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Bryant PA, Lawrence J, Boyce S, Simpson CM, Sinclair G, Chong C, Lewis P, Lee S, Hughes R, Dalton S, Lacey C, Nisbet LC, Smith TE, Chapman S, Lakshminarayanan S, Hurd K, Smith K, Savill B, Ibrahim LF. Hospital bed replacement for acute care of children at home during the COVID-19 pandemic through a Hospital-in-the-Home programme. Arch Dis Child 2023:archdischild-2022-325004. [PMID: 36828574 DOI: 10.1136/archdischild-2022-325004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/08/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVES During the COVID-19 pandemic, we expanded our Hospital-in-the-Home (HITH) programme to increase capacity and manage COVID-19-positive children. We aimed to assess impact on overall HITH activity and COVID-19-positive outcomes. DESIGN Prospective comparative cohort study. SETTING The largest paediatric HITH in Australasia, at The Royal Children's Hospital Melbourne. PATIENTS Children 0-18 years admitted to HITH during the pandemic. INTERVENTION We developed a COVID-19 responsive service, and a guideline for COVID-19-positive patients. We compared overall activity prior to and during the pandemic, and COVID-19-positive admissions with different variants. MAIN OUTCOMES We compared outcomes for all HITH patients before and during the pandemic, and for COVID-19-positive patients admitted first to hospital versus directly to HITH. RESULTS HITH managed 7319 patients from March 2020 to March 2022, a 21% increase to previously, with a 132% telehealth increase. 421 COVID-19-positive patients (3 days-18.9 years) were admitted to HITH, predominantly high risk (63%) or moderately unwell (33%). Rates of childhood infection in Victoria, with proportion admitted to HITH were: original/alpha variant-3/100 000/month, 0.7%; delta-92/100 000/month, 0.8%; omicron-593/100 000/month, 0.3%. Eligible parents of only 29 of 71 (41%) high-risk children were vaccinated. COVID-19-positive children admitted directly to HITH were less likely to receive COVID-19-specific treatment than those admitted to hospital first (14 of 113 (12%) vs 33 of 46 (72%), p<0.001), reflecting more severe respiratory, but not other features in inpatients. 15 of 159 (10%) were readmitted to hospital, but none deteriorated rapidly. CONCLUSIONS COVID-19-positive children at high risk or with moderate symptoms can be managed safely via HITH at home, the ideal place for children during the pandemic.
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Affiliation(s)
- Penelope A Bryant
- Infectious Diseases, The Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia .,Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia.,Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Joanna Lawrence
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia.,Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,School of Population Health, University of New South Wales, Kensington, NSW 2033, Australia
| | - Suzanne Boyce
- Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,General Medicine, The Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia
| | - Catherine M Simpson
- Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Centre for Community Child Health, The Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - Gemma Sinclair
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Candie Chong
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Phillipa Lewis
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Stephanie Lee
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Rebecca Hughes
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Samuel Dalton
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Cara Lacey
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Lauren C Nisbet
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Tessa E Smith
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Sarah Chapman
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Swathi Lakshminarayanan
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Kahlia Hurd
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Katie Smith
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Brenda Savill
- Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Laila F Ibrahim
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia.,Murdoch Children's Research Institute, Parkville, VIC 3052, Australia.,Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,General Medicine, The Royal Children's Hospital Melbourne, Parkville, VIC 3052, Australia
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Cabrera López IM, Agúndez Reigosa B, Adrados García S, Villalobos Pinto E, Cano Fernández J, Jiménez García R. Home-hospital care for children with acute illnesses: A 2-year follow-up study. J Paediatr Child Health 2022; 58:969-977. [PMID: 34967977 DOI: 10.1111/jpc.15870] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/21/2021] [Accepted: 12/05/2021] [Indexed: 11/29/2022]
Abstract
AIM Procedures normally performed in the hospital setting are increasingly delivered as part of hospital at home (HAH) programmes. The aim of this study is to describe the procedures and diseases treated during the first 2 years of a new paediatric HAH programme. METHODS This is a retrospective, observational study conducted in the HAH programme of Niño Jesús Children's Hospital (Spain). We included demographic data, diagnosis and procedures delivered to patients admitted to the HAH programme from November 2018 to November 2020. RESULTS There were 935 admissions of 833 patients. The median age was 5 years (interquartile range 2.3-9.5). Seventy-five percent of patients were previously healthy. The most frequent illnesses were acute infections (37%) (e.g. complicated appendicitis and ENT, genitourinary, skin and soft tissue infections) and acute respiratory diseases (17.3%) (e.g. asthma, bronchiolitis and pneumonia). Thirty-six percent of admissions underwent nocturnal polysomnography. The median length of stay was 4 days (SD 4.9 days). Eight percent of the episodes studied required care in the emergency department due to condition worsening (55.3%) and problems with devices (36.1%). Hospital readmission was required in 5.6% of cases, 42.4% of which later resumed care in the HAH. The estimated daily cost of HAH is 330.65 euros, while the hospital per-day costs of polysomnography, asthma and endovenous therapy are 1899.24, 1402.5, and 976.26 euros. Ninety percent of families reported a high level of satisfaction. CONCLUSIONS Paediatric HAH programmes are a feasible, cost-effective alternative to hospital care. Further studies should compare the evolution of patients treated in the traditional hospital setting and those in HAH.
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Affiliation(s)
- Isabel M Cabrera López
- Pediatric Hospital at Home Department, Niño Jesús University Children´s Hospital, Menéndez Pelayo, Madrid, Spain
| | - Beatriz Agúndez Reigosa
- Pediatric Hospital at Home Department, Niño Jesús University Children´s Hospital, Menéndez Pelayo, Madrid, Spain
| | - Sandra Adrados García
- Pediatric Hospital at Home Department, Niño Jesús University Children´s Hospital, Menéndez Pelayo, Madrid, Spain
| | - Enrique Villalobos Pinto
- General Pediatrics Department, Niño Jesús University Children´s Hospital, Menéndez Pelayo, Madrid, Spain
| | - Julia Cano Fernández
- General Pediatrics Department, Niño Jesús University Children´s Hospital, Menéndez Pelayo, Madrid, Spain
| | - Raquel Jiménez García
- Pediatric Hospital at Home Department, Niño Jesús University Children´s Hospital, Menéndez Pelayo, Madrid, Spain.,General Pediatrics Department, Niño Jesús University Children´s Hospital, Menéndez Pelayo, Madrid, Spain
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Sonis JD, Berlyand Y, Yun BJ, Aaronson EL, Raja AS, Brown DFM, Pestka SB, White BA. Patient Experiences With Transfer for Community Hospital Inpatient Admission From an Academic Emergency Department. J Patient Exp 2021; 7:946-950. [PMID: 33457526 PMCID: PMC7786737 DOI: 10.1177/2374373520949168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Emergency department (ED) crowding continues to be a major challenge and has important ramifications for patient care quality. One strategy to decrease ED crowding has been to implement alternative pathways to traditional hospital admission. Through a survey-based retrospective cohort study, we aimed to assess the patient experience for those who agreed to transfer and admission to an affiliated community hospital from a large, academic center’s ED. In all, 85% of participants rated their overall experience as either great or good, 92% did not find it hard to make the decision to be transferred, and 95% found the transfer process itself to be easy.
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Affiliation(s)
- Jonathan D Sonis
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Yosef Berlyand
- Harvard Medical School, Boston, MA, USA.,Harvard-Affiliated Emergency Medicine Residency, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, MA, USA
| | - Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - David F M Brown
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Steven B Pestka
- Division of Adult Inpatient Medicine, Department of Medicine, Newton-Wellesley Hospital, Newton, MA, USA
| | - Benjamin A White
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Bryant PA. Ethical dilemmas in providing acute medical care at home for children: a survey of health professionals. BMJ Paediatr Open 2020; 4:e000590. [PMID: 32099907 PMCID: PMC7015051 DOI: 10.1136/bmjpo-2019-000590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/18/2020] [Accepted: 01/21/2020] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE Acute care at home is increasing. We aimed to determine the views of healthcare professionals on the ethics of providing home care and compare the impact of situational changes on their opinions. DESIGN An analysis of opinions of home healthcare professionals. SETTING The Australasian Hospital-in-the-Home Annual Conference, November 2017. PARTICIPANTS Eighty physicians, nurses and allied health staff who provide acute care for children and adults at home. METHODS Clinical scenarios were presented about a 14 years old receiving intravenous antibiotics at home via an established home care pathway, and participants were asked to vote manually on whether providing home care was ethical. MAIN OUTCOMES The proportions of healthcare professionals who believed that provision of home care was ethical in different situations. RESULTS For each question the response rate ranged from 71% to 100%. While the provision of acute home care was deemed ethical by the majority (77/80, 96%), this decreased when other factors were involved such as domestic violence (37/63 (59%) OR 0.06, 95% CI 0.02 to 0.20, p<0.001) and parental reluctance (28/67 (42%) OR 0.02, 95% CI 0.008 to 0.09, p<0.001). The age of consent affected the proportion who considered home care ethical against parental wishes: 16 years (48/58, 83%) versus 14 years (33/53, 52%) OR 4.4, 95% CI 1.9 to 10.1, p<0.001. The lowest proportion to consider home care ethical (16%) was when home care was deemed less than hospital care. CONCLUSIONS Home healthcare providers are supportive of the ethics of providing acute care at home for children, although differ among themselves with situational complexities. Applying the tenets of medical ethics (autonomy, non-maleficence, beneficence and justice) can provide insights into the factors that may influence opinions.
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Affiliation(s)
- Penelope A Bryant
- Hospital-in-the-Home Department & Infectious Diseases Unit, General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Infection, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Abstract
PURPOSE OF REVIEW Over recent years, there has been a marked increase in the number of centres delivering paediatric outpatient parenteral antimicrobial therapy (pOPAT). Various factors have fuelled this drive, including the significant economic pressures faced by high-income countries to contain the cost of healthcare, resulting in a significant reduction of in-patient beds over the past 20 years. It is essential that pOPAT services have formal clinical governance structures in place to ensure the safe and effective management of children being ambulated on intravenous antibiotics. They also require oversight of antimicrobial decisions by a medically qualified infection specialist to ensure that the principles of antimicrobial stewardship are adhered to. This review aims to provide an evidence-based framework for delivering pOPAT services. RECENT FINDINGS There is increasing data supporting the implementation of admission avoidance strategies for children with cellulitis and pyelonephritis. In addition, recent data supports the management of a subset of children with febrile neutropenia within pOPAT services. Above all, there is a clear recognition that embedding antimicrobial stewardship within pOPAT services reduces duration of intravenous antibiotics (IVAbs) and improves patient management. pOPAT services are safe, cost-effective and associated with high levels of parent/patient satisfaction. Further research is required to develop risk prediction models for children being considered for pOPAT. Further data about the use of elastomeric devices in children and the acceptability of parental administration of IVAbs are also required.
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Affiliation(s)
- Sanjay Patel
- Department of Paediatric Infectious Diseases & Immunology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Mailpoint 43, Tremona Road, Southampton, SO16 6YD, UK. .,NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK. .,NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Helen Green
- Department of Paediatric Infectious Diseases & Immunology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Mailpoint 43, Tremona Road, Southampton, SO16 6YD, UK
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Abstract
BACKGROUND This article reports on a systematic review conducted to critique safety, quality, length of stay, and implementation factors regarding criteria-led discharge. PURPOSE Improving patient flow and timely bed capacity is a global issue. Criteria-led discharge enables accelerated patient discharge in accordance with patient selection. METHODS A systematic review was conducted to identify literature on criteria-led discharge from 2007 to 2017. The quality of articles was appraised using a tool for disparate studies. Two reviewers extracted relevant data independently. RESULTS Fifteen studies were identified that showed no increase in patient readmission or complication rates with criteria-led discharge, demonstrating patient safety. The quality of the patient discharge was unremarkable. None of the studies showed an increase in length of stay. CONCLUSIONS The safety, quality, and length of stay for patients discharged through criteria-led discharge are inextricably linked to the process adopted for its implementation.
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Tenbensel T, Chalmers L, Jones P, Appleton-Dyer S, Walton L, Ameratunga S. New Zealand's emergency department target - did it reduce ED length of stay, and if so, how and when? BMC Health Serv Res 2017; 17:678. [PMID: 28950856 PMCID: PMC5615466 DOI: 10.1186/s12913-017-2617-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/13/2017] [Indexed: 11/10/2022] Open
Abstract
Background In 2009, the New Zealand government introduced a hospital emergency department (ED) target – 95% of patients seen, treated or discharged within 6 h - in order to alleviate crowding in public hospital EDs. While these targets were largely met by 2012, research suggests that such targets can be met without corresponding overall reductions in ED length-of-stay (LOS). Our research explores whether the NZ ED time target actually reduced ED LOS, and if so, how and when. Methods We adopted a mixed-methods approach with integration of data sources. After selecting four hospitals as case study sites, we collected all ED utilisation data for the period 2006 to 2012. ED LOS data was derived in two forms-reported ED LOS, and total ED LOS - which included time spent in short-stay units. This data was used to identify changes in the length of ED stay, and describe the timing of these changes to these indicators. Sixty-eight semi-structured interviews and two surveys of hospital clinicians and managers were conducted between 2011 and 2013. This data was then explored to identify factors that could account for ED LOS changes and their timing. Results Reported ED LOS reduced in all sites after the introduction of the target, and continued to reduce in 2011 and 2012. However, total ED LOS only decreased from 2008 to 2010, and did not reduce further in any hospital. Increased use of short-stay units largely accounted for these differences. Interview and survey data showed changes to improve patient flow were introduced in the early implementation period, whereas increased ED resources, better information systems to monitor target performance, and leadership and social marketing strategies mainly took throughout 2011 and 2012 when total ED LOS was not reducing. Conclusions While the ED target clearly stimulated improvements in patient flow, our analysis also questions the value of ED targets as a long term approach. Increased use of short-stay units suggests that the target became less effective in ‘standing for’ improved timeliness of hospital care in response to increasing acute demand. As such, the overall challenges in managing demand for acute and urgent care in New Zealand hospitals remain. Electronic supplementary material The online version of this article (10.1186/s12913-017-2617-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tim Tenbensel
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand.
| | - Linda Chalmers
- Nursing Development Unit, Auckland City Hospital, Private Bag 92024, Auckland, 1142, New Zealand
| | - Peter Jones
- Adult Emergency Department, Auckland City Hospital, Private Bag 92024, Auckland, 1142, New Zealand
| | - Sarah Appleton-Dyer
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand
| | - Lisa Walton
- Health Systems, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand
| | - Shanthi Ameratunga
- Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag, 92019, Auckland, 1142, New Zealand
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