PMC:7536903 JSONTXT

{"target":"http://pubannotation.org/docs/sourcedb/PMC/sourceid/7536903","sourcedb":"PMC","sourceid":"7536903","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7536903","text":"Planning and clinical role of acute medical home care services for COVID‐19: consensus position statement by the Hospital‐in‐the‐Home Society Australasia\nHospital‐in‐the‐Home during COVID‐19\nBryant et al.\n\nAbstract\nAbstract\nDuring a pandemic when hospitals are stretched and patients need isolation, the role of hospital‐in‐the‐home (HITH) providing acute medical care at home has never been more relevant. We aimed to define and address the challenges to acute home care services posed by the COVID‐19 pandemic. Planning for service operation involves staffing, equipment availability and cleaning, upskilling in telehealth and communication. Planning for clinical care involves maximising cohorts of patients without COVID‐19 and new clinical pathways for patients with COVID‐19. The risk of SARS‐CoV‐2 transmission, specific COVID‐19 clinical pathways and the well‐being of patients and staff should be addressed in advance.\n\nHospital‐in‐the‐home (HITH) provision of acute medical care at home is increasingly advocated as safe, effective, psychologically beneficial and reducing financial burden on hospitals and patients. 1 , 2 , 3 During a pandemic where hospitals are at capacity and patients need to be isolated, the role of ambulatory services has never been more relevant. 4\n\nThe role of acute home care services\nThe role of HITH is to provide hospital‐level patient‐centred care that can safely and effectively be delivered at home to keep patients out of hospital, 5 for example, outpatient parenteral antibiotic therapy, chemotherapy and physiotherapy. The COVID‐19 pandemic does not change this, but the role of HITH may be impacted through: (i) increased referrals of patients without COVID‐19 to maximise hospital inpatient capacity; and (ii) new referrals of patients suspected or confirmed to have COVID‐19 with clinical features on the less severe end of the spectrum but requiring some element of hospital‐level care.\n\nChallenges posed by the COVID‐19 pandemic\nThere are several challenges unique to HITH posed by the COVID‐19 pandemic. First, there are duelling priorities of proactively trying to increase patient referrals while managing patient load to allow for that. 6 , 7 Second, new referrals for COVID‐19 add to this increased workload and create the risk of transmission of SARS‐CoV‐2 to staff and other patients. 8 Third, staff may become unwell, need quarantine or to provide care for their own families, reducing the available workforce with a specific skill set. Finally, there are unique challenges with managing personal protective equipment (PPE) and cleaning items taken into the home and cars.\nThis is a consensus statement by the HITH Society Australasia on the planning and clinical role of HITH during the COVID‐19 pandemic. The HITH Society Australasia represents doctors, nurses, allied health and other healthcare workers who provide HITH care in Australia and New Zealand, Asia and the Pacific. 9 As the peak HITH body in the region for 20 years, it is well placed to consider planning for the impact on HITH services. The content should be used in conjunction with health department and infection control guidelines.\n\nOverall goals of HITH during COVID‐19 pandemic\nTo provide safe, effective patient‐centred care at home for all HITH patients, while managing increased demand for HITH services.\nTo plan for new clinical pathways to care for COVID‐19 patients.\nTo minimise the impact of staff shortages.\nTo minimise the risk of SARS‐CoV‐2 exposure to staff and patients.\n\nIssues to consider in planning for HITH preparedness\nIt is recommended that all home care services consider what is achievable within current capacity, and the responses to increased demand for HITH services with potentially decreased staff. A checklist of issues to consider can support this process (Fig. 1).\nFigure 1 Checklist for optimising hospital‐in‐the‐home (HITH) service during COVID‐19 pandemic.\n\nManaging staffing\nWorkforce planning: resources required for projected increases in patient numbers, and impact of leave.\nWorkforce flexibility: changing shift times, teleconferencing from home, especially for those with increased risk from COVID‐19.\n\nManaging HITH equipment use and availability\nHITH equipment use: minimising the risk as a source of infection through determining what needs to be in the home, cleaning requirements and lifespan of PPE stored in hot cars.\nEquipment stock availability and cars: ensuring sufficient stock or supply chain of usual and additional (PPE, flocked swabs) equipment for the duration of the pandemic.\nTelehealth equipment: ensuring good connection; access to videoconferencing is not universal in patients' homes, and may need to be replaced by telephone calls.\n\nManaging patient workload\nMeasures to decrease current HITH workload will maximise the number of patients that can be transferred home to free up hospital beds.\nManaging interventions: minimising simple referrals, frequency of interventions and duration on HITH; 10 education and support of patients remotely in their own care; deferral of elective referrals.\nManaging need for in‐home visits: replacement of some in‐home visits with telehealth; 11 use of home observation kits (thermometer, oximeter) with remote monitoring; decreased driving distance, and if too far, engaging local services or rehousing patients locally.\n\nMinimising risk of exposure to and transmission of SARS‐CoV‐2\nStaff should follow current health department guidelines for screening, testing and PPE.\nRisk factor screening script use: at referral and prior to every visit.\nEducation and training staff for PPE use: guidance on donning, doffing and waste disposal, because every visit is in an unfamiliar environment.\nLimiting exposure during visits: family members should be limited in number, physically distanced and if unwell, not in the room with visiting staff.\nDecreasing risk for staff at increased risk (co‐morbidities, increased age): telehealth and non‐clinical duties.\n\nCommunications\nCommunication is critical in ensuring that staff and patients feel informed and supported.\nHITH staff: to provide updates and support, emphasise the importance of hand hygiene and other measures and provide moral support.\nHospital staff: to remind referrers of the role and capacity of HITH in ongoing institutional pandemic planning.\nGeneral practitioners, community physicians and other healthcare workers: to ensure care is co‐ordinated with other healthcare workers providing supportive care to patients at home.\nPatients: to ensure they feel safe receiving home care; development of information for all patients receiving care via HITH during the pandemic and additional information for patients with COVID‐19. 12 This may include child‐orientated language or pictures.\n\nSupporting each other\nWe support our own HITH team and our colleagues by treating everyone with respect and kindness, inclusion, regular communication, understanding of natural anxiety, reassurance and advocacy for infection protection for them in their role as front‐line carers.\n\nClinical role of HITH for COVID‐19\nThe clinical role of HITH will depend on the pathways that already exist and what capacity the HITH service has to expand or modify services and to develop new pathways.\n\nProvision of safe effective HITH care to meet increased hospital demand\nDuring a pandemic, the first priority is to optimise current care. However, there may be opportunities to think about the role of HITH for more patient groups.\nMaximise referral of usual HITH patients: transferring all cohorts that the institutional HITH usually takes; using communication, education and advertising signage about HITH.\nModify usual care to include additional HITH patients: extension of limits of current patient groups: acuity/severity, referral timing and intervention frequency, without decreasing level of care.\nOpportunities to develop new HITH pathways: development for new patient cohorts and new interventions. HITH societies are well positioned to establish sharing of information across hospitals.\n\nReferral of new patients to HITH with COVID‐19\nThe role of HITH for patients with suspected or confirmed COVID‐19 is untested and likely to evolve. Current case definition criteria should be used: patients with mild disease can go home without HITH, patients with severe disease need hospital admission, and the role of HITH lies in between. HITH may also be a source of reassurance for people who are safe to go home but feel frightened by their diagnosis.\nReferral processes: who will review, relay results and give isolation advice, in and out of hours.\nClinical criteria appropriate for HITH suggested for COVID‐19: these should be based on usual institutional HITH criteria:Requirement for ongoing assessment and/or management for moderate illness, for example, respiratory effort but not needing oxygen, decreased fluid intake, moderate secondary bacterial pneumonia requiring IV antibiotics.\nCOVID‐specific modifications may be considered, for example, tolerance of fevers and/or mild hypoxia in otherwise suitable patients.\nMonitoring those at higher risk of deterioration: those with respiratory/cardiac/oncological co‐morbidities, neonates and elderly should be considered individually.\nDuration of HITH admission: symptoms should be clearly improving before discharge; deterioration may occur beyond day 5 of the illness.\nAdditional interventions that may increase use of HITH: depending on HITH capability: equipment kits for patient self‐observation, nasogastric/intravenous hydration, oxygen using concentrators and remote monitoring.\n\nMode of HITH care for patients with COVID‐19\nMode of care depends on patient medical needs and risk of transmission of COVID‐19 infection.\nTelehealth for assessment/review: if no clinical intervention required; also semi‐urgent review of new symptoms or potential need to escalate care.\nIn‐person assessment: if intervention, for example, intravenous antibiotics required, or clinical examination for deterioration alerted by telehealth or patient/family phone call.\nResponsive mobile unit: consideration for ability to respond to need for an in‐person visit after a telehealth review.\n\nTransfer from HITH back to hospital of deteriorating patients with COVID‐19\nUse of standard procedure for escalation of care for deteriorating patients: contact numbers and signs to watch out for on information provided to the patient.\nConsideration of specific criteria in COVID‐19 patients: worsening respiratory status, for example, oxygen saturations \u003c92%; poor urinary output or other clinical concerns.\nTransfer back to hospital: clear process for both in hours and after hours, including where and by which team patient will be reviewed.\n\nConclusion\nAs the pandemic progresses, HITH activities will need to be updated, to align with recommendations from health departments and infection control, and in response to experience of COVID‐19 infection. This is the current consensus position of a large group of healthcare workers experienced in HITH care, with the aim of facilitating preparedness for institutions to provide acute home care in the early stages of the COVID‐19 pandemic.\n\nAcknowledgements\nP. A. Bryant is the recipient of the Dr Nicholas Collins Fellowship from the HITH Society Australasia. P. A. Bryant and A. C. Bowen hold NHMRC Investigator Grants. As this position paper is based on HITH‐COVID‐19 Guidelines of the HITH Society Australasia, we would like to acknowledge their role in reviewing the 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