A few months ago, I had a young patient who was struck by a car and was left with a broken tibia (that’s your shinbone). We fixed him on the same day, and, thanks to relatively non-invasive laparoscopic surgery, he could walk immediately after his operation. In fact, given that he was young, healthy and motivated, he could have gone home the very next day. And he should have. But given his family’s anxiety about his leaving so soon after major surgery, I relented, allowing him to stay an extra night.
My patient started having bouts of diarrhea the next morning. A stool sample showed he contracted C. difficile, a bacterium, often found in hospitals, that attacks the large intestines, causing bouts of watery diarrhea—and, in rare cases, bowel necrosis and even death. His constant stools left him with low blood pressure and electrolyte imbalances. His sudden deterioration forced us to send him to the critical care unit for closer monitoring. Almost a week later, he finally escaped the hospital, having suffered only a few abdominal cramps and runny stools with no permanent damage.
I can’t say that the extra day in the hospital led to his infection, but it certainly increased his risk. The reality is that even the newest and fanciest hospital is less a hotel than a noisy petri dish festering with drug-resistant bacteria and crowded, even before COVID-19 showed up, with truly sick and possibly contagious patients. If you’re going to the hospital, you should have the same philosophy as you do when renewing a driver’s license—get in and get out as quickly as you can.
Patients are sitting targets for hospital germs, many of which have resisted all attempts at eradication despite all the antibiotics we throw at them. Notoriously, bacteria like Pseudomonas that often attack our lungs notoriously thrive in hospitals and have already acquired resistance to several classes of antibiotics. Those that worked as recently as a decade ago have lost effectiveness. These multidrug resistant bacteria have exponentially complicated the treatments for once straightforward illnesses like pneumonia, sometimes requiring multiple antibiotics to treat. And in the midst of a rampant pandemic, with coronavirus carriers streaming in and out of our hospital, our patients are especially vulnerable to contracting that illness as well.
The science is unequivocal: hospitals are not ideal for healing. They can never compete with the comfort and familiarity and safety of our homes. Patients are nowhere close to achieving the precious rest required to heal their wounds and maintain their immune systems. A multicenter survey of hospitalized patients showed patients averaged a measly six hours of sleep. Nurses wake them multiple times in the middle of the night to monitor their vital signs. Phlebotomists stick their arms with needles to draw blood before dawn. Their rooms are bombarded with constant noise, from the beeping from IV machines to screeching overhead announcements. Given all of these interruptions, patients might be even more sleep-deprived than their doctors.
Older patients are especially vulnerable to hospital complications; even a brief stay in the hospital can be an irrecoverable blow to their health. To prevent falls, they’re ordered to stay in bed, quickly becoming deconditioned as their muscles wither from poor nutrition and lack of exercise. One study showed patients only consume 50 percent of the nutrients needed to maintain their normal energy levels. That dangerous combination of claustrophobic living quarters and irregular sleep patterns predispose them to delirium. Some of my patients become so disoriented that they lose track time and fail to recognize their own family members. The benefits of staying in hospital quickly lose ground to the dangers.
So, I try to persuade all my patients to get out of the hospital as quickly as possible, sometimes mere hours after the fog of surgery has lifted. Often, the patient and the family are taken aback by my advice. Anecdotes abound of patients who were discharged from the hospital too early and were readmitted for wound complications or uncontrolled pain. They often suspect my recommendations are influenced by the interests of the insurance companies or the hospital, or out of my own self-interest.
They’re not entirely wrong. Hospitals and insurance companies have strong incentives to get patients out of the hospital. The average cost of just a one-day stay in the United States is $5,220, according to one estimate. That’s money that the hospital or insurance companies could potentially save with an early discharge. And as more hospitals rely on revenue from “bundled” payments that cover the entire cost of a patient’s hospital stay and rehabilitation, going home earlier means more leftover money. For me, one fewer patient means one fewer phone call to answer in the middle of the night and one fewer note to write in the morning.
But however much financial incentives and convenience may play a part in reducing the length of hospital stays, better medicine plays an even larger one. In 1980, the average stay was over a week long. Now it’s around four days. Over the past decade, there have been a wave of advances in medicine that allow most patients to go home safely and swiftly.
Let me give you one example. Total knee replacement was once a morbid surgery. If you had your knee replaced in the 1980s, you would need to stay in the hospital for three weeks, and the operation carried significant risks. You could get devastating infections; the incisions might not heal properly; you would often need blood transfusions. And afterward, you’d be bedbound from the crippling pain.
But surgical technique and medical optimization for joint replacement surgeries have become so precise the entire procedure can take less than an hour. With more than 600,000 of these operations done each year, total joint replacement is one the most successful surgeries in medicine, with the some of the highest patient satisfaction and greatest improvements in quality of life. And these earlier discharges haven’t increased the frequency of readmissions, proving we can let these patients go safely.
Though we are inundated with news stories of unfair billing hospital billing practices and greedy insurance claim denials, the trend towards shorter hospitals stays may be one bright spot where patient well-being intersects with corporate profits.
But instead of shortening hospital stays, we may be unknowingly encouraging patients to stay longer. Some hospital facilities look more like hotels in the hopes of better rankings and publicity. Profits are reinvested in luxuries to attract insurance plans attached to the fattest reimbursement rates, leading patients to become too comfortable for their own good during their stay. After all, why leave the hospital where you can stay in a private suite with a flat-screen television, cable television and room service while doctors, nurses and pain medications are just a call button away? But no matter how fancy or highly ranked a hospital, underneath the bells and whistles is the dark and dirty underbelly of medical care.
When I was a medical student, the surgery resident would tell his patients on morning rounds that the hospital is a wonderful place to be treated but a terrible place to heal. I repeat this mantra to each of my patients every morning. Our responsibility to our patients does not end once the last suture is tied or laboratory tests have normalized. We must also get them to the sanctuary of their homes, where they can properly and safely get better.