June 18, 2018

4 ways hospitals can 'heal as well as treat'

Daily Briefing

    The U.S. health care system often operates under a "false dichotomy" in which hospitals focus on health care, while leaving wellness to the yoga studios and spas—but both are essential to health care delivery and treating disease, Rich Joseph, an internal medicine resident at Brigham and Women's Hospital, writes for NEJM Catalyst.

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    Increasingly, Joseph writes, hospitals and health systems are taking steps to improve patients' wellbeing. He outlines four ways hospitals are "encourage[ing], and even accelerat[ing], patient recovery" through wellness: 

    1.  Help them rest

    Sleep "boosts immunity, quells the stress response, and speeds recovery," Joseph writes, yet hospitals "often" regard sleep as "an afterthought." Patients are disrupted by overnight lab draws, medication administration, and vital sign checks every four hours—a standard of care that dates back to the 1890s, Joseph writes. In fact, research shows that nearly half of patients are unnecessarily woken up for vitals checks—a practice linked with poor health outcomes.

    In most cases, the solution for sleep deprivation is a sedative, such as Ativan or trazodone—"quick fixes that increase the risk" of conditions such as delirium, Joseph writes.

    But, he writes, some hospitals are adopting practices that "create a more sleep-friendly environment." For example, Massachusetts General Hospital, implemented mandatory quiet hours in the evening and early morning, Joseph writes. During quiet hours, "noise is limited and lighting is dimmed." Similarly, Yale New Haven Hospital has reduced unnecessary wake-ups by allowing nurses to align the times they administer medication to their patients' sleep schedules.

    According to Joseph, hospitals should consider some of these strategies, as well as others like "adjusting the frequency of overnight checks based on clinical status, substituting medications that require frequent dosing for those dosed less often, and assigning a single nurse to simultaneously draw labs, administer medications, and check vitals."

    2. 'Let food be thy medicine'

    Patients admitted for lengthy stays in the hospital often "suffer nutritionally," Joseph writes, which can worsen health outcomes and increase morbidity.

    To address this problem, Joseph recommends hospitals "eliminate any barriers that keep dieticians from fully managing diet orders and orchestrating nutrition care," while also better leveraging family insight to understand a "patient's personal and cultural food preferences," perhaps even by encouraging family members to feed their loved ones.

    Moreover, hospitals should consider healthy meal options "not only a core competency, but a point of competitive advantage," Joseph writes. For instance, while hospitals often  contract with large food manufacturers—and in some cases fast food restaurants—he notes that Henry Ford West Bloomfield Hospital created its own greenhouse and education center to teach nutrition while also providing organic produce.

    3. Get moving

    "[M]ovement is also essential to health," Joseph writes, "yet in the hospital, idleness—with the psychological and often physical attachment to bed—is the default mode."

    Being bedridden for even a few days can be detrimental, Joseph says. "Only a few short days of bed rest can cause a precipitous loss of strength, which accelerates functional decline, leads to frailty, and thereby increases the risk of falling down and falling ill," Joseph writes.

    But research shows patients who walk more during their hospitalization are more likely to be discharged earlier and less likely to be rehospitalized. For instance, Joseph cites one study that found having pneumonia patients walk "early and often" reduced their hospital stay and saved an average of $1,000 per patient, Joseph writes.

    To encourage movement, Joseph writes that hospitals should "better stratify patients to determine which ones can ambulate on their own and with family members and which need nursing supervision." Hospitals should also implement physical therapy as a default for all patients, providing patients with a "personalized workout plan consisting of a circuit of exercises that can be done in or out of bed, as appropriate."

    For example, the University of Alabama at Birmingham Hospital-Highlands encourages its patients to move by providing a walker in every room while ensuring that there are a number of handrails, the floors are skid-free, and that the lighting is low-glare.

    4. Encouraging social connections

    Loneliness has been linked in a number of studies to poor health and an earlier death, Joseph writes, and in the hospital, patients are frequently isolated, especially if they don't have friends and family to provide companionship.

    To combat this, Ronald Reagan UCLA Medical Center has volunteer companions within their geriatric unit. "Such programs are an excellent opportunity for younger people who are interested in a career in health services to get hands-on experience," Joseph writes. "Patients benefit from the companionship, while volunteers practice communication skills and become familiar with the hospital workflow."

    Joseph also recommends that hospitals provide common spaces for patients to have communal meals, take walks, or simply talk.

    To more effectively manage illnesses while also promoting functional recovery, Joseph writes that "hospital leadership should open their eyes and ears to their colleagues in the world of wellness. Together, we can create innovative solutions that incorporate these fundamental tenets of vitality into a more holistic patient care experience" (Joseph, NEJM Catalyst, 6/11).

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