What if Hospitals Were Good for Health?

Reimagining the buildings and systems that have probably succeeded despite themselves

Image by Freepik

There are many challenges facing modern medicine, in fact as someone who “left the system” so to speak, it quite scares me. There’s the factors in the public discourse; funding, staffing and aging populations and these should not be belittled. That said, information on these is abundant.
For me, though, the concerns also include the mismatch between tool and task.

The current system was developed using a paradigm of disease care focussed on germ theory; a single problem has occurred with a single cause and a single solution. Think: bacterial pneumonia, requiring antibiotics (this is overly simplistic because as one of the fathers of modern medicine William Osler famously said; “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has” - but I digress and you get the point). Another example may be: broken bone, requiring a cast or surgery. Increasingly, the burden of disease is shifting away from these though. They are still present, but more and more chronic disease is at least a contributing factor (if not the presenting issue). Yes, some of this burden, perhaps the majority, will be seen outside of the hospital per se or not in an inpatient setting, but the point remains. The task is increasingly changing whilst the tool becomes less suited to it as a result.

Food

Until recently, I had never seen hospital food that REMOTELY resembled anything anyone would call “healthy”. This recent experience has restored my view that there’s a chance for hospital based nutrition. That said this was probably the exception rather than some semblance of the future.

What hasn’t changed is the reality that most food vendors on site at hospitals are nobody’s idea of healthy. This is unfortunately what family’s are eating, what they are taking patients to eat at times and what doctors are often eating. Yes, doctors “should know better” or something like that, but motivation and knowledge can only overcome environment for so long.

The Fix:

Partnerships with local producers and chefs, to serve nutritionally sound meals. Thankfully the range of inpatient needs will likely fit into an 80/20 distribution for complexity (20% of patients will complex dietary needs) but the majority will require high enough protein (healing is protein intensive) and high enough in vegetables. (fibre to help prevent constipation from inactivity & medication and micronutrients to all help people who are healing). Yes there are a subset of people with low appetites or who need higher energy alternatives. Thankfully, the upside to our obesity epidemic is that society is showing us how to easily increase energy intake: drink calories. It’s foreseeable (again, these needs are rarely outliers) that many people have similar needs and something like fruit and protein smoothies are scalable to a degree.

Light

Most hospitals are fluorescently lit quasi-jails. The benefits of natural light (let’s ignore fresh air for now - that’s it’s own article) whilst seemingly small are huge - especially when you’ve worked in a hospital. One example is “sundowning”, one of the toughest, most confronting and saddest parts of working in wards with the elderly. The fluorescent (blue) light, is quite arousing and wakening - which is helpful to night staff trying to stay awake and day staff, but an be an issue when people are having problems sleeping.

The Fix

Often lights are minimised or turned off during the night, but better circadian lighting is infinitely possible, as is a better emphasis on natural light (though I will concede both are big asks for current hospitals as opposed to new ones).

Sleep

Thankfully the world has woken up (you’re welcome) to the importance of sleep. Unfortunately this is not something we allow most patients to do much off - alarms are beeping, people are bustling about and things like blood pressure are being taken. In my time in the USA I even saw bloods being drawn in the early hours of the morning so it was ready for a 6am ward round - a sure fire way to make sure someone isn’t sleeping.

The Fix

Again, I live in the real world - I concede some of this is unavoidable and even necessary. The very unwell or post operative patients need regular observation at the cost of sleep, their acute risk outweighs the chronic problem of lack of sleep. But there are surely better ways to do things more generally (HELLLO wearables). Using medical grade sensors we can surely achieve some semblance of continuous tracking (which would be more useful than regular spot checks anyway) and it’s likely that it would be less invasive too. Continuous monitoring of: heart rate, glucose, blood pressure, respiratory rate, heart rate variability and temperature already exists on the consumer market, we could (read should) bring this across to medical care easily. The knock on benefit of this is freeing up overloaded nursing staff.

Exercise

Hopefully the benefits of exercise are not foreign and the thought that they may extend to the unwell is not surprising. Despite this though, with each passing year, the medical fraternity continues to be surprised be the benefits of exercise in situations previously thought to be an issue.
What do I mean? Well the thought of standing up and starting to mobilize (aka walk) within a day of a hip replacement was once laughable and yet is now common place. Similarly the delay to start post heart attack exercise (phrased cardiac rehab but let’s call a spade a shovel) continues to decrease. There’s also been great research in the ICU, of all places, where the sickest patients reside on passive movement and it’s benefits to rehabilitation post ICU stay.

These positive steps aside, most patients still spend north of 22 hours a day in bed. Again, if a patient is truly unwell, this could well be appropriate but for a majority of patients they’d see significant benefits to moving more. Given significant burden of healthcare associated pathology (the CDC cites a rate of 1/31 patients getting an hospital associated infection) we should be doing all in our power to prevent these situations. Hospital associated infections can at times be in part a result of inactivity and don’t include other healthcare related problems like pressure ulcers some of which may also be avoided through more exercise or less sedentary time. To illustrate the point, a surgeon I know who trained in South Africa told some colleagues a story of his time there. In short given the lack of resources (read beds) patients had to share beds, rotating through. One of the things they did, or were made to do, between shifts in bed; ride an exercise bike. Sure, great, so what? Well their recovery was significantly quicker as a result!

The Fix

This will dovetail well with some of the rest of this article on humanising and dressing patients below, but getting people up and moving would help greatly on numerous fronts including patients generally feeling better. Wards and rooms could have recumbent bike type of setups that allow patients to have the pedals rolled up to chairs in their room to pedal and/or arm cycling ergometers set up similarly. As they progress there’s the potential to have actual bikes available too. Physiotherapists already have rehab equipment and this could be expanded for a resistance training type set up in rooms using the tubing already used.
The big requirement would be one of mindset and approach change from “who needs to do exercise for rehab” and “let’s tell them what they can’t do” to “what can they be doing to move as much as possible and recover as a result”.

Attire and Humanising

I will admit this idea came to me from a senior of mine in the hospital but I can’t remember when or where unfortunately. It is one of those ideas that’s like looking for your glasses only to be wearing them: impossible to see without someone else mentioning it, but aftewards that the most obvious thing in the world.

Wearing a hospital gown and lying in bed dehumanises patients to a degree and definitely encourages them ‘playing the role’ of sick. This isn’t a criticism or suggestion that they aren’t sick, but getting up, showered and changed makes a world of difference to people - as does getting out of bed. In case of disagreement; spend next Sunday in your pyjamas in bed all day and comment below about how you felt.

The Fix

Change the default. As mentioned above in the exercise section, the standard belief is patients will spend the majority of their day in their gown and in bed. Again, I live in the real world and have worked in hospitals, this exists for a reason, but we could be more encouraging in facilitation of the opposite. Getting people out of bed, doing some movement, perhaps putting on normal clothes. Yes this is not for everyone, in fact it may only be a small portion who do all of it, for a small period of time whilst in hospital, but if we adjust our default expectations and work to facilitate more of this we may be surprised by the results.
I recently read this and was pleased to see other people thinking laterally in the situation.

Many of the potential solutions above actually address multiple factors, for instance more exercise will mean better sleep, as will better nutrition. They also amplify each other meaning the benefit of all together is greater than the sum of the parts.

What of the Staff?

Let’s be very clear, patient outcomes track with quality of care which is impacted by a variety of factors. Attracting quality staff to the organisation (and healthcare professions in general), happiness and health of staff amongst other things. Like any industry there is a spectrum of all of these factors, but unlike many industries, staff are required at all times, so some staff inevitably have to work shifts they don’t want or like (and are remunerated appropriately for this either financially or it being required for their training etc). Similarly, unlike most industries, decisions are in fact life or death and mistakes can be of significant consequence so ensuring decision making is optimised and staff make fewer mistakes should be at the forefront of everyone’s minds.

Enter the pillars of health and performance:

• Sleep

• Exercise

• Nutrition

• Stress management

• Community

Some of these are much harder to address for organisations than others (for example community). Others, however, are relatively easy to at least make some inroads into. Staff should be treated like high performance individuals (think executives or sports people), with the above being key focusses of their employers.

The Fix

Exercise - onsite gyms (that could be used by patients too) could be free for staff to use. This is something I experienced in my time in the USA, and whilst the gym was rudimental and small - it was well attended by staff. Those who attended it (myself included) certainly had a bit of a feeling of community too.

Nutrition - Healthy options need to be available and not significantly more expensive than less healthy options. Despite my preferences and biases we won’t be as naive as to say these things should be provided or subsidised (that said in a world where medical staff are harder to come by this might help). Similarly we live in the real world, so banning or further taxing the unhealthy food isn’t what we will suggest.

The above two factors, would work in concerto and amplify each other but also other factors like improving sleep and stress management. Likewise the hope would be that these made the healthcare profession more attractive (at a time it’s never been less attractive). This too dovetails into the earlier portion of the article focussing on patient’s health, improving that through better healthcare practitioner health.

I will concede some of the above is a big ask for an archaic system which is very reluctant to change (an article for another day perhaps), but I am hoping this article serves as a bit of lesson on what not to do.

Now for the part you can use more specifically.

What Can you Do?

Don’t worry there is no link to any petitions, or templates to write to your local member of parliament. The hope is that discourse like this can help us change the way way we operate in society more broadly.

For you specifically though, help your loved ones and yourself to do some of the above when/if in hospital.

Get up, get dressed, get moving and get outside if possible (and/or get sunlight) .

Bring food if hospital food isn’t doing the job on the protein and fibre front.