Optimizing Patients' Vital Interests Post-Discharge.

I n this issue of JGIM, Nguyen et al. present empirical evidence highlighting the potential value of using a patient’s instability at hospital discharge as a diagnostic test to predict the likelihood of future adverse events. Based upon prior empirical evidence regarding the role of abnormal vital signs in predicting vital status,, the authors define instability at hospital discharge as temperature ≥37.8 °C, heart rate ≥100 beats per minute, respiratory rate >24 breaths per minute, systolic blood pressure ≤90 mmHg, or oxygen saturation <90 %. Using electronic health record data for adults hospitalized during 2009 and 2010 in their six-center observational cohort study, the authors demonstrate that almost one in five general medicine patients was discharged with at least one documented vital sign instability within 24 h prior to discharge. Among those with fever on the day of discharge, 38 % had fever at admission, and among those with tachycardia at discharge, 76 % had the unstable sign at discharge. Learning that patients are sick at admission reassures us that hospital resources are allocated for patients with (often multiple) health needs that may benefit from the intense clinical and technological data-gathering, decision-making, treatment, and surveillance that hospitals offer. However, learning that patients are sick at discharge raises questions about the effectiveness of the hospital stay, notably among Nguyen et al.’s study cohort, which consisted of 32,835 hospitalized patients with a mean relatively young age of 61 years and an overall median length of stay of 4 days. Closer examination of these hospitalized patients shows that, within the prior 12 months, more than one in four had visited the emergency department (ED), and nearly one in three had been hospitalized. One in five had a Charlson comorbidity index score of 2+, indicating substantial comorbidity. These characteristics suggest that this hospitalized cohort, or at least a subset, had a heavy burden of preexisting chronic conditions. While hospitals are designed to treat patients, and particularly the illness that prompted the hospital stay, hospital stays—especially on medical wards—most often serve to diagnose and stabilize, rather than cure, patients of their disease. Curative, disease-controlling, or symptom-management treatment plans may be developed or implemented in either the ambulatory or hospital setting or across these settings. Most often, treatment for the reason for admission continues long after an acute care hospital stay. Using this framework, the 19 % prevalence of instability at discharge found by Nguyen et al. is not surprising. Most hospitalized patients were sick before hospitalization, and much of their sickness could not be cured, at least not with a 4-day hospital stay. That 14 % of the hospitalized patients in Nguyen’s study were readmitted or died within 30 days after hospital discharge highlights the importance of the preexisting and ongoing disease trajectories for hospitalized patients. Among this 14 % of hospitalized patients, 36 % had had an ED visit and 46 % had had a hospital stay within the previous year, suggesting their illness required substantial assistance beyond family support or clinic visits. While we know little about the social status of this cohort, we are told that only 36 % are married, suggesting that many may not have had a structured home support system to which they could return after discharge. Using instability at discharge as a diagnostic test for predicting post-discharge adverse events meets many standard criteria for a feasible, reliable, and valid signal of patient risk for adverse events. Data about vital signs are clinically simple, available routinely and periodically, usually reliably measured within and between observers, and reproducible across diverse patient cohorts and clinical venues. Furthermore, the authors highlight the importance of the dose-dependent relationship between the number of vital sign abnormalities at discharge and the odds of post-discharge adverse events. The adjusted odds for death was 2.12 among those with one instability, 3.26 among those with two, and 3.80 among those with three or more instabilities at discharge, even though hospice patients were excluded from the analysis. A similar but not quite as strong pattern is noted for readmissions.