Friday, January 18, 2013

An Evidence-Based Intervention to Reduce Post-Hospital Syndrome



There's an interesting Perspective in the NEJM titled "Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk," by Harlan Krumholz, a cardiologist at Yale.

In his article, Krumholz proposes that during the month after hospitalization, many people find themselves in an acquired, transient, vulnerable state, which may "derive as much from the allostatic and physiological stress that patients experience in the hospital as they do from the lingering effects of the original acute illness." He notes that approximately a fifth of Medicare patients are rehospitalized within 30 days, often for conditions different from the index admission.

How might this post-hospitalization syndrome emerge? He goes on to describe the many stressors we know affect patients during hospitalization, including interrupted sleep, psychoactive medications, deconditioning, inadequately managed pain, and delirium.

What to do? He writes that "Recognition of the post-hospital syndrome can provide the impetus for developing novel interventions to promote recovery." He then suggests we do a better job of assessing patients' functional status, and work on mitigating the stressors during hospitalization.

End of article.

Am I the only one thinking "I love that he's coined a name for this phenomenon. But wait a minute. I know of an evidence-based intervention to reduce this syndrome."

If you're a geriatrician, you probably know it too. If you're not, then you should learn about it because it's a good intervention and it just might be available at a hospital near you. (And if it's not, ask for it anyway. Then the hospital will consider providing it.)

It's the...[drum roll] Acute Care for Elders Unit!

[Ta-dah!]

That's right, some hospitals have special units in place designed to minimize all those stresses Krumholz writes about. And they've been studied and proven to improve outcomes.

Plus, if you've ever talked to patients who've had the chance to be hospitalized in an ACE unit, chances are they will tell you it was a much better experience than a usual hospital stay.

So why weren't ACE units mentioned by Krumholz? After all, they aren't exactly a new idea. Seth Landefeld published his groundbreaking randomized trial demonstrating the effectiveness of the ACE unit in the NEJM itself, back in 1995.

Since then, ACE units have been further studied, and further implemented; according to this recent UCSF news story, ACE units are being piloted in 200 U.S. hospitals, serving an estimated 100,000 patients annually. That UCSF story, by the way, was related a June 2012 Health Affairs paper: "Acute Care For Elders Units Produced Shorter Hospital Stays At Lower Cost While Maintaining Patients’ Functional Status."

In the end, as I don't know Dr. Krumholz, I expect I'll never quite know why ACE units aren't mentioned in this very interesting Perspective piece on the Post-Hospital Syndrome. Maybe it's because the syndrome isn't about older adults in particular -- though they are disproportionately vulnerable to the syndrome -- whereas "Acute Care for Elders" sounds too geriatrics-focused.

Still, what we've learned from ACE units could surely help hospital patients of all ages. So if you're looking for an evidence-based approach to reduce the syndrome, don't forget to think of ACE units.

Might help you to develop the novel interventions that we apparently need.


by: Leslie Kernisan, MD MPH

10 comments:

Harlan Krumholz said...

Leslie: Thanks for your comment on my article and your idea that ACE units might be the solution to the post-hospital syndrome. The Acute Care for Elders program is indeed an interesting idea and has potential to improve care. For those unfamiliar with it, here is a brief description: "Interdisciplinary team rounds were conducted daily by the medical director (a geriatrician) and a geriatric clinical nurse specialist with bedside nurses, physicians, social workers, and physical therapists. Patients were assessed daily for fall risk, mobility, self-care, skin integrity, nutrition, incontinence, confusion, depression, and anxiety; and nursing care plans were implemented as needed. In addition, medications and procedures were reviewed for appropriateness by the medical director." The patients are in a separate inpatient unit and a team-based approach is used. The studies of this intervention have generally focused on inpatient outcomes - the recent Health Affairs article showed it could reduce length of stay and inpatient cost - but it did not reduce readmission rates. Other studies have indicated that it improves functioning without increasing costs. The focus has not been directly on the stressors that patients endure as part of what I describe as the post-hospital syndrome - and the absence of an effect after discharge made me think that while it may be a worthwhile change in practice, it may not directly affect the acquired, transient period of generalized risk that patients experience. I did think that some of the interventions we do to prevent delirium might have utility - but in my discussions with Sharon Inouye I found that they had rarely looked at patient outcomes after discharge - so we need more study of that. I do think that geriatricians have the right idea - team-based and patient-centered care - much like the pediatricians have the right idea - now we need to find the interventions that will mitigate this period of risk - and help our patients succeed in their recovery.

Thanks again for your interest in my piece even as you felt I missed something important. Let's all work together to see if we can help patients.

bruce said...

Another care model, among many that have been developed in geriatrics over the last 20 years, to use to help our patients avoid the post-hospital syndrome, is a model that helps our patients avoid entirely the hospital, namely, Hospital at Home.

In Hospital at Home, patients receive acute hospital-level care in the home as a full substitute for a hospital admission. That is, go directly from the ED to home.

The evidence base for this model is robust. A recent meta-analysis identified over 60 randomized trials of Hospital at Home and found that compared with usual hospital care, Hospital at Home was associated with lover mortality (NNT=50) and reductions in readmissions (NNT=25). Hospital at Home is also associated with reductions in delirium, better satisfaction, and better functional outcomes.

The challenge remains with implementation and scaling up of innovative service delivery models in our health system.

SB. Leavitt, MA, PhD said...

It is unfortunate that there is but one reference in the above article and comments to "inadequately managed pain." That may be a key stressor exacerbating the others and account for many rehospitalizations. There seems to be little excuse for poorly managed pain in patients of any age, during hospitalization and and in the period immediately following.

leslie kernisan said...

Harlan, thank you so much for taking the time to respond, I really appreciate it.

Here is the description of an ACE unit that I had in mind (this is from the first link above, which links to a lay publication rather than a scholarly manuscript):

"The unit creates a homelike setting with uncluttered hallways and rooms and a peaceful quiet zone for patients and visitors. Everything from low-glare flooring and a warm color palette to a common dining area is designed to promote mobility and socialization, two cornerstones of recovery for the elderly patient. Simple activities such as enjoying the fresh air and sunshine on the unit’s patio can mitigate depression as does eating in a communal dining room. Improving mobility is high on the priority list as it makes it easier for a patient to return to their own home rather than a nursing home.

The success of the ACE program is based on the expertise of the interdisciplinary care giving team. The ACE team includes an advanced practical nurse, a social worker, a nutritionist, an occupational therapist, a pharmacist, and a medical doctor collaborating to create an individualized care plan to improve patients’ mobility, reduce depression, and maximizes overall satisfaction."

Obviously, the success of any particular ACE unit depends on how it is set up and operated, but in general, the goal is to offer a hospital experience that is less stressful and debilitating to the older patient.

It's true that ACE units were not created for the purpose of reducing 30 day readmissions, which has become a high priority recently for obvious reasons. Rather, ACE units were created to reduce the functional decline that most older adults experience.

I'll now quote from the later part of your article:
"Comprehensive strategies for mitigating post-hospital syndrome and its accompanying risks might begin with efforts to target the stressors that probably contribute to vulnerability in patients soon after discharge. We should more assertively apply interventions aimed at reducing disruptions in sleep, minimizing pain and stress, promoting good nutrition and addressing nutritional deficiencies, optimizing the use of sedatives, promoting practices that reduce the risk of delirium and confusion, emphasizing physical activity and strength maintenance or improvement, and enhancing cognitive and physical function. During hospitalization, clinicians should not only address the urgencies of the acute illness but also seek to promote health actively by strengthening patients and contributing to their physiological reserve. Attention to sleep, nutrition, activity, strength, and judicious symptom management may pay great dividends."

I can't help it. When I read this, I think "Like an ACE unit!"

But what can I say, I'm a UCSF geriatrician and I've been drinking the koolaid for several years now.

And yes, let's definitely all keep working together:)

best, leslie
ps:Eventually we should discuss what outcome we'd measure if we were to test an intervention to reduce post-hospital syndrome specifically. Would it be 30-day readmission?

leslie kernisan said...

Hi SB Leavitt,

I agree with you that pain management during hospitalizations (and after!) is extremely important.

I imagine people hospitalized on ACE units are more likely to get good pain management, but one shouldn't need to be in a special unit to get adequate pain control.

leslie

Miquel A Mas, MD said...

A possible way is to find alternatives to conventional hospitalization. I agree With Bruce Hospital-at-home schemes for selected group of vulnerable patients are essential, not only to avoid admissions but also to early discharge patients at home completing comprehensive interventions when an hospitalization has been necessary for medical initial inestability. Early discharge and continuing hospitalization at home is an opportunity from a Geriatrics perspective due to high risk of hospital-bed-related geriatric syndromes in older patients with acute conditions. Home is a good setting to mantain stability of geriatric conditions and home care can allows community readaptation during first risky weeks postdischarge.

Anne Ruggiero, CRRN said...

Thanks for this informational article. Is there, in fact, an ICD-9 code for this syndrome?

Ninette, CRRN said...

Hi Leslie great post. I too am curious about post-hospital syndrome and care transitions. I wrote this article on select models and would love to have your input.

https://www.openplacement.com/blog/2013/04/which-care-transition-model-is-best

Joseph said...

Wonderful post. I would like to share an example over here. When my father in law returned from hospital, he was very weak. More mentally than physically, which was soon manifesting in his physical strength too. Then the entry of a stray dog in his life, while strolling outside the house, changed everything for him. Some how he was feeling detached from all of us, in spite of all our efforts to make him feel happy and at ease. To our surprise he was sharing a special bond with this dog, his new friend. He would talk to him, play with him and take care of him. He made his health secondary but to our surprise he was improving and was much better with every passing day. May be one just need to feel responsible and of some use, to help others to come out of this post hospital syndrome.

Anonymous said...

This was an interesting article. I was glad to see mention of the need for socialization especially for patients that have had extended hospital stays.

My mother is now home after four months in the hospital. Although she had a plethora of hospital personnel in her room, she was lonely and felt very alone at times.

I was unaware that some hospitals had ace units. This would certainly have helped my mother who is now experiencing some depression and a general feeling of disassociation. Her convalescence is being complicated by a fall she had while in the hospital resulting in two pelvic cracks and a pic line that developed bacteria, now resulting in antibiotic infusion every other day.

My question is: if we have hospitals specifically for children than why haven't hospitals been willing to develop ACE floor units for our elderly population in general hospitals?

Linda Sears