The goal of any hospitalization is to resolve the issue that brought the patient to our doorstep in the first place. Focus is the watchword. Whether it's routine care or quality improvement work, most of our efforts pinpoint the single diagnosis for which the patient was admitted to the hospital.
We've had a fair amount of success with this approach as an industry. Using a transactional model, we've evolved to provide great transactional care. You come in for disease X, you're treated for disease X.
But in a world where more than half of all Americans have a chronic disease, it is time to create new models of care.
These patients have high risk for harm when hospitalized, yet their chronic disease is often not addressed. Given this reality, a patient's hospitalization should not be just a one-off transaction. Rather, it presents a valuable chance to intervene on chronic disease issues unrelated to the diagnosis at admission — an opportunity we too often let pass us by.
By adopting a more proactive mindset, we can provide safer care for our patients during their hospitalization, while guiding them toward better health outcomes once they're discharged. Along the way, we can reimagine and redefine what a hospitalization can be. As a healthcare industry, we have ample room for improvement when it comes to factoring in a patient's chronic disease status into hospital care.
Patients undergoing surgery, for example, often have a chronic disease that elevates their risk of harm, yet patient safety programs generally identify every patient admitted with a specific diagnosis as having identical risk. Healthcare lacks a systematic way to identify and mitigate harm when these types of patients are hospitalized.
Take the example of patients with Parkinson's disease. Among the 1 million Americans with the condition, more than 300,000 are hospitalized each year. Most of these patients are hospitalized for other health conditions, yet their Parkinson's increases their risk of adverse events. Research shows evidence of patients not receiving medications on time, deteriorating motor function, increased complications and increased length of stay during hospitalization.
Patients suffer needlessly because many American hospitals are simply not set up to identify Parkinson's patients and activate a care plan at admission. According to one study, just 25% of U.S. hospitals have a mechanism to identify Parkinson's patients on admission and contact the physician managing their care.
At my institution, we're working with support from the Parkinson's Foundation to create a new and better care model to remedy this. It involves ordering and administering a patient's Parkinson's medications in strict accordance with their at-home regimen, and avoiding potentially harmful medications, such as dopamine-blocking agents.
Two other key aspects: Parkinson's patients should be mobilized three times a day, with supervision if needed, and screened for dysphagia within 24 hours of admission — with measures to prevent aspiration and pneumonia, if needed. We're optimistic that this model can work and be widely duplicated for other diseases and in other health systems.
We have several studies to evaluate the use of these interventions and their impact on patient harms and costs. Research is ongoing, for example, to determine how mobilization rates among Parkinson's patients compare to our patient population in general — which now stands at 70%. Perhaps an even more important question: Does mobility shorten a Parkinson's patient's length of hospital stay?
Parkinson's is just one example of a chronic disease that can be addressed during a patient's hospitalization. Imagine if we incorporated the voluminous health history information provided at admission and used it to begin a conversation about optimal therapy for their chronic disease.
For our patients with chronic obstructive pulmonary disease, chronic kidney disease and congestive heart failure, the window of opportunity presented by a hospitalization could be a game-changer.
The stress and sense of enormity of the moment may make the patient more resolved to stay with guideline-directed therapy — or make a positive change to get there. On average, fewer than 20% of patients with chronic disease are receiving guideline-recommended therapy, and most of these gaps are invisible to clinicians and patients.
Many of us got into healthcare for two reasons — a fascination with the complexity of human biology and a desire to make a difference in people's lives. Now is the time to incorporate both into the care we provide. We must embrace our patients in all their humanity and complexity — and all their diagnoses. Yes, they have a diagnosis at admission — but they are so much more.
By using a hospitalization as more than a one-off transaction, we'll go a long way toward helping people be truly well.
Peter J. Pronovost, MD, PhD, FCCM, is Chief Quality and Clinical Transformation Officer, Veale Distinguished Chair in Leadership and Clinical Transformation, at University Hospitals, Cleveland, Ohio.