While Home Health Agencies are strengthening their “Falls Risk Programs” and looking at ways to reduce hospital readmissions, are we missing a structured program to expand our overall patient assessment to potentially combat “post-hospital syndrome? There were several questions provoked by this article so, a follow-up seems to be in order.
The New England Journal of Medicine published an article about Post-Hospital Syndrome- An Acquired, Transient Condition of Generalized Risk in early 2013. Have you read much follow up? Rehospitalizations remain an ongoing problem. Should we focus attention on this research? The research found that patients who are hospitalized, then discharged, are not only recovering from their acute illness, but they also experience a transient period of generalized risk for a wide range of adverse health events. Patients hospitalized for one condition may become so weakened that they become vulnerable for a very different condition. Post acute caregivers usually focus efforts of care on issues related to the acute condition that necessitated the hospitalization. The clinical care plan should reflect aftercare for the acute condition as well as the related conditions associated with the post hospital syndrome.
The research shows that one fifth of Medicare patients discharged from the hospital develop another acute condition and that condition requires another hospitalization within 30 days. Many of those patients were readmitted for heart failure, pneumonia, COPD, infections, GI conditions, mental illness, and trauma (Krumholz, www.ncbi,nih.gov/pmc/articles/PMC3688067),
How does this syndrome occur? Hospitalization can be stressful at many levels. Patients frequently cite pain, sleep disturbances, and disruption of normal circadian rhythms. They complain of poor nourishment due to decreased food choices or meals cancelled or postponed meals due to tests. Patients frequently receive medications that can alter cognition, and negatively impact physical functioning.
Assess meds carefully. Look for signs of altered or diminished cognitive functioning. Listen carefully/
Generalized weakness can occur due to decreased physical activity and confusion or disorientation can be experienced due to altered daily activities coupled with altered sleep patterns and anxiety. Assess sleep patterns. Look for signs and symptoms of confusion.
Researcher, Dr Harlan Krumholz states that hospitalization can adversely affect health and cause an inability to fight off disease. He states hospitalized patients suffer from reduction in sleep time and REM time. This deprivation negatively affects “cognitive performance, physical functioning and coordination, immune function, coagulation cascade, and cardiac risk”. Patients experience more pronounced “jet-lag” type disabilities which includes dysphoric mood, cognitive impairment , and GI disturbances. Assess for signs and symptoms of depression.
Nutritional issues take their toll showing, in one study, that 1/5 hospitalized patients over 65 suffer a 50% decrease in calculated energy requirements. These deficits are usually not discussed at discharge, even though the patients frequently are suffering from protein energy malnutrition with weight loss and decreased blood albumin levels. Nutrition is coming to the forefront as one of the chief predictors of outcomes. Malnutrition, even short term, has been found to impair wound healing, decrease cardiac and respiratory function, and cause or exacerbate GI disorders. Discussing their meals planned and who is preparing them.
Pain with unpredictable hospital schedules impacts cognition and can cause mood disturbance, hypercatabolism, immunosuppression, and hypercoagulability. Assess pain levels and whether this is acute or chronic pain.
Over sedation can impact senses and impact judgment. Discuss hospital sedation and whether the patient is being sedated presently. Impaired stamina and strength conditioning can lead to a type of post-traumatic stress disorder.
The article suggests that discharge planners have an opportunity to educate patients and their families as to the potential syndrome. Just the shear fact that loss of functional dexterity, stamina, and muscle strength can suggest the potential need for home health care. What is the patient’s plan for self efficacy?
Home Health Care
Home health Agency personnel should be knowledgeable regarding the syndrome and the potential consequences of the recent hospitalization on their patient. They should be aware of the potential sleep disturbances that can occur in the hospital and the resulting consequences. They should assess for cognitive performance, decreased functional dexterity, and increased cardiac risk due potentially to syndrome caused disturbances. They should assess for confusion that may have been situationally or environmentally induced.
The assessing clinician should engage the patient in conversation to assess nutrition in the hospital. Weight should be noted. If there is a wound, healing will need to be assessed. Being aware of increased infections and pressure ulcers, along with decreased respiratory and cardiac function will allow the clinician to expand their assessment in these areas.
OASIS requires a functional assessment and with a recent hospitalization, loss of muscle tone, muscle strength, and stamina place the patient at greater risk for falls. It also places the patient in a weaker position to follow through with discharge instructions. They may need encouragement and assistance to keep physician appointments. Does your program and Integrated Care Model encouraging the use of motivational interviewing and moving patients toward self-efficacy?
Inadequate assessment can result in rehospitalization for falls, heart attacks, GI disorders, and other conditions. The physician researcher reminds the reader of Hillary Clinton’s hospital admission in 2012. She suffered from a GI disorder which caused dehydration and weakness which led to a fall resulting in a concussion. Trauma to her head led to the blood clot and the resulting rehospitalization.
Preventing rehospitalization now also requires attention to post hospitalization syndrome along with the original reason for the hospital admission. An assessment for post hospitalization syndrome should be considered for every patient in this category.