Objectives To compare treatment of acute illness at home and in hospital, assessing safety, effect on geriatric complications, and patient/carer satisfaction. Design Randomised controlled trial. Setting A tertiary referral hospital affiliated with the University of New South Wales. Participants 100 patients (69% older than 65 years) with a variety of acute conditions, who were assessed in the emergency department as requiring admission to hospital. Interventions Patients were allocated at random to be treated by a hospital‐in‐the‐ home (HIH) service in their usual residence or to be admitted to hospital. Main outcome measures Geriatric complications (confusion, falls, urinary incontinence or retention, faecal incontinence or constipation, phlebitis and pressure areas), patient/carer satisfaction, adverse events, and death. Results There was a lower incidence of confusion (0 v. 20.4% [95% Cl, 9.1%–31.7%); P=0.0005), urinary complications (incontinence or retention) (2.0% [95% Cl, –1.8%, 5.8%) v. 16.3% [95% Cl, 6.0%, 26.6%); P=0.01), and bowel complications (incontinence or constipation) (0 v. 22.5% [95% Cl, 10.7%, 34.1%); P=0.0003) among HIH‐treated patients. No significant difference in number of adverse events and deaths (to 28 days after discharge) in the two groups was found (although numbers were small). Patient and carer satisfaction was significantly higher in the HIH group. Conclusions Home treatment appears to provide a safe alternative to hospitalisation for selected patients, and may be preferable for some older patients. We found high levels of both patient and carer satisfaction with home treatment.

older patients are at increased risk of readmission within 4 weeks of being sent home from the emergency department. It is possible to identify high-risk patients by a questionnaire. This allows targeting of these patients for more intensive follow-up in an attempt to ameliorate further deteriorations in their health.

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This study demonstrates that changes in care provision that result in shorter LOS and greater cost effectiveness may better meet patients' needs than existing systems.

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Objective: To study the clinical effects of re‐engineering the processes associated with elective surgery. Design: A prospective, historical controlled trial. Control patients were enrolled from March 1995 to January 1996, and postintervention patients from February 1996 to October 1996. Setting: A major teaching, tertiary care hospital (Prince of Wales Hospital, Sydney). Patients: 224 patients (123 before and 101 after the intervention) undergoing elective herniorrhaphy or laparoscopic cholecystectomy who lived in the local area. Intervention: Introduction of a re‐engineered surgical service consisting of preadmission assessment and education, admission on day of surgery, and postacute care after discharge. There were no changes to the operative methods or infection control procedures. Main outcome measures: Length of stay, operative complications, pain scores and patient satisfaction. Results: The risk of a patient suffering one or more complications was reduced in the postintervention group (postintervention v. control patients: 25.7% v. 38.2%; relative risk [RR], 0.66; 95% confidence interval [Cl], 0.44–0.98; P=0.035) because of a reduced risk of wound infections (5.0% v. 16.3%; RR, 0.30; 95% Cl, 0.12–.78; P=0.0075). Other complications (perioperative or postoperative) and pain scores were unchanged. Patients treated by the re‐engineered service had a significantly shorter length of stay, reported a higher level of satisfaction with the preoperative and postdischarge care, and were more likely to say that they would have the same treatment again (92.9% v 82.6%; P=0.037). Conclusions: Re‐engineering surgical services, with an associated reduction in length of stay, does not lead to a deterioration in care and may decrease postoperative complications and increase patient satisfaction.

Judging by reports in medical magazines and journals, 'early discharge schemes', better termed 'post acute care', are not popular with doctors. However, government policy encourages earlier discharge from hospital, so that the choice facing clinicians is to discharge patients early with support, or early without support, or deal with the consequences of length of stay overruns. Fortunately, government funding for post acute care is increasing. There is a strong rationale for post acute care based on better patient outcomes and cost-effectiveness, but these desirable results will only be achieved if scrupulous attention is paid to detail, as embodied in the 10 principles of post acute care. To function optimally, post acute care should be coordinated by the hospital which provided the acute care.