Monday, September 12, 2011

Befuddlement at Hospital Discharge

Hospitalizations present a host of dangers to an older patient, and perhaps one of the most hazardous parts of hospitalization is the discharge home. All sorts of things can go wrong as health care is transferred from the controlled environment of the hospital to the outpatient setting. Often, health care plans after hospital discharge are poorly communicated to the patient and outpatient providers. The days after discharge to home are also a period of high risk for medication errors. Perhaps it is no wonder so many seniors need to return back to the hospital within one month of discharge.

To address this problem, a number of interventions have been developed to smooth the transition to home. A central component of these interventions is intensive patient education and training before they go home. This sure seems like a great idea.

But, an innovative study from Geriatrician Lee Lindquist of Northwestern University suggests there may be an Elephant In The Room. What if the patient is confused and not able to understand much of this education and training. Lindquist's recent publication in the Journal of General Internal Medicine suggests this may be a surprising common problem.

Lindquist measured cognitive function at discharge, and one month later, in 200 older persons (average age of 83)discharged from a hospital medical service. What was remarkable about this study was that Lindquist specifically targeted patients believed to have normal cognitive function. She excluded patients who had a diagnosis of dementia, or were diagnosed with delirium during the hospitalization.

Remarkably, nearly one third (31%) of these subjects had abnormal congnitive function when they were discharged. Abnormal cognitive function was defined as a mini mental status exam (MMSE) score of less than 25. In most cases, this cognitive impairment was temporary. 58% of these patients tested normal one month later. Among those with cognitive impairment at discharge, MMSE score improved 4 points over the month. (A 4 point change on the MMSE is huge).

So this suggests that even when an older patient has no known cognitive problem, there is a very good chance there is significant cognitive impairment at the time of discharge. In this case, much of the discharge planning and education we do at discharge will be quite ineffective. We will need to extend the period of patient education and training into the home. As the authors note:

"Ultimately, patient self management may be better taught as an outpatient following discharge and not at the actual hospital discharge itself. Discharge interventions should incorporate screening of seniors for low cognition prior to discharge to provide optimal transitional care."

The study also warns us that the needs older patients will have for help when they go home may be greater than we usually anticipate. This study also teaches us that it is essential we view hospitalization of an elder as an integrated component of their health care rather than a discrete episode of care.

by: Ken Covinsky

5 comments:

Educating Jessie through information sharing said...

As a hospice nurse I find this true of many of my clients and their family and not just the elderly. We are trying to move to the chronic self management model of care but those going home from discharge need a mentor or coach / educator to understand what changes have occurred in their plan of care without them really understanding. We talk about the importance of collaborative care and allowing the patient and their family to have a say in that plan of care, but are we really taking the time across the care continuum to evaluate their understanding? I see this problem at all ages, not just the elderly. I believe I heard that medicare was going to start keeping inpatient care areas accountable for the patient's that are discharged from their care for up to a month post discharge. We need to improve on bridging the care between inpatient and outpatient care. Many times the patient or their family does not understand the importance of seeing their primary care provider within the first week of discharge to review changes in their plan of care. Who should be following up on this? If the patient is lucky enough to be referred to home care or hospice services or a chronic disease case manager they have a chance at not needing a readmission within the first month after discharge. Any one aware of studies that show this benefit? With the aging population of baby boomers and the shift in health care reform to outpatient primary care, these services will expand and be in high demand at a time when many will be retiring from the profession-I see another shortage of such providers down the road...

Dandan said...

As a recent graduate of an internal medicine residency encompassing three different hospitals, I know that planning a discharge is like fighting a war. Therefore the old saying "Know thy enemy" holds true. To achieve that goal, we are currently conducting a qualitative study interviewing patients age 65 and older who are recently discharged from a major academic hospital, with the main question "What help with medicines did you need after leaving the hospital?" It's a chance to hear from patients what challenges they have faced and make sure their needs are being met by our complicated discharge system. Very preliminary data is already surprising: a small subset of subjects state they had no problems with medicines simply because "my head was clear," or "I have all my marbles." Patients themselves recognize the protective benefits of cognition, sometimes from the very system that's trying to make them better. As one subject put succinctly: "I might be old, but I am not stupid.”

Another theme that's been prominent is the importance of family in helping patients with medications. Often, the reason someone is "very confident" in taking their pills right is because of a family member. This suggests a very feasible target for education and support.

Perhaps with time, we can avoid creating such patient recollections of a hospitalization: "I think I just got through World War III!"

Sharon Wildwind said...

We have four adult hospitals locally. Each one of them have Transition Services nurses, with a nurse assigned to each unit and nurses in the Emergency Room on day and evening shifts. The staff refers all patients who they think might have issues after discharge to be screened by these nurses, who make referrals to home care and other services as needed before the person is discharged.

I work in a community-based geriatric program for frail older people. We're in touch with Transition as soon as one of our clients goes to the emergency room or into hospital, and they send us faxed information on the hospital stay and any medication changes when the person is discharged.

CyndiC, RN said...

Several years ago I worked quite a bit in home health until it was decimated through reimbursement.
Nurses in this area used to really get to know their patients & look out for them. They were allowed to gradually get them back into a stable post-hospital situation.

There was a big growth in home health at one time and a subsequent growth in the field. But, between some unscrupulous providers to worked the system, and our every healthcare knowledgeable politicians who saw the big increase in money going to homehealth (what did they expect when people were pushed out of the hospitals sooner and homehealth was supposed to be the answer?) it has now turned into a place with an admission, 1 visit, and a discharge. Not enough time for these "befuddled" seniors to get back to their baseline.

One patient that I vividly remember was a woman with severe PVD who lived alone quite well. When I made my fist post-hospital visit, her sister was ready to send her to a Nursing Home because she was too confused to be alone. Seeing that she had been put on a sleeping pill in the hospital, I told her to not give her anything for sleep for a few days and give her a week to straighten out. Luckly, she listened to the homehealth nurse who really new her sister and this woman came out of her confusion and was back to her old self within a week. If she had gone to that Nursing Home, I would be my bottom dollar they would have restarted the sleeper and she would have ended her days befuddled, in a strange environment, without her beloved little dog...

We've lost an important cog in patient recovery with the loss of this kind of relationship in the home.

N Swallow MD said...

Our Medicine floor nurses (I can't speak for the surgical floor nurses - they may as well) do a wonderful job of trying to include additional family members/caregivers when they review the discharge medication list, discharge instructions, etc. An extra set of eyes and ears can help avoid mistakes at home, and we've found the family members often less hesitant to ask questions. Additionally, most if not all of the inpatient internists in my group touch base with not only the patient about the discharge plans but also the designated "contact" person for that patient (whether it be the official POA or a different individual of the patient's choosing) on the day prior to discharge or day of discharge to relay critical information to another set of ears (eyes as well if they happen to be present with rounds).
Not a perfect solution, but a step...and one that we take regardless of perceived cognitive function.