key: cord-0924257-32uaw7ut
authors: Coloma, Emmanuel; Nicolás, David
title: Hospital At Home Units In The Post‐Covid 19 ERA
date: 2020-08-27
journal: Eur J Clin Invest
DOI: 10.1111/eci.13390
sha: e8972b4bfd839e811780fd9ecfc7262152a677ef
doc_id: 924257
cord_uid: 32uaw7ut

Since the start of the SARS‐CoV‐2 outbreak in China in December 2019 COVID‐19 has affected nearly 4,5 million people around the world, with almost 286,000 fatalities reported as of the current date(1). The World Health Organization declared COVID‐19 as a Public Health Emergency of International Concern on January 30(th), 2020 and on March 11(th) COVID‐19 was declared a pandemic disease(2). In Spain, first cases were diagnosed in early February, with the incidence peak occurring between the last week of March and the first week of April. At the time of writing this article 227,000 patients were infected and 26,000 patients had died of COVID‐19(1). The rapid spread of the virus and the severity of the disease has been a real challenge to the health systems of most affected countries, compelling to the transformation of hospitals in COVID‐19 monographic centres. In order to cover COVID‐19 overwhelming necessities, non‐COVID activity was reduced to the minimum, cancelling non‐urgent surgery, outpatient clinics and treatments, and diagnostic tests.

Since the start of the SARS-CoV-2 outbreak in China in December 2019 COVID-19 has affected nearly 4,5 million people around the world, with almost 286,000 fatalities reported as of the current date(1). The World Health Organization declared COVID-19 as a Public Health Emergency of International Concern on January 30 th , 2020 and on March 11 th COVID-19 was declared a pandemic disease (2) . In Spain, first cases were diagnosed in early February, with the incidence peak occurring between the last week of March and the first week of April. At the time of writing this article 227,000 patients were infected and 26,000 patients had died of COVID-19(1). The rapid spread of the virus and the severity of the disease has been a real challenge to the health systems of most affected countries, compelling to the transformation of hospitals in COVID-19 monographic centres. In order to cover COVID-19 overwhelming necessities, non-COVID activity was reduced to the minimum, cancelling non-urgent surgery, outpatient clinics and treatments, and diagnostic tests.

Once the acute phase of the pandemic is being overcome a new, unprecedented, scenario is challenging health systems. This post-COVID19 era is characterized, by one side, by the menace of a new COVID-19 outbreak, especially nosocomial outbreaks affecting high risk population, such as fragile and immunosuppressed patients. In the other side, safety of healthcare professionals is a major issue since the start of the pandemic, with high rates of infected workers causing fear and stress among health staff.

In order to create safe environments for both patients and workers, Hospitals will need to adequate spaces, ie. avoiding shared rooms and other service facilities, this is: Hospitals need to become "liquid". This objective can be difficult to achieve in antique, obsolete buildings, with rigid structures and spaces.

In this context Hospital at Home (HaH) Units appear as an ideal solution to palliate these deficiencies. Hospital at Home is defined as a model capable to provide twenty-four hours a day, seven days a week, hospital-level care at home without the need of conventional admission(3).

The benefits of the model, such as the better outcomes in terms of health recovery and costs has been published in literature (4) .This model has been worldwide implemented during the last 20 years, although with different idiosyncrasies due to different health system's policies. Spanish public health system has fostered the creation and implementation of strong and multidisciplinary HaH Units in both tertiary and secondary hospitals.

This article is protected by copyright. All rights reserved Previously to the SARS-CoV-2 outbreak, HaH were focused in avoiding conventional admission in patients consulting in the Emergency Room (ER) or in Primary Care (5) , and providing early discharge service for surgical and non-surgical hospital services(6) (Figure 1 ). HaH Units usually include nurse and medical staff with the support of administrative staff, physiotherapists, social workers and other professionals. Visits at home are performed by a nurse and a doctor, and along with clinical and physical assessment a variety of procedures are available such as blood test, microbiology cultures, bed-side ultrasound, midline placement, EKG, peak-flow, etc.

Personal protection equipment such as gloves, hat, glasses, facemask and gown are used when entering in the home of patients with indication for air or contact isolation (ie. drug resistant bacteria, influenza virus infection), assuring a safe contact for both patient and healthcare professional. HaH has recently proven to be not only a safe but also a less expensive alternative to conventional hospitalization, with costs up to 38% lower than a complete hospital admission (7) . Moreover, HaH are easily scalable devices, as nurse and medical staff volume can be adapted to the work load at each time, rapidly scalable in times of need, such as the influenza season in winter (8) 

This article is protected by copyright. All rights reserved and therefore the risk of nosocomial infections, HaH feasibility should be assessed for each patient admitted to conventional ward and reevaluated every 48h of admission. This strategy is remarkably useful in surgical services, in order to optimize discharge for non-complicated postsurgical patients, which has proved to be safe and improve patient recovery in different fields such as thoracic surgery or orthopedics (9) but also for complicated post-surgeries such as wound infections, orthopedic prosthetic infections, comorbidities decompensation, etc. In medical wards, early discharge should also be evaluated for every patient, especially in infected patients needing long antibiotic treatments such as infective endocarditis or osteomyelitis (10) .

Day Hospitals work as outpatient centers for evaluation, diagnosis and treatment of patients with chronical or subacute conditions. Examples of these are DH of Oncology or Hematology where patients receive chemotherapy and can be assessed without previous appointment in case of clinical worsening. Although DH are useful resources to replace hospital admission and also to avoid ER visits, can be a risky environment both for at risk patients and professionals, due to a high turnover and occupation rate and unknown COVID19 status. HaH Units may compliment DH services, providing home visits for programmed intravenous treatments (antibiotics, chemotherapy…) or clinical assessment and evaluation in acutely ill patients. Complex wound care is a great burden for DH, especially those of Dermatology or Vascular surgery. For these patients shared care between specialist and HaH is a safe alternative, providing wound care with specialized nurses at home, and telematic follow up of the wound by medical staff.

Finally, HaH Units have played different roles during the COVID-19 pandemic, but mostly provided first line care of COVID-19 patients at their homes or in medicalized civil buildings such as hotels (11) . During this period, HaH units have accumulated a large amount of experience in dealing with COVID-19 patients, the evolution of the disease and the criteria for HaH admission ( 

This article is protected by copyright. All rights reserved

In conclusion, we believe that HaH units are easily scalable, and with a cost effective growth capacity alternatives to conventional hospitalization. These units can play a major role in the reorganization of hospitals and health systems aiming to avoid unnecessary visits of the patients to health centers and therefore diminishing the risk of COVID-19 (and also other communicable diseases) nosocomial outbreaks and healthcare professionals infections. In order to protect patients and healthcare workers in a post-COVID 19 scenario, HaH units should be strengthened to assure pre-COVID quality levels in health assistance.

The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Both authors contributed to the conception, writing

World Health Organization. World Health Organization Health topics

Hospital at Home Program Cuts Costs, Improves Patient Health and Satisfaction

Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care

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Hospital at home in elective total hip arthroplasty

Outpatient Parenteral Antibiotic Treatment for Infective Endocarditis: A Prospective Cohort Study from the GAMES Cohort

Hospital at Home for the Management of COVID-19: A Case Series of 63 Patients

Accepted Article