Prevention and treatment of hospital-acquired conditions is as much a part of the care of the hospitalized patient as treatment of the primary diagnosis. The development of deep venous thromboses, stress-induced ulcers, and pressure ulcers can have a lasting, negative impact on a patient's medical condition, requiring additional treatment and increasing the length of hospitalization. Also important in minimizing the length of hospitalization is fall avoidance, fluid and electrolyte management, and adequate nutrition. Infection control and isolation can limit the spread of multi-drug-resistant organisms, prompt removal of urinary catheters prevents catheter-associated urinary tract infections, and appropriate placement and site care of central venous catheters can prevent central line-associated bloodstream infections. Finally, the use of advanced care plans and early consultation of palliative care or hospice can assist in the care of the dying patient.
The hospital is a complex environment and a setting for the acute care of a patient’s medical needs. There are many players involved, including the patient, the patient’s family, physicians, nurse practitioners and physician assistants, nurses, nurse’s aids, physical and occupational therapists, phlebotomists, lab technicians, radiology technicians, transport staff, dieticians, pharmacists, housekeepers, social workers, nurse case managers, and the list goes on. Coordination of care and communication among these players are tantamount to improving patient experience and patient outcomes.
There is a newly recognized syndrome called post-hospital syndrome due to events related to being in the hospital environment. This relates to alterations in cognition, sleep deprivation and disruption of normal sleep cycles, malnutrition due to poor appetite in acute illness, and physical deconditioning from being in bed more than usual. This syndrome impacts a patient’s recovery, and prevention where possible in the hospital is crucial.1
In addition to the acute care of the patient’s medical needs, there are innate risks to having an acute medical illness beyond the active medical needs. Many of these are preventable, and systems should be in place to help prevent such events including hospital-acquired infections, venous thromboembolism, pressure ulcers, injuries due to falls, and medication errors due to inadequate medication reconciliation.
When the time comes to decide if aggressive medical care should continue in a patient, we are not as prepared to talk with patients about end of life and may feel inadequately equipped to manage symptoms at the end of life. Patients may also have advanced directives that have been established or should be established in order to make their wishes known.
It is with these thoughts in mind that we have constructed this chapter.
Mr. S is an 86-year-old left-handed man with a history of hypertension, hyperlipidemia, diabetes mellitus, and chronic kidney disease who presents to the emergency department with left arm and left leg weakness and slurred speech. He had been having symptoms for about 6 hours. He is diagnosed with an acute stroke ...