Doctor Visits

Doctors with equipped medical vehicles are ready to visit patients 24 hours a day

Nurse Visits

Registered nurses visit patients at home to perform procedures such as stoma and ulcer care, wound care, catheter replacement etc.

Hospital at Home

The patient is treated at home as if he were in a hospital...

Advanced Technology permits the provision of
Advanced Hospital Care in the patients’ homes

Elias Papazissis

Citation: Papazissis E. Advanced Technology permits the provision of Advanced Hospital Care in the patients' homes. In I. Iakovidis, P.Wilson, J,C. Healy (eds) e-Health-Current Situation and Examples of Implemented and Beneficial e-Health Application: IOS Press-Studies in Health Technology and Informatics. Amsterdam 2004;100:190 -199.

Abstract.

Improvements in disease management and the aging of populations in Western countries are the main factors that have resulted in a disquieting rise in demand for expensive hospital beds. The patient-centred and family-friendly concept “Hospital at Home” has recently appeared on the global scene of health services, promising to offer a solution. This type of service has proved to be very welcome to patients and those they live with.
However, Hospital at Home schemes reported in the literature are organized only to provide improved primary care services, usually to patients who are discharged from hospital a few days early and for the rest of their treatment. These services are mainly provided by nurses who perform one or fewer home visits a day and the medical contribution, if any, is limited to telephone consultations when necessary. Whenever something unusual happens the patient is readmitted. Some Hospital at Home settings, which are characterized as “admission avoidance”, actually include only patients with conditions so stable that they might have stayed at home anyway, with some good primary care support.
Yet Hospital at Home has much more to offer. Incorporated in the administrative structure of a hospital as real wards, manned with doctors, nurses and other health professionals on 24-hour duty in shifts and providing frequent –at least twice a day– regular home visits by doctors and nurses, Hospital at Home can reproduce real hospital conditions in the patients’ homes.
Portable medical devices enable the performance of a wide range of examinations at home, while information and communication technology neutralizes distances and makes collaboration between the virtual team and other contributors feasible and effective. Almost any patient whose condition neither requires prompt surgical operation nor meets the criteria for admission to an intensive care unit can be safely hospitalised at home, provided that he is attended by a properly organized, properly equipped and highly alert Hospital at Home service.

Introduction

From prehistoric times and for ages afterwards pain, injury, illness, and natural forces in general, so much exceeded human power that man practically surrendered himself to superstition. Therapeutic interventions were limited to palliative treatment, such as cold poultices on a febrile patient. Any other attempt at healing was desperately experimental and usually ineffective. Doctors were people who felt a real calling to relieve human suffering, both in body and mind, often at considerable self-sacrifice. And of course very often an evil incentive led some other people to call themselves “doctors”, to invent fake “therapeutic techniques” and maliciously benefit from the suffering of their fellow men.
Although Hippocrates and other brilliant figures did not effectively manage to dissolve the darkness in knowledge, the contribution of their wisdom to our civilization is an invaluable legacy. They gave the moral orientation by which today’s medical ethics are guided.
In the last two centuries things changed dramatically. The nature of diseases started to be discovered one by one. Illnesses began to be attacked at their root and the light of science irreversibly replaced the darkness of ignorance.
A major characteristic of the industrial revolution was the concentration of production in large units, which was the means to achieve massive productivity of goods. Medicine could not escape this process. The rapid development of technology and the substantial understanding of biology led to an increasingly sophisticated management of disease. We passed from the healers’ art to the industry of treatment. The diagnosis and treatment of disease increasingly demanded both the contribution of doctors of different specialities and the availability of expensive facilities. So the model that prevailed was the hospital.
From prehistoric times man’s warmest shelter has always been his dwelling place, where his body and mind could relax. No matter if it was a cave or a hut, a vessel or an igloo, a peaceful house in a forest or an apartment in a city, man has always had a warm feeling of safety and protection at home. Home Care first appeared at the dawn of the 20th century. The Home Care concept embodies the idea of relieving a person’s pain in the place that gives the greatest mental calm: the patient’s own home. Today home care is available in at least 63 countries and probably in the near future almost all nations of the world, both developed and developing, will have to provide increasing quantities and varieties of home care services.
Most recently the increasing pressure for acute hospital beds has given birth to a new type of home care, which is specifically defined as the “provision of health care services to patients at home, who otherwise would have to be treated in hospital”. This type of home care, named “Hospital at Home” or “Hospital in the Home”, is the most advanced version of home care, aiming to provide a hospital setting in the home environment. The challenge is to achieve this shift of services from hospital to home, without depriving the patient of the undoubted benefits of biotechnology and expertise found in the hospital environment.

1. Home Care in the World

The system has its roots in the USA, which is the country with the longest tradition in home care provision. The first associations appeared between 1885 and 1889, when home was the workplace for most nurses. , By the year 1905 455 visiting nurses were employed by 171 associations. Today there are as many as 20,215 home care organizations in the USA, providing home care to more than 7 million residents, services which cost over $38 billion every year! Although today most countries seek for randomised controlled trial evidence to decide whether they will support the development of home care, the Americans are so accustomed to the home care notion that they spend these huge amounts of money on home care provision without RCT evidence.
In January 2003 the Canadian Government committed itself to the 2003 First Ministers Accord on Health Care Renewal, in recognition of Canadians’ views, to provide a first dollar coverage for a core set of fully portable acute home care services to be available by the year 2006.
In the UK 2.7 million contact hours of home care were provided to around 424,000 households, during a survey week in September 1999.
World Homecare and Hospice Organization (WHHO) made in 1995 an attempt to collect in one place information on what home care services were available in each country of the world. After soliciting 187 countries, 63 of them reported that some form of formal home care services was in current operation in their countries.
Assistance to the disabled, nursing, health education, palliative treatment, social work, physiotherapy, rehabilitation, vaccinations, wound care, are some of the vast fields in which home care has its predominant role.

2. Hospital at Home. The International Scene and Present Innovations.

Increased life expectancy and the consequent aging of the population, along with the recent and ongoing improvements in disease management, have led to an increasing pressure for hospital beds in almost all countries. Any alternative that could relieve this pressure would obviously be very welcome.
During the last few years the idea of providing care at home, so as to save some length of stay, has emerged and, being fascinating, promising and challenging, it has been realized in a few schemes. Although these practices are actually advanced Home Care services, they are usually called “Hospital at Home” or “Hospital in the Home”, to be discriminated and evaluated separately from more conventional home services.
Most of the reported Hospital at Home settings are mainly oriented to early discharge of patients, previously treated in hospital and usually for the last few days of their treatment, when minimal interventions are required. Some Hospital at Home are called “admission avoidance” or “total episode substitutions”. However these patients are initially evaluated in the emergency room of a hospital and usually hospitalized for one day. Furthermore only patients who have a definite diagnosis and whose conditions require very “light” support are judged to be eligible for Hospital at Home. In almost all of the cases care is offered only by nurses and in very few of them is there some contribution by general practitioners. There is no reported Hospital at Home in which hospital-like activities take place at home.
In this chapter we shall describe how hospital conditions can be efficiently reproduced at home with proper administrative structures and assisted with the support of present and future technologies.

3. From Hospital to Home: The Evidence

Several small randomized controlled trials (RCTs) have been carried out to evaluate Hospital at Home set up by hospitals, to early discharge patients most commonly with stroke, hip fracture, knee replacement, deep venous thrombosis, cellulitis and exacerbations of COPD. Parameters considered for evaluation were safety, cost effectiveness (better results at same cost) or cost efficiency (similar results at lower cost), patient and carer satisfaction. A few studies have examined the impact of Hospital at Home on prevention of hospital-related problems such as exacerbation of dementia, depression, bowel or urinary incontinence.
Almost all authors agree that there is a higher degree of patient satisfaction in patients treated at home, than in hospital. However all reviewers agree that evidence is insufficient to show the impact of Hospital at Home on slowing down the health care cost escalation and on management of hospital beds.
Due to the variation of conditions managed, small size of the studies, variable degrees of care intensity and different methodologies, results are often contradictory.

4. What is a Hospital?

The first reported hospital was created by the Christian Orthodox Church in AD 300-400. A large variety of disparate places and institutions have been called hospitals since then. Hospitals in nunneries, mobile military hospitals on the battle-field, asylums, psychiatric hospitals, sanatoriums and modern general tertiary hospitals. What is that specific element, which is common in everyone of them and without which an institution would not continue to be a hospital anymore? For example there are, or have been reported, hospitals without operating theaters, without intensive care units, without emergency departments and even without laboratories. Yet the element of short distances between patients, facilities, doctors and nurses has always been there and it is exactly that which characterizes a hospital and facilitates:
1. Teamwork
2. Close observation of patients
3. Smooth diagnostic and therapeutic flow.
4. Rapid intervention in case of life-threatening complications.
If we move a patient from a hospital to his or her own home, these distances become inevitably much longer. How can we overcome this barrier?
In this chapter we shall describe how the application of an advanced Hospital at Home model, with the support of modern technology, can overcome, can neutralize the disadvantages of having a patient away from a hospital. In other words how we can make the inevitably long distances become virtually short.
Let’s follow the elements of the hospital model one by one and examine the techniques and the structures with which we reproduce them in the Hospital at Home model.

5. The Proximity between Nurses and Patients

In a hospital nurses are NEAR the patients. The benefits deriving from this proximity are that nurses can easily perform regular ward rounds, to record patient’s vital signs, to monitor rates of solution infusion, to administer medication on time according to schedule and to hurry back to any patient, when something goes wrong.
In the Hospital at Home model teams of nurses and assistants also perform every day as many regular home visits as required, to record vital signs, to monitor infusion rates and to administer medication on time via any route (IV, IM, PA, SC etc). They also remain on call for additional home visits, if required, as for example for implementation of a new care plan following the doctors’ instructions, or to correct the patency of an IV line when a problem is reported.
Acquisition of vital signs and other biosignals such as ECG can be alternatively and additionally accessed from a distance, provided that they are continuously recorded with the use of bedside monitors. Nurses, doctors or other appropriate and authorized health professionals can have remote access to these data via telephonic or other connection (GSM, GPRS etc). This technology provides maximal and rapid information, without necessarily the physical encounter between nurses and patients. Telematic transmission of “heavy” information such as pictures and videos, which was very difficult some years ago, is now obtainable in sufficiently good quality. Cameras that can be tele-controlled allow health professionals to monitor patients as from the bedside. However it should be stessed that patients’ rights to privacy have to be thoroughly addressed, respected and secured.
Electronic IV pumps are a good example of automation in patient’s treatment, which is abundantly available and widely used. They secure both constant infusion rates and automatic administration of medication at scheduled intervals, as they permit constant and intermittent infusion at once. Furthermore they provide security by giving alarm at any flow obstruction or at any presence of air in the infusion line. The operation of such devices is easy to control from a distance. For safety reasons nursing personnel on call must stay alert, so as to rapidly access the patient, in any case of malfunction.

6. Patients’ Access to Major Facilities

The diagnostic process often requires examinations such as computerized tomography (CT), Magnetic Resonance (MRI), Nuclear Medicine, Positron Emission Tomography (PET) etc. The decision to proceed to a new examination is not always predictable, but rationally based on clinical thought in the light of the latest acquired results of other examinations. On the other hand, for the patient’s safety and treatment’s effectiveness, the diagnostic process has to be completed as quickly as possible. Hence the benefit of having a patient in a place where all these laboratories are established is more than obvious.
Technological improvements in making the machines required for such examinations less bulky are amazing and ongoing, but still incapable of shifting the standard place of performance from hospital to home. Portable computerized tomographers are today in use by many hospitals. They are mainly used in intensive care units for critically ill patients whose transportation is better avoided. They weigh not more than 450 kg, they can be easily transported on elevators and through corridors, and can pass through 90 cm doorways! The expectation that portable CT scanners will be much lighter and that they will be easily carried from home to home in ordinary vehicles in the future is absolutely reasonable. However we should not expect that any of the above-mentioned facilities will be abundantly available in the home environment in the near future. Patients for long time ahead will inevitably have to be transferred to hospital for some examinations, but they may return to their homes as soon as a group of examinations is completed. Such a scheme to be beneficial in terms of patients’ safety and satisfaction has to ensure:
1. Easy access to laboratories without time-consuming negotiations or waiting lists.
2. Transportation of patients with minimal discomfort.
3. Rapid acquisition of results and prompt information to the attending doctors.
The degree of achievement of any of these tasks is an indicator of good Hospital at Home performance, insofar as they reproduce in-hospital conditions.

7. The Era of Portable Devices

As the development of micro-electronics permits the manufacture of more compact devices, the list of high-tech examinations which can be performed by portable equipment, becomes longer and longer.
Portable X-ray units are nowadays sufficiently reliable. The use of digital cassettes provides extra quality and brings digital x-ray technology into the patients’ homes. Portable real time digital radioscopy with laptop connection is now commercially available for dentistry, , so it is expected to be soon available for medical examinations too.
Encephalography, electromyography, sleep apnea study, and spirometry are some examples of examinations out of many which can be easily performed at home.
Portable ultrasonography machines are getting impressively small, light and effectively compete with the capacity of the big units. However, ultrasonography is a highly counteractive examination requiring the “real-time” involvement of a highly experienced doctor. The reliability of the examination is directly dependent on the doctor’s expertise. Moving such an experienced doctor from home to home will reduce his productivity with concomitant increase of the examination cost and thus adversely influence cost-efficiency.
Schemes in which general practitioners perform the u/s scanning and send videos and/or still images, in real time or not, to specialists for confirmation of diagnoses have been evaluated in some small studies. Until enough evidence is there to prove the sufficient degree of validity in such practices and until standards are agreed and established, they cannot be recommended for clinical application at the present. Yet another amazing facility is already a reality: robotic remote control of ultrasound machines! , Although this sounds like something out of science fiction, it will be a part of everyday clinical practice, sooner than expected.
Endoscopy of the alimentary tract is at almost the same stage of interactivity as ultrasonography is. Furthermore endoscopy requires extra skills, causes more discomfort and implies more risk to the patient than ultrasonography. On the other hand still endoscopic pictures are much more useful than still ultrasound images. So, provided that a general practitioner’s skills are sufficient, telemedicine consultation with specialists may result in comparable results with conventional endoscopies. However the development of the most fascinating endoscopic capsule is clear reassurance that new brilliant technology is on its way here to give us new convenient alternatives. We only have to wait for its arrival.

8. The Close Working Relationship between Doctors and Nurses.

In a hospital the patient’s unique care record is usually somewhere in the small physical space between his bed, the nurses’ station and doctors’ office. Any examination result or report is immediately filed in it. The nurses update it with the last measurements of vital signs, look for new doctor’s instructions and check the medication card, as soon as they administer a new dose. Doctors can easily access the file, they get the new information and write their instructions, which are promptly implemented by nurses. The file with the ongoing information, the instructions and the feedback from implementation of the instructions are quickly transferred between different persons. It is essential that these persons are physically very close to each other, otherwise this process gets very slow, with an inevitably adverse impact on the patient’s safety.
In the Hospital at Home setting involved persons who need to exchange information may be at any time located in different places in a usually large geographic area. Thus a traditional paper patient-file would be of little value and make the system so inflexible that the eligibility criteria of patients to be treated would have to be limited to very simple cases.
An advanced Hospital at Home clinic can hardly be efficient enough to avoid admission of acutely ill patients, without a powerful patient management software application. The file is “virtual” so as to counterbalance the burden of distances. The “virtual” file enables handling of the same patient’s record by different care workers at different places simultaneously. Data are promptly uploaded to the server from anywhere, so whenever the patient’s file is re-downloaded to any laptop it has been updated with the new lab results, vital signs and all the other doctors’ and nurses’ remarks. Doctors get quick information from nurses and nurses rapidly undertake and follow doctors’ instructions for implementation.

9. Doctors NEAR their Patients

Doctors in a hospital visit the patient regularly on at least a daily basis, to closely follow his condition. Doctors of different specialities are often asked to visit the patient and contribute with their consultations to the diagnosis and treatment.
In the advanced Hospital at Home medical teams perform regular “ward rounds” once or twice a day, as they would do in a hospital, by performing home visits. Telemedicine facilities such as transmission of pictures, videos, sounds from electronic stethoscopes and bio signals and on the other hand a complete multimedia medical record greatly reduce the necessity of physical bedside presence of other specialists, who can contribute with their excellent expertise from a distance.
The most important of all, is that doctors in a hospital are there near the patients, to act rapidly, in case a life-threatening condition occurs. In any Hospital at Home setting, a lot of attention has to be paid, in order to reproduce in-hospital conditions in such adverse situations. Medical and nursing teams have to be on a “round the clock” alertness, to quickly access the patient, and they also have to be trained, experienced and properly equipped, to be able to act at the site of the crisis and provide aid, exactly as they would do in the emergency department of a hospital.
Whenever the patient’s safety requires, bedside nurses in shifts on a 24-hour basis, in continuous communication with the doctors, can act with therapeutic life-saving interventions, within seconds after the occurrence of a complication, or discontinue infusions of specific medications as soon as a critical condition is controlled. Such a structure makes conditions at home resemble those in a high dependency care unit.
If the complication requires admission to hospital, airway patency, oxygen supply, venous canulation, fluid replacement and prompt initiation of standard treatment have always to be secured prior to the transportation, so as to be done with the maximum safety.

10. Eligibility of Patients. Selection Criteria

Some Hospital at Home studies adopt very narrow eligibility criteria, which exclude for example any patient who requires intravenous therapy, whereas some others dare include more acutely ill patients.
Safety is closely related to the efficiency of the supporting mechanism. Thus standards on inclusion and exclusion criteria for Hospital at Home, have to thoroughly address the following parameters:
1. Nature of the disease to be managed, co-morbidities and the risk of life-threatening unforeseen complications.
2. Intensity of care (degree of monitoring)
3. Efficiency of the service (skills of doctors and nurses, equipment).
4. Response of the service (maximum time from the report of a complication to access the patient). All possible adverse situations such as traffic hold-ups have to be considered.
Well organized Hospital at Home units with high capacity regarding the above key-issues can provide complete substitution for hospitalisation in a wide range of both acute and subacute conditions.

11. Is Hospital at Home Cost-Effective?

Many attempts have been made to prove the cost-effectiveness or the cost-efficiency of hospital at home. However there are many variables influencing the results such as:
1. Conditions managed at home are very variable; they require different types of intervention (IV infusions, SC injections, inhalations, physiotherapy) and different quantities of resources.
2. Substitution of the final (less costly) days of hospitalisation, or the whole episode.
3. The total length of stay may be longer in some mixed schemes, than it would be with in-hospital treatment alone.
4. Cost of in-hospital treatment is difficult to evaluate. Most of the studies take into account the price which the insurance has to pay but not the real costs.
5. Insidious costs (involvement of informal carers) and unapparent cost savings (helping family members not to decrease their professional productivity because of their relative’s illness) were not addressed. Furthermore the economic significance of the social benefits (convenience of the family) has never been.
These barriers have led to confusing and contradictory results of economic evaluation of the system, with some studies concluding that Hospital at Home is less costly than in-hospital care and others not.
Complete and careful addressing of all cost-influencing parameters is imperative. Any bias in economic evaluation has to be eliminated in future studies. Moreover hospital at home should not be regarded as a standard concept, leading to false comparisons between unlike services. An attempt at classification of comparable Hospital at Home schemes into categories would be very helpful.

12. Go ahead or not?

It is a global experience that health professionals are usually resistant to adopting new technology, particularly when technology is not directly practice-oriented but aims to facilitate work, to increase productivity and to ensure safety, as information and communication technology does. On the other hand preventable medical errors have proved to be a leading cause of death. In the US alone deaths due to avoidable adverse medical events (at least 44,000 every year and possibly as many as 98,000) exceed the deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297) or AIDS (16,516)! Information and communication technology has been proved able to prevent most of these errors , saving thousands of lives.
Although safety can stand alone as a reason for tuning into the technological wavelength of the present and the future, safety is not the only benefit. The World is changing, so people, attitudes and styles of life do. Technology opens horizons. Man has the choice to fly over them. And he does. It is a historical ironlaw that has never failed yet. Once technology has opened the way to safe, advanced hospital treatment in the home environment and people are happy with the idea, nobody can stop its evolution. It will definitely take place sooner or later.

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X-Rays at Home

X-rays are easily performed at home with the aid of digital technology without any patient discomfort. They are digitally developed during the visit and they can be sent by e-mail to any recipient.

Bedside blood tests

Important blood examinations can be performed during a doctor's home visit in only a few minutes:

BUN, Glucose, Creatinine, Potassium, Sodium, Hematocret, Hemoglobin, Anion gap, Blood gases, Lactate, PT/INR, Troponine, BNP.

These blood tests help the doctor to promptly correct any severe abnormality such as water and electrolyte disorders, hyperglycemia etc. or to diagnose early life-threatening conditions such as MI or hypercapnia.