“Hospital at Home” for Neuromuscular Disease Patients With Respiratory Tract Infection: A Pilot Study

Abstract

BACKGROUND:The "hospital-at-home" model may provide adequate care without an adverse effect on clinical outcome, and is generally well received by users. Our objective was to compare hospital-at-home and in-patient hospital care for neuromuscular disease (NMD) patients with respiratory tract infections. METHODS: We conducted a prospective randomized controlled trial in a university teaching hospital offering secondary care service to a population of approximately 500,000. We recruited selected NMD patients with respiratory tract infection for whom hospital admission had been recommended after medical assessment. Hospital-at-home was provided as an alternative to in-patient admission. The main outcome measures were need for hospitalization, treatment failure, time to recovery, death during the first 3 months following exacerbation, and cost of patient care. RESULTS: Among 59 consecutive NMD patients eligible for the study, 53 met the criteria for hospital-at-home. Twenty-six subjects were randomized to home care and 27 to hospital care. No significant differences were found in treatment failure (8/26 vs 13/27, P ‫؍‬ .19), time to recovery (8.9 ؎ 4.6 vs 9 ؎ 8.9 d, P ‫؍‬ .21), or mortality at 3 months (3/26 vs 4/27 deaths, P ‫؍‬ .42) between the groups. Hospital-at-home failure was independently correlated with type of NMD (P ‫؍‬ .004) with an odds ratio of failure of 17.3 (95% CI 2.1 to infinity) for subjects with amyotrophic lateral sclerosis. The total and daily direct cost of patient healthcare was significantly lower for the subjects who were successfully treated at home, compared to the hospitalized individuals. CONCLUSIONS: Hospital-at-home is an effective alternative to hospital admission for selected NMD patients with respiratory tract infections.

What are physiotherapists and occupational therapists doing in services that replace acute hospital admission? A systematic review

“…One role that was uniquely reported among physiotherapists, and not shared with OTs, was respiratory interventions (three included studies), although the level of detail of what this included was similarly variable. Two of these studies, provided no indication of the criteria for respiratory physiotherapy intervention, although in one it appeared to be standard practice for all patients to receive basic respiratory physiotherapy.…”

“…Two of these studies, provided no indication of the criteria for respiratory physiotherapy intervention, although in one it appeared to be standard practice for all patients to receive basic respiratory physiotherapy. The third included study reporting respiratory physiotherapy interventions included only patients with respiratory compromise . Objective markers (eg, oxygen saturation and changes in ventilator requirements) were used in this study to determine timing of input and to guide length of treatment sessions.…”

“…In HaH services (n = 3), a limited number of roles were reported, both specific to therapists (Figure A) and among teams overall (Appendix ). Only physiotherapist provision of respiratory interventions was reported in more than one included study (two studies). The other reported roles in HaH teams were reported only once each.…”

“…A number of the reported roles have been investigated in other healthcare settings—for example, passive range of movement following shoulder arthroplasty, ADL practice, mobility practice, task‐specific training and augmented coughing . Additionally, services replacing acute hospital admission, including those in the studies included in this review, have demonstrated effectiveness in improving patient and service level outcomes (eg, lower cost, greater short‐term survival and reduced readmission rate) following presentation for an acute deterioration in health status . Given that at least some of the roles that therapists are undertaking in these services have proven effective in other contexts, the absence of evidence within this setting is not evidence of absence of effect …”

Practical approach to respiratory emergencies in neurological diseases

“…In these patients, the best and easiest parameter used to monitor respiratory muscle strength is FVC. Patients who have an FVC < 50% of predicted value should be trained in protocols that allow successful home treatment managed by well-trained family members or healthcare professionals during respiratory exacerbations [50,62].…”