/10.1056/NEJMp1212324
|Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia. JAMA. 2013;309(4):355-363. http://jama.jamanetwork.com/article.aspx?articleid=1558276
|David U. Himmelstein, Deborah Thorne, Elizabeth Warren, Steffie Woolhandler. “Medical Bankruptcy in the United States, 2007: Results of a National Study.” The American Journal of Medicine – August 2009 (Vol. 122, Issue 8, Pages 741-746). http://download.journals.elsevierhealth.com/pdfs/journals/0002-9343/PIIS0002934310009915.pdf
|“Majority of children readmitted to hospital following transplant.” Dana-Farber Cancer Institute 24 April 2013. (Accessed 21 May 2013.) http://www.dana-farber.org/Newsroom/News-Releases/Majority-of-children-readmitted-to-hospital-following-transplant.aspx
|Heather L Tubbs-Cooley, Jeannie P Cimiotti, Jeffrey H Silber, et al. “An observational study of nurse staffing ratios and hospital readmission among children admitted for common conditions.”BMJ Qual Saf 7 May 2013. http://qualitysafety.bmj.com/content/early/2013/05/03/bmjqs-2012-001610.full
|Sarah Boesveld. “Top surgeon performed mastectomy on patient who didn’t have cancer.” The Globe and Mail. 17 Feb 2010. (Accessed 25 may 2013.) http://www.theglobeandmail.com/news/national/top-surgeon-performed-mastectomy-on-patient-who-didnt-have-cancer/article4306509/