Insights From Rapid Deployment of a "Virtual Hospital" as Standard Care During the COVID-19 Pandemic

A time-series analysis examining implementation strategies to increase use of an early-supported discharge hospital at home model

BACKGROUND

Early-supported discharge (ESD) hospital-at-home (HaH) programs facilitate hospitalized patients to receive ongoing acute-level care at home, thereby promoting patient-centeredness while improving hospital throughput.

OBJECTIVES

The current study aimed to test multiple implementation strategies to increase and sustain HaH ESD utilization.

METHODS

We conducted interrupted time series analyses to evaluate the effectiveness of implementation strategies on weekly HaH ESD referrals and capacity utilization at five hospitals. Intervention 1 included provider-focused education and HaH nurse navigator support (July 2021 to May 2022). Intervention 2 added provider-level referral performance feedback and daily electronic health record-based eligibility reports (May 2022 to December 2022). During postintervention (January 2023 to June 2023), implementation strategies were no longer supported by the study team. Clinical outcomes were assessed over time and between patient subgroups.

RESULTS

There were 5951 HaH ESD patients overall. After Intervention 2, we observed immediate increases in weekly HaH ESD referrals (level change mean difference [MD, 95% confidence interval]: 14.8, 5.9-23.6) and capacity utilization (level change MD: 13.9%, 6.2%-21.5%) and additional week-to-week increases in capacity utilization (slope change MD: 0.6%, 0.2%-0.9%), compared to Intervention 1 trends. HaH ESD referrals and capacity utilization were sustained postintervention. The proportion of provider-initiated referrals increased over time (Intervention 1: 79.4%, Intervention 2: 90.9%, postintervention: 95.2%). As HaH ESD utilization increased, we observed shorter inpatient length of stay and fewer HaH ESD encounters per visit (p < 0.01). There were small, statistically significant differences in 30-day mortality and readmission for residents of rural and socioeconomically disadvantaged areas.

CONCLUSION

Applying referral-focused provider feedback and daily eligibility reports were effective within a multicomponent approach to increase and sustain HaH ESD utilization.

Incorporating patient, caregiver, and provider perspectives in the co-design of an app to guide Hospital at Home admission decisions: a qualitative analysis

Objective

Hospital at Home (HaH) programs currently lack decision support tools to help efficiently navigate the complex decision-making process surrounding HaH as a care option. We assessed user needs and perspectives to guide early prototyping and co-creation of 4PACS (Partnering Patients and Providers for Personalized Acute Care Selection), a decision support app to help patients make an informed decision when presented with discrete hospitalization options.

Methods

From December 2021 to January 2022, we conducted semi-structured interviews via telephone with patients and caregivers recruited from Atrium Health's HaH program and physicians and a nurse with experience referring patients to HaH. Interviews were evaluated using thematic analysis. The findings were synthesized to create illustrative user descriptions to aid 4PACS development.

Results

In total, 12 stakeholders participated (3 patients, 2 caregivers, 7 providers [physicians/nurse]). We identified 4 primary themes: attitudes about HaH; 4PACS app content and information needs; barriers to 4PACS implementation; and facilitators to 4PACS implementation. We characterized 3 user descriptions (one per stakeholder group) to support 4PACS design decisions. User needs included patient selection criteria, clear program details, and descriptions of HaH components to inform care expectations. Implementation barriers included conflict between app recommendations and clinical judgement, inability to adequately represent patient-risk profile, and provider burden. Implementation facilitators included ease of use, auto-populating features, and appropriate health literacy.

Conclusions

The findings indicate important information gaps and user needs to help inform 4PACS design and barriers and facilitators to implementing 4PACS in the decision-making process of choosing between hospital-level care options.

Effectiveness of a Multifaceted Implementation Strategy to Increase Equitable Hospital at Home Utilization: An Interrupted Time Series Analysis

BACKGROUND

The number of Hospital-at-Home (HaH) programs rapidly increased during the COVID-19 pandemic and after issuance of Centers for Medicare and Medicaid Services' (CMS) Acute Hospital Care at Home (AHCaH) waiver. However, there remains little evidence on effective strategies to equitably expand HaH utilization.

OBJECTIVE

Evaluate the effects of a multifaceted implementation strategy on HaH utilization over time.

DESIGN

Before and after implementation evaluation using electronic health record (EHR) data and interrupted time series analysis, complemented by qualitative interviews with key stakeholders.

PARTICIPANTS

Between December 2021 and December 2022, we identified adults hospitalized at six hospitals in North Carolina approved by CMS to participate in the AHCaH waiver program. Eligible adults met criteria for HaH transfer (HaH-eligible clinical condition, qualifying home environment). We conducted semi-structured interviews with 12 HaH patients and 10 referring clinicians.

INTERVENTIONS

Two strategies were studied. The discrete implementation strategy (weeks 1-12) included clinician-directed educational outreach. The multifaceted implementation strategy (weeks 13-54) included ongoing clinician-directed educational outreach, local HaH assistance via nurse navigators, involvement of clinical service line executives, and individualized audit and feedback.

MEASURES

We assessed weekly averaged HaH capacity utilization, weekly counts of unique referring providers, and patient characteristics. We analyzed themes from qualitative data to determine barriers and facilitators to HaH use.

RESULTS

Our evaluation showed week-to-week increases in HaH capacity utilization during the multifaceted implementation strategy period, compared to discrete-period trends (slope-change odds ratio-1.02, 1.01-1.04). Counts of referring providers also increased week to week, compared to discrete-period trends (slope-change means ratio-1.05, 1.03-1.07). The increase in HaH utilization was largest among rural residents (11 to 34%). Barriers included HaH-related information gaps and referral challenges; facilitators included patient-centeredness of HaH care.

CONCLUSIONS

A multifaceted implementation strategy was associated with increased HaH capacity utilization, provider adoption, and patient diversity. Health systems may consider similar, contextually relevant multicomponent approaches to equitably expand HaH.

Managing Patients With COVID-19 in Armenia Using a Remote Monitoring System: Descriptive Study

BACKGROUND

The COVID-19 pandemic has imposed immense stress on global health care systems, especially in low- and middle-income countries (LMICs). Armenia, a middle-income country in the Caucasus region, contended with the pandemic and a concurrent war, resulting in significant demand on its already strained health care infrastructure. The COVID@home program was a multi-institution, international collaboration to address critical hospital bed shortages by implementing a home-based oxygen therapy and remote monitoring program.

OBJECTIVE

The objective of this study was to describe the program protocol and clinical outcomes of implementing an early discharge program in Armenia through a collaboration of partner institutions, which can inform the future implementation of COVID-19 remote home monitoring programs, particularly in LMICs or low-resource settings.

METHODS

Seven hospitals in Yerevan participated in the COVID@home program. A web app based on OpenMRS was developed to facilitate data capture and care coordination. Patients meeting eligibility criteria were enrolled during hospitalization and monitored daily while on oxygen at home. Program evaluation relied on data extraction from (1) eligibility and enrollment forms, (2) daily monitoring forms, and (3) discharge forms.

RESULTS

Over 11 months, 439 patients were screened, and 221 patients were managed and discharged. Around 94% (n=208) of participants safely discontinued oxygen therapy at home, with a median home monitoring duration of 26 (IQR 15-45 days; mean 32.33, SD 25.29) days. Women (median 28.5, mean 35.25 days) had similar length of stay to men (median 26, mean 32.21 days; P=.75). Despite challenges in data collection and entry, the program demonstrated feasibility and safety, with a mortality rate below 1% and low re-admission rate. Opportunities for operational and data quality improvements were identified.

CONCLUSIONS

This study contributes practical evidence on the implementation and outcomes of a remote monitoring program in Armenia, offering insights into managing patients with COVID-19 in resource-constrained settings. The COVID@home program's success provides a model for remote patient care, potentially alleviating strain on health care resources in LMICs. Policymakers can draw from these findings to inform the development of adaptable health care solutions during public health crises, emphasizing the need for innovative approaches in resource-limited environments.

Remote patient monitoring in patients with COVID-19 at home: literature review

BACKGROUND

During the pandemic healthcare providers implemented remote patient monitoring (RPM) for patients suffering from COVID-19. RPM is an interaction between healthcare professionals and patients who are in different locations, in which a certain number of patient's functioning parameters is assessed and followed up for a certain duration of time. By implementing RPM for these patients they obtained to reduce the strain on hospitals and primary care.

OBJECTIVE

With this literature review we aim at describing the characteristics of the RPM interventions, reporting on the patients with COVID-19 included in RPM, and providing an overview of outcome variables such as length of stay (LOS), hospital (re)admissions, and mortality.

METHODS

A combination of different searches in several database types (traditional databases, trial registers, daily (google) searches and daily Pubmed alerts) were run daily from March 2020 till December 2021. A search update for randomized clinical trials (RCT's) was done in April 2022.

RESULTS

The initial search yielded more than 4448 articles (not including daily searches). After deduplication and assessment for eligibility, 241 articles were retained describing 164 telemonitoring studies from 160 centres. None of the 164 studies covering 248,431 included patients reported on the presence of a randomized control group. Studies described a 'prehosp' group (96 studies) with patients who had a suspected or confirmed COVID-19 diagnosis and for whom it was decided not to hospitalize them yet, but closely monitor them at home, or a 'posthosp' group (32 studies) with patients who were monitored at home after hospitalization for COVID-19; 34 studies described both groups, in 2 studies it was unclear. There is a large variety in number of emergency department (ED) visits (0-36% and 0-16%) and no convincing evidence that RPM leads to less or more ED-visits as well as hospital (re)admissions (0-30% and 0-22%) in prehosp and posthosp, respectively. Mortality was generally low, and there is weak to no evidence that RPM is associated with lower mortality. There is neither evidence that RPM shortens previous LOS. A literature update detected three small scale RCT's which could not demonstrate statistically significant differences in these outcomes. Most papers claim savings, however the scientific base for these claims is doubtful. The overall patient experiences with RPM were positive, as patients felt more reassured, although many patients declined RPM for several reasons (eg, technological embarrassment, digital literacy, etc.).

CONCLUSIONS

Based on these results, there is no convincing evidence that RPM in COVID-19 patients could avoid ED-visits or hospital (re)admissions, could shorten LOS or reduce mortality, but neither is there evidence that RPM has adverse outcomes. Further research should focus on developing, implementing, and evaluating an RPM framework.

CLINICALTRIAL

Home-First or Hospital-First? A Propensity Score-Weighted Retrospective Cohort Study

OBJECTIVES

This study aimed to compare clinical and utilization outcomes between home-first and hospital-first models of care in the operation of a hospital-at-home (HaH) program.

DESIGN

This is a retrospective cohort study in which the primary outcome was a composite of oxygenation, intensive care unit admission, and all-cause mortality and the primary utilization outcome was length of stay (hospital and home bed days).

SETTINGS AND PARTICIPANTS

The study sample included 1025 patients with COVID-19 admitted to an HaH program in Singapore from September 23, 2021, to February 29, 2022.

METHODS

Propensity score weighting and regression analysis were used to adjust for confounding between both groups.

RESULTS

There was no significant difference in the odds of occurrence of the primary outcome between the home-first and hospital-first groups (OR, 1.17; 95% CI, 0.44-3.10). Home-first patients had a shorter length of stay by an average of 2.02 (95% CI, 1.10-2.93) days with no statistically significant difference in clinical outcomes compared with hospital-first patients.

CONCLUSIONS AND IMPLICATIONS

Patients with COVID-19 suitable for HaH should be considered for direct admission to HaH without need for an initial hospital stay.

A Primary Health Care Program and COVID-19. Impact in Hospital Admissions and Mortality

BACKGROUND

Most patients with mild or moderate COVID infection did not require hospital admission, but depending on their personal history, they needed medical supervision. In monitoring these patients in primary care, the design of specific surveillance programs was of great help. Between February 2021 and March 2022, EDCO program was designed in Tenerife, Spain, to telemonitor patients with COVID infection who had at least one vulnerability factor to reduce hospital admissions and mortality.

OBJECTIVE

The aim of this study is to describe the clinical course of patients included in the EDCO program and to analyze which factors were associated with a higher probability of hospital admission and mortality.

DESIGN

Retrospective cohort study.

PATIENTS

We included 3848 patients with a COVID-19 infection age over 60 years old or age over 18 years and at least one vulnerability factor previously reported in medical history.

MAIN MEASURES

Primary outcome was to assess risk of admission or mortality.

KEY RESULTS

278 (7.2%) patients required hospital admission. Relative risks (RR) of hospital admission were oxygen saturation ≤ 92% (RR: 90.91 (58.82-142.86)), respiratory rate ≥ 22 breaths per minute (RR: 20.41 (1.19-34.48), obesity (RR: 1.53 (1.12-2.10), chronic kidney disease (RR:2.31 (1.23-4.35), ≥ 60 years of age (RR: 1.44 (1.04-1.99). Mortality rate was 0.7% (27 patients). Relative risks of mortality were respiratory rate ≥ 22 breaths per minute (RR: 24.85 (11.15-55.38), patients with three or more vulnerability factors (RR: 4.10 (1.62-10.38), oxygen saturation ≤ 92% (RR: 4.69 (1.70-15.15), chronic respiratory disease (RR: 3.32 (1.43-7.69) and active malignancy (RR: 4.00 (1.42-11.23).

CONCLUSIONS

Vulnerable patients followed by a primary care programme had admission rates of 7.2% and mortality rates of 0.7%. Supervision of vulnerable patients by a Primary Care team was effective in the follow-up of these patients with complete resolution of symptoms in 91.7% of the cases.

Medical Information Protection in Internet Hospital Apps in China: Scale Development and Content Analysis

BACKGROUND

Hospital apps are increasingly being adopted in many countries, especially since the start of the COVID-19 pandemic. Web-based hospitals can provide valuable medical services and enhanced accessibility. However, increasing concerns about personal information (PI) and strict legal compliance requirements necessitate privacy assessments for these platforms. Guided by the theory of contextual integrity, this study investigates the regulatory compliance of privacy policies for internet hospital apps in the mainland of China.

OBJECTIVE

In this paper, we aim to evaluate the regulatory compliance of privacy policies of internet hospital apps in the mainland of China and offer recommendations for improvement.

METHODS

We obtained 59 internet hospital apps on November 7, 2023, and reviewed 52 privacy policies available between November 8 and 23, 2023. We developed a 3-level indicator scale based on the information processing activities, as stipulated in relevant regulations. The scale comprised 7 level-1 indicators, 26 level-2 indicators, and 70 level-3 indicators.

RESULTS

The mean compliance score of the 52 assessed apps was 73/100 (SD 22.4%), revealing a varied spectrum of compliance. Sensitive PI protection compliance (mean 73.9%, SD 24.2%) lagged behind general PI protection (mean 90.4%, SD 14.7%), with only 12 apps requiring separate consent for processing sensitive PI (mean 73.9%, SD 24.2%). Although most apps (n=41, 79%) committed to supervising subcontractors, only a quarter (n=13, 25%) required users' explicit consent for subcontracting activities. Concerning PI storage security (mean 71.2%, SD 29.3%) and incident management (mean 71.8%, SD 36.6%), half of the assessed apps (n=27, 52%) committed to bear corresponding legal responsibility, whereas fewer than half (n=24, 46%) specified the security level obtained. Most privacy policies stated the PI retention period (n=40, 77%) and instances of PI deletion or anonymization (n=41, 79%), but fewer (n=20, 38.5%) committed to prompt third-party PI deletion. Most apps delineated various individual rights, but only a fraction addressed the rights to obtain copies (n=22, 42%) or to refuse advertisement based on automated decision-making (n=13, 25%). Significant deficiencies remained in regular compliance audits (mean 11.5%, SD 37.8%), impact assessments (mean 13.5%, SD 15.2%), and PI officer disclosure (mean 48.1%, SD 49.3%).

CONCLUSIONS

Our analysis revealed both strengths and significant shortcomings in the compliance of internet hospital apps' privacy policies with relevant regulations. As China continues to implement internet hospital apps, it should ensure the informed consent of users for PI processing activities, enhance compliance levels of relevant privacy policies, and fortify PI protection enforcement across the information processing stages.

Effect of a Structured Multilevel Telehealth Service on Hospital Admissions and Mortality During COVID-19 in a Resource-Limited Region in Brazil: Retrospective Cohort Study

BACKGROUND

The COVID-19 pandemic represented a great stimulus for the adoption of telehealth and many initiatives in this field have emerged worldwide. However, despite this massive growth, data addressing the effectiveness of telehealth with respect to clinical outcomes remain scarce.

OBJECTIVE

The aim of this study was to evaluate the impact of the adoption of a structured multilevel telehealth service on hospital admissions during the acute illness course and the mortality of adult patients with flu syndrome in the context of the COVID-19 pandemic.

METHODS

A retrospective cohort study was performed in two Brazilian cities where a public COVID-19 telehealth service (TeleCOVID-MG) was deployed. TeleCOVID-MG was a structured multilevel telehealth service, including (1) first response and risk stratification through a chatbot software or phone call center, (2) teleconsultations with nurses and medical doctors, and (3) a telemonitoring system. For this analysis, we included data of adult patients registered in the Flu Syndrome notification databases who were diagnosed with flu syndrome between June 1, 2020, and May 31, 2021. The exposed group comprised patients with flu syndrome who used TeleCOVID-MG at least once during the illness course and the control group comprised patients who did not use this telehealth service during the respiratory illness course. Sociodemographic characteristics, comorbidities, and clinical outcomes data were extracted from the Brazilian official databases for flu syndrome, Severe Acute Respiratory Syndrome (due to any respiratory virus), and mortality. Models for the clinical outcomes were estimated by logistic regression.

RESULTS

The final study population comprised 82,182 adult patients with a valid registry in the Flu Syndrome notification system. When compared to patients who did not use the service (n=67,689, 82.4%), patients supported by TeleCOVID-MG (n=14,493, 17.6%) had a lower chance of hospitalization during the acute respiratory illness course, even after adjusting for sociodemographic characteristics and underlying medical conditions (odds ratio [OR] 0.82, 95% CI 0.71-0.94; P=.005). No difference in mortality was observed between groups (OR 0.99, 95% CI 0.86-1.12; P=.83).

CONCLUSIONS

A telehealth service applied on a large scale in a limited-resource region to tackle COVID-19 was related to reduced hospitalizations without increasing the mortality rate. Quality health care using inexpensive and readily available telehealth and digital health tools may be delivered in areas with limited resources and should be considered as a potential and valuable health care strategy. The success of a telehealth initiative relies on a partnership between the involved stakeholders to define the roles and responsibilities; set an alignment between the different modalities and levels of health care; and address the usual drawbacks related to the implementation process, such as infrastructure and accessibility issues.

Individual- and Community-Level Predictors of Hospital-at-Home Outcomes

Advanced Care at Home is a Mayo Clinic hospital-at-home (HaH) program that provides hospital-level care for patients. The study examines patient- and community-level factors that influence health outcomes. The authors performed a retrospective study using patient data from July 2020 to December 2022. The study includes 3 Mayo Clinic centers and community-level data from the Agency for Healthcare Research and Quality. The authors conducted binary logistic regression analyses to examine the relationship among the independent variables (patient- and community-level characteristics) and dependent variables (30-day readmission, mortality, and escalation of care back to the brick-and-mortar hospital). The study examined 1433 patients; 53% were men, 90.58% were White, and 68.2% were married. The mortality rate was 2.8%, 30-day readmission was 11.4%, and escalation back to brick-and-mortar hospitals was 8.7%. At the patient level, older age and male gender were significant predictors of 30-day mortality (P-value <0.05), older age was a significant predictor of 30-day readmission (P-value <0.05), and severity of illness was a significant predictor for readmission, mortality, and escalation back to the brick-and-mortar hospital (P-value <0.01). Patients with COVID-19 were less likely to experience readmission, mortality, or escalations (P-value <0.05). At the community level, the Gini Index and internet access were significant predictors of mortality (P-value <0.05). Race and ethnicity did not significantly predict adverse outcomes (P-value >0.05). This study showed promise in equitable treatment of diverse patient populations. The authors discuss and address health equity issues to approximate the vision of inclusive HaH delivery.

Transforming health care: Investigating Influenzer, a novel telemedicine-supported early discharge program for patients with lower respiratory tract infection: A non-randomized feasibility study

BACKGROUND

The COVID-19 pandemic has posed unprecedented challenges to healthcare systems globally, necessitating innovative care models like hospital-at-home and virtual care programs. The Influenzer telemedicine program aims to deliver hospital-led monitoring and treatment to patients at home. Integrating telemedicine technology with domestic visits provides an alternative to traditional hospitalization, with the aim of easing the burden on healthcare facilities without compromising patient safety. To evaluate the effectiveness of the Influenzer program, a randomized controlled trial is proposed. This study aimed to assess the feasibility of the proposed clinical trial design.

METHODS

A non-randomized feasibility study was conducted at the Department of Pulmonary and Infectious Diseases at Nordsjaellands Hospital offering a telemedicine-supported early discharge program to patients with lower respiratory tract infections, including COVID-19. The feasibility of trial procedures, including recruitment, adherence, and retention, was analyzed. Also, participants' characteristics and trajectory during the intervention, including telemedicine and domestic services, were assessed.

RESULTS

Nineteen patients were enrolled from June 2022 to April 2023 and treated at home. Forty patients were not enrolled as 15 (25%) were non-eligible according to study protocol, 15 (25%) refused to participate and 10 (17%) had not been approached. Subjects treated at home had comparable clinical outcomes to those treated in the acute hospital, no major safety incidences occurred and patients were highly satisfied. Participants demonstrated 99% adherence to planned daily monitoring activities. In total, 63% completed all survey assessments at least partially including baseline, at discharge, and 3 months post-discharge, while 89% participated in a follow-up interview. No participants withdrew their consent.

CONCLUSIONS

The feasibility study documented that the Influenzer home-hospital program was feasible and well accepted in a Scandinavian setting in terms of no withdrawals and excellent participant adherence to the planned daily monitoring activities. Challenges in the organizational structures including patient recruitment and data collection required resolution prior to our randomized clinical trial. Insights from this feasibility study have led to the improved design of the final Influenzer program evaluation trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05087082. Registered on 18 August 2021.

The hospital at home in the USA: current status and future prospects

The annual cost of hospital care services in the US has risen to over $1 trillion despite relatively worse health outcomes compared to similar nations. These trends accentuate a growing need for innovative care delivery models that reduce costs and improve outcomes. HaH-a program that provides patients acute-level hospital care at home-has made significant progress over the past two decades. Technological advancements in remote patient monitoring, wearable sensors, health information technology infrastructure, and multimodal health data processing have contributed to its rise across hospitals. More recently, the COVID-19 pandemic brought HaH into the mainstream, especially in the US, with reimbursement waivers that made the model financially acceptable for hospitals and payors. However, HaH continues to face serious challenges to gain widespread adoption. In this review, we evaluate the peer-reviewed evidence and discuss the promises, challenges, and what it would take to tap into the future potential of HaH.

Designing a Virtual Hospital-at-Home Intervention for Patients with Infectious Diseases: A Data-Driven Approach

BACKGROUND

Virtual hospital-at-home care might be an alternative to standard hospital care for patients with infectious diseases. In this study, we explore the potential for virtual hospital-at-home care and a potential design for this population.

METHODS

This was a retrospective cohort study of internal medicine patients suspected of infectious diseases, admitted between 1 January and 31 December 2019. We collected information on delivered care during emergency department visits, the first 24 h, between 24 and 72 h, and after 72 h of admission. Care components that could be delivered at home were combined into care packages, and the potential number of eligible patients per package was described. The most feasible package was described in detail.

RESULTS

763 patients were included, mostly referred for general internal medicine (35%), and the most common diagnosis was lower respiratory tract infection (27%). The most frequently administered care components were laboratory tests, non-oral medication, and intercollegiate consultation. With a combination of telemonitoring, video consultation, non-oral medication administration, laboratory tests, oxygen therapy, and radiological diagnostics, 48% of patients were eligible for hospital-at-home care, with 35% already eligible directly after emergency department visits.

CONCLUSION

While the potential for virtual hospital-at-home care is high, it depends greatly on which care can be arranged.

Impact of the COVID-19 pandemic on the prevalence of respiratory viral pathogens in patients with acute respiratory infection in Shanghai, China

Objective

This study aimed to evaluate the impact of nonpharmaceutical interventions (NPIs) taken to combat COVID-19 on the prevalence of respiratory viruses (RVs) of acute respiratory infections (ARIs) in Shanghai.

Methods

Samples from ARI patients were collected and screened for 17 respiratory viral pathogens using TagMan low density microfluidic chip technology in Shanghai from January 2019 to December 2020. Pathogen data were analyzed to assess changes in acute respiratory infections between 2019 and 2020.

Results

A total of 2,744 patients were enrolled, including 1,710 and 1,034 in 2019 and 2020, respectively. The total detection rate of RVs decreased by 149.74% in 2020. However, detection rates for human respiratory syncytial virus B (RSVB), human coronavirus 229E (HCoV229E), human coronavirus NL63 (HCoVNL63), and human parainfluenza virus 3 (HPIV3) increased by 91.89, 58.33, 44.68 and 24.29%, in 2020. The increased positive rates of RSVB, HPIV3, resulted in more outpatients in 2020 than in 2019. IFV detection rates declined dramatically across gender, age groups, and seasons in 2020.

Conclusion

NPIs taken to eliminate COVID-19 had an impact on the prevalence of respiratory viral pathogens, especially the IFVs in the early phases of the pandemic. Partial respiratory viruses resurged with the lifting of NPIs, leading to an increase in ARIs infection.

Using technology to improve reconnection to remote monitoring in cardiac implantable electronic device patients

Background

Remote monitoring (RM) of cardiac implantable electronic device (CIED) patients is now considered standard of care. However, a fundamental requirement of RM is continuous connectivity between the patient's implanted device and the CIED manufacturer's central server. This study examined the rate of RM disconnections in CIED recipients and the impact of short message service (SMS) to facilitate reconnections.

Methods

Using a platform that collects RM data from CIED manufacturers, we retrospectively examined the disconnection and reconnection events in 6085 patients from 20 medical centers. Each medical center reported their usual practice regarding RM disconnections, which consisted of either an automatic SMS from the platform to patients who were disconnected for 2 weeks or the standard of care (SC) of a phone call to patients.

Results

During a 1-year period, 43% of patients had at least 1 disconnection. Half of these patients experienced multiple disconnections. The use of SMS reduced the time to reconnection by 43% in comparison to SC. The median time to reconnect a disconnected patient was 11.0 [3.2, 29.0] days for SC vs 6.3 [1.3, 22.0] days for SMS (P < .0001). Furthermore, there was a high rate of reconnections within the first 48 hours of the SMS message, which was nearly double that in the SC arm.

Conclusion

This study demonstrates the feasibility of an automatic system to deliver an SMS to patients with a disconnected CIED to facilitate early reconnection to RM.

Digital health for remote home monitoring of patients with COVID-19 requiring oxygen: a cohort study and literature review

Background

The clinical course and outcome of COVID-19 vary widely, from asymptomatic and mild to critical. Elderly patients and patients with comorbidities are at increased risk of respiratory failure and oxygen requirements. Due to the massive surge, the pandemic has created challenges for overwhelmed hospitals. Thus, the original home management of COVID-19 patients requiring oxygen and remote monitoring by a web app and a nurse at home were implemented in our center. We aimed to evaluate the outcome of patients with COVID-19 requiring oxygen who benefited from home remote monitoring management.

Methods

We performed a retrospective cohort study on all COVID-19 patients requiring oxygen (< 5 L/min) who consulted from October 2020 to April 2021 at our emergency department and were managed with home remote monitoring by a web app and an in-home nurse. We also carried out a literature review of studies on COVID-19 patients requiring oxygen with remote monitoring.

Results

We included 300 patients [184 (61.3%) male patients, median age 51 years]. The main comorbidities were cardiovascular disease (n = 117; 39.0%), diabetes mellitus (n = 72; 24.0%), and chronic respiratory disease (n = 32; 10.7%). Among the 28 (9.3%) patients readmitted to the hospital, 6 (1.9%) were hospitalized in the intensive care unit, and 3 (0.9%) died. In the multivariable analysis, risk factors for unplanned hospitalization were chronic respiratory failure (odds ratio (OR) =4.476, 95%CI 1.565-12.80), immunosuppression (OR = 3.736, 95%CI 1.208-11.552), and short delay between symptoms onset and start of telemonitoring (OR = 0.744, 95%CI 0.653-0.847). In the literature review, we identified seven other experiences of remote monitoring management. Mortality rate and unplanned hospitalization were low (maximum 1.9 and 12%, respectively).

Conclusion

Our study confirms the safety of home remote monitoring of patients with COVID-19 who require oxygen, as well as our literature review. However, patients with chronic respiratory failure and immunosuppression should be closely monitored.

The Evolving Practice of Hospital at Home in the United States

Hospital at Home (HaH) provides hospital-level services in the home to eligible patients who would otherwise require facility-based hospitalization. In the last two decades, studies have shown that HaH can improve patient outcomes and satisfaction and reduce hospital readmissions. Improved technology and greater experience with the model have led to expansion in the scope of patients served and services provided by the model, but dissemination in the United States has been hampered by lack of insurance coverage until recently. HaH is likely at the tipping point for wide adoption in the United States. To realize its full benefits, HaH will need to continue volume expansion to achieve culture change in clinical practice as facilitated by increased insurance coverage, technological advancements, and improved workforce expertise. It is also essential that HaH programs maintain high-quality acute hospital care, ensure that their benefits can be accessed by hard-to-reach rural populations, and continue to advance health equity.

Outcomes in novel hospital-at-home model for patients with COVID-19: a multicentre retrospective cohort study

BACKGROUND

Hospital-at-home (HaH) care has been proposed as an alternative to inpatient care for patients with coronavirus disease (COVID-19). Previous reports were hospital-led and involved patients triaged at the hospitals. To reduce the burden on hospitals, we constructed a novel HaH care model organized by a team of local primary care clinics.

METHODS

We conducted a multicentre retrospective cohort study of the COVID-19 patients who received our HaH care from 1 January to 31 March 2022. Patients who were not able to be triaged for the need for hospitalization by the Health Center solely responsible for the management of COVID-19 patients in Osaka city were included. The primary outcome was receiving medical care beyond the HaH care defined as a composite outcome of any medical consultation, hospitalization, or death within 30 days from the initial treatment.

RESULTS

Of 382 eligible patients, 34 (9%) were triaged for hospitalization immediately after the initial visit. Of the remaining 348 patients followed up, 37 (11%) developed the primary outcome, while none died. Obesity, fever, and gastrointestinal symptoms at baseline were independently associated with an increased risk of needing medical care beyond the HaH care. A further 129 (37%) patients were managed online alone without home visit, and 170 (50%) required only 1 home visit in addition to online treatment.

CONCLUSIONS

The HaH care model with a team of primary care clinics was able to triage patients with COVID-19 who needed immediate hospitalization without involving hospitals, and treated most of the remaining patients at home.

Antimicrobial Stewardship at Transitions of Care

Antimicrobial stewardship interventions have historically been siloed in different care settings; recently, a need for stewardship interventions at care transitions has arisen as inappropriate prescribing at care transitions may result in patient harm. There are several care areas that should be considered for optimizing antibiotic prescribing. Interventions can be difficult to implement as they often require the efforts of a multidisciplinary team and are resource intensive. Antimicrobial stewardship programs should prioritize interventions at transitions of care to improve prescribing and patient outcomes.

Modelled economic evaluation of a virtual emergency department in Victoria

OBJECTIVE

Virtual ED (VED) can potentially alleviate ED overcrowding which has been a public health challenge. The aim of the present study was to conduct a return-on-investment analysis of a VED programme developed in response to changing healthcare needs in Australia.

METHODS

An economic model was developed based on initial patient outcome data to assess the healthcare costs, potential costs saved and return on investment (ROI) from the VED. The VED programme operating as part of Alfred Health Emergency Services. The participants were the first 188 patients accessing the Alfred Health VED. VED is the delivery of emergency assessment and management of specific patients virtually via audio-visual teleconferencing. ROI ratios that compare cost savings with intervention costs.

RESULTS

The mean total operational cost of VED for 79 days for 188 patients was A$344 117 (95% uncertainty interval [UI] $296 800-$392 088). The VED led to a potential A$286 779 (95% UI $241 688-$330 568) healthcare cost saving from reductions in emergency visits and A$97 569 (95% UI $74 233-$123 117) cost saving in ambulance services. The ROI ratio was estimated at 1.12 (95% UI 0.96-1.32).

CONCLUSIONS

The VED was cost neutral in a conservatively modelled scenario but promising if any hospital admission could be saved. Ongoing research examining a larger cohort with community follow up is required to confirm this promising result.

Home-based initiatives for acute management of COVID-19 patients needing oxygen: differences across The Netherlands

OBJECTIVE

During the COVID-19 pandemic new collaborative-care initiatives were developed for treating and monitoring COVID-19 patients with oxygen at home. Aim was to provide a structured overview focused on differences and similarities of initiatives of acute home-based management in the Netherlands.

METHODS

Initiatives were eligible for evaluation if (i) COVID-19 patients received oxygen treatment at home; (ii) patients received structured remote monitoring; (iii) it was not an 'early hospital discharge' program; (iv) at least one patient was included. Protocols were screened, and additional information was obtained from involved physicians. Design choices were categorised into: eligible patient group, organization medical care, remote monitoring, nursing care, and devices used.

RESULTS

Nine initiatives were screened for eligibility; five were included. Three initiatives included low-risk patients and two were designed specifically for frail patients. Emergency department (ED) visit for an initial diagnostic work-up and evaluation was mandatory in three initiatives before starting home management. Medical responsibility was either assigned to the general practitioner or hospital specialist, most often pulmonologist or internist. Pulse-oximetry was used in all initiatives, with additional monitoring of heart rate and respiratory rate in three initiatives. Remote monitoring staff's qualification and authority varied, and organization and logistics were covered by persons with various backgrounds. All initiatives offered remote monitoring via an application, two also offered a paper diary option.

CONCLUSIONS

We observed differences in the organization of interprofessional collaboration for acute home management of hypoxemic COVID-19 patients. All initiatives used pulse-oximetry and an app for remote monitoring. Our overview may be of help to healthcare providers and organizations to set up and implement similar acute home management initiatives for critical episodes of COVID-19 (or other acute disorders) that would otherwise require hospital care.

Six-Lead Electrocardiography Enables Identification of Rhythm and Conduction Anomalies of Patients in the Telemedicine-Based, Hospital-at-Home Setting: A Prospective Validation Study

BACKGROUND

The hospital-at-home (HAH) model is a viable alternative for conventional in-hospital stays worldwide. Serum electrolyte abnormalities are common in acute patients, especially in those with many comorbidities. Pathologic changes in cardiac electrophysiology pose a potential risk during HAH stays. Periodical electrocardiogram (ECG) tracing is therefore advised, but few studies have evaluated the accuracy and efficiency of compact, self-activated ECG devices in HAH settings. This study aimed to evaluate the reliability of such a device in comparison with a standard 12-lead ECG.

METHODS

We prospectively recruited consecutive patients admitted to the Sheba Beyond Virtual Hospital, in the HAH department, during a 3-month duration. Each patient underwent a 12-lead ECG recording using the legacy device and a consecutive recording by a compact six-lead device. Baseline patient characteristics during hospitalization were collected. The level of agreement between devices was measured by Cohen's kappa coefficient for inter-rater reliability (Ϗ).

RESULTS

Fifty patients were included in the study (median age 80 years, IQR 14). In total, 26 (52%) had electrolyte disturbances. Abnormal D-dimer values were observed in 33 (66%) patients, and 12 (24%) patients had elevated troponin values. We found a level of 94.5% raw agreement between devices with regards to nine of the options included in the automatic read-out of the legacy device. The calculated Ϗ was 0.72, classified as a substantial consensus. The rate of raw consensus regarding the ECG intervals' measurement (PR, RR, and QT) was 78.5%, and the calculated Ϗ was 0.42, corresponding to a moderate level of agreement.

CONCLUSION

This is the first report to our knowledge regarding the feasibility of using a compact, six-lead ECG device in the setting of an HAH to be safe and bearing satisfying agreement level with a legacy, 12-lead ECG device, enabling quick, accessible arrythmia detection in this setting. Our findings bear a promise to the future development of telemedicine-based hospital-at-home methodology.

Why U.S. Patients Declined Hospital-at-Home during the COVID-19 Public Health Emergency: An Exploratory Mixed Methods Study

To understand why US patients refused participation in hospital-at-home (H@H) during the coronavirus disease 2019 Public Health Emergency, eligible adult patients seen at 2 Mayo Clinic sites, Mayo Clinic Health System-Northwest Wisconsin region (NWWI) and Mayo Clinic Florida (MCF), from August 2021 through March 2022, were invited to participate in a convergent-parallel study. Quantitative associations between H@H participation status and patient baseline data at hospital admission were investigated. H@H patients were more likely to have a Mayo Clinic patient portal at baseline (P-value: .014), indicating a familiarity with telehealth. Patients who refused were more likely to be from NWWI (P-value < .001) and have a higher Epic Deterioration Index score (P-value: .004). The groups also had different quarters (in terms of fiscal calendar) of admission (P-value: .040). Analyzing qualitative interviews (n = 13) about refusal reasons, 2 themes portraying the quantitative associations emerged: lack of clarity about H@H and perceived domestic challenges. To improve access to H@H and increase patient recruitment, improved education about the dynamics of H@H, for both hospital staff and patients, and inclusive strategies for navigating domestic barriers and diagnostic challenges are needed.

Hospital-at-home care for immunodeficient patients with COVID-19: Approach to persistent COVID-19 infection

Key Clinical Message

Patients with COVID-19 who have undergone B-cell depletion therapy could have prolonged SARS-CoV-2 infection; therefore, even in the hospital-at-home setting, primary care physicians should carefully consider the treatment regimen and the timing of ending isolations in such cases, and should not hesitate to consult with infectious disease specialists if necessary.

Abstract

We presented the first reported case of hospital-at-home care for a patient with persistent COVID-19 who had undergone B-cell depletion therapy. He received hospital-at-home care, including two courses of remdesivir; however, he ultimately failed to recover and was transferred to the hospital.

Evaluating Racial/Ethnic Differences in Care Escalation Among COVID-19 Patients in a Home-Based Hospital

The novel coronavirus disease 2019 (COVID-19) has infected over 414 million people worldwide with 5.8 million deaths, as of February 2022. Telemedicine-based interventions to expand healthcare systems' capacity and reduce infection risk have rapidly increased during the pandemic, despite concerns regarding equitable access. Atrium Health Hospital at Home (AH-HaH) is a home-based program that provides advanced, hospital-level medical care and monitoring for patients who would otherwise be hospitalized in a traditional setting. Our retrospective cohort study of positive COVID-19 patients who were admitted to AH-HaH aims to investigate whether the rate of care escalation from AH-HaH to traditional hospitalization differed based on patients' racial/ethnic backgrounds. Logistic regression was used to examine the association between care escalation within 14 days from index AH-HaH admission and race/ethnicity. We found approximately one in five patients receiving care for COVID-19 in AH-HaH required care escalation within 14 days. Odds of care escalation were not significantly different for Hispanic or non-Hispanic Blacks compared to non-Hispanic Whites. However, secondary analyses showed that both Hispanic and non-Hispanic Black patients were younger and with fewer comorbidities than non-Hispanic Whites. The study highlights the need for new care models to vigilantly monitor for disparities, so that timely and tailored adaptations can be implemented for vulnerable populations.

Disparities in Level of Care and Outcomes Among Patients with COVID-19: Associations Between Race/Ethnicity, Social Determinants of Health and Virtual Hospitalization, Inpatient Hospitalization, Intensive Care, and Mortality

OBJECTIVE

To examine the role of race/ethnicity and social determinants of health on COVID-19 care and outcomes for patients within a healthcare system that provided virtual hospital care.

METHODS

This retrospective cohort study included 12,956 adults who received care for COVID-19 within an integrated healthcare system between 3/1/2020 and 8/31/2020. Multinomial models were used to examine associations between race/ethnicity, insurance, neighborhood deprivation measured by Area Deprivation Index (ADI), and outcomes of interest. Outcomes included (1) highest level of care: virtual observation (VOU), virtual hospitalization (VACU), or inpatient hospitalization; (2) intensive care (ICU); and (3) all-cause 30-day mortality.

RESULTS

Patients were 41.8% White, 27.2% Black, and 31.0% Hispanic. Compared to White patients, Black patients had 1.86 higher odds of VACU admission and 1.43 higher odds of inpatient hospitalization (vs. VOU). Hispanic patients had 1.24 higher odds of inpatient hospitalization (vs. VOU). In models stratified by race/ethnicity, Hispanic and Black patients had higher odds of inpatient hospitalization (vs. VOU) if Medicaid insured compared to commercially insured. Hispanic patients living in the most deprived neighborhood had higher odds of inpatient hospitalization, compared to those in the least deprived neighborhood. Black and Hispanic patients had higher odds of ICU admission and 30-day mortality after adjustment for other social determinants.

CONCLUSIONS

Insurance and ADI were associated with COVID-19 outcomes; however, associations varied by race/ethnicity. Racial/ethnic disparities in outcomes are not fully explained by measured social determinants of health, highlighting the need for further investigation into systemic causes of inequities in COVID-19 outcomes.

Hospital Days Reduced for Moderate and Severe COVID-19 Patients Through a Home Monitoring Program With Oxygen

While the COVID-19 pandemic continues to strain the healthcare system, it has also expanded telemedicine. There is a subset of hospitalized moderate to severe COVID-19 patients requiring oxygen but no other intervention. This is a retrospective study of patients ≥18 years with moderate to severe COVID-19 that participated in a home monitoring program with supplemental oxygen (HMP-O₂) (N = 25). For study outcomes, HMP-O₂ participants were compared to patients meeting the same inclusion criteria but did not participate in the program (N = 60). On average, the HMP-O₂ patients spent 5.8 days (±5.5 days) in the hospital compared to 8.12 days (±5.5 days) for non-program patients. This resulted in 19% cost-savings for HMP-O₂ patients. Lessons learned from this program can be applied to future HMPs for either COVID-19 or other conditions that would benefit from telecare.

Impact of a hospital policy to redistribute admission flow across clinical services for capacity relief during COVID-19 surges

BACKGROUND

Increased hospital admissions due to COVID-19 place a disproportionate strain on inpatient general medicine service (GMS) capacity compared to other services.

OBJECTIVE

To study the impact on capacity and safety of a hospital-wide policy to redistribute admissions from GMS to non-GMS based on admitting diagnosis during surge periods.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective case-controlled study at a large teaching hospital. The intervention included adult patients admitted to general care wards during two surge periods (January-February 2021 and 2022) whose admission diagnosis was impacted by the policy. The control cohort included admissions during a matched number of days preceding the intervention.

MAIN OUTCOMES AND MEASURES

Capacity measures included average daily admissions and hospital census occupied on GMS. Safety measures included length of stay (LOS) and adverse outcomes (death, rapid response, floor-to-intensive care unit transfer, and 30-day readmission).

RESULTS

In the control cohort, there were 365 encounters with 299 (81.9%) GMS admissions and 66 (18.1%) non-GMS versus the intervention with 384 encounters, including 94 (24.5%) GMS admissions and 290 (75.5%) non-GMS (p < .001). The average GMS census decreased from 17.9 and 21.5 during control periods to 5.5 and 8.5 during intervention periods. An interrupted time series analysis confirmed a decrease in GMS daily admissions (p < .001) and average daily hospital census (p = .014; p < .001). There were no significant differences in LOS (5.9 vs. 5.9 days, p = .059) or adverse outcomes (53, 14.5% vs. 63, 16.4%; p = .482).

CONCLUSION

Admission redistribution based on diagnosis is a safe lever to reduce capacity strain on GMS during COVID-19 surges.

Implementing a COVID-19 Virtual Observation Unit in Emergency Medicine: Frontline Clinician and Staff Experiences

The COVID-19 pandemic pushed hospitals to deliver care outside of their four walls. To successfully scale virtual care delivery, it is important to understand how its implementation affects frontline workers, including their teamwork and patient-provider interactions. We conducted in-depth interviews of 17 clinicians and staff involved with the COVID-19 Virtual Observation Unit (CVOU) in the emergency department (ED) of an academic hospital. The program leveraged remote patient monitoring and mobile integrated health care. In the CVOU (vs. the ED), participants observed increases in interactions among clinicians and staff, patient participation in care delivery, attention to nonmedical factors, and involvement of coordinators and paramedics in patient care. These changes were associated with unintended, positive consequences for staff, namely, feeling heard, experience of meaningfulness, and positive attitudes toward virtual care. This study advances research on reconfiguration of roles following implementation of new practices using digital tools, virtual work interactions, and at-home care delivery.

Outcomes of a “hospital at home” programme for the supervised home recovery of COVID-19 patients in Singapore

Background

The Singapore General Hospital COVID-19 Virtual Ward is a “hospital at home” (HaH) programme for the supervised home recovery of higher-acuity COVID-19 patients from the hospital and the community.

Objective

To describe how an existing HaH programme was redesigned so that COVID-19 patients could be remotely monitored at home and report the outcomes of the first 100 patients in this Virtual Ward.

Methods

Patients received an admission package comprising instructions and equipment for home monitoring, and uploaded their parameters into a clinical dashboard via a secure messaging app. Medical staff conducted video or telephone consultations daily. Patients were discharged according to time-based criteria, although some required SARS-CoV-2 PCR testing, which were conducted at home by a third-party medical provider. De-identified data of the first 100 patients were analysed by demographic details, indication for enrolment into the Virtual Ward, and the need for subsequent inpatient readmission.

Results

Of the first 100 patients admitted into the Virtual Ward, 58 were female, mean age was 63.1 years old (23–95 years), and 76 were fully vaccinated. There were 77 hospital referrals and 23 community referrals. The number of days of inpatient hospitalisation avoided was 717 days (average of 7.9 days per patient). Three hospital referrals (3.9%) were readmitted, while seven community referrals (30.4%) required subsequent hospitalisation.

Conclusion

The Virtual Ward programme demonstrates that selected COVID-19 patient can safely recover at home with remote medical support and monitoring, thereby expanding hospital capacity.

Diagnosis Related Groups of Patients Admitted from an Urban Academic Medical Center to a Virtual Hybrid Hospital-at-Home Program

Background

The diagnosis related group (DRG) is used as an economic patient classification system based on clinical characteristics, hospital stay, and treatment costs. Mayo Clinic's virtual hybrid hospital-at-home program, advanced care at home (ACH), offers high-acuity home inpatient care for a variety of diagnosis. This study aimed to determine the DRGs admitted to the ACH program at an urban academic center.

Methods

A retrospective study was performed on all patients discharged from the ACH program at Mayo Clinic Florida from July 6, 2020, to February 1, 2022. DRG data were extracted from the Electronic Health Record (EHR). Categorization of DRG was done by systems.

Results

The ACH program discharged 451 patients with DRGs. Categorization of the DRG demonstrated that the most frequent code assigned corresponded to respiratory infections (20.2%), followed by septicemia (12.9%), heart failure (8.9%), renal failure (4.9%), and cellulitis (4.0%).

Conclusion

The ACH program covers a wide range of high-acuity diagnosis across multiple medical specialties at its urban academic medical campus, including respiratory infections, severe sepsis, congestive heart failure, and renal failure, all with major complications or comorbidities. The ACH model of care may be useful in taking care of patients with similar diagnosis at other urban academic medical institutions.

Relevance of prediction scores derived from the SARS-CoV-2 first wave, in the evolving UK COVID-19 second wave, for safe early discharge and mortality: a PREDICT COVID-19 UK prospective observational cohort study

OBJECTIVE

Prospectively validate prognostication scores, SOARS and 4C Mortality Score, derived from the COVID-19 first wave, for mortality and safe early discharge in the evolving pandemic with SARS-CoV-2 variants (B.1.1.7 replacing D614) and healthcare responses altering patient demographic and mortality.

DESIGN

Protocol-based prospective observational cohort study.

SETTING

Single site PREDICT and multisite ISARIC (International Severe Acute Respiratory and Emerging Infections Consortium) cohorts in UK COVID-19 second wave, October 2020 to January 2021.

PARTICIPANTS

1383 PREDICT and 20 595 ISARIC SARS-CoV-2 patients.

PRIMARY OUTCOME MEASURES

Relevance of SOARS and 4C Mortality Score determining in-hospital mortality and safe early discharge in the evolving UK COVID-19 second wave.

RESULTS

1383 (median age 67 years, IQR 52-82; mortality 24.7%) PREDICT and 20 595 (mortality 19.4%) ISARIC patient cohorts showed SOARS had area under the curve (AUC) of 0.8 and 0.74, while 4C Mortality Score had AUC of 0.83 and 0.91 for hospital mortality, in the PREDICT and ISARIC cohorts respectively, therefore, effective in evaluating safe discharge and in-hospital mortality. 19.3% (231/1195, PREDICT cohort) and 16.7% (2550/14992, ISARIC cohort) with SOARS of 0-1 were candidates for safe discharge to a virtual hospital (VH) model. SOARS implementation in the VH pathway resulted in low readmission, 11.8% (27/229) and low mortality, 0.9% (2/229). Use to prevent admission is still suboptimal, as 8.1% in the PREDICT cohort and 9.5% in the ISARIC cohort were admitted despite SOARS score of 0-1.

CONCLUSIONS

SOARS and 4C Mortality Score remains valid, transforming complex clinical presentations into tangible numbers, aiding objective decision making, despite SARS-CoV-2 variants and healthcare responses altering patient demographic and mortality. Both scores, easily implemented within urgent care pathways for safe early discharge, allocate hospital resources appropriately to the pandemic's needs while enabling normal healthcare services resumption.

Influences of COVID-19 pandemic on hospital-at-home functions in Finland - a questionnaire survey

OBJECTIVE

To investigate functions of Finnish hospital-at-home (HAH) during the first year of COVID19-pandemic 2020 compared with the previous year 2019.

DESIGN

Retrospective questionnaire survey.

SETTING

Finnish HAHs from Northern, Eastern, Southern, Western and Central parts of Finland participated in a questionnaire web-based questionnaire survey. The numbers of patients, activities and staff in 2019 and 2020, participation in the care of COVID19 patients, availability of protective clothing, attitudes of patients towards home care and development of new practices in the corona era were asked using both predefined and free questions.

SUBJECTS

questionnaire was sent to the nurses and physicians in charge of the HAHs (N = 13), 77% responded. The HAHs provided services to a total of 1,196,783 inhabitants in their municipalities.

RESULTS

There were no significant changes in the numbers of patients, staff or activities between the years 2019 and 2020. Although nurses did viral tests, COVID19 patients were cared only in 40% of HAHs. Protective clothing was well available. New instructions for infection management were created.

CONCLUSIONS

The COVID-19 pandemic did not largely influence the functions of the examined Finnish HAHs in 2020. Most activities and patients' characteristics remained unchanged from 2019. The role of HAHs should be further developed in Scandinavian countries, particularly during pandemics.Key PointsHospital-at-home (HAH) is a cost-effective model to provide hospital-like services.Data about the role of HAHs during COVID19 pandemics is lacking in the Nordic countries.This study shows that, the large Finnish municipal HAHs have been not influenced by pandemics.

Remote vs In-home Physician Visits for Hospital-Level Care at Home: A Randomized Clinical Trial

IMPORTANCE

Home hospital care is the substitutive provision of home-based acute care services usually associated with a traditional inpatient hospital. Many home hospital models require a physician to see patients at home daily, which may hinder scalability. Whether remote physician visits can safely substitute for most in-home visits is unknown.

OBJECTIVE

To compare remote and in-home physician care.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial assessed 172 adult patients at an academic medical center and community hospital who required hospital-level care for select acute conditions, including infection, heart failure, chronic obstructive pulmonary disease, and asthma, between August 3, 2019, and March 26, 2020; follow-up ended April 26, 2020.

INTERVENTIONS

All patients received acute care at home, including in-home nurse or paramedic visits, intravenous medications, remote monitoring, and point-of-care testing. Patients were randomized to receive physician care remotely (initial in-home visit followed by daily video visit facilitated by the home hospital nurse) vs in-home care (daily in-home physician visit). In the remote care group, the physician could choose to see the patient at home beyond the first visit if it was felt to be medically necessary.

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of adverse events, compared using multivariable Poisson regression at a noninferiority threshold of 10 events per 100 patients. Adverse events included a fall, pressure injury, and delirium. Secondary outcomes included the Picker Patient Experience Questionnaire 15 score (scale of 0-15, with 0 indicating worst patient experience and 15 indicating best patient experience) and 30-day readmission rates.

RESULTS

A total of 172 patients (84 receiving remote care and 88 receiving in-home physician care [control group]) were randomized; enrollment was terminated early because of COVID-19. The mean (SD) age was 69.3 (18.0) years, 97 patients (56.4%) were female, 77 (45.0%) were White, and 42 (24.4%) lived alone. Mean adjusted adverse event count was 6.8 per 100 patients for remote care patients vs 3.9 per 100 patients for control patients, for a difference of 2.8 (95% CI, -3.3 to 8.9), supporting noninferiority. For remote care vs control patients, the mean adjusted Picker Patient Experience Questionnaire 15 score difference was -0.22 (95% CI, -1.00 to 0.56), supporting noninferiority. The mean adjusted 30-day readmission absolute rate difference was 2.28% (95% CI, -3.23% to 7.79%), which was inconclusive. Of patients in the remote group, 16 (19.0%) required in-home visits beyond the first visit.

CONCLUSIONS AND RELEVANCE

In this study, remote physician visits were noninferior to in-home physician visits during home hospital care for adverse events and patient experience, although in-home physician care was necessary to support many patients receiving remote care. Our findings may allow for a more efficient, scalable home hospital approach but require further research.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04080570.

Staff and patient experience of the implementation and delivery of a virtual health care home monitoring service for COVID-19 in Melbourne, Australia

BACKGROUND

Provision of virtual health care (VHC) home monitoring for patients who are experiencing mild to moderate COVID-19 illness is emerging as a central strategy for reducing pressure on acute health systems. Understanding the enablers and challenges in implementation and delivery of these programs is important for future implementation and re-design. The aim of this study was to explore the perspectives of staff involved with the implementation and delivery, and the experience of patients managed by, a VHC monitoring service in Melbourne, Australia during the COVID-19 pandemic.

METHODS

A descriptive qualitative approach informed by naturalist inquiry was used. Staff interviews were analysed using the Consolidated Framework for Implementation Research (CFIR). Patient experience was captured using a survey and descriptive statistics were used to describe categorical responses while content analysis was used to analyse free text responses as they related to the CFIR. Finally, data from the interviews and patient experience were triangulated to see if patient experience validated data from staff interviews.

RESULTS

All 15 staff were interviewed, and 271 patients were surveyed (42%). A total of four final overarching themes emerged: service implementation enablers, service delivery benefits for patients, fragmentation of care, and workforce strengths. 19 subthemes aligned with 18 CFIR constructs from staff and patient data.

CONCLUSION

Rapid implementation was enabled through shared resources, dividing implementation tasks between senior personnel, engaging furloughed healthcare staff in design and delivery, and having a flexible approach that allowed for ongoing improvements. Benefits for patients included early identification of COVID-19 deterioration, as well as provision of accurate and trustworthy information to isolate safely at home. The main challenges were the multiple agencies involved in patient monitoring, which may be addressed in the future by attributing responsibility for monitoring to a single agency.

Treating acutely ill patients at home: Data from Singapore

INTRODUCTION

Hospital-at-home programmes are well described in the literature but not in Asia. We describe a home-based inpatient substitutive care programme in Singapore, with clinical and patient-reported outcomes.

METHODS

We conducted a retrospective cohort study of patients admitted to a hospital-at-home programme from September 2020 to September 2021. Suitable patients, who otherwise required hospitalisation, were admitted to the programme. They were from inpatient wards, emergency department and community nursing teams in the western part of Singapore, where a multidisciplinary team provided hospital-level care at home. Electronic health record data were extracted from all patients admitted to the programme. Patient satisfaction surveys were conducted post-discharge.

RESULTS

A total of 108 patients enrolled. Mean age was 67.9 (standard deviation 16.7) years, and 46% were male. The main diagnoses were skin and soft tissue infections (35%), urinary tract infections (29%) and fluid overload (18%). Median length of stay was 4 (interquartile range 3-7) days. Seven patients were escalated back to the hospital, of whom 2 died after escalation. One patient died at home. There was 1 case of adverse drug reaction and 1 fall at home, and no cases of hospital-acquired infections. Patient satisfaction rates were high and 94% of contactable patients would choose to participate again.

CONCLUSION

Hospital-at-home programmes appear to be safe and feasible alternatives to inpatient care in Singapore. Further studies are warranted to compare clinical outcomes and cost to conventional inpatient care.

Approach to the management of COVID-19 patients: When home care can represent the best practice

BACKGROUND

The pandemic that began around February 2020, caused by the viral pathogen SARS-CoV-2 (COVID-19), has still not completed its course at present in June 2022.

OBJECTIVE

The open research to date highlights just how varied and complex the outcome of the contagion can be.

METHOD

The clinical pictures observed following the contagion present variabilities that cannot be explained completely by the patient's age (which, with the new variants, is rapidly changing, increasingly affecting younger patients) nor by symptoms and concomitant pathologies (which are no longer proving to be decisive in recent cases) in relation to medium-to-long term sequelae. In particular, the functions of the vascular endothelium and vascular lesions at the pre-capillary level represent the source of tissue hypoxia and other damage, resulting in the clinical evolution of COVID-19.

RESULTS

Keeping the patient at home with targeted therapeutic support, aimed at not worsening vascular endothelium damage with early and appropriate stimulation of endothelial cells, ameliorates the glycocalyx function and improves the prognosis and, in some circumstances, could be the best practice suitable for certain patients.

CONCLUSION

Clinical information thus far collected may be of immense value in developing a better understanding of the present pandemic and future occurrences regarding patient safety, pharmaceutical care and therapy liability.

The COVID Positive Pathway: a collaboration between public health agencies, primary care, and metropolitan hospitals in Melbourne

OBJECTIVES

To assess the capacity of the COVID Positive Pathway, a collaborative model of care involving the Victorian public health unit, hospital services, primary care, community organisations, and the North Western Melbourne Primary Health Network, to support people with coronavirus disease 2019 (COVID-19) isolating at home.

DESIGN, SETTING, PARTICIPANTS

Cohort study of adults in northwest Melbourne with COVID-19, 3 August - 31 December 2020.

MAIN OUTCOME MEASURES

Demographic and clinical characteristics, and social and welfare needs of people cared for in the Pathway, by care tier level.

RESULTS

Of 1392 people referred to the Pathway by the public health unit, 858 were eligible for enrolment, and 711 consented to participation; 647 (91%) remained in the Pathway until they had recovered and isolation was no longer required. A total of 575 participants (81%) received care in primary care, mostly from their usual general practitioners; 155 people (22%) received care from hospital outreach services, and 64 (9%) needed high tier care (hospitalisation). Assistance with food and other basic supplies was required by 239 people in the Pathway (34%).

CONCLUSIONS

The COVID Positive Pathway is a feasible multidisciplinary, tiered model of care for people with COVID-19. About 80% of participants could be adequately supported by primary care and community organisations, allowing hospital services to be reserved for people with more severe illness or with risk factors for disease progression. The principles of this model could be applied to other health conditions if regulatory and funding barriers to information-sharing and care delivery by health care providers can be overcome.

An Outpatient Management Strategy Using a Coronataxi Digital Early Warning System Reduces Coronavirus Disease 2019 Mortality

Background

The coronavirus disease 2019 (COVID-19) pandemic has caused sudden, severe strain to healthcare systems. Better outpatient management is required to save lives, manage resources effectively, and prepare for future pandemics.

Methods

The Coronataxi digital early warning (CDEW) system deployed in Rhein-Neckar County and Heidelberg, Germany is an outpatient care system consisting of remote digital monitoring via a mobile application, a medical doctor dashboard, and medical care delivery to COVID-19 patients in home quarantine when indicated. Patients reported their symptoms, temperature, breathing rate, oxygen saturation, and pulse via the app. This single-center cohort study compared outcomes of the population with and without using the CDEW system. The primary outcome was mortality; the secondary outcomes were hospitalization, duration of hospitalization, intensive care therapy, and mechanical ventilation.

Results

Mortality rate was 3- to 4-fold lower and hospitalization rate was higher in the CDEW cohort (459 patients) compared with the cohort without CDEW in the same test area and other regions (Mannheim, Karlsruhe town, Karlsruhe district, and Germany), (mortality rate: 0.65% [95% confidence interval {CI}, .13%-1.90%] versus 2.16%, 2.32%, 2.48%, 2.82% and 2.76%, respectively, P < .05 for all; hospitalization rate: 14.81% [95% CI, 11.69%-18.40%] versus 6.89%, 6.93%, 6.59%, 6.15%, and 7.22%, respectively, P < .001 for all). The median duration of hospitalization in the CDEW cohort was significantly lower compared with a national sentinel cohort (6 days [interquartile range {IQR}, 4-9.75 days] versus 10 days [IQR, 5-19 days]; Z = -3.156; P = .002). A total of 1.96% patients needed intensive care and 1.09% were mechanically ventilated.

Conclusions

The CDEW system significantly reduced COVID-19 mortality and duration of hospitalization and can be applied to the management of future pandemics.

Hospital at home for acute medical illness: The 21st century acute medical unit for a changing population

Recent trends across Europe show a year-on-year increase in the number of patients with acute medical illnesses presenting to hospitals, yet there are no plans for a substantial expansion in acute hospital infrastructure or staffing to address demand. Strategies to meet increasing demand need to consider the fact that there is limited capacity in acute hospitals and focus on new care models in both hospital and community settings. Increasing the efficiency of acute hospital provision by reducing the length of stay entails supporting acute ambulatory care, where patients receive daily acute care interventions but do not stay overnight in the hospitals. This approach may entail daily transfer between home and an acute setting for ongoing treatment, which is unsuitable for some patients living with frailty. Acute hospital at home (HaH) is a care model which, thanks to advances in point of care diagnostic capability, can provide a credible model of acute medical assessment and treatment without the need for hospital transfer. Investment and training to support scaling up of HaH are key strategic aims for integrated healthcare systems.

Hospital at Home for Elderly COVID-19 Patients: A Preliminary Report with 100 Patients

Hospital-at-home (HaH) care is useful for patients with COVID-19 and an alternative strategy when hospital capacity is under pressure due to patient surges. However, the efficacy and safety of HaH in elderly patients with COVID-19 remain unknown. In Kyoto city, we conducted a retrospective medical record review of HaH care focused on elderly COVID-19 patients from 4 February to 25 June 2021. Eligible patients were (1) COVID-19 patients aged ≥70 years and those who lived with them or (2) COVID-19 patients aged <70 years with special circumstances and those who lived with them. During the study period, 100 patients received HaH care. Their median age was 76 years (interquartile range 56−83), and 65% were over 70 years. Among 100 patients, 36 (36%) had hypoxia (oxygen saturation ≤ 92%), 21 (21%) received steroid medication, and 34 (34%) received intravenous fluids. Although 22 patients were admitted to the hospital and 3 patients died there, no patients died during HaH care. HaH care may be safe and effective in elderly patients with COVID-19. Our study shows that HaH provides an alternative strategy for treating COVID-19 patients and can reduce the healthcare burden at hospitals.

Virtual Behavioral Medicine Program: A Novel Model of Care for Neuropsychiatric Symptoms in Dementia

BACKGROUND

Patients with severe neuropsychiatric symptoms (NPS) due to dementia are often uprooted from their familiar environments in long-term care or the community and transferred to emergency departments, acute care hospitals, or specialized behavioral units which can exacerbate NPS. To address this issue, we developed the Virtual Behavioral Medicine Program (VBM), an innovative model of virtual care designed to support management of patients with NPS in their own environment.

OBJECTIVE

To determine efficacy of VBM in reducing admission to a specialized inpatient neurobehavioral unit for management of NPS.

METHODS

We reviewed outcomes in the first consecutive 95 patients referred to VBM. Referrals were classified into two groups. In one group, patients were referred to VBM with a simultaneous application to an inpatient Behavioral Neurology Unit (BNU). The other group was referred only to VBM. The primary outcome was reduction in proportion of patients requiring admission to the BNU regardless of whether they were referred to the BNU or to VBM alone.

RESULTS

For patients referred to VBM plus the BNU, the proportion needing admission to the BNU was reduced by 60.42%. For patients referred to VBM alone, it was 68.75%.

CONCLUSION

VBM is a novel virtual neurobehavioral unit for treatment of NPS. Although the sample size was relatively small, especially for the VBM group, the data suggest that this program is a game changer that can reduce preventable emergency department visits and acute care hospital admissions. VBM is a scalable model of virtual care that can be adopted worldwide.

Provider Evaluation of a Novel Virtual Hybrid Hospital at Home Model

Background

Healthcare provider’s experience with new models of care is crucial for long-term success. In July 2020, Mayo Clinic implemented a novel virtual hybrid hospital at home program called Advanced Care at Home (ACH). This model allows virtual providers in a command center to care for high-acuity patients in the home setting through collaboration with a vendor-mediated supply chain. This study aims to describe the outcomes obtained from a survey applied to the ACH providers to determine their acceptance of the quality and safety of the virtual hybrid care model, their perception towards the decision-making and teamwork between the command center and supplier network, and determine if the overall experience with ACH was rewarding.

Methods

A 15-question anonymous survey was distributed via email quarterly to all the physicians and nurse practitioners registered in ACH program at Mayo Clinic. The survey encompassed questions related to the overall experience in ACH concerning work environment, quality of care, service reliability, teamwork, decision-making, and satisfaction. All the questions were Likert-like scale choice, and a descriptive analysis using frequency distribution and percentages of the data was performed.

Results

Between September 1, 2020 and April 30, 2021, three quarterly surveys were sent to a total of 21 physicians and nurse practitioners caring for patients virtually in ACH. The response rate reported was 72%, 33%, and 66%, respectively, at the first, second, and third quarters. Eighty percent or more of providers consistently gave positive scores to all three areas analyzed throughout the 8-month study.

Conclusion

Providers found the ACH virtual hybrid model of home hospital care very rewarding. They were able to deliver high-quality and safe care to their patients through positive teamwork with a vendor-mediated supply chain. This novel model of hospital at home has the potential to be a great provider satisfier moving forward.

Many people admitted to hospital with a provisional diagnosis of nonserious back pain are subsequently found to have serious pathology as the underlying cause

To determine the proportion of patients admitted to the hospital for back pain who have nonserious back pain, serious spinal, or serious other pathology as their final diagnosis. The proportion of nonserious back pain admissions will be used to plan for future 'virtual hospital' admissions. Electronic medical record data between January 2016 and September 2020 from three emergency departments (ED) in Sydney, Australia were used to identify inpatient admissions. SNOMED-CT-AU diagnostic codes were used to select ED patients aged 18 and older with an admitting diagnosis related to nonserious back pain. The inpatient discharge diagnosis was determined from the primary ICD-10-AM codes by two independent clinician-researchers. Inpatient admissions were then analysed by sociodemographic and hospital admission variables. A total of 38.1% of patients admitted with a provisional diagnosis of nonserious back pain were subsequently diagnosed with a specific pathology likely unsuitable for virtual care; 14.2% with a serious spinal pathology (e.g., fracture and infection) and 23.9% a serious pathology beyond the lumbar spine (e.g., pathological fracture and neoplasm). A total of 57% of admissions were identified as nonserious back pain, likely suitable for virtual care. A challenge for implementing virtual care in this setting is screening for patients with serious pathology. Protocols need to be developed to reduce the risk of patients being admitted to virtual hospitals with serious pathology as the cause of their back pain. Key Points • Among admitted patients provisionally diagnosed in ED with non-serious back pain, 38.1% were found to have 'serious spinal pathologies' or 'serious pathologies beyond the lumbar spine' at discharge. • Spinal fractures were the most common serious spinal pathology, accounting for 9% of all provisional 'non-serious back pain' admissions from ED. • 57% of back pain admissions were confirmed to be non-serious back pain and may be suitable to virtual hospital care; the challenge is discriminating these patients from those with serious pathology.