Early Discharge in Adults With Respiratory Infection
We have shown that using defined criteria for recruitment and a defined interventional package, it is feasible for some patients with LRTI and pneumonia, who would otherwise have been treated in hospital, to be treated at home. Using our current model however large numbers of patients needed to be screened (n = 200) in order to recruit low numbers (n = 14). The ESDS package was successfully implemented in 7 patients with no adverse events. Randomisation was acceptable to patients and only deters those who do not wish to go home. The main obstacle to eligibility was lack of capacity to give informed consent. The number of eligible patients could be doubled if chronically confused or demented patients were included. Virtual visits (via telephone), rather than home visits may be adequate after the first 48 hrs after discharge.
The main strengths of this study are its novelty. We have been able to recognise common recruitment obstacles and find solutions to aid future project development. It has been noted previously in similar schemes that patient/carer refusal tends to reduce if a scheme becomes an adopted hospital service rather than a research project.
The weaknesses of this study are that it is a small feasibility study in a single city therefore no powered outcome data is available. The criterion of 'requiring at least one more night of hospitalisation' may be considered by some to be a weak criterion. The overall aim of the study is to reduce hospital bed days within a 'real-life' hospital setting in the UK. One more night of hospitalisation may be due to a variety of reasons and cannot simply be defined according to pre-defined signs or symptoms, as appropriate time for discharge for a patient with LRTI is physician-specific and no specific guidelines exist. We considered reasons that a patient would have 'taken up' a bed in hospital for at least one more night if ESDS were not available, these included: the need for further daily INR checks and low molecular weight heparin administration (with no facilities to have this performed immediately daily in the community), physician suggesting a further period of inpatient review for at least 24 hours after having changed from intravenous to oral antibiotics to ensure no pyrexia develops, no ability to get food supplies in at the patient's home until the next day and insufficient ward staff to organise oxygen delivery and transport the same day, all leading to delayed discharge. All patients recruited received more intensive medical care than standard hospital care due to clinician sampling visits; this may affect the results of satisfaction questionnaires. Questionnaire data may be subject to recall bias. Also day 0 was defined as the day that the patient was deemed fit to be discharged home with support and not the first day of illness or day of admission; therefore this may not have captured the peak impact of the illness on their symptoms.
Our study, like previous studies of AA and ESDS for CAP and LRTI have shown recruitment may be difficult. In one study, 985 patients needed to be screened to find 214 eligible and 84 recruits, of which 53 had a diagnosis of CAP, in another 540 were screened to recruit 25 in each arm of study. Low programme acceptance has been noted due to decline by physician (11%), patient (38%) or next of kin (36%). A study recruiting 55 patients with CAP in New Zealand in 2005 showed improved patient satisfaction by 40% (p < 0.001) and improved sleep but increased total days of care and no improvement in symptom score or function at 2 & 6 weeks. Other studies have shown reduced bed days and hospitalisation (12% reduction) and overall cost reductions of $1489 and $(CAN)1016.
We have previously shown in a retrospective study where two reviewers used pre-defined inclusion and exclusion criteria to assess eligibility to an ESDS, 48% of patients were deemed suitable for early supported discharge. The mean age of patients was 70 yrs old (range 18–96), 58% CURB-65 ≤ 2 and co-morbidities were common; COPD (30%) and dementia (15%). The total potential reduction in length of stay was calculated at 2.75 (range 1–7) days; amounting to a potential saving of 687,500 bed days annually in England.
The potential patient-related (reduced risk of HAI, care in own home, improved sleep, increased recovery rate, improved patient and carer satisfaction, reduced risk of delirium and later post-hospital discharge institutionalisation) and health-service benefits (reduced risk of HAI, improved self-management, reduced hospital LOS and therefore cost) are critical in assessing service impact. Strategies to increase the proportion of low-risk patients with CAP treated in the community have been developed and have been reported as safe, effective and acceptable to patients. There is an urgent need for more evidence regarding ESDS to facilitate the discharge of patients with more complicated needs, due to the increasing bed pressures on acute hospital trusts. A significant number of patients who have complex social/mental health needs or co-morbidities will however still require inpatient care.
Future developments to our model may include accepting patients in whom clear decisions have been made that no escalation in care is appropriate if after 48 hrs no improvement is seen as terminal care may be more appropriately delivered at home. Accepting patients on IV antibiotics and developing closer links with 'early response teams' in order to facilitate fast and effective discharge of more complex patients may be useful, as the numbers of hospital beds reduce in the UK.
We interpret our data to indicate that to improve recruitment future study directions should include: (1) Hospital logistics - working with hospital management to improve hospital systems to reduce time spent screening ineligible patients, increasing recruitment hours up to 12 hours-per-day, 7-days-per-week and improved ESDS 'marketing' (2) Medical conditions - the use of consultee declarations and retrospective consent allowing recruitment of suitable patients who lack capacity (3) Staff - improving physician education with regards to pneumonia and LRTI diagnosis and PE risk in order to reduce over-investigation/defensive practice, better study and clinical team integration (knowledge that the study team can reduce the team's workload by facilitating discharge and conducting out-patient appointments) thereby decreasing physician refusal and earlier patient contact with the study team, enabling closer relationships to be formed thereby reducing the likelihood of 'mixed messages'.
We estimate that by implementing the various methods described to overcome barriers to recruitment we could improve recruitment by 37.5%.
Discussion
We have shown that using defined criteria for recruitment and a defined interventional package, it is feasible for some patients with LRTI and pneumonia, who would otherwise have been treated in hospital, to be treated at home. Using our current model however large numbers of patients needed to be screened (n = 200) in order to recruit low numbers (n = 14). The ESDS package was successfully implemented in 7 patients with no adverse events. Randomisation was acceptable to patients and only deters those who do not wish to go home. The main obstacle to eligibility was lack of capacity to give informed consent. The number of eligible patients could be doubled if chronically confused or demented patients were included. Virtual visits (via telephone), rather than home visits may be adequate after the first 48 hrs after discharge.
The main strengths of this study are its novelty. We have been able to recognise common recruitment obstacles and find solutions to aid future project development. It has been noted previously in similar schemes that patient/carer refusal tends to reduce if a scheme becomes an adopted hospital service rather than a research project.
The weaknesses of this study are that it is a small feasibility study in a single city therefore no powered outcome data is available. The criterion of 'requiring at least one more night of hospitalisation' may be considered by some to be a weak criterion. The overall aim of the study is to reduce hospital bed days within a 'real-life' hospital setting in the UK. One more night of hospitalisation may be due to a variety of reasons and cannot simply be defined according to pre-defined signs or symptoms, as appropriate time for discharge for a patient with LRTI is physician-specific and no specific guidelines exist. We considered reasons that a patient would have 'taken up' a bed in hospital for at least one more night if ESDS were not available, these included: the need for further daily INR checks and low molecular weight heparin administration (with no facilities to have this performed immediately daily in the community), physician suggesting a further period of inpatient review for at least 24 hours after having changed from intravenous to oral antibiotics to ensure no pyrexia develops, no ability to get food supplies in at the patient's home until the next day and insufficient ward staff to organise oxygen delivery and transport the same day, all leading to delayed discharge. All patients recruited received more intensive medical care than standard hospital care due to clinician sampling visits; this may affect the results of satisfaction questionnaires. Questionnaire data may be subject to recall bias. Also day 0 was defined as the day that the patient was deemed fit to be discharged home with support and not the first day of illness or day of admission; therefore this may not have captured the peak impact of the illness on their symptoms.
Our study, like previous studies of AA and ESDS for CAP and LRTI have shown recruitment may be difficult. In one study, 985 patients needed to be screened to find 214 eligible and 84 recruits, of which 53 had a diagnosis of CAP, in another 540 were screened to recruit 25 in each arm of study. Low programme acceptance has been noted due to decline by physician (11%), patient (38%) or next of kin (36%). A study recruiting 55 patients with CAP in New Zealand in 2005 showed improved patient satisfaction by 40% (p < 0.001) and improved sleep but increased total days of care and no improvement in symptom score or function at 2 & 6 weeks. Other studies have shown reduced bed days and hospitalisation (12% reduction) and overall cost reductions of $1489 and $(CAN)1016.
We have previously shown in a retrospective study where two reviewers used pre-defined inclusion and exclusion criteria to assess eligibility to an ESDS, 48% of patients were deemed suitable for early supported discharge. The mean age of patients was 70 yrs old (range 18–96), 58% CURB-65 ≤ 2 and co-morbidities were common; COPD (30%) and dementia (15%). The total potential reduction in length of stay was calculated at 2.75 (range 1–7) days; amounting to a potential saving of 687,500 bed days annually in England.
The potential patient-related (reduced risk of HAI, care in own home, improved sleep, increased recovery rate, improved patient and carer satisfaction, reduced risk of delirium and later post-hospital discharge institutionalisation) and health-service benefits (reduced risk of HAI, improved self-management, reduced hospital LOS and therefore cost) are critical in assessing service impact. Strategies to increase the proportion of low-risk patients with CAP treated in the community have been developed and have been reported as safe, effective and acceptable to patients. There is an urgent need for more evidence regarding ESDS to facilitate the discharge of patients with more complicated needs, due to the increasing bed pressures on acute hospital trusts. A significant number of patients who have complex social/mental health needs or co-morbidities will however still require inpatient care.
Future developments to our model may include accepting patients in whom clear decisions have been made that no escalation in care is appropriate if after 48 hrs no improvement is seen as terminal care may be more appropriately delivered at home. Accepting patients on IV antibiotics and developing closer links with 'early response teams' in order to facilitate fast and effective discharge of more complex patients may be useful, as the numbers of hospital beds reduce in the UK.
We interpret our data to indicate that to improve recruitment future study directions should include: (1) Hospital logistics - working with hospital management to improve hospital systems to reduce time spent screening ineligible patients, increasing recruitment hours up to 12 hours-per-day, 7-days-per-week and improved ESDS 'marketing' (2) Medical conditions - the use of consultee declarations and retrospective consent allowing recruitment of suitable patients who lack capacity (3) Staff - improving physician education with regards to pneumonia and LRTI diagnosis and PE risk in order to reduce over-investigation/defensive practice, better study and clinical team integration (knowledge that the study team can reduce the team's workload by facilitating discharge and conducting out-patient appointments) thereby decreasing physician refusal and earlier patient contact with the study team, enabling closer relationships to be formed thereby reducing the likelihood of 'mixed messages'.
We estimate that by implementing the various methods described to overcome barriers to recruitment we could improve recruitment by 37.5%.
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