Most people know that being a patient in a hospital can be dangerous while, at the same time, providing critical care. This post catalogs the dangers of hospitalization, particularly for older people and recommends some ways of lessening the hazards. The next three paragraphs are a direct quote from an NPR report on the program “All Things Considered.”
“Until March of this year, Janet Prochazka was active and outspoken, living by herself and working as a special education tutor. Then a bad fall landed her in the Zuckerberg San Francisco General Hospital.
Doctors cared for her wounds and treated her for pneumonia, but Prochazka, who Is 75, didn’t sleep or eat well in the hospital, and she became confused and agitated. Then she contracted a serious stomach infection.
Patients over 65 tend to be less resilient during a hospital stay than younger patients, research finds, and more vulnerable to mental or physical deterioration, even if they recover from the illness or injury that brought them there. One study, published in 2011, found that about a third of patients older than 70 and more than half of the patients over 85 left the hospital more disabled than when they came.”
The sobering case described is not unusual. In fact, hospitalization can be the beginning of a downward slide for an elderly person, followed by declining function, reduced quality of life, placement in a skilled nursing facility or nursing home, and death. This post shares some of the common factors that cause complications and how they can, where possible, be prevented.
Conceptually, all of us have physiologic reserves that we call into play when there are challenges to the body’s well being. However, reserves decline with age due to loss of muscle strength, heart and lung capacity, immune function, cognitive function and general physiologic resilience. At the extreme, there are the “frail elderly,” who are most likely to do poorly in the hospital. Add the challenges that greet people in a hospital to the underlying loss of reserves, and it is a recipe for disaster. What are those challenges?
Immobility: It is surprising how many complications can be caused by the inability to get out of bed and ambulate. In no particular order, immobility can lead to pressure sores, rapid development of muscle weakness (which in turn contributes to falls), under expansion of the lungs (contributing to pneumonia), blood clots that can break loose and go to the lungs and loss of orientation.
Hyper-stimulation: Patients in hospitals must endure the almost constant noise, lights, machines, waking to be checked and other interruptions to sleep and rest. This is particularly true for patients in an ICU. Adding this to an unfamiliar environment can cause disorientation or a delusional state complete with hallucinations. Over medication can be another contributor to this set of events.
Infections: Hospitals are associated with many factors that lead to infections. Breaking our first line of defense, the skin, and invading the body through surgery, bedsores or procedures that puncture, reduce the body’s natural defenses. Similarly, organisms can invade the body through catheters placed in the bladder and through the air that is breathed, particularly if tubes are used for ventilation. Urinary infections are very common in people who have catheters in their bladder for more than a couple of days. Recumbence, pain and loss of muscle strength can make it more difficult for a person to fully expand their lungs, and partially collapsed lungs are a setup for pneumonia to develop. Add to that the proliferation of “super bugs,” virulent and resistant to antibiotics, any of the above sites can be susceptible to life-threatening infection. These organisms are carried from patient to patient primarily by the hospital staff, such as physicians and nurses who don’t always wash or disinfect their hands when going from patient to patient.
Our bodies are home to literally billions of organisms with which we live in harmony. These organisms are kept in check through barriers to entry, the skin, the lining of the gut and respiratory tract, through secretions like saliva and mucous and by the immune system. Patients who are sick, and particularly the elderly, have depressed immune function and less able to fight off microbes. When they have a chance to invade through breaks in the normal defenses, even ordinary cohabitants can become the cause of serious infection.
Errors: Medical professionals are subject to errors. They are caring for a large number of very sick patients in a complex environment, and it is easy to become distracted, overlook something or make an outright mistake. Some mistakes are egregious, like removing the wrong limb. Some are easier to understand, like misreading a doctor’s order and giving the wrong dose of medication. The elderly generally cannot tolerate medication doses that are standard for younger patients. Many errors are preventable by using standardized procedures and protocols and by putting in safety checks. Quality hospitals are implementing the tools of modern industry in the hope that like modern industry, errors can be reduced to one in a million.
Accidents: Falls are the most common accident occurring in a hospital. A combination of weakness and disorientation are usually responsible. After that, accidents can be caused by equipment malfunctioning, by a medical procedure gone awry or by failure to adequately supervise a young professional.
So to what end this litany of medical woes associated with hospitalization? What can we do to lessen these dangers given that although they are best avoided, hospitals can be life saving and are absolutely necessary at some points? I would give the following advice to someone entering a hospital and to their significant others who may need to be on guard if the patient can’t be. It is easy to be passive and compliant in the confusing setting of a hospital, but it is important to be one’s own advocate.
Avoid immobility: Even seriously ill patients including patients with recent surgery or on a respirator can be gotten out of bed to sit in a chair for a while, and preferably to walk short distances. My wife was hospitalized in an ICU for several days after a biking accident. She complained bitterly about how uncomfortable she felt when she sat up in a chair, but the staff persisted in getting her out of bed for short periods.
Advocate for periods of uninterrupted rest: It is difficult to avoid the consultations and monitoring of vital functions, particularly with patients in an ICU. However, protecting some time to sleep quietly is essential to avoiding exhaustion and disorientation. Talking to the staff about scheduling events in bunches, leaving time for rest, can help the patient recover.
Understand what is being done and why: It is difficult to get physicians’ attention in the hospital. They are usually in a rush when making rounds, and getting them to stop and answer questions can be a challenge. When my wife was in the hospital, doctors seemed invisible. They made rounds at 6 or 7 am, and they were often in the operating room or somewhere else during the day. I had to be persistent to get someone to talk to us. Other than in an emergency, you should understand the rationale for major tests and treatments, the benefits and the risks.
Be your own (or family members’) best advocate: When things are going well, compliments go a long way. However, if you are concerned about something, respectfully speak up; it may be a clue that something is awry. Know what medications you are being given and what they look like. I’ve had nurses bring a medication to my bedside that was actually intended for another patient. In the extreme case, chemotherapy has been given to the wrong patient.
Don’t be intimidated by the technology or staff: At times, the hospital procedures seem bewildering, and the staff may seem busy and brusque. As a patient, it is your right to know what is happening and as a visitor, you provide an important function, namely, being a friendly point of reference reminding the patient of who they are outside. If a patient can’t be their own advocate, it is best if one person speaks for the family so that the staff is not getting repeated or conflicting questions. Hospital staffs are usually concerned human beings who want to do what’s best for the patient, but they are busy and working in a complex environment. It’s often best to begin your inquiry with the nurse, who can bring in the physician as needed.
Hospitals can do miraculous things, and at times they are absolutely essential, but they can be dangerous. It is best to know where the dangers lie and to take steps to prevent them.