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Thursday, January 10, 2013

Addendum to patient safety: the "Post Hospital Syndrome"

Harlan Krumholz, a Yale University professor of cardiology and public health, just published an article in the New England Journal of Medicine entititled "The Post-Hospital Syndrome--An Acquired, Transient Condition of Increased Risk." In it he points out that, not only are there many under-recognized complications of hospitalizations, mostly the same things I mentioned in my previous post, but these things lead to a very vulnerable period for patients after they are released from the hospital. Patients, especially elderly ones, often come back, sick, to the hospital with a new condition that was not directly related to what got them in trouble in the first place. Instead they come back with new issues, related to the fact that they were in the hospital, being unfed, un-exercised, treated with medications, and stressed in a myriad of ways which have consequences later on.

I notice a few things that relate to this, in my job as a hospitalist and primary care internist. First is the fact that emergency physicians often want to admit patients to the hospital and come into conflict with hospitalists or primary care doctors who want the patient to stay at home, out of the hospital. The emergency doctors have seen dramatic instances in which patients sent home from the emergency department come back later with much worse symptoms. They also have oodles of successes, in which patients are successfully treated and go home to recover. Since these patients don't come back to the ER, the ER doctors don't know about the successes, usually. We, as primary care doctors or hospitalists, see patients admitted to hospitals who get the usual complications, stay far too long and have trouble becoming re-established in whatever their previous situation was.

Patients and families often lose their nerve after a hospitalization and think that the patient is less capable of independence than they truly are. Patients then end up staying still longer in the hospital and being discharged either to nursing homes or with home health nurses or physical therapists, which sometimes are fabulously helpful but mostly are not.

When I visited the Republic of Georgia, where medical care is not great, but there are also no nursing homes to speak of, and less tendency to use hospitals, I visited a woman who was supposed to have been our hostess (Nana 1, we called her--having found lodging with Nana 2.) She was unable to have us stay because she was recovering from pneumonia. She was still feeling pretty puny, not getting out of bed much and cared for by her neighbor. At her bedside were the packaging for an antibiotic which I would have chosen for a hospitalized patient with pneumonia and pills which I would also have used. The doctor, apparently, came to her house every day and gave her an injection of the first, and made sure she was doing better. In the US we are trying to introduce programs that bring doctors into peoples' homes in situations where home care would be most appropriate, but the patient is not well enough to come back and forth to the office. This will be a good way of avoiding some in-hospital complications and thus the "post-hospital syndrome." At this point there is no financial incentive to do things this way, since we make much more for seeing patients in the hospital and we can save time by not going to and from patients' homes. Ideally, though, the way we treat patients would optimize their health, not our convenience.

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