Thursday, September 8, 2016
A silent epidemic affecting our hospitals
There's a huge problem we have right now affecting our nations' hospitals. It's not a disease you've ever heard of before, or something that cutting edge research or treatments are going to solve. It's a seemingly simple issue that has been lacking in every single hospital I've ever worked in, whether it be a large academic teaching hospital or a small rural medical center. It's rarely talked about, but endemic nevertheless. I'm hereby going to assign it a name:
“Sinking in bed syndrome”
What on earth is it you may ask? Well, the scenario goes something like this. A patient, usually elderly, is admitted to hospital with an acute medical illness. During the first few days of treatment, they are basically lying in bed while receiving all their treatments. They get more and more sunk into their bed, becoming weaker and weaker at the same time (even though their actual illness is improving). As they recover, they find it more difficult to get up out of bed and start walking again. The longer they are in bed, the more difficult it will be. Muscles have become tense and joints are stiffer. Because of this deconditioned state, recovery will be prolonged and patients will spend longer getting back to their baseline state.
All hospital-based doctors see this type of scenario unfold on a weekly basis. Sadly, lots of these patients actually report having quite reasonable and independent function prior to their admission. Of course, they have been unwell, and their illness itself will set them back. But having seen how we leave patients “sinking” in their bed for days at a time, I'm of the firm belief that keeping them in this state really sets them back even more.
In short, we just need to get them up much sooner. Unfortunately, it's not in our systemic culture to do that, and in almost all places I've worked, I sometimes need to plead just to get our patients up out of bed to the chair simply to make sure they are not lying down flat all the time. Sometimes sadly, it's family members who are the ones voicing their concern to me that their loved ones have become weak and need to sit up and walk more. It's a shame too that many health care institutions only think of getting physical therapy involved when discharging from the hospital is imminent, when actually it should be done much sooner.
Only a few decades ago, the culture was to keep patients who were sick in the hospital on complete bed rest for an extraordinarily long amount of time. Patients having heart attacks would be kept in and observed for several weeks. We now know that such a prolonged hospitalization is not only unnecessary, but also very bad for our patients.
So why do we not get our patients up sooner? I believe it's not a question of laziness or lack of resources. Nurses and nurses' aides are the most hardworking people I've ever encountered, and most nurses are aware that it's good to get patients up and moving. However, in the haze and hustle of a hospital admission, with intravenous lines, telemetry monitors, strong medications and constant tests, we lose sight of the simple little things that can make an enormous difference. In my experience, patients even just look so much better sitting up in a chair as opposed to lying in the bed.
So here's what the world of health care should really push for: A National Ambulate the Patient Week. This should involve:
Education for all healthcare professionals about the importance of ambulation. Physicians should be encouraged to write “OUT OF BED TO CHAIR AT LEAST 3 TIMES DAILY” as an order for nearly all hospitalized patients as soon as they can, usually from hospital day 2. With that order should be assumption to “ENCOURAGE AMBULATION”, either with or without assistance depending on the circumstance,
Invest in more physical therapy services and also dedicated PT-aides, also known as “walkers or mobility aides,” to get people up and moving early,
Administrative oversight from charge nurses and unit supervisors to raise a red flag when they see a patient who potentially has “sinking in bed syndrome”,
Posters around hospitals encouraging early ambulation and walks around the hospital floor,
More comfortable chairs! This may sound rudimentary, but a common complaint I hear everywhere is that hospital chairs are very uncomfortable. However much they are purportedly designed for hospitalized patients, just glancing at them and testing them out myself, I'm very skeptical about how comfortable patients can feel sitting in them. I get the same feedback from relatives who test them out. If healthy people don't feel comfortable in any given place, how on earth do we expect sick people to?
There are certain departments that are actually already very good at mobilizing their patients. One such example is orthopedics, where surgeons are almost obsessive about getting people up as early as possible after hip or knee surgery. If they can do it, so can everyone else.
Richard Asher, the British endocrinologist and forward-thinker from the early part of the 20th Century, once said: ”Look at the patient lying long in bed. What a pathetic picture he makes! The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder and the spirit evaporating from his soul.”
That quote was from 1947. I will leave it to your imagination to think what scybala is!
Seventy years later, while we are not as bad as we were in the 1930s and 1940s, we can still do a lot better. So let's make it a national priority get all our hospitalized patients up and moving earlier. Starting from today.
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
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Suneel Dhand, MD, ACP Member
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