A deeper look at inpatients with blindness

Hospital patients who have severe vision impairment or blindness may have worse clinical outcomes, a study found.

Researchers looked at the National Inpatient Sample to compare rates of in-hospital mortality, odds of being discharged home, length of stay, and total hospital charges among more than 30 million patients hospitalized in 2017, of whom 37,200 had severe vision impairment or blindness in both eyes.

They found that this patient population had significantly higher in-hospital mortality (3.9% vs. 2.2%) and lower odds of being discharged home (adjusted odds ratio, 0.54) compared to those without vision issues, according to results published in June 2021 by BMC Ophthalmology. Hospital charges were not significantly different between groups, but length of stay was about half a day longer for patients who had severe vision impairment or blindness.

ACP Hospitalist recently discussed the study results with lead author Ché M. Harris, MD, FACP, a hospitalist and an assistant professor of medicine at Johns Hopkins University School of Medicine in Baltimore.

Q: What led you to study this issue?

A: Over the years, I've noticed more patients coming into the hospital who have some type of visual impairment or are blind. Working with [study coauthor Scott M. Wright, MD], we wanted to see if this was something that was not just limited to our hospital but was on a broader level. … We could see from the literature that patients with blindness in other countries had higher mortality, but we couldn't find anything that had been done in the U.S. as far as looking at mortality in the hospital for this patient population. Also, given that millions of Americans are either visually impaired or blind and the incidence is on the uprise, we are pretty confident that hospitalists will encounter more and more patients with this condition.

Q: What was your reaction to the results?

A: We weren't surprised about the [increased] mortality and length of stay. It's a little disappointing because the World Health Organization did set forth some initiatives to increase awareness in health care settings for providers since those studies in other countries have come out.

Q: What are some potential explanations for the worse outcomes in hospitalized patients with blindness or severe visual impairment?

A: Because it's an observational study, we really can't say exactly why. … We're not sure if maybe these patients are presenting a little later, when something's going on, in the outpatient setting. Maybe they're presenting to us a bit sicker, so there may be delays in presentation when they come in. We're not sure whether or not things are taking place in the hospital like falls or delirium. Are nosocomial infections occurring, or are … these readmissions for maybe some medication errors or something that wasn't clear on the discharge? There may be challenges with the discharge instructions and following that. Or it could be a combination of these things. I'm not sure what the specific driver is, but I think definitely we need more studies to work on trying to determine etiology.

Q: How could inpatient care be improved for this population?

A: I think some type of screening … maybe could be initiated early with the nursing staff to help increase our detection of these patients, and staff education to help increase understanding and awareness. There's a [2015] study in the Journal of Hospital Medicine about screening patients for blindness, and I think that's a great start for capturing these patients as early as possible.

For those patients who come in [already diagnosed] with vision impairment or blindness, I think communication with these patients, making sure that we're addressing their needs, making sure medication reconciliations are accurate, doing things to prevent injury and falls in the hospital [and] things like delirium that could worsen the inpatient outcome as far as mortality. I think we have to work on planning in advance as far as disposition, as far as making sure they have resources or helping them with resources on discharge to help get them home.

Q: What can individual hospitalists do to optimize care for this population?

A: When you have a patient who has vision impairment or blindness, I think one of the first things you have to think about as a hospitalist is that this patient is at risk for higher mortality and longer length of stay during this hospitalization. I think they have to think about that and take a step back to see what they can do as far as making sure that they address anything that they can see in that patient's room as far as any fall risk or injury potential. Review the medications—is there anything that could potentiate delirium during the hospital course? Planning in advance with the social workers to address any social barriers on discharge, making sure that they communicate with the patient to make sure all needs are addressed, working with the nursing staff to make sure the patient's oriented to their surroundings in the room to make sure they can reduce potential falls, making sure that items are close by, such as walking devices. Those are some things that an individual hospitalist can do.