Dr John Mandrola

Disclosures

March 10, 2013

" I want to stay in the hospital as long as it takes. I want to make sure . . ."

You have heard that phrase more than once. Patients and families often worry about not staying in the hospital. They worry about not being monitored.

Of course there are times when they are right, but this logic assumes that the hospital is good place to get "well."

Is a hospital environment really that soothing?

Hospitals have been placed on alert. There will be no missing things. There will be safety. And we will document every last imperfection of the human body.

Hospitals monitor stuff. They alarm and beep, which then beckon nurses to the bedside. Monitors signal disease, and they warrant action: bright lights, probing questions (are you sure you were asleep?), and most worrisome, alarms lead to testing. Alarms and beeps imply illness, and in the case of many patients with arrhythmia, illness begets illness.

This is why I think Shelley Wood, managing editor of theheart.org, picked a great presentation to write about:

"Alarming" use of unnecessary ECG monitors, ubiquitous, possibly harmful .

In the PULSE study, researchers from Yale show what any hospital-based doctor or nurse knows: that we overexpose people to monitors, alarms, and perhaps even overtreatment in the hospital. Primary investigator Dr Marjorie Funk actually called this inpatient noise pollution a "cacophony," which is defined as "a harsh and discordant bunch of sounds." Perfect.

It's kind of old-fashioned, but isn't there something to the archaic ways of treating heart disease: peace and quiet?

Take the example of a typical (not high-risk) patient with atrial fibrillation: Many get walloped in the hospital. What I mean is this: rather than reassuring the patient with atrial fibrillation, placing them in a calm, peaceful environment, perhaps giving them a cautious dose of a beta-blocker, we admit them to rooms with bright lights and beeping monitors. Then we bolus them with IV medications—none of which have an evidence base supporting any meaningful change in outcomes.

Nobody gives peace a chance. In the hospital, action is the word.

There is a real danger in all that we do in the name of better safe than sorry. There are consequences to all this action.

Thank goodness there are sane minds in research that have the common sense to study common sense. We need to question this default to action. STEMI care doesn't generalize to all of medicine. More, and faster, and louder, is not necessarily better.

Although the PULSE study won't make big headlines, the narrative here is important. If you doubt less could be more, just look at day 1 of theheart.org's coverage of the American College of Cardiology meeting. We learned that intense glycemic control in diabetics ups the risk of CHF, while raising HDL with niacin isn't the same as improving health.

We mustn't forget that the human body has powerful healing properties. If we exercise it, feed it well, and give it adequate rest, we'd be surprised what it can do.

Good care does not always require an IV, or a pill, or even a monitor.

JMM

For a different take: ECG monitoring? The lack thereof--that's what's alarming!

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