Thursday, 14 February 2013
Hospital is a dangerous place, especially for the old and very sick — which is one reason why a measure of a hospital’s efficiency is the speed with which it discharges patients home after treatment. Another reason for this measure is, of course, economy. Long stays in hospital are hugely expensive.
However, aiming to discharge patients as quickly as possible may be neither humane nor efficient. People are not units of accounting or components in an assembly line or mere mechanical contrivances. Hospitals are not car repair shops.
An article in the New England Journal of Medicine reflects upon the fact that nearly a fifth of patients treated under Medicare, 2.6 million individuals, return to hospital for further treatment within 30 days of their discharge as cured or sufficiently improved to manage at home.
Rather surprisingly, perhaps, the chances of a patient having to return to hospital do not reflect the seriousness of his original condition, nor are re-admissions invariably for the same condition as that for which the patient was admitted in the first place. On the contrary, in the majority of cases the patient is readmitted for something quite different. For example, 63, 71 and 64 percent of patients readmitted after treatment for heart failure, pneumonia, or chronic obstructive pulmonary disease are readmitted for reasons other than their original diseases.
This means that their stays in hospital have had harmful effects upon them. The author calls the totality of the illnesses caused by a hospital admission the post-hospital syndrome, which is to say “an acquired, transient condition of generalized risk.”
Irrespective of their original condition, patients who have been in hospital often return with heart failure, pneumonia, infections of various kinds, gastrointestinal disturbances, mental illnesses such as confusion and paranoia, metabolic upsets, and trauma. The hazards of hospital are evidently various and often severe.
But what are the hazardous factors? Patients are often deprived of sleep, because of their medical condition, the unfamiliarity of their surroundings, and the constant interruption of sleep by noise. Deprivation of sleep, or reduction in its quality, has various harmful effects: on the heart, on the immune system, on blood coagulation, and on physical co-ordination. A harmful effect on the latter increases the risk of trauma caused by falls, for example; reduction in immune functioning predisposes to infections (and in hospital there are a lot of possible infections around for a weakened person to catch).
To all this may be added poor nutrition. One study showed that a fifth of elderly patients in hospital received less than a half of their daily food requirements. In other words, such patients are in effect starving under the eyes of doctors and nurses. Weight loss and lower protein levels in the blood predict patient readmission to hospital.
Elderly patients have reduced cognitive reserve: that is to say, they have less flexibility in appreciating new situations, and unfortunately hospitals have grown ever more bewilderingly kaleidoscopic, partly for reasons of technology and partly because of organizational changes. It is not uncommon, for example, for patients not to meet the same staff twice; bewilderment is a precursor of paranoia.
Is there a solution to all this? As our hospitals have grown ever more sophisticated technologically and more capable of seemingly miraculous technical procedures, so the human being who should be the focus of all this activity, and even common sense, seems often to be lost sight of. Theoretically, it should be possible and even easy to ameliorate many of the factors that lead to post-hospital syndrome; but I suspect that the same or very similar article will be apposite in twenty years’ time.
First published in PJ Media.
Posted on 02/14/2013 8:12 AM by Theodore Dalrymple
14 Feb 2013
Hospital chaplains, along with lay-people people willing to volunteer as regular visitors, can do a little to provide a social/ psychological lifeline. And they need to know about basic infection control procedures, such as washing hands before entering wards, and washing hands before and after any physical contact with a person they are visiting (if, for example, they hold someone's hands whilst praying with them).
And humble hospital employees such as the tea-and-coffee lady, the wardsman who pushes your wheelchair or your trolley-bed, and even the cleaners, can also serve a 'continuity' function; if they like people and have cheerful, friendly faces. (The cleaners are, of course, doing one of the most important jobs in the whole hospital; helping prevent the spread of infection).
My husband's brother worked as a wardsman for many years (before changing careers and becoming, as he had always wished to be from childhood, a train driver). On at least one occasion, being intelligent and a 'noticing' kind of person, he realized that the patient whom he was transporting from A to B had been mixed up with someone else of a similar name, and was being sent in for the wrong procedure; he spoke up loud and clear, and the error was corrected.
The cooks and the dietitians in the hospital kitchens are as important as the pharmacists in the dispensary. Food is medicine.