Five years of Hospital at Home adoption in Catalonia: impact, challenges, and proposals for quality assurance.

BACKGROUND: Hospital at home (HaH) was increasingly implemented in Catalonia (7.7 M citizens, Spain) achieving regional adoption within the 2011-2015 Health Plan. This study aimed to assess population-wide HaH outcomes over five years (2015-2019) in a consolidated regional program and provide context-independent recommendations for continuous quality improvement of the service. METHODS: A mixed-methods approach was adopted, combining population-based retrospective analyses of registry information with qualitative research. HaH (admission avoidance modality) was compared with a conventional hospitalization group using propensity score matching techniques. We evaluated the 12-month period before the admission, the hospitalization, and use of healthcare resources at 30 days after discharge. A panel of experts discussed the results and provided recommendations for monitoring HaH services. RESULTS: The adoption of HaH steadily increased from 5,185 episodes/year in 2015 to 8,086 episodes/year in 2019 (total episodes 31,901; mean age 73 (SD 17) years; 79% high-risk patients. Mortality rates were similar between HaH and conventional hospitalization within the episode [76 (0.31%) vs. 112 (0.45%)] and at 30-days after discharge [973(3.94%) vs. 1112(3.24%)]. Likewise, the rates of hospital re-admissions at 30 days after discharge were also similar between groups: 2,00 (8.08%) vs. 1,63 (6.58%)] or ER visits [4,11 (16.62%) vs. 3,97 (16.03%). The 27 hospitals assessed showed high variability in patients' age, multimorbidity, severity of episodes, recurrences, and length of stay of HaH episodes. Recommendations aiming at enhancing service delivery were produced. CONCLUSIONS: Besides confirming safety and value generation of HaH for selected patients, we found that this service is delivered in a case-mix of different scenarios, encouraging hospital-profiled monitoring of the service.

Optimización del circuito de medicación de Farmacia a Hospitalización a Domicilio en un hospital urbano / Optimization of the medication circuit from Pharmacy to Hospital at Home in a urban hospital

Introducción: Se detectaron severas ineficiencias en los circuitos entre el Servicio de Far-macia Hospitalaria (SFH) y el Servicio de Hospitalización a Domicilio (HAD), lo que motivó la realización de un análisis, con el soporte de Calidad, y la definición e implementación posterior de varias acciones de mejora. Método: Análisis del flujo de medicación entre los SFH y HAD del Hospital Dos de Maig. Los objetivos propuestos fueron reducir las interrupciones a los profesionales, aumentar la eficiencia de los circuitos, y garantizar la disponibilidad de la medicación. Se identificaron ineficiencias en el sistema de solicitud y dispensación de medicación, y desajustes en la dotación y revisión del stock. Se acordó un cambio de modelo de dispensación, se ajustó la dotación del stock, se agilizaron las revisiones del mismo, y se aplicó una nueva herramienta de solicitud vía informática de medicación. Resultados: El equipo de HAD consiguió mayor autonomía, se redujeron las interrupciones entre ambos servicios y la dispensación ganó en seguridad. La dispensación global de fármacos fuera de stock disminuyó en un 61%, y los técnicos del SFH ganaron casi media hora diaria. Conclusiones: El cambio en la logística entre el SFH y HAD ha sido muy positivo, obteniendo unos logros importantes, que repercuten positivamente en la organización y en la seguridad del paciente, con un flujo de medicación más fluido y eficiente, y el registro sistemático de las entregas que incrementa la seguridad en la dispensación. (AU)

Introduction: Severe inefficiencies were detected in the circuits between the Hospitalary Pharmacy Service (HPS) and the Home Hospital at Home Service (HaH), which led to an analysis, with the support of Quality, and the defini-tion and subsequent implementation of various improvement actions. Method: Analysis of the flow of medication between HPS and HaH at Hospital Dos de Maig. The proposed objectives were to reduce interruptions to professionals, increase the efficiency of circuits, and ensure the availability of medi-cation. Inefficiencies were identified in the sys-tem of requesting and dispensing medication, and mismatches in the supply and review of the stock. A change of dispensation model was agreed, the stock was adjusted, revisions of the same were expedited, and a new application tool was applied via computer medication. Results: The HaH team achieved greater au-tonomy, interruptions between both services were reduced and dispensing became safer. The overall dispensing of out-of-stock drugs de-creased by 61%, and HPS technicians gained almost half an hour a day.Conclusions: The change in logistics between HPS and HaH has been very positive, obtaining important achievements, which have a posi-tive impact on the organization and the safety of the patient, with a flow of medications more fluid and efficient, and the systematic recording of deliveries which increases the security of dispensing.

Atención a pacientes con úlceras y heridas en un servicio de hospitalización a domicilio: estudio retrospectivo / Care for patients with ulcers and wounds in a home hospitalization service: a retrospective study

Introducción: Las Unidades de Hospitalización a Domicilio (HAD) atienden en sus domicilios a pacientes que precisan tratamientos de intensidad hospitalaria, que incluyen medicaciones endovenosas y cuidados de alta complejidad no asumibles por otro nivel asistencial.Objetivos:Cuantificar y describir los pacientes con úlceras y heridas en la HAD del Hospital Dos de Maig (HDM) de Barcelona durante de diez años.Método:Estudio retrospectivo y análisis de los pacientes con heridas llevados por la Unidad de Hospitalización a Domicilio del Hospital Dos de Mayo de Barcelona durante el periodo 2011-202. Variables recogidas: número de pacientes; estancias media y totales; etiología (presión, vasculares, pie diabético, complicaciones de heridas quirúrgicas, lesiones traumáticas con o sin celulitis); pacientes con tratamiento endovenoso y destino al alta.Resultados:1111 pacientes (12% del total ingresaron por úlceras o heridas o complicaciones de las mismas, con una estancia media de 14 días de ingreso (rango 1-79), sumando un total de 16.254 estancias. Etiologías: 447 complicaciones de heridas quirúrgicas, 252 úlceras vasculares y 187 úlceras por presión, 95 heridas traumáticas, hematomas o picaduras con celulitis, 56 amputaciones con complicación o dehiscencia, 54 heridas en pie diabético sin intervención quirúrgica y 20 post operatorios sin complicación en la herida. El 92% de pacientes requirieron tratamiento endovenoso. El 2% de los pacientes precisó ingreso imprevisto por complicaciones.Conclusiones:Las úlceras y heridas complejas con criterio de ingreso hospitalario son un motivo frecuente de atención en una HAD, con buenos resultados al alta. (AU)

Introduction: Hospital at Home Units (HAH) attend Patients than are hospitalized in their homes to receive intravenous treatments or complex wounds healing than cannot be done for another assistant level than hospital.Objectives:Demonstrate that wounds and ulcers have been treated in Hospital at Home services of Hospital Dos de Mayo(HDM) in Barcelona and record what type of injuries have been treated last 10 years.Method:Retrospective study and analysis of all the injuries taken by Home Hospitalization Unit of HDM in Barcelona during the period 2011-2020; variables collected: number of patients, average and total stays and types of wounds according to the following classification: pressure ulcers, vascular ulcers, diabetic foot, surgical wound complications, post-surgical intervention injuries without complications and traumatic injuries with or without cellulite; patients with intravenous treatment and destination at dischargeResults:The 12% of patients in HAH 1111(9327) were entered with a diagnosis related injuries or complications thereof, 14 average stay (1-79). They add up to a total of 16.254 stays. Classifications of wounds: 56 amputations with complication or dehiscence, 95 traumatic wounds and/or bruises with cellulitis, 447 complications of surgical injuries from trauma or general surgery, 54 diabetic foot wounds without surgical intervention, 20 post operative wounds without complications in the wound, 252 vascular ulcers and 187 pressure ulcers. The 8% don’t take intravenous treatment and only 2% required unexpected admission due to complications.Conclusions:Ulcers and complex wounds with criteria for hospital admission are a frequent reason for care in an HAD, with good results at discharge. (AU)

Executive summary of outpatient parenteral antimicrobial therapy: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases and the Spanish Domiciliary Hospitalisation Society / Resumen ejecutivo del tratamiento antimicrobiano domiciliario endovenoso: guía de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica y la Sociedad Española de Hospitalización a Domicilio

Outpatient parenteral antimicrobial therapy (OPAT) programmes make it possible to start or complete intravenous antimicrobial therapy for practically any type of infection at home, provided that patient selection is appropriate for the type of OPAT programme available. Although the clinical management of infections in the home setting is comparable in many respects to that offered in conventional hospitalization (selection of antibiotics, duration of treatment, etc.), there are many aspects that are specific to this care modality. It is essential to be aware of them so that OPAT continues to be as safe and effective as inpatient care. The objective of this clinical guideline is therefore to provide evidence- and expert-based recommendations with a view to standardizing clinical practice in this care modality and contribute to a progressive increase in the number of patients who can be cared for and receive intravenous therapy in their own homes

Los programas de tratamiento antibiótico domiciliario endovenoso (TADE) permiten iniciar o completar el tratamiento antimicrobiano por vía endovenosa de prácticamente cualquier tipo de infección en el domicilio, siempre y cuando se realice una selección del paciente acorde al tipo de programa de TADE que se dispone. Aunque hay aspectos del manejo clínico de las infecciones en el domicilio que son superponibles en la mayoría de los casos a la realizada en la hospitalización convencional (selección de la antibioterapia, duración del tratamiento, etc.), existen numerosos aspectos que son específicos de esta modalidad asistencial. Resulta imprescindible conocerlos para que el TADE siga siendo igual de eficaz y seguro que la hospitalización convencional. El objetivo de esta guía clínica es por tanto, proporcionar recomendaciones basadas en la evidencia realizadas por expertos para homogeneizar la práctica clínica de esta modalidad asistencial y contribuir a que se incremente progresivamente el número de pacientes que pueden ser atendidos y recibir tratamiento endovenoso en su propio domicilio

Executive summary of outpatient parenteral antimicrobial therapy: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases and the Spanish Domiciliary Hospitalisation Society.

Outpatient parenteral antimicrobial therapy (OPAT) programmes make it possible to start or complete intravenous antimicrobial therapy for practically any type of infection at home, provided that patient selection is appropriate for the type of OPAT programme available. Although the clinical management of infections in the home setting is comparable in many respects to that offered in conventional hospitalization (selection of antibiotics, duration of treatment, etc.), there are many aspects that are specific to this care modality. It is essential to be aware of them so that OPAT continues to be as safe and effective as inpatient care. The objective of this clinical guideline is therefore to provide evidence- and expert-based recommendations with a view to standardizing clinical practice in this care modality and contribute to a progressive increase in the number of patients who can be cared for and receive intravenous therapy in their own homes.