Is Early Hospital Discharge Going Too Far?

Each year, nearly half a million North Americans undergo heart surgery - everything from heart bypasses to valve replacements. For some patients, a debilitating side effect threatens their recovery. That's the main conclusion of a study just published in the Canadian Medical Association Journal. To me, the study raises questions about the care heart patients receive in the days following surgery, especially the growing trend of sending patients home early following surgery.
Researchers from l'Université de Montréal studied nearly twelve hundred and fifty patients age eighteen and older who underwent heart surgery in four Canadian cities:  Montreal, Quebec City, Toronto and Halifax.  What they discovered is that a full two years following surgery, nearly one in ten patients suffered from pain in the chest.  Of those patients with persistent pain, sixty percent said it was mild but forty percent said the pain was severe or moderately severe.

I want to stress that the pain these patients feel was not caused by blocked coronary arteries. Instead, the pain may be coming from the ribs, the breast bone, the cartilage and the muscles that make up the front of the chest.

Whatever the cause, persistent pain makes it hard for patient to take part in cardiac rehabilitation programs that aid their recovery from open-heart surgery. Fearful that they're having another heart attack, many such patients go back to the ER again and again.  I see people like that all the time.  We order all kinds of blood tests, scans, treadmill tests and even angiograms which is squirting dye into the coronary arteries to see if there are any new blockages that need further bypasses.  All of these tests turn out to be normal.  

Even when we reassure these patients that their hearts are okay, they go away feeling worried that we've missed something.  Or, they get depressed because the pain affects their quality of life.

Surprisingly to me, younger patients were more likely than seniors to have persistent pain following surgery.  Perhaps it's because they tried to be more active than older patients in the days following surgery.  Women more than likely than men to have long-lasting pain.  Patients who had other forms of pre-existing chronic pain prior to surgery - things like back pain or arthritis or a condition called fibromyalgia - were also more likely to have persistent chest pain. 

Interestingly, patients who were more worried prior to surgery about their prospects for recovery were also more likely to have noticeable pain some two years later.

Although the authors didn't come right out and say it, I think they uncovered some disturbing links between pain following surgery and the quality of care that the patients received. Patients who had severe pain during the first week following surgery were more likely to have pain that persisted two years later. That was especially true for patients with pain so severe it interfered with the their ability to get out of bed and walk around the wards.  Not only that, but if the pain immediately following surgery was severe, then the pain the patient had two years later was likewise unbearable.  

In addition, the connection between patient anxiety and persistent pain bears on the care given by the hospital. The better the relief of pain, the less the anxiety, and the less likely the patient ends up with pain two years later.  

The researchers also found that early discharge from hospital following heart surgery was associated with severe persistent pain later on.  Early hospital discharge is a seemingly unstoppable trend that is increasingly associated with risks - as evidenced by rising hospital readmission rates.  

One can speculate that patients sent home early with moderate to severe pain were less likely to manage it well at home than had they remained in hospital.

What should be done about this problem? The authors of the study say more research needs to be done on how to prevent or at least minimize the pain. But they also concluded that two risk factors for pain two years following the operation -   patient anxiety prior to surgery and severe pain in the first few days following surgery - are treatable and perhaps even preventable.  Using medications as well as other treatments, health professionals like me can control both factors. I think the authors are saying that doctors and nurses have to do a much better of relieving pain in the days immediately following surgery.  

What they didn't say outright is that hospitals need to reconsider sending patients home too soon following the operation.  That's a major trend in hospitals that in this case - one that in this case may be doing more harm than good.

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