Anticoagulants; Increased, Asthma, Atrial Fibrillation Rapid, Chronic Kidney Diseases, Chronic Obstructive Pulmonary Disease, Gout Flare, Heart Failure, Hypertensive Urgency, Infection
Conditions
Keywords
home hospital, hospital at home, hospital in the home
Brief summary
This study examines the implications of providing remote physician care to home hospitalized patients compared to usual home hospital care with in-person/in-home physician visits.
Detailed description
Home hospital care is hospital-level care at home for acutely ill patients. In multiple publications, home hospital care delivered cost-effective, high-quality, excellent experience care with similar quality and safety as traditional hospital care. Most home hospital models require a licensed independent practitioner to see their patients physically in their home. To further improve the efficiency and scalability of home hospital care, the investigators propose to test remote care, where the physician would provide care via a video interaction, instead of in-home/in-person care. The investigators propose a non-inferiority evaluation of this intervention.
Interventions
OTHERRemote Visit
After an initial in-home visit, the physician will see home hospitalized patients by facilitated video.
Sponsors
Brigham and Women's Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Resides within either a 5-mile or 20 minute driving radius of emergency department * Has capacity to consent to study OR can assent to study and has proxy who can consent * \>= 18 years-old * Can identify a potential caregiver who agrees to stay with patient for first 24 hours of admission. Caregiver must be competent to call care team if a problem is evident to her/him. After 24 hours, this caregiver should be available for as-needed spot checks on the patient. This criterion may be waived for highly competent patients at the patient and clinician's discretion. * Primary or possible diagnosis of cellulitis, heart failure, complicated urinary tract infection, pneumonia, COPD/asthma, other infection, chronic kidney disease, malignant pain, diabetes and its complications, gout flare, hypertensive urgency, previously diagnosed atrial fibrillation with rapid ventricular response, anticoagulation needs, or a patient who desires only medical management that requires inpatient admission, as determined by the emergency room team.
Exclusion criteria
* Undomiciled * No working heat (October-April), no working air conditioning if forecast \> 80°F (June-September), or no running water * On methadone requiring daily pickup of medication * In police custody * Resides in facility that provides on-site medical care (e.g., skilled nursing facility) * Domestic violence screen positive * Acute delirium, as determined by the Confusion Assessment Method2 * Cannot establish peripheral access in emergency department (or access requires ultrasound guidance, unless point-of-care ultrasound is available) * Secondary condition: end-stage renal disease on hemodialysis, acute myocardial infarction, acute cerebral vascular accident, acute hemorrhage * Primary diagnosis requires multiple or routine administrations of intravenous narcotics for pain control * Cannot independently ambulate to bedside commode, unless home-based aides are available * As deemed by on-call MD, patient likely to require any of the following procedures: computed tomography, magnetic resonance imaging, endoscopic procedure, blood transfusion, cardiac stress test, or surgery * High risk for clinical deterioration * Home hospital census is full
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Adverse events, # | From date of admission to date of discharge (except for 30-day mortality), an expected average of 4 days | The per patient count of adverse events, including fall, delirium, potentially preventable venous thromboembolism, new pressure ulcer, thrombophlebitis at peripheral IV site, catheter-associated urinary tract infection, new Clostridium difficile, new methicillin-resistant Staphylococcus aureus, new arrhythmia, hypokalemia, acute kidney injury, transfer back to hospital, mortality (unplanned) during admission, mortality (unplanned) 30-day post-discharge. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Unplanned readmission after index admission, y/n | Day of discharge to 30 days later | — |
| Picker experience questionnaire, score | Day of discharge, an expected average of 4 days | Score between 0 and 15, with higher scores signifying better experience |
| Global experience, score | Day of discharge, an expected average of 4 days | Score between 0 and 10, with higher scores signifying better experience |
Countries
United States
Outcome results
None listed