Acute Pediatric Home Hospital Care

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Acute Pediatric Home Hospital Care

Julia Pian, BA,a_{Jean E. Klig, MD}a,b

Pediatric inpatient hospitalization can be lifesaving; yet it also can be costly and fraught with nosocomial risks. As of 2014, health care–related injury, morbidity, disability, or death occurs to 1 in 50 hospitalized children in the United States.1Some patients are admitted for common illnesses, yet their stay is prolonged by hospital-acquired infection, procedure-related complications, or other detrimental sequelae. As US hospital inpatient and observation units overﬂow with admissions, a new paradigm is needed to safely transition select lower-acuity cases to the patient’s home.

Pediatric home health care in the United States now primarily serves patients with chronic medical needs and those transitioning from hospital to home. Yet a new model can emerge as technology advances whereby children with certain acute illnesses are“admitted home”from the emergency department or outpatient center, with daily direct visits by mobile hospitalists and nurses and telemedicine monitoring as needed. Hospital-comparable services at home could include supplemental oxygen, intravenousﬂuids or medications, nebulized

medications, and select laboratory tests. Pilot programs can target uncomplicated cases of bronchiolitis, wheezing, pneumonia, dehydration, and cellulitis that otherwise would require observation or lower-acuity inpatient care. These 5 diagnoses alone constituted 20% of the∼2 million US pediatric inpatient hospitalizations in 2012.2If one-fourth of this cohort met“home hospital”inclusion criteria, 5% of pediatric

hospitalizations, or 100 000 children nationwide, could beneﬁt from the innovation. The model can also uphold the primary care therapeutic alliance by including the primary care provider in the acute care team, who can function as a partner in supporting the patient and family at home.

Acute home hospital pediatric care is not an established option in the United States, although programs exist in other countries. A randomized control trial of 399 children in England compared nurse-run home hospital with traditional inpatient pediatric care for common illnesses including bronchiolitis, asthma, and dehydration3and demonstrated equivalent overall clinical effectiveness. Patients and parents notably reported a preference for the home option, and the program continues to operate.

a_{Harvard Medical School, Harvard University, Boston, Massachusetts;}

andb_{Massachusetts General Hospital for Children, Boston,} Massachusetts

Ms Pian researched the topic and wrote the manuscript; Dr Klig provided mentorship and revisions on the manuscript; and both authors approved theﬁnal manuscript as submitted and agree to be accountable for all aspects of the work.

DOI:https://doi.org/10.1542/peds.2019-0074 Accepted for publication Oct 29, 2019

Address correspondence to Julia Pian, Harvard Medical School, Harvard University, 25 Shattuck St, Boston, MA 02115. E-mail: julia_pian@hms.harvard.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

FINANCIAL DISCLOSURE:The authors have indicated they have noﬁnancial relationships relevant to this article to disclose.

FUNDING:No external funding.

POTENTIAL CONFLICT OF INTEREST:The authors have indicated they have no potential conﬂicts of interest to disclose.

To cite:Pian J and Klig JE. Acute Pediatric Home Hospital Care.Pediatrics. 2020;145(6):e20190074

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Acute home hospitalization is gaining traction for adult patients in the United States. Several pilot projects exist, and theﬁrst published randomized control trial for acute care home hospitalization in 2018 revealed a 52% decrease in direct costs through home hospital as compared to regular hospital, with no change in adult patient satisfaction.4 Home hospital can safely decrease health care costs and preserve vital inpatient resources for more acutely ill patients. Both outcomes are essential, particularly as an

accountable care organization model emerges to reign in health care costs.

To envision a successful pediatric home hospital program, one can draw from lessons of the adult world, with pediatric-speciﬁc elements. A pediatric program must include education of the parent and/or guardian, a suitable home

environment for recovery, and unique symptom-monitoring approaches. These metrics are achievable over time and can have long-term beneﬁts. Parents and guardians can learn the skills needed to enable home hospital care for a child. Educating parents on clinical signs and proper supportive care applicable to many common childhood illnesses is a key goal. Evidence from the Sartain et al3home hospital trial revealed more

readmissions in the hospital group within theﬁrst week after discharge, suggesting that parents in the home hospital group may have gained skills that improved ongoing care.4

Enabling parents to attain skills in caring for their child during illness remains a key goal of pediatric care in all realms.

There certainly are barriers to overcome for pediatric home hospital to become a sustainable option in US health care. Health policy must support its development within the workforce and as accountable, affordable care. Pediatric home hospital could develop as a natural extension of the existing hospital

workforce for some institutions, although it may pose a challenge for other hospitals. Guidelines must be established to assure consistency of care, allow home hospital models to expand, and deter legal concerns. A randomized control trial introduced home oxygen therapy for infants with acute bronchiolitis and importantly revealed no difference in safety and efﬁcacy between home versus inpatient oxygen therapy.5Such promising results are unlikely to overturn established models of pediatric acute care without deliberate innovation and action. We can either continue toﬂex the capacity of our current pediatric observation and inpatient units or we can foster innovative pathways for comparable treatment at home in the future.

The medical components of pediatric home hospital must be carefully developed to ensure optimal outcomes. Realistic criteria are essential to identify pediatric patients who will beneﬁt from home hospital care and those who will not. A quantitative approach including retrospective data analysis can help establish inclusion and exclusion criteria, the latter targeting those at risk for a complication that may require intensive care. Such analysis can be used to identify both the appropriate lower age limits and the key clinical parameters (vital signs, urine output, etc) needed for a child to be eligible for home hospital.4 Current technology equips us to provide noninvasive, remote 24-hour vital sign monitoring to detect clinical status changes that warrant

intervention. Coupled with intensive parent education on signs of

deteriorating clinical status, similar to current return precautions at discharge, technology would allow the medical team to be aware of any impending changes and assure safety.

Although the home environment can seem less suitable for hospital-style health care, it is arguably a more

optimal environment for the recovery of a child. Hospitalization and/or separation from parents can have detrimental psychological effects. In a British study, 90% of parents and 63% of children stated a clear preference for home hospitalization, citing less psychosocial disruption and a perception that children recover more quickly with comfortable surroundings.3The parents also reported spending approximately the same amount of time taking physical care of their child in the hospital as compared to at home, with more time spent per day engaging the child in play in the hospital given the challenges of a new environment.6Appropriate screening methods for parental conﬁdence, skill, and overall bandwidth, including access to resources, health status, and job status, is key to success.

Reliably identifying patients whose home environments have no

impediments to physical recovery and are safe and accessible to health care providers is key. For example, a patient with an acute asthma exacerbation due to home

environmental allergens would not be eligible for home hospital.

Implementation in certain geographic locations may also not be initially possible, such as rural areas where the number of patients can be low and access to resources may be scarce.

We propose further exploration of acute pediatric home hospital as an option for the treatment of common illnesses in the United States. The design and testing of a pediatric home hospital system is not only timely but also will advance our understanding of clinical outcomes, cost, parent education on childhood illnesses, and the health care experience of both patient and family during acute illness. As the US health care system struggles to meet an ever-growing demand for inpatient beds, the home constitutes a promising environment

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for delivery of care to pediatric patients who require a lower-acuity hospitalization or observation-unit stay. It is possible to create a future in which we empower families to bring excellent clinical care home with their ailing child in a way that is safe, cost-effective, and family effective.

ACKNOWLEDGMENT

We thank Dr David Levine for his mentorship on the home hospital program at Brigham and Women’s Hospital.

REFERENCES

1. Berchialla P, Scaioli G, Passi S, Gianino MM. Adverse events in hospitalized paediatric patients: a systematic review and a meta-regression analysis._{J Eval}

Clin Pract. 2014;20(5):551–558

2. Leyenaar JK, Ralston SL, Shieh M-S, Pekow PS, Mangione-Smith R, Lindenauer PK. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States._{J Hosp Med}. 2016;11(11): 743–749

3. Sartain SA, Maxwell MJ, Todd PJ, et al. Randomised controlled trial comparing an acute paediatric hospital at home

scheme with conventional hospital care._{Arch Dis Child}. 2002;87(5):371–375

4. Levine DM, Ouchi K, Blanchﬁeld B, et al. Hospital-level care at home for acutely ill adults: a pilot randomized controlled trial._{J Gen Intern Med}. 2018;33(5): 729–736

5. Bajaj L, Turner CG, Bothner J. A randomized trial of home oxygen therapy from the emergency department for acute bronchiolitis.

Pediatrics. 2006;117(3):633–640

6. Bagust A, Haycox A, Sartain SA, Maxwell MJ, Todd P. Economic evaluation of an acute paediatric hospital at home clinical trial._{Arch Dis Child}. 2002;87(6): 489–492

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DOI: 10.1542/peds.2019-0074 originally published online May 28, 2020;

2020;145;

Pediatrics

Julia Pian and Jean E. Klig

Acute Pediatric Home Hospital Care

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DOI: 10.1542/peds.2019-0074 originally published online May 28, 2020;

2020;145;

Pediatrics

Julia Pian and Jean E. Klig

Acute Pediatric Home Hospital Care

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