How safe is hospital-in-the-home care?

Generation of Indicators to Assess Quality of Health Care in Hospital at Home Through e-Delphi

BACKGROUND AND OBJECTIVES

The quality of health care in hospital at home (HaH) has been measured in different countries using simple indicators and clinical results that only contribute to some dimensions of the quality of health care. We sought to generate indicators to comprehensively evaluate the quality of health care provided to HaH users through the e-Delphi technique.

METHODS

The e-Delphi technique was performed with the participation of 17 HaH experts. The methodological strategy applied in this study was divided into the following 3 phases: a preparatory phase; consultation phase; and consensus phase. Three rounds of consultations were conducted with experts. In round 1, they were asked to identify which aspects of HaH they believed should be evaluated using an indicator for each of the following 6 dimensions of health care quality: effectiveness; efficiency; timeliness; patient-centered care; equity; and safety. In round 2, they were asked to rate each indicator using a 5-point Likert-type scale with the following values: (1) Totally disagree; (2) Disagree; (3) Moderately agree; (4) Agree; and (5) Totally agree. The criteria for evaluating each indicator were as follows: (1) The indicator is a useful measure for assessing the quality of health care provided to HaH users. (2) The indicator is clearly and specifically written and does not require modification. (3) The indicator is essential and incorporates information that can be extracted from HaH program records. An indicator was considered approved if it received at least 65% approval from the expert panel for each evaluation criterion. In round 3, experts were asked to reassess their ratings, taking into account the opinions of the other experts. The reliability of this technique was ensured through credibility, reliability, and confirmability. We obtained ethical approval of the corresponding institutions and informed consent from the participating experts.

RESULTS

Nine unpublished and reliable indicators were generated. In addition, 13 indicators were incorporated that evaluate aspects previously analyzed by other authors and/or national and international institutions, which were adapted to be used in HaH. The total indicators generated (n = 22) represented all dimensions of the quality of health care: safety; opportunity; effectiveness; efficiency; equity; and patient-centered care.

CONCLUSIONS

The 22 indicators generated through the e-Delphi technique permit a comprehensive evaluation of the quality of health care provided to HaH users.

Risk assessment of failure during transitioning from in-centre to home haemodialysis

BACKGROUND

Introducing a de-novo home haemodialysis (HHD) program often raises safety concerns as errors could potentially lead to serious adverse events. Despite the complexity of performing haemodialysis at home without the supervision of healthcare staff, HHD has a good safety record. We aim to pre-emptively identify and reduce the risks to our new HHD program by risk assessment and using failure mode and effects analysis (FMEA) to identify potential defects in the design and planning of HHD.

METHODS

We performed a general risk assessment of failure during transitioning from in-centre to HHD with a failure mode and effects analysis focused on the highest areas of failure. We collaborated with key team members from a well-established HHD program and one HHD patient. Risk assessment was conducted separately and then through video conference meetings for joint deliberation. We listed all key processes, sub-processes, step and then identified failure mode by scoring based on risk priority numbers. Solutions were then designed to eliminate and mitigate risk.

RESULTS

Transitioning to HHD was found to have the highest risk of failure with 3 main processes and 34 steps. We identified a total of 59 areas with potential failures. The median and mean risk priority number (RPN) scores from failure mode effect analysis were 5 and 38, with the highest RPN related to vascular access at 256. As many failure modes with high RPN scores were related to vascular access, we focussed on FMEA by identifying the risk mitigation strategies and possible solutions in all 9 areas in access-related medical emergencies in a bundled- approach. We discussed, the risk reduction areas of setting up HHD and how to address incidents that occurred and those not preventable.

CONCLUSIONS

We developed a safety framework for a de-novo HHD program by performing FMEA in high-risk areas. The involvement of two teams with different clinical experience for HHD allowed us to successfully pre-emptively identify risks and develop solutions.

Pediatric Tele-Home Care Compared to Usual Care: Cost-Minimization Analysis

BACKGROUND

Although home hospitalization has been a well-known and widespread practice for some time in the adult population, it has not been the same case in the pediatric setting. Simultaneously, telemedicine tools are a facilitator of the change in the health care model, which is increasingly focused on home care. In a pioneering way in Spain, the in-home hospitalization program of the Hospital Sant Joan de Déu in Barcelona allows the child to be in their home environment at the time they are being monitored and clinically followed by the professionals. Besides being the preferred option for families, previous experience suggests that pediatric home hospitalization reduces costs, primarily thanks to savings on the structural cost of the stay.

OBJECTIVE

The aim of this study is to compare the average cost of a discharge by tele-home care with the usual care and to analyze the main drivers of the differential costs of both care models.

METHODS

A cost-minimization analysis is conducted under a hospital's perspective, based on observational data, and estimated retrospectively. A historical control group of similar patients in terms of clinical casuistry to children hospitalized at home was used for comparison.

RESULTS

A 24-hour stay at the hospital costs US $574.19, while the in-home hospitalization costs US $301.71 per day, representing a saving of almost half (48%) of the cost compared to usual care. The main saving drivers were the personnel costs (US $102.83/US $284.53, 35.5% of the total), intermediate noncare costs (US $6.09/US $284.53, 33.17%), and structural costs (US $55.16/US $284.53, 19.04%). Home hospitalization involves a total stay 27.61% longer, but at almost half the daily cost, and thus represents a saving of US $176.70 (9.01%) per 24-hour stay.

CONCLUSIONS

The cost analysis conducted under a hospital perspective shows that pediatric tele-home care is 9% cheaper compared to regular hospital care. These results motivate the most widespread implementation of the service from the point of view of economic efficiency, adding to previous experiences that suggest that it is also preferable from the perspective of user satisfaction.

A Home Hospitalisation Strategy for Patients with an Acute Episode of Heart Failure Using a Digital Health-Supported Platform: A Multicentre Feasibility Study - A Rationale and Study Design

BACKGROUND

Heart failure (HF) is a common cause of hospitalisation and mortality in elderly. The frequent rehospitalisations put a serious burden on patients, health-care budgets, and health-care capacity. Frequent hospital admissions are also associated with a substantial additional hazard for serious complications and reduced quality of life. The NWE-Chance project will explore the feasibility and scalability of providing home hospitalisation supported by a newly developed digital health-supported platform and daily visits of specialised nurses.

METHODS/DESIGN

Hundred patients with chronic HF will be recruited over a 1-year period. The digital health-supported home hospitalisation strategy will be tested in 3 hospitals with different experience in delivering home hospitalisation: Isala Zwolle, Maastricht UMC+, both in The Netherlands, and Jessa Hospital, Hasselt in Belgium. The home hospitalisation intervention will have a maximal duration of 14 days. Feasibility will be measured with acceptability, satisfaction, and usability questionnaires for patients, nurses, and physicians. Furthermore, safety and costs will be assessed for 30 days after the start of the home hospitalisation intervention.

DISCUSSION

The NWE-Chance project will be one of the first studies to examine the feasibility of a digital health-supported home hospitalisation platform for HF patients. It has the potential to augment current standard HF care and quality of life of HF patients and to innovate the standard HF care to potentially lower the hospitalisation-related complications, the burden of HF on health-care systems, and to potentially implement more patient-centred care strategies.

Clinic- and Hospital-Based Home Care, Outpatient Parenteral Antimicrobial Therapy (OPAT) and the Evolving Clinical Responsibilities of the Pharmacist

Clinic- and hospital-based home care describes models of care where services commonly associated with hospital inpatient care are provided at the patient's home or in an outpatient or community-based clinic. Hospital in the Home (HITH), also termed Hospital at Home (HaH) in parts of Europe and America, is a common and important example of this type of care. Other examples include infusion centers, skilled nursing facilities (particularly in the USA), self-administration models (including home infusion services) and administration through outpatient or community clinics. Different models of HITH care are used internationally and these encompass a wide range of services. Medication administration, particularly outpatient parenteral antimicrobial therapy (OPAT), is an important element in many of these models of care. There is a key role for pharmacists since the provision of medication is integral in this model of patient care outside the hospital setting. Data on the growing importance of HITH and OPAT as well as the administration of medications suited to clinic- and hospital-based home care, including subcutaneous and intramuscular injectables, immunoglobulins and other blood fractions, cancer chemotherapy, total parenteral nutrition, biologicals/biosimilars, vasopressors and enzymes, using differing service models, are described. The pharmacist's role is evolving from that involved primarily with dose preparation and supply of medications. Their clinical expertise in medication management ensures that they are an integral member and leader in these models of care. Their role ensures the safe and quality use of medicines, particularly across transitions of care, with the pharmacist taking on the roles of educator and consultant to patients and health professional colleagues. Activities such as antimicrobial stewardship and ongoing monitoring of patients and outcomes is fundamental to ensure quality patient outcomes in these settings.

Problem Solving by Telephone in Palliative Care: Use of a Predetermined Assessment Tool within a Program of Home Care Technology

In the Rotterdam Cancer Institute, nurses from the palliative care unit take care of accessibility outside office hours for patients transferred home with technical equipment for symptom control. The nurses use a predetermined assessment tool (PAT) for handling telephone calls. A retrospective evaluation on the registration forms used over the years 1997–1999 was performed to evaluate the telephone service. A total of 124 patients in need of technical support was transferred from the hospital during the study period: 52 in 1997, 33 in 1998, and 39 in 1999. Over the years, 157 calls were registered from 64 (52%) patients. In 1997, the majority of the calls (73%) came from the patient or the family. The frequency of calls from the general practitioner did not change, but calls from the district nurse increased from 12% in 1997 to 35% in 1998, and 48% in 1999. Professionals working in nursing homes have used the telephone service since 1998. The reasons for calling were pain (40%), symptoms other than pain (19%), technical problems (33%), general information and advice (6%), and logistic problems (2%). In 152 of the 157 telephone calls (97%), problems could be solved without admission. The mean time to answer a call was 16 minutes. The telephone service and the use of the PAT made it possible to solve 97% of problems without admission.

Safety and effectiveness of 'hospital in the home' and 'outpatient parenteral antimicrobial therapy' in different age groups: A systematic review of observational studies

OBJECTIVE

The aim of this study was .to systematically review the published literature of observational studies evaluating the safety and effectiveness of hospital in the home (HITH) and outpatient parenteral antimicrobial therapy (OPAT) in the general population, older people and children.

STUDY DESIGN

The review included retrospective studies and prospective studies performed on HITH and OPAT within different age groups. Only the studies that analysed the safety and effectiveness of HITH and OPAT were included for review.

DATA SOURCES

A literature search of electronic databases CINAHL, Web of Science, PubMed and SCOPUS from 1997 to 2016 was performed.

DATA SYNTHESIS

Forty-four studies met the inclusion criteria. Five studies were undertaken on HITH within the general population, 26 studies were undertaken on OPAT within the general population, 8 studies were on HITH and OPAT for older people and 5 studies were on OPAT with children. More than 88% of the studies reported a cure or treatment success rate of greater than 80%. Adverse events with drugs ranged from 0% to 30.2%; adverse events with vascular access devices ranged from 0% to 29%; readmission rate varied from 1% to 26%; mortality varied from 0% to 27.5%.

CONCLUSIONS

This review quantifies the rates of success and harm in real world practice, and demonstrates that while most patients experience treatment success, adverse events may be high in some groups. However, the methodologies used to measure these parameters were inconsistent and some demographic groups had only a small number of studies.

The treatment of nursing home-acquired pneumonia using a medically intensive Hospital in the Home service

OBJECTIVES

To compare the outcomes for patients with nursing home-acquired pneumonia (NHAP) treated completely in a Hospital in the Home (HITH) setting with those of patients treated in a traditional hospital ward.

DESIGN

Case-control study.

SETTING AND PARTICIPANTS

All patients admitted by the Royal Melbourne Hospital for treatment of NHAP from 1 July 2013 to 31 January 2014.

INTERVENTION

Admission to the Royal Melbourne Hospital HITH Unit within 48 hours of presentation.

MAIN OUTCOME MEASURES

Length of stay, in-hospital and 30-day mortality, hospital readmissions (30-day), complications and unplanned returns to hospital.

RESULTS

Sixty HITH patients and 54 hospital (control) patients were identified. Thirty-two patients (53%) were admitted directly to HITH without any hospital or emergency stay, 25 (42%) were referred directly from the emergency department. HITH patients were more likely to be male, older and dehydrated, and less likely to have an advanced care directive or to have had non-invasive ventilation. There were no significant differences in CURB-65 or CORB scores between the two patient groups; similar proportions were given intravenous fluids or supplemental oxygen. There were no adjusted differences in median length of stay between HITH and control patients (-1.00 days; 95% CI, -2.72 to 0.72; P = 0.252) or in overall mortality at 30 days (HITH v control patients: adjusted odds ratio [aOR], 1.97; 95% CI, 0.67-5.73). Inpatient mortality was lower for HITH patients (aOR, 0.19; 95% CI, 0.05-0.75) but unadjusted postdischarge 30-day mortality was higher (OR, 13.25; 95% CI 1.67-105.75). There were no differences between the two groups with regard to complications (falls and pressure wounds) and 30-day readmission rates (aOR, 1.59; 95% CI, 0.30-8.53).

CONCLUSIONS

This study suggests that HITH may be an effective and safe alternative to hospital treatment for residents of aged care facilities presenting with NHAP.

Specialist home-based nursing services for children with acute and chronic illnesses

BACKGROUND

Specialist paediatric home-based nursing services have been proposed as a cost-effective means of reducing distress resulting from hospital admissions, while enhancing primary care and reducing length of hospital stay. This review is an update of our original review, which was published in 2006.

OBJECTIVES

To evaluate specialist home-based nursing services for children with acute and chronic illnesses.

SEARCH METHODS

We searched the following databases in February 2012: the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2012 Issue 2, Ovid MEDLINE, EMBASE, PsycINFO, CINAHL and Sociological Abstracts. We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of children from birth to age 18 years with acute or chronic illnesses allocated to specialist home-based nursing services compared with conventional health care. Outcomes included utilisation of health care, physical and mental health, satisfaction, adverse health outcomes and costs.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data from the studies independently and resolved any discrepancies by recourse to a third author. Meta-analysis was not appropriate because of the clinical diversity of the studies and the lack of common outcome measures.

MAIN RESULTS

We screened 4226 titles to yield seven RCTs with a total of 840 participants. Participants, interventions and outcomes were diverse. No significant differences were reported in health outcomes; two studies reported a reduction in the hospital stay with no difference in the hospital readmission rates. Three studies reported a reduction in parental anxiety and improvement in child behaviours was reported in three studies. Overall increased parental satisfaction was reported in three studies. Also, better parental coping and family functioning was reported in one study. By contrast, one study each reported no impact on parental burden of care or on functional status of children. Home care was reported as more costly for service providers with substantial cost savings for the family in two studies, while one study revealed no significant cost benefits for the family.

AUTHORS' CONCLUSIONS

Current research does not provide supporting evidence for a reduction in access to hospital services or a reduction in hospital readmission rate for children with acute and chronic illnesses using specialist home-based nursing services; however, the only summary finding across a few studies was that there is a significant decrease in length of hospitalisation. The preliminary results show no adverse impact on physical health outcomes and a number of papers reported improved satisfaction with home-based care. Further trials are required, measuring health, satisfaction, service utilisation and long-term costs.

Good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults in the UK: a consensus statement

These good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) are an update to a previous consensus statement on OPAT in the UK published in 1998. They are based on previous national and international guidelines, but have been further developed through an extensive consultation process, and are underpinned by evidence from published literature on OPAT. They provide pragmatic guidance on the development and delivery of OPAT services, looking at all aspects of service design, care delivery, outcome monitoring and quality assurance, with the aim of ensuring that OPAT services provide high-quality, low-risk care, whatever the healthcare setting. They will provide a useful resource for teams developing new services, as well as a practical set of quality indicators for existing services.

A structure and process evaluation of an Australian hospital admission avoidance programme for aged care facility residents

AIM

To describe and evaluate the structures and processes involved in a hospital in the Nursing Home programme.

BACKGROUND

Older Australians are the largest consumers of healthcare, and as a result of the ageing process are at risk of developing hospital acquired iatrogenic complications. Hospital admission avoidance programmes that aim to provide care for patients in their own environment include Hospital in the Home and, more recently, Hospital in the Nursing Home.

METHODS

In 2006, a qualitative evaluation of a nurse-led Hospital in the Nursing Home programme using semi-structured interviews with 19 stakeholders was undertaken. Data analysis involved using start codes and content analysis.

FINDINGS

Effective referral and communication strategies were important for Hospital in the Nursing Home implementation. Furthermore, the Hospital in the Nursing Home programme manager had acute care and community experience and worked in an advanced practice role. These elements were integral to the programme's operation.

CONCLUSION

As the population ages, reducing hospital admissions for aged-care facility residents has the potential to improve patient outcomes. A structurally and procedurally sound programme is a key element in achieving this aim.

Adverse events experienced by homecare patients: a scoping review of the literature

PURPOSE

The paper summarizes the results of a scoping review that focused on the occurrence of adverse events experienced by homecare patients.

DATA SOURCES

The literature search covered published and grey literature between 1998 and 2007. Databases searched included: MEDLINE, EMBASE, CINAHL and EBM REVIEWS including the Cochrane Library, AGELINE, the National Patient Safety Foundation Bibliography, Agency for Healthcare Research and Quality and the Patient Safety Net bibliography.

STUDY SELECTION

Papers included research studies, review articles, policy papers, opinion articles and legal briefs. Inclusion criteria were: (i) homecare directed services provided in the home by healthcare professionals or caregivers; (ii) addressed a characteristic relevant to patient experienced adverse events (e.g. occurrences, rates, definitions, prevention or outcomes); and (iii) were in English. Data extraction A pool of 1007 articles was reduced to 168 after analysis. Data were charted according to six categories: definitions, rates, causes, consequences, interventions and policy.

RESULTS

Eight categories emerged: adverse drug events, line-related, technology-related, infections and urinary catheters, wounds, falls, studies reporting multiple rates and other. Reported overall rates of adverse events ranged from 3.5 to 15.1% with higher rates for specific types. Few intervention studies were found. Adverse events were commonly associated with communication problems. Policy suggestions included the need to improve assessments, monitoring, education, coordination and communication.

CONCLUSION

A standardized definition of adverse events in the homecare setting is needed. Prospective cohort studies are needed to improve estimates and intervention studies should be undertaken to reduce the risk that homecare patients will experience adverse events.

Early discharge hospital at home

BACKGROUND

'Early discharge hospital at home' is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would require acute hospital in-patient care. If hospital at home were not available then the patient would remain in an acute hospital ward.

OBJECTIVES

To determine, in the context of a systematic review and meta-analysis, the effectiveness and cost of managing patients with early discharge hospital at home compared with in-patient hospital care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register , MEDLINE (1950 to 2008), EMBASE (1980 to 2008), CINAHL (1982 to 2008) and EconLit through to January 2008. We checked the reference lists of articles identified for potentially relevant articles.

SELECTION CRITERIA

Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing early discharge hospital at home with acute hospital in-patient care. Evaluations of obstetric, paediatric and mental health hospital at home schemes are excluded from this review.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality. Our statistical analyses were done on an intention-to-treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. For the IPD meta-analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set. The calculated log hazard ratios were combined using fixed-effect inverse variance meta-analysis.

MAIN RESULTS

Twenty-six trials were included in this review [n = 3967]; 21 were eligible for the IPD meta-analysis and 13 of the 21 trials contributed data [1899/2872; 66%]. For patients recovering from a stroke and elderly patients with a mix of conditions there was insufficient evidence of a difference in mortality between groups (adjusted HR 0.79, 95% CI 0.32 to 1.91; N = 494; and adjusted HR 1.06, 95% CI 0.69 to 1.61; N = 978). Readmission rates were significantly increased for elderly patients with a mix of conditions allocated to hospital at home (adjusted HR 1.57; 95% CI 1.10 to 2.24; N = 705). For patients recovering from a stroke and elderly patients with a mix of conditions respectively, significantly fewer people allocated to hospital at home were in residential care at follow up (RR 0.63; 95% CI 0.40 to 0.98; N = 4 trials; RR 0.69, 95% CI 0.48 to 0.99; N =3 trials). Patients reported increased satisfaction with early discharge hospital at home. There was insufficient evidence of a difference for readmission between groups in trials recruiting patients recovering from surgery. Evidence on cost savings was mixed.

AUTHORS' CONCLUSIONS

Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.

Outpatient parenteral antibiotic therapy in Singapore

Outpatient parenteral antibiotic therapy (OPAT) remains in its infancy in Singapore, with the first patients enrolled 4 years ago. Singapore's three largest hospitals, with over 3000 inpatient beds, now have designated and approved OPAT services. This study reviews the demographic, clinical and cost data of all patients enrolled in 2005 to facilitate benchmarking between services in Singapore and abroad and also to identify common needs for further development. In 2005, 225 OPAT enrollments in 208 different patients resulted in 4050 days of OPAT care. Orthopaedic diagnoses constituted 40% of admissions. Vancomycin was the most frequently used antibiotic (34%). The re-admission rate was 8.9%, but complications of OPAT care were only occasionally implicated. An estimated $207,200 was saved by patients despite there being significant financial disincentives to subsidised patients. OPAT is a safe, cost-efficient system that is becoming increasingly accepted in Singapore by patients, clinicians and management. Our three services have evolved independently into very similar practices. There is potential for further innovation, including outreach and carer-delivered dosing. However, major financial disincentives require review.

Specialist home-based nursing services for children with acute and chronic illnesses

BACKGROUND

Specialist paediatric home-based nursing services have been proposed as a cost-effective means of reducing trauma resulting from hospital admissions, while enhancing primary care and reducing length of hospital stay.

OBJECTIVES

To evaluate specialist home-based nursing services for children with acute and chronic illnesses.

SEARCH STRATEGY

Electronic searches were made of CENTRAL (Cochrane Central Register of Controlled Trials) 2005 (Issue 2); MEDLINE (1966 to August 2005); EMBASE (1980 to August 2005); PsycINFO (1887 to August 2005); CINAHL (1982 to August 2005); Sociological Abstracts (1963 to August 2005). Optimally sensitive search strategies for randomised controlled trials (RCTs) were combined with medical subject headings and text words specific for ambulatory paediatrics, nursing outreach and 'hospital in the home', and no language restrictions were applied.

SELECTION CRITERIA

RCTs of children aged 0-18 with acute or chronic illnesses allocated to specialist home-based nursing services compared with conventional medical care. Outcomes included utilisation of health care, physical and mental health, satisfaction, adverse health outcomes and costs.

DATA COLLECTION AND ANALYSIS

Meta-analysis was not appropriate because of the clinical diversity and lack of common outcomes measures

MAIN RESULTS

1655 titles yielded 5 RCTs with a total of 771 participants. Participants, interventions and outcomes were diverse. No significant differences were reported in health outcomes; two studies reported improvements in child and parental anxiety; one study reported no significant difference in readmissions; two studies reported significantly fewer bed days; increased satisfaction was reported ; home care was more costly for service providers, but less expensive for parents.

AUTHORS' CONCLUSIONS

While current research does not provide definitive support for specialist home-based nursing services in reducing access to hospital services or length of stay, preliminary results show no adverse impact on physical health outcomes and a number of papers reported improved satisfaction with home-based care. Further trials are required, measuring health, satisfaction, service utilisation and long-term costs.

Hospital in the home: constructions of the nursing role - a literature review

Acute medical and nursing treatment in the home is increasingly seen as an alternative to hospitalization. Models such as hospital in the home (HITH) or acute home care are said to provide a safe, comfortable environment for patients that is conducive to healing. A review of the literature reveals the embryonic nature of the research and discussion related to this alternative care delivery model. In general, the benefits of hospital in the home programmes are presented in an uncritical manner. Medical practitioners have embraced the move to home care as a means of expanding the use of advanced technologies and improved drug regimes beyond the hospital walls. The nursing response has been mechanistic and recipe-like while advancing the HITH nursing role as an opportunity for specialty practice by virtue of the increased autonomy and independence required. This review demonstrates the influence of a professional mandate for specialization, and the ideological and scientific interests that have influenced the role of the nurse.

The peripherally inserted central catheter (PICC): a prospective study of its natural history after cubital fossa insertion

A prospective cohort study was undertaken to describe the natural history of the cubital fossa peripherally inserted central catheter (PICC), determine which factors influenced the hazard of complication and develop a standard methodology for evaluation of a PICC service. A total of 4349 patient days of PICC observation were analysed using survival analysis techniques. The median time to PICC removal for a complication was 60 days. The most common complications were phlebitis, malposition and tip migration. Complications usually occurred during the first week. There was only one episode of line-related sepsis. Size 3 French gauge catheters had a complication rate of 7.3 per 1,000 line days compared to 14.2 for 4 French catheters (hazard rate 1.26 90% CI 1.02 to 1.55). PICCs requiring two or more attempts at insertion were more likely to develop complications than those inserted at the first attempt: 20 per 1,000 line days vs 10.5 but the confidence intervals were wide (hazard rate 1.91, 90% CI 0.90 to 4.05). Operator (amongst the four experienced operators who inserted all PICCs), arm of placement, or medial or lateral placement in the cubitalfossa did not influence PICC survivaL

A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients

OBJECTIVE

To test the cost effectiveness of Hospital in the Home compared to hospital admission for acute medical conditions.

METHOD

Randomised controlled trial at the Prince of Wales Hospital, Sydney, from October 1995 to February, 1997; 100 patients with acute medical conditions admitted through the Emergency Department.

RESULTS

The Hospital in the Home (HITH) group costs per separation ($1,764, CI 95% $1,416-$2,111, n = 50) were significantly lower (p < 0.0001, Mann-Whitney U-Wilcoxon Rank Sum) than the control group hospital separation ($3,614, CI 95% $2,881.37-$4,347.27, n = 47) with no significant difference in clinical outcomes, and comparable or better user satisfaction.

CONCLUSION

Given the favourable clinical outcomes the HITH model produces at a lower cost, the cost-effectiveness of the care mode is high, and the allocative efficiency favourable.

IMPLICATIONS

As a care model and critical pathway, HITH offers hospitals real bed day savings that can either be used to rationalise resource usage for a given level of activity, or increase throughput.

Hospital and home

This paper addresses the hospital/community interface as an emerging context of health care practice. As a consequence of industry reforms health service managers are looking to the community space as a location for delivery of acute health care. This focus on the community is sharpened by the promise of cost savings and enhanced by the seemingly limitless potential of biomedical technology. The paper argues that the interface of hospital and community is a conceptual space where two different types of health services meet, bringing with them different cultural practices and expectations. The 'hospital in the home' programs that structure health care at this interface provide the delivery of acute nursing and medical care and the accoutrements of this care in the community, the neighbourhood, the home. Consequently, the home is becoming the new site for high technology 'hospital' care. This domestication of illness technology is contrasted with the notion of home as a place of sanctuary, familiarity and belonging.