key: cord-0816732-iicyfguk
authors: Nogués, Xavier; Sánchez-Martinez, Francisca; Castells, Xavier; Díez-Pérez, Adolfo; Sabaté, Rosa Ana; Petit, Irene; Brasé, Ariadna; Horcajada, Juan Pablo; Güerri-Fernández, Roberto; Pascual, Julio
title: Hospital-at-home expands hospital capacity during COVID-19 pandemic
date: 2021-01-31
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.01.077
sha: d1ba8cbe5ff2356ea344b582f5c4266dde62536b
doc_id: 816732
cord_uid: iicyfguk

A COVID-19-specific Hospital-at-Home was implemented in a 400-bed tertiary hospital in Barcelona, Spain. Senior or immune-compromised physicians oversaw patient care. The alternative to inpatient care more than doubled beds available for hospitalization and decreased the risk of transmission among patients and healthcare professionals. Mild cases from either the emergency department or after hospital discharge were deemed suitable for admission to the Hospital-at-Home. More than half of all patients had pneumonia. Standardized protocols and management criteria were provided. Only 6% of cases required referral for inpatient hospitalization. These results are promising and may provide valuable insight for centers undertaking Hospital-at-Home initiatives or in the case of new COVID-19 outbreaks.

The COVID-19 pandemic posed as an unprecedented challenge for health systems. 23

At its peak, hospitals experienced a shortage of beds, doctors and supplies. 24

Similarly, senior physicians, whose experience and decision-making skills would 25 prove essential during the health crisis, faced a high risk of developing a COVID-19 26 infection due to their age 1 . Lack of personal protective equipment and 27 overcrowding in hospital facilities further increased their exposure to the virus 2 . 28

The cumulative result led to difficulties in providing quality patient care while 29 minimizing the risk of transmission of COVID-19 among patients and healthcare 30 professionals. 31

The city of Barcelona recorded its first cases of SARS-CoV-2 between February 22 nd 32 and 29 th , 2020. Peak incidence occurred 5 weeks later between March 23 rd and 33 29 th , 2020. In the area served by our hospital, peak incidence of new cases per 34

week was 178.5 per 100,000 inhabitants. After 15 weeks, the total number of cases 35 in our area was 3,642, with a cumulative incidence of 1,146 per 100,000 36 inhabitants (http://www.aisbcn.cat/wp-37 content/uploads/2020/06/20200605_QC-EPI.pdf). 38

Given that COVID-19 infections would create a burden on our center, especially 39 with respect to risk of transmission and availability of hospital beds and resources, 40 we established a COVID-19-specific Hospital-at-Home (COVID-HaH). Our center 41 has overseen a hospital-at-home program since 2000. It can currently attend 30 42 patients and has a staff comprising of seven nurses, three doctors, one clerical 43 worker and one social worker. It has maintained a positive relationship with 44 primary care services. Therefore, to take advantage of their experience and 45 logistical resources, we quickly built a new section called the COVID-HaH. Hospital-46 at-Home is defined by Bruce Leff as a community-based provision of services that 47 is usually associated with acute inpatient care and executed with different models 48 those who received traditional acute hospital care and will complete intravenous 52 infusions or orthopedic programs with multidisciplinary interventions, as well as 53 patients with conditions such as infections, heart failure, chronic obstructive 54 pulmonary disease and stroke. 55

In the last few years, implementation of Hospital-at-Home has risen in frequency 56 after reductions in mortality and complications and, conversely, increases in 57 patient satisfaction and cost-efficiency were demonstrated 5,6 . Several Hospital-at-58 Home models have been carried out, from exclusive support for conventional 59 hospitalization to reduce length of stay, to direct care of emergency room patients 60 to prevent a collapse in the system. However, admission criteria are restricted to 61 patients with specific conditions. Patients eligible include all those who reside in 62 specified geographic reference areas; live with family members, caretakers or in a 63 nursing home; and who (or whose family member) provides consent for their 64 admission and medication administration at home 3 . The most important reasons 65 that Hospital-at-Home has been implemented progressively within the last 20 66 years have been that it has demonstrated to be a great tool for reductions in 67 emergency department visits, hospitalizations, and costs 7 . The challenge that 68

Hospital-at-Home faces is how to adapt to new situations or diseases and integrate 69 technological or medical advances effectively for optimal patient care 8 . 70

Here we report the deployment and methodology of an Hospital-at-Home initiative 71 during a public health emergency and highlight its importance as a complementary 72 structure to such a crisis. Additionally, 634 patients were admitted to IHC with moderate or severe 141 pneumonia (Table 3 ). These patients were older than those in HaH and prevalence 142 of at least one comorbidity being present was 48.5%, Hypertension was the most 143 frequent comorbidity (49%), followed by chronic kidney disease (41%) and 144 diabetes (18%). J o u r n a l P r e -p r o o f

C Severe vomiting or diarrhea Other complications (cardiovascular, metabolic) §

* Walking 4 meters back and forth

Dyspnea at minimal exercise or worsening 354 §based on clinical criteria

Table 3: Instructions on Isolation and Hygiene Practice provided to Hospital-358 at-Home Patients with COVID-19

Single room for isolation, keep door closed at all times Maintain at least 2 meters of distance with co-inhabitants Wash hands with soap or an alcoholic solution before leaving the room Wear a mask outside of the room Good air circulation in the isolation room and all other shared spaces Wash the bathroom with bleach frequently Individual tools for cleanliness Individual bin with plastic bag fastener Discard gloves and mask in individual bin Wash clothes between 60º and 90º; do not shake clothing before placing it into the washing machine Wash dishes and utensils with soap and hot water Wash hands before handling food and after touching trash Clean surfaces frequently (nightstand, bed