Medically-managed Hospital in the Home: 7 year study of mortality and unplanned interruption

Abstract

Background. Hospital in the Home (HIH) research is characterised by small samples in new programs. We sought to examine a large number of consecutive HIH admissions over many years in an established, medically-managed HIH service in to determine whether: (1) HIH is a safe and effective method of delivering acute hospital care, under usual operating conditions in an established unit; and (2) what patient, condition and treatment variables contribute to a greater risk of failure.

Method. A survey of all patients admitted to a medically-managed HIH unit from 2000–2007.

Results. A total of 3423 admissions to HIH were examined. Of these 2207 (64.5%) were admitted directly into the HIH from Emergency Department or rooms, with the remainder admitted from hospital wards. A total of 26 653 HIH bed days were delivered, with a mean of 9.3 nursing visits and 4.1 medical visits per admission. A total of 143 patients (4.2%) required an interruption via an unplanned return to hospital; 106 (3.1%) did not subsequently return to HIH. The commonest reasons for unplanned returns to hospital were: no clinical improvement; cardiac conditions; fever; breathlessness and pain. Patients over the age of 50, and those receiving intravenous antibiotic therapy, were more likely to require a return to hospital. Two patients died unexpectedly while in HIH, and a further three patients died unexpectedly after their unplanned return to hospital. This is a total unexpected mortality rate of 0.15%.

Conclusion. This sample of HIH patients is five times the number of HIH patients ever enrolled in randomised trials studies of this area. Further, outcomes were achieved in ‘ordinary’ working conditions over a long time period. Care was completed without interruption (return to hospital) in 95.8% of all episodes. Interruption was associated with patients referred from inpatient wards, older patients, and patients who were treated with intravenous antibiotics. Patients referred from Emergency Departments experienced fewer interruptions. Nursing home residents were no more likely to require an interruption to their HIH care.

What is known about the topic? Hospital in the Home is the delivery of acute hospital services to patients at home. There is no consensus on the best model of HIH. Studies of HIH have small sample sizes, so support for HIH is often qualified.

What does this paper add? This paper describes activity and outcomes for 3423 consecutive patients admitted into a medically-managed HIH over 7 years. This represents an extensive long-term survey of HIH patient care outcomes.

What are the implications for practitioners? Medically-managed HIH is able to deliver acute hospital care with low rates of unexpected mortality and unplanned returns to hospital. Trials using low frequency events such as mortality and delirium as outcomes will require very large samples, and such large trials are unlikely to occur. The impact of medically-managed HIH on access to acute hospital services for certain diagnostic groups could be significant and deserves further expansion. The concept of hospitalisation can be refined to include HIH.