Hospital in the Home: During a pandemic

Guideline number: QH-GDL-379-2

Effective date: 22 December 2023

Review date: 22 December 2026

Supersedes: Version 1

1. Statement
2. Scope
3. Related documents
4. Recommendations for HITH services
5. Approval
6. Version control

1. Statement

This guideline provides recommendations regarding best practice for public Hospital in the Home (HITH) services across Queensland in the event of a pandemic (e.g. COVID-19), which is defined as the worldwide spread of a new disease (refer Section 3. Related documents).

Unless mentioned in this guideline or Clinic-based Hospital in the Home (CBHITH): Block-funded facilities and Clinical Services Capability Framework Medical Services 3 and below, all other requirements under the HITH guideline remain applicable.

HITH is an essential service during times of healthcare crisis. HITH services provide a safe alternative to hospital-based care to increase healthcare capacity when the health system is under extreme pressure. When the World Health Organization (WHO) issues a pandemic notification (e.g. COVID-19) there are significant impacts on the health system, including the closure of services. As such, HITH services need to be agile and responsive to meet increased healthcare demand and to manage changing needs throughout pandemics.

During a pandemic, a high demand on health services is anticipated, with demand potentially exceeding supply. HITH services will be required to provide clinical interventions to patients who have the pandemic condition, in addition to treating traditional HITH patients.

HITH in Queensland is defined as providing care in a patient’s permanent or temporary residence, for conditions that require ongoing clinical governance, monitoring and/or treatment, as a substitution for in-hospital admitted care.

Note:

• An alternative patient preferred location can be requested by the patient, ensuring the rationale is appropriately documented in the patient record (where appropriate)
  

  AND/OR

• An alternative safe location can be nominated by the HITH service, ensuring the rationale is appropriately documented in the patient record (where appropriate)

During times of a pandemic, HITH services may support new functions of healthcare service delivery, such as treatments, procedures, and short-term restorative care.

2. Scope

The purpose of this guideline is to support best practice advice, and ensure standardisation of HITH admissions, processes, and reporting during a pandemic. This guideline provides guidance to public HITH services across Queensland and should be considered in the development of local HITH processes.

Compliance is not mandatory, however sound reasoning must exist for departing from the recommendations contained within this guideline.

3. Related documents

The following documents support the implementation of this guideline:

• Hospital in the Home guideline (inclusive of HITH suggested key performance indicators (KPIs)/minimum data set)
• Clinic-based Hospital in the Home: Block-funded facilities and Clinical Services Capability Framework Medical Services 3 and below
• Hospital in the Home: Standards of care (outlines standards that define the type and quality of care to be provided by Queensland public HITH services)
• Queensland Hospital Admitted Patient Data Collection (QHAPDC) Manual
• COVID-19 information for Queensland clinicians

4. Recommendations for HITH services

The following recommended requirements are provided to inform and support best practice in the event of a pandemic. Outlined recommendations correlate with applicable headings (where appropriate) in the HITH guideline.

It is recognised there may be multiple types of patient activity managed by HITH services during the pandemic.

Multi-day admitted HITH activity (COVID-19 or Non COVID-19)

To be assigned a code such as Home Ward care. All patients that meet the Queensland Health admission criteria, receiving hospital Emergency Department (ED) avoidance and hospital inpatient substitution are to be recorded in the HOME ward (as per Queensland Hospital Admitted Patient Data Collection (QHAPDC) Manual.

Admitted same day HITH activity (COVID-19 or Non COVID-19)

To be assigned a code such as HOME Ward care. All patients that meet the Queensland Health admission criteria, where care substitutes an admitted same day occasion of service are to be recorded in the HOME ward (as per QHAPDC).

Note: 

Non-admitted (outpatient activity) that does not meet Queensland Health admission criteria and there is no clinical decision to admit the patient, are to be managed through existing non-admitted systems using local clinic type identifier, and assigned a Corporate Clinic Code (CCC): for example 376 – Infectious Diseases – COVID19.

For patients in rural and remote areas

Due to the unique challenges, both cultural and geographical, faced within rural and remote Queensland, it is essential care is provided in a different and more flexible way. As such for patients that are COVID-19 positive that reside in rural and remote areas of Queensland it is recommended that these patients are admitted to a HOMECO ward with location of HCOV. These patients may not meet the admission requirements, however due to the tyranny of distance, the potentially reduced ability to access urgent medical support, the inability to meet isolation requirements or for cultural reasons, these patients may require greater monitoring, and therefore may need to be admitted. The Statewide Rural & Remote Clinical Network has developed a model of care in the Clinic-Based Hospital in the Home (CBHITH) – Block funded facilities and Clinical Services Capability Framework Medical Services 3 and below guideline (refer Section 3. Related documents) outlining the service requirements. Services are encouraged to follow this guidance to ensure safe practice.

4.1 Corporate and clinical governance

Corporate governance

HITH services are to be incorporated into Hospital and Health Service (HHS) pandemic plans.

Clinical governance

Clinical governance and responsibility for admitted patients remains under the admitting clinician and aligns to the most suitable inpatient admitting team or authorised officer, as clinically appropriate.

Clinical governance for non-admitted patients remains with the general practitioner (GP), as per standard billing arrangements.

4.2 HITH inclusion and exclusion criteria

Inclusion criteria

COVID-19 / pandemic positive patients

Physical environment:

• Admitted patients who are deemed by the treating team/Infectious Diseases to have a suitable home environment will be referred to HITH services to support home isolation and limit the risk of exposure to other home occupants.

Service modality and frequency:

• Where daily face-to-face visits may not be practicable, intervention can be undertaken through virtual technology, such as telehealth and Remote Patient Monitoring (RPM), where clinically appropriate.
• Whilst daily intervention is preferable, if deemed not practicable, intervention regardless of service modality (face-to-face or virtual) must occur every two days at a minimum.

Clinical criteria:

The following clinical criteria must be met for an admission and/or transfer of a Pandemic patient (COVID-19) to the HITH service:

Non-COVID-19 / pandemic patients

• Care to be given in the patient’s permanent or temporary residence, and only where aligns to the patient’s wishes, in a clinic or hospital setting (excluding medical review).
• Patients must have access to a telephone.

Exclusion criteria

Admitted patients who:

Specialty areas requiring further consideration for inclusion/exclusion

• If the patient or treating team requires access to specialist care, such as palliative care/mental health treatment which are unable to be provided at home.

4.3 Patient care

Admission/transfer of care

• A direct phone call referral system (24-hour) should be in place.
• A simple direct-referral process for GPs and ward transfer process from Emergency Departments should be developed and implemented. Specific pathways for patients with the pandemic condition should be developed and implemented, if clinically appropriate.

Management of the deteriorating patient

• Deteriorating patients should be identified and managed as per the usual local protocol, viz. via the Queensland Adult Deterioration Detection System (Q-ADDS) or the “Between the Flags” protocols (where in use).

Patient discharge

• Non-COVID-19 patients are discharged according to usual local protocols.
• COVID-19 patients are discharged as per current public health guidelines.

Patient education and health literacy

HITH patients should be provided with information regarding:

• self-isolation
• hygiene
• signs and symptoms of deterioration
• waste management.

4.4 Quality and safety

HITH services should:

• Create a local exposure plan for staff who may have been exposed to the pandemic condition and employ standard isolation practices according to local HHS protocol.
• Ensure adequate access to personal protective equipment (PPE) for staff.
• Educate staff on correct procedure to don and doff PPE.
• Ensure staff members don PPE as per protocol and place biohazard container and bag outside the place of residence, or treatment room (if applicable).
• Waste generated during the clinical care of suspected and confirmed cases of the pandemic illness should be disposed of as clinical waste. Local process should be followed to adhere to the correct process for managing clinical waste.
• Ensure staff clean equipment prior to putting it in the vehicle between patient encounters.
• Provide staff with emotional support and ensure there is adequate fatigue leave and access to employee assistance services as required.
• Develop staff wellness strategies to implement to support staff.

Death during a HITH admission

Services should:

• For non-COVID-19 patients, adhere to the local HHS protocol for management of death during a HITH admission.
• For COVID-19 positive patients, adhere to the local HHS protocol for management of the death of such a patient.
• Refer to Coroner Reporting requirements.

4.5 Corporate functions

Staffing workforce profile, training, and competencies

HITH services should:

• Employ the recommended PPE and relevant procedure (i.e. COVID-19 swabs) training as per current local HHS protocol.
• Provide training for staff regarding the new and emerging pandemic condition.
• Work with specialty services to upskill staff in specialist care e.g. palliative care.

Staffing models/requirements

HITH services should consider:

• Utilisation of student nurses and support staff to assist within their scope of practice to expand the reach of clinical service delivery (ensuring adequate clinical supervision is provided).
• Utilisation of acute redeployed staff to supplement the usual HITH workforce e.g. surgical outpatient department nursing staff.

5. Approval

Document custodian
Director, Healthcare Improvement Unit, Clinical Excellence Queensland (CEQ)
Approval officer
Executive Director, Healthcare Improvement Unit, CEQ
Approval date: 22 December 2023

6. Version control