Michael Montalto

Hospital at Home

Although the acute hospital is the standard venue for treating acute serious illness, it is often a difficult environment for older adults who are highly susceptible to functional decline and other iatrogenic consequences of hospital care. Hospital care is also expensive. Providing acute hospital-level care at home, in lieu of usual institutional care, is viable. As an emerging service model, the definition of hospital at home (HaH) remains unsettled. Data favor HaH models that provide substantial physician inputs and are geared toward substituting for hospital care, provide service that is highly satisfying to patients and their caregivers, are associated with less iatrogenic complications, and are less expensive. Dissemination of HaH in integrated delivery systems is feasible. Widespread dissemination of HaH in the United States will require payment reform that acknowledges the role of HaH in the health care system.

Evaluation of a Mobile X-Ray Service for Elderly Residents of Residential Aged Care Facilities

OBJECTIVE The Royal Melbourne Hospital established a mobile X-ray service (MXS) in 2013. The goal of the MXS is to address the radiology needs of frail, elderly or demented residents of residential aged care facilities (RACFs) who would otherwise require transportation to attend for X-ray. The present study describes the activity of the MXS, and the impact of the MXS on emergency department (ED) attendances by residents of RACFs. METHODS The study is a descriptive study and uses a before-and-after cohort approach. Activity for the first year of operation was collected and described. At the end of the first year of operation, the top 30 RACF users of the MXS were identified. The hospital Department of Radiology database was examined to find all plain X-rays performed on any patient presenting from the same 30 RACFs for the 1 year before commencement of the MXS (1 July 2012-30 June 2013) and for the 1 year period after the commencement of the MXS (1 July 2013-30 June 2014). Attendances were compared. RESULTS The MXS delivered 1532 service attendances to 109 different RACFs. The mean age of patients receiving MXS services was 86 years (range 16-107 years). In all, 1124 services (73.4%) were delivered to patients in high-care RACFs. Most patients (n = 634; 41.4%) were bed or wheelchair bound, followed by those who required assistance to ambulate (n = 457; 29.8%). The most common X-ray examinations performed were chest, hip and pelvis, spine and abdomen. There were 919 service attendances to the top 30 RACFs using the MXS (60.0% of all attendances). There was an 11.5% reduction in ED presentations requiring plain X-ray in the year following the commencement of the MXS (95% confidence interval 0.62-3.98; P = 0.019). CONCLUSION The present study suggests a reduction in hospital ED attendances for high users of the MXS. This has benefits for hospitals, patients and nursing homes. It also allows the extension of other programs designed to treat patients in their RACFs. Special rebates for home-based radiology service provision should be considered.

Hospital in the home: a lot's in a name.

o he int T measure the effectiveness of innovations in alth care, it is critically important to define the ervention studied. Unfortunately, this step is often lacking in health services research: definitions are often inadequate for reproducibility, and outcomes attributed to the intervention are consequently difficult to adjust for other variables. Meta-analysis can become messy. Defining a health service clearly can be especially difficult when dealing with a service whose properties are in dispute or evolving. “Hospital in the home” (HITH) is an example of such a service. HITH is the delivery of acute hospital services to patients at home: without the HITH service, the patient would require usual hospital admission. It has been nearly 20 years since the concept first appeared in the pages of the Journal, and there has been enormous progress in that time.1,2 There has also been confusing heterogeneity in the definition and program structure of HITH — despite robust argument around the globe, it is still not settled.3 HITH has been considered as everything from high-technology acute hospital medicine through to outpatient therapy and postdischarge community care. Some who baulk at the financial, organisational and cultural investment required to establish a fully-fledged HITH service are still keen to leverage the HITH label to deliver an altogether different service. However, in a meta-analysis of HITH in this issue of the Journal, Caplan and colleagues follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and accept only randomised controlled trials for inclusion.4 On re-examining this body of work, they concentrate on research where HITH care involves a substitution for part or all of the episode of care in hospital: substituting for at least 7 days in hospital or HITH care that replaces at least 25% of control admission duration. They hypothesise that by excluding research that does not meet this arbitrary standard, previously equivalent or negative meta-outcomes might change. Indeed, this is the case, and this is a welcome finding. While the goal of clinical equivalence should be enough, they show that HITH care reduces mortality and readmissions by about 20% and is more acceptable and more efficient.4 Some issues need to be considered in this analysis. Only four studies were excluded on the grounds of not meeting one of these studies was on. Many of the included completely describe their many describe non-acute we personally would no es such as mortality and ; in most cases, they refer nly. Improving the impact of future HITH meta-analysis requires improving the standards of individual HITH studies. Rapid technology change, humble research resources, poor definitions, patient and hospital unwillingness to be randomly assigned to non-HITH arms, and the intricacies of negotiating HITH access have been mountainous barriers toward a rational scientific examination of HITH. It has been argued that the randomised trial design is impoverished because it tries to reduce complex health service intervention (like HITH) into reproducible bite-sized nuggets where the context of the surrounding health care delivery environment is adjusted away by trial design.5 Hospital treatment is, and always has been, the outcome of a complex array of decisions regarding access, safety, technology, expertise, mercy, patient acceptance and reimbursement. In another article in this issue, Sarode and colleagues offer a poignant and illustrative case report.6 While they do not identify it, the intervention they describe meets our definition of HITH: they took intensive care technology and expertise home with a patient who would have otherwise remained in hospital. The hospital bore the responsibility and costs. Direct affiliated hospital medical care was provided, adapted to fit the context, and protocols that usually govern this situation were respected. The benefits and anxieties they describe are common to HITH. HITH offers a clinical and financial structure for delivering innovative care in this situation, and many similar clinical situations that occur in hospitals. The principles of applying the care described by Sarode et al are very similar to the principles of applying care in other situations in which HITH is regularly involved, such as: treating patients with endocarditis or end-stage heart failure; caring for selected patients who present to the emergency department with pulmonary emboli; caring for older patients with aspiration pneumonia and hypernatraemia in residential care; administering intravenous antibiotics, antivirals and antifungals for communityand hospital-acquired (sensitive and multiresistant) infections; and giving blood or intravenous fluid. These interventions have all been described in interesting and innovative case reports and descriptive outcome studies, and many have fallen into routine high-quality HITH practice — generally before the availablility of, or in the absence of, the highest grades of evidence. HITH research could be significantly advanced by establishing an international expert consensus statement to settle the definition of HITH. Reimbursement aids this goal. In Victoria, reimbursement itself has driven a sharper focus on the definition and inputs of HITH.7

Temperature profiles of antibiotic-containing elastomeric infusion devices used by ambulatory care patients

Purpose The temperature profiles of antibiotic‐containing elastomeric infusion devices used by ambulatory care patients under various environmental conditions were evaluated. Methods A prospective, descriptive survey of temperature exposure was conducted in 4 publically funded hospitals. Over a 12‐month period, electronic temperature‐recording devices were attached to the antibiotic infusion devices (infusers) of prospectively randomized hospital‐in‐the‐home (HITH) participants. Temperatures were recorded immediately after infuser connection and every 5 minutes thereafter for 24 hours. A structured data collection form was used to collect information on basic clinical and demographic characteristics and aspects of daily living (i.e., how and where the infuser was carried during the day, times the participant went to and arose from bed, location of the infuser while sleeping, and dates and times the infuser was connected and disconnected). Results A total of 115 patients successfully completed the study (17–91 years old, 55% males). A total of 31,298 temperature readings were collected. The storage location of the infuser did not influence daytime readings. However, the overnight storage location did have a significant impact on the temperatures recorded overnight. The mean temperatures of infusers stored on the bed or on the body overnight were significantly higher than those for infusers stored away from the bed. Diurnal and seasonal influences were also detected. Significantly warmer temperatures were recorded in afternoons and evenings and during the summer months. Conclusion Antibiotics administered to HITH patients via continuous infusion were frequently exposed to temperatures in excess of 25 °C. Specific patient behaviors and seasonal and chronological factors influenced temperatures. The findings challenge the validity of current fixed‐temperature models for testing stability, which do not reflect conditions found in clinical practice.