What does jet lag have in common with being discharged home following a hospital stay? After Yale cardiologist Dr. Harlan Krumholz returned from an overseas trip suffering from a particularly bad case of jet lag, he described the similarities like this:
“People were talking to me, but I couldn’t concentrate. I was a little clumsy. I could have fallen. I realized that I felt just like my hospital patients do when they go home.”
He recognized that many hospital stays can actually confer jet lag-type disabilities. In his article published in the New England Journal of Medicine, Dr. Krumholz dubbed this post-hospital discharge distress post-hospital syndrome. (1)
For example, he notes that most hospital patients:
- are commonly deprived of sleep
- experience disruption of normal circadian rhythms
- are nourished poorly
- have pain and discomfort
- confront a baffling array of mentally challenging situations
- receive medications that can alter cognition and physical function
- become de-conditioned by bed rest or inactivity
In other words, he explains, “We are not really taking into account what happens to people when they are hospitalized.”
As a result, Dr. Krumholz doubts that the term post-hospital syndrome has actually caught on yet in most hospitals:
“I don’t think hospitals are understanding this as a strategy to improve recovery and reduce re-admission. We have so far to go to make the hospital a truly healing environment rather than one in which we (implicitly) say, ‘Tough it out. We’re taking care of your acute problem. Be grateful that you’re getting the attention you’re getting.
His colleagues in medicine would do well to pay attention to this lack of understanding. As Forbes journalist Matthew Herper once described Dr. Krumholz:
“Doctors trust him because he speaks his mind and puts patients first.”
He also believes that it’s possible to significantly reduce hospital re-admission rates by identifying predictable issues that seem to cause those expensive and distressing re-admissions.
This year, he revisited his NEJM article during an interview with Dr. Robert M. Wachter posted on the Patient Safety Network of the U.S. government’s Health and Human Services division.
Dr. Wachter wondered why his guest had become so interested in what happens to patients after they leave the hospital. The answer:
“In the 1990s, we were focusing on whether people were getting the right treatments or not.
“But the issue of re-admissions nagged me. At the time, a landmark article had been published on re-admission – but almost a decade had passed with no action.
“I had noticed, even before I discovered that article, that many patients were coming back to the hospital and I published a paper looking at patients with heart failure – and saw that about half the patients were admitted again within six months. I haven’t stopped thinking about it since then.
“We never used to see hospital discharge summaries as a tool for communication, or as essential to communicating what had happened in the hospital to the patient.
“That led me to want to study their journey – and that led me to the post-discharge period and re-admission.”
Consider the serious nutritional issues that are commonly experienced during hospitalization.
Dr. Krumholz cites one study, for example, that found one fifth of hospitalized patients 65 years of age or older had an average nutrient intake of less than 50% of their recommended energy maintenance requirements.
And patients are commonly ordered to have nothing by mouth for specified periods, during which they are not fed by any alternative means. Cancellations and rescheduling of procedures or tests can extend these long periods of time.
Malnutrition can affect every system in the body, resulting in the following risks:
- impairment of wound healing
- increased risk of infections and pressure ulcers
- decreased respiratory and cardiac function
- poorer outcomes of chronic diseases
- increased risk of cardiovascular and gastrointestinal disorders
- poorer physical function
Consider also the impact on hospital patients of what doctors call de-conditioning (the resulting loss of muscle tone and endurance after days or weeks of chronic disease, immobility, or loss of function).
Patients commonly become de-conditioned, resulting in impaired stamina, coordination, and strength, which in turn place them at greater risk for accidents and falls. These limitations may also reduce their ability to follow even the most basic of post-discharge instructions, resume basic activities or attend follow-up appointments.
Speaking of post-discharge instructions, we know that the process of sending patients home from most hospitals is woefully ineffective in including a written care plan to help them adjust to life at home. See also Study: “91% discharged from hospital without care plan”
And Dr. Krumholz warns that increasingly shorter lengths of stay mean it’s even more important to start preparing patients for a successful convalescence starting from the first day of hospitalization – instead of just during the final few overwhelming minutes as they’re leaving their hospital beds.
As Dr. Eric Coleman of the University of Colorado, Denver sums up succinctly:
“There couldn’t be a worse time, a less receptive time to offer patients information than the 11 minutes before they leave the building.”
Here’s how Dr. Krumholz explains the basic practice as it generally happens now: people come into the hospital with a medical condition, and then doctors immediately try to jump in to mitigate and cure, if possible.
“In the course of that care, we are causing a lot of collateral damage, which we’ve tended to discount as ‘they may be a little uncomfortable. They may have roomed with someone who was up all night. We may have poked them at 4 a.m.
“But the big thing is that we are saving their lives – so we just push forward.”
Dr. Krumholz points out that hospital staff can do one of two things for their patients:
- ease the path, catch them gently, and help them make a successful transition, or
- they can say “You’re punch-drunk from everything we’ve done to you, and now we’re going to set an obstacle course in front of you, wish you luck, and see how this stress test plays out for you in the next couple of weeks.”
Far better, warns Dr. Krumholz, to “make the hospitalization more soothing, more healing, more supportive, more restful – and, maybe, better position people for the post-hospital period.”
In the end, he explains, it’s not so much about hospital re-admission; it’s more about improving recovery.
But how to accomplish this? Here’s how Dr. Krumholz believes it can happen:
“We need to make sure that the patient gets adequate sleep, in an environment conducive to that.
“I would have patients in their own room.
“I would be sure people are well nourished. We would encourage, as preferred by the patient, social support and visits.
“We would surround them by bright colors and sounds and odors designed to lift their mood.
“We would avoid blood draws, Foley catheters, tests and procedures except what is absolutely necessary.
“We would give people a schedule every day so they know what to expect and when, enabling them to have a sense of control and understanding.
“We would avoid a lot of the uncertainty. For example, on the consult service, we don’t tell people when we’re going to visit them. So, they are stuck in the room most of the day because they are afraid to miss us.
“It is as if we implement systems that give people anxiety, and we’re making it hard for them to be active in any way.”
Harlan M. Krumholz. “Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk”. January 10, 2013. N Engl J Med; 368:100-102.
Q: Have you encountered post-hospital syndrome after being sent home?
NOTE FROM CAROLYN: I wrote much more about before, during and after hospital discharge in my book, “A Woman’s Guide to Living with Heart Disease” (Johns Hopkins University Press, 2017).