When hospitalization makes patients sicker

High trauma of hospitalization has been associated with readmission risk.

While the hospital can make patients healthier, it also gives some another problem: posthospital syndrome.

Researchers in Canada recently linked disturbances during hospitalization to readmission risk. Of 207 adults (mean age, 60.3 years) admitted to an internal medicine ward for more than 48 hours, 36.2% reported sleep disturbance, 78.3% reported mobility disturbance, 55.1% reported nutrition disturbance, and 23.2% reported mood disturbance, according to results published in December 2018 by JAMA Internal Medicine.

Disturbance in three or four domains of function was considered high trauma of hospitalization, while disturbance in zero to two domains was considered low trauma. Nearly 30% of patients had high trauma of hospitalization. Compared to patients with low trauma, they had a 15.8% greater absolute risk of readmission or an ED visit within 30 days.

ACP Hospitalist recently spoke about the findings with lead author Shail Rawal, MD, MPH, a hospitalist at Toronto Western Hospital, and senior author Amol Verma, MD, MPhil, a hospitalist at St. Michael's Hospital in Toronto, both assistant professors at the University of Toronto in Ontario.

Q: What led you to study this issue?

Photo courtesy of Dr Rawal
Photo courtesy of Dr. Rawal

A: Dr. Rawal: A few years ago, there were a couple papers published that were quite influential amongst hospitalists. There was a paper [in 2013 in the New England Journal of Medicine] by Harlan Krumholz, MD, who described his observation that patients who are admitted for one condition oftentimes return to hospital in the 30 days after discharge with a different condition. He hypothesized that maybe there's something that we're doing in the hospital that leads to something called the “posthospital syndrome” that leads to patients being vulnerable to being readmitted to hospital. Then Dr. Krumholz wrote a paper with Allan Detsky, MD, that was published in JAMA [in 2014] that describes an idea called the “trauma of hospitalization,” which went into a bit more detail about what they thought was actually happening to patients in hospital that left them vulnerable to a new medical problem developing when they were at home. For us, the papers were very compelling because they described what we saw in our daily practice as hospitalists. They led to the question of, “How do we assess whether or not this hypothesis really bears out in real life?”

Q: What did you find?

Photo courtesy of Dr Verma
Photo courtesy of Dr. Verma

A: Dr. Verma: Our main finding was that the trauma of hospitalization was very common. . . . The people who experienced disturbance in multiple domains were much more likely to be readmitted to hospital, even after we controlled for the duration of time they spent in hospital, the severity of their illness, and other age and demographic factors. It was surprising to me how prevalent the co-occurrence of multiple disturbances was in our patient population.

Dr. Rawal: Younger patients and older patients experienced a similar level of disturbance. For me, that was surprising. One might have imagined that the younger population might have been more resilient or immune to some of the disturbances in a way that the elders in our study would not have been.

Q: How do you explain the association between trauma of hospitalization and readmission?

A: Dr. Rawal: The idea would be that the accumulation of disturbances in a person's functioning leaves the patient vulnerable in some way once they're discharged home. So you might be admitted to hospital with pneumonia, but you don't get out of bed, it's a very stressful experience, your diet is completely deranged from normal, you don't sleep, and then you go home to convalesce but find yourself vulnerable to a new problem, like developing heart failure, and that brings you back to the hospital.

Dr. Verma: The way I've come to interpret it is that hospitals are designed to deliver health care efficiently to a large number of people. They're not as well designed to support the process of recovery from serious illness, which I think we would all say includes things like rest, nutrition, getting back on your feet, and a comforting, safe environment.

Q: What can hospitals and clinicians do to reduce these disturbances?

A: Dr. Rawal: The first thing is to recognize that the act of hospitalizing a patient can have significant impact on these different domains and may be associated with returning back to the hospital after discharge. That might alter the calculus when it comes to a decision to admit for some patients. With respect to what can be done in hospital, it makes sense that any approach to reducing the trauma of hospitalization would be multimodal. . . . For sleep, there's some evidence around reducing nighttime alarms, using eye masks, earplugs, white noise machines. Mobility has been studied as a domain in and of itself, with interventions to get patients up and out of bed or have them come and eat in a communal setting. Similarly with nutrition, you can imagine interventions that might include counseling patients' [families] to bring food in from home if that's more palatable than what's in the hospital or avoiding unnecessarily prescribing things like a low-salt or a low-calorie diet. With respect to mood, it seems like patients would benefit from clear communication about what is happening when they are hospitalized, who the members of their team are, and what an agenda for a day in hospital might be.

Dr. Verma: These suggestions are much easier to make than to implement, and also I think there are probably a lot of blind spots that we as health care providers have to the actual experience of being hospitalized. I think there is a rich opportunity to codesign these interventions with patients and with other frontline health care providers and hospital staff.