Insight into the post-hospital syndrome

Han Wang ,Si-Qi Xiong ,Yun Ning ,Lyu Cheng ,Wen-Jiao Li ,Chang-De Jin

1Graduate College,Tianjin University of Traditional Chinese Medicine,Tianjin 301617,China.2School of Nursing,Tianjin University of Traditional Chinese Medicine,Tianjin 301617,China.

Abstract After hospitalization,the patient faces a brief fragile period of susceptibility to disease and a high incidence of adverse events (re-admission or death,etc.),which is described by cardiologist Harlan M.Krumholz as post-hospital syndrome (PHS).PHS is characterized by the risk of early re-hospitalization towing to physiologic stressors from the initial admission,including disruption in sleep-wake cycles,inadequate pain control,deconditioning,and changes in nutritional status.Almost 1 in 6 patients hospitalized for acute myocardial infarction and 1 in 5 of those admitted for heart failure are readmitted within 30 days of discharge.Notably,only 10% and 35%are readmitted for the same diagnosis as that of the original hospitalization,respectively.Through a systematic review,this paper discusses the related concepts,hazards and influencing factors of PHS,and summarizes the counter measures based on the domestic status,in order to provide reference for domestic clinical medical personnel to formulate relevant measures to reduce the incidence of PHS.

Keywords:Post-hospital,Syndrome,Harm,Influencing factor,Measure

Post-hospital syndrome(PHS)and it's harm

After hospitalization,the patient faces a brief fragile period of susceptibility to disease and a high incidence of adverse events (re-admission or death,etc.),which is described by cardiologist Harlan M.Krumholz as PHS [1].PHS is characterized by the risk of early re-hospitalization towing to physiologic stressors from the initial admission,including disruption in sleep-wake cycles,inadequate pain control,deconditioning,and changes in nutritional status[1,2].

PHS can increase the rate of re-admissions,emergency visits,and complications in patients within 30 days of discharge [3-5].The survey shows that nearly 20% patients will be re-admitted to other diseases within 30 days of discharge,and the diagnosis at admission is mostly independent of the initial diagnosis [1].For example,among patients with heart failure,acute myocardial infarction,pneumonia,and chronic obstructive pulmonary disease,the same rates of re-admission and the cause of first admission were only 37%,10%,29%,and 36%,respectively [6,7].Among patients aged 80 years or older,the mortality rate after discharge is more than double that of non-inpatients.The most obvious upward trend in the first 6 months after discharge was a manifestation of PHS[8].Additionally,PHS is closely related with high rates of re-admission in patients initially hospitalized for heart failure,acute myocardial infarction,or pneumonia [9],as well as with generally higher risk for adverse events for these patients in the year following hospitalization compared to the elderly general population [10].In addition to increasing the risk of re-admission and death,PHS has also been shown to be associated with adverse outcomes for patients after surgery,for patients exposed to PHS,the incidence of adverse events within 30 days (11.8%)was significantly higher than that of patients not exposed to PHS (5.8%) [11].PHS patients also suffer from cognitive dysfunction,impaired mobility or systemic dysfunction.Therefore,it is important to prevent the occurrence of PHS.Therefore,it is very important to prevent the occurrence of PHS,but there are few related studies on PHS in China.Therefore,this article reviews the risk factors of PHS and preventive measures,aiming to provide reference and reference for future clinical medical staff to formulate appropriate measures to reduce the incidence of PHS.

Factors affecting PHS

The allostatic overload hypothesis

The cause of PHS maybe relate to The allostatic overload .Adaptation and recovery from stress is called “ectopic stagnation”,and its main mediators are the hypothalamus-pituitary-adrenal axis and the autonomic nervous system.When a person faces a threat,this mechanism changes hemodynamics and metabolic parameters,triggering a “war or escape”response,thereby enhancing the individual's ability to face challenges.However,continuous pressure exposure will disrupt these adaptation mechanisms and,when faced with new threats,will impair the response of the hypothalamus-pituitary-adrenal axis and the autonomic nervous system.Inadequate adaptation of this state is called adaptation overload,and its consequences include deterioration of function and cognitive ability and dysfunction of various physiological systems[5].

Impaired sleep

Impaired sleep is one of the risk factors for PHS [1].Inpatients are affected by noise(talks between medical staff,patients in the same ward,alarm sounds,walkie-talkies,alarm clocks,etc.[12,13]),pain [13],light [14],etc.,which are difficult to obtain plenty of sleep at night.Surveys by Freedman [15] show that noise accounts for 17% of impaired sleep,and light affects sleep more severely than noise.Because the body regulates our sleep through light-sensing information [16],proper light conditions during the day are good for good sleep [17],and excessive lighting at night is seriously destructive to sleep [18].Acute and chronic pain is also a source of impaired sleep[19].Impaired sleep can lead to circadian rhythm disorders,which in turn adversely affects the body's metabolism,cognition,gastrointestinal function,and mood,and eventually leads to PHS[1,20,21].

The impact of disease and patients

During the patient's stay in the hospital,his or her activities will be limited due to illness,treatment needs(intravenous infusion,catheterization,etc.) and pain[22,23].Long-term limited mobility will lead to increased mobility disorders,leading to massive loss of skeletal muscle (especially the lower limbs) and the formation of deep vein thrombosis [24],increasing the incidence of falls,other adverse events and read missions,that is,PHS[25,26].

Studies have found that malnutrition is also a risk factor for PHS [4].Patients are susceptible to nutritional absorption due to illness [27],and dietary preferences based on different races,regional cultures or personal preferences [4] can also lead to malnutrition.Surveys show that the incidence of malnutrition in hospitals is between 20% and 50%,especially in older patients [28].Malnutrition can lead to slow wound healing,decreased muscle strength[29],decreased immunity,prone to infection [30],prolong the length of hospital stay [21,31],increase the incidence of complications and mortality[32,33].

Incomplete health education

In the transition period after discharge,patients bear the main responsibility for their own care,but patients have a low level of understanding of health education at discharge,and they may miss re-examination due to forgetting or misunderstanding discharge instructions,or fail to detect red flags in time and cause patients to re-admission [25].Re-admission within seven days after discharge of a patient indicates that there are problems in the discharge process [27,34].Poor communication between doctors and patients [25],low-level quality of care [35] and social support after discharge [25] are all factors that lead to imperfect health education and disease education for patients,causing PHS the reason.

Precaution of PHS

Comfortable medical environment

PHS is similar to post-traumatic stress disorder.Preventing PHS must first reduce trauma during hospitalization.Optimizing the ward lighting conditions can help prevent sleep disorders in patients,and appropriate and reasonable lighting interventions can improve the sleep quality of hospitalized patients[16].According to the patient's sleep time,the ward lighting is individually adjusted,and a 24-hour dynamic change is implemented.Because proper lighting is good for the health of patients and medical staff,hospitals should strive to develop more comprehensive lighting strategies.At the same time,avoiding the operation of blood collection,blood pressure measurement and infusion at night to reduce the noise level at night,Milani [36] found that noise control can reduce the risk of patients being re-admitted after being discharged.The hospital minimizes the interference of the environment on sleep and circadian rhythm by formulating corresponding rules and regulations,so as to prevent the occurrence of syndromes after discharge.

Promote activities and increase nutrition intake

Establish a safe hospital space structure that is conducive to patient activities,and promote patient activities.By installing handrails in hospital corridors,developing personalized exercise plans for patients,and providing beautiful exercise venues,patients are encouraged to walk independently without relying on medical staff or family members to help patients recover step by step.At the same time,planned outdoor sports activities can prevent patients from missing various examinations,treatments and rounds of medical staff to the greatest extent.

In terms of the nutritional supply of patients,medical staff should consider the daily caloric consumption required by the patient,and ensure that the patient's dietary intake of three meals a day should meet the caloric requirement if the disease allows.Enhance the appetite of patients by increasing the richness of hospital diets,improving the taste,color and appearance of food.Because the nutritional status of the patient is important to promote the rapid recovery of the patient,the daily food intake and nutritional status of the patient should be monitored,which helps to detect the malnutrition of the patient early and deal with it in a timely manner.

Multidisciplinary cooperation

Research on PHS requires the cooperation of multiple disciplines.Based on the results of multi-disciplinary,multi-dimensional,standardized assessment tools for health,rehabilitation,and nursing needs assessments[37],a “hospital quality and patient experience” round is established to discuss the patient's hospitalization experience,care continuity,health education,and safety issues [38].Studies have shown that multidisciplinary team management can reduce the readmission rate of patients [39,40],and readmission is the adverse consequence of PHS,so we can try to prevent the occurrence of PHS from the perspective of reducing readmission.Multidisciplinary cross-disciplinary cooperation to develop personalized treatment plans for different patients will not only shorten the length of hospitalization of patients,but also reduce the risk of re-admission of elderly patients for three months [41],thereby reducing the incidence of PHS.For details,please refer to the collaborations of foreign continuum teams [37],quality care plan[42].

Improve patient self-care ability and strengthen health education

Strengthening the health education of patients during hospitalization and improving their self-care ability can enable patients to participate in the process of disease treatment and rehabilitation,give full play to their subjective initiative,and promote faster and better recovery.Through the daily treatment and care plan provided to the patients,the patients can understand the current status of the disease and treatment during the hospitalization,and actively cooperate with the medical staff for the diagnosis and treatment of the disease.The process of the patient's participation in the treatment of the disease also virtually enhances the patient's recovery.Confidence promotes their enthusiasm for daily activities.For example,the Head and Neck Institute [37] tried to install a whiteboard in each ward to display the name of the patient's attending doctor,the responsible nurse,the patient's routine treatment,the time of each drug use and the upcoming examination.At the same time,in the process of health education,patients are provided with comprehensive disease information,and by watching videos related to the disease,patients are provided with disease-related knowledge and self-management health education.Studies have shown that one-to-one health education between nurses and patients [43],educational interventions for medication compliance and diet control [44],and educational interventions combined with before and after discharge interventions will have a positive impact on patient rehabilitation[37].

Construction of a continuing care platform

Perfect and safe continuous care is one of the effective measures to promote the rapid recovery of patients in the transition phase after discharge [45,27].Continuing care during the transition period after discharge will reduce the adverse consequences associated with PHS s such as complications and readmissions [46,47].As patients are prone to maladjustment during the transition period after discharge,continuous care can help patients to detect complications or other adverse reactions after discharge in a timely manner,so that timely and effective treatment measures can be given to maintain the disease in a controllable range inside.The continuous care platform can arrange home visits by high-level medical teams or experienced nurses to provide guidance and care for patients during the transition period after discharge,prevent PHS,reduce the incidence of re-admission of patients and other adverse events.

Discussion and summary

In clinical practice,while focusing on the treatment of patients with acute diseases,the factors that lead to vulnerability during hospitalization and early rehabilitation should not be ignored.During the hospitalization,there are steps that need to be taken with regard to PHS,such as actively promote the cooperation between the discipline team,establish a safe and comfortable medical environment for patients,reduce the stressors during the hospitalization,ensure adequate sleep for patients,balance nutrition supply,improve the body's immunity,and better promote patients regain health.The transition period after patients' discharge is currently the weakest part of medical management in China,and the continuous care after patients' discharge is strengthened.Real-time monitoring of the patient's condition with the aid of the auxiliary platform ensures that medical staff can respond to abnormal data of physical indicators in a timely manner.Only from the two parts of the hospital and outside the hospital to ensure that all aspects of the patient before the rehabilitation of medical staff to participate in and control can effectively prevent the occurrence of PHS.

The prevention of PHS is a social medical problem to be solved urgently in China,but a systematic management system suitable for the current medical environment has not yet been formed,and there is a serious lack of research on PHS.The purpose of this article is to provide reference for constructing preventive measures for PHS to promote patient rehabilitation.