Dr Michael Montalto: Hospital in the Home

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Dr Michael Montalto

Dr Michael Montalto describes the Hospital in the Home programme in Victoria, Australia, at The King's Fund's implementing primary and acute care systems conference.

Dr Michael Montalto - Hospital in the Home

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Dr Michael Montalto - Hospital in the home

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This presentation really is about an unusual kind of health service. It’s kind of a mutation that grew out of a 20 year old quite experimental health policy, but over that time it’s become a very important aspect of the way we deliver acute hospital services in my state.  So today hopefully what I’ll do is... is examine the general factors contributing to Hospital in the Home, then describe a little bit about the specific issues and evaluation in Victoria, and if I’ve got a little time we’ll talk about the future.

The point I want to make here is that for a couple of millennia, before Florence Nightingale, all acute care was totally portable. The components were all there, it’s just that the best of care was delivered outside of hospitals and there was no obligatory link between being in a hospital bed and receiving good acute care.  That’s changed obviously in the last 120 years, and I guess the conceptual point I want to make is that in that change, in linking a person who is unwell, who is resident in a hospital, the intellectual property of hospital care, the technology around hospital care, has been based on the assumption that we will have a body in a bed in an institution, and that’s then led to further cementing of the relationship between acute care and the hospital over that period of time.

So in the context of that I want to talk about what... what Hospital in the Home is, and unfortunately there isn’t an eminent international reference group I can give you a consensus statement from so you’ll have to take this on my word, and as far as I’ve concerned what I’m talking about is the management of patients in their own homes where otherwise that patient would require traditional hospital admission. So what that means is that this is a substitution service, it requires, as I’ve said, the kind of staff, the kind of skills and the kind of technologies that are currently only maintained in acute hospitals, and so what that’s doing is addressing... challenging that conceptual link that’s been firmly entrenched for a long, long time.

So why... why challenge that link? Why think about Hospital in the Home?  Generally speaking some of these things are obvious to you and we have had no net growth in public beds, we’ve lost public beds, as have many systems throughout the world.  Health in Australia sits at about 9% of GDP and is not going to move, there’s the rising cost of capital and land to build new beds, and over the last 20 years the discussion has been... as you’ve had this morning... around system capacity rather than bed capacity, and bed capacity is not necessarily any more the proxy for acute care capacity.  And just to plot that for you, at least in our context, we’ve seen in a bit more than a generation the reduction in beds by about half and an increase in separations by about 50%.  This is the graph the Hospital in the Home was born into on the right hand side.  We count in that activity, it’s not just reducing length of stays that has resulted in that change, but that’s been the primary driver over a period of time, and there’s a point at which reducing length of stays become difficult to achieve benefits.

And the next factor is people, and people... sick people are no more portable than they ever were. They’re actually quite difficult to move, but staff are easily portable and always have been.  The difference I guess nowadays is that along with those staff go the capacity to transmit voice, data and images readily, so we don’t have staff on bicycles who can rarely communicate with each other much less back to base.  We have people who make use of significant advances in what I call domestic technologies where we can turn them to the advantage of caring for people at home.

There are more and very important advances. In pharmaceuticals the development of drugs which make our job possible, and in particular antibiotics, but certainly in other areas of drug development where drug companies looking at proposals for new drugs and new compounds are going to keep in mind me... which is nice... they’re going to make drugs that can be given intermittently, safely, quickly and not over a long period of time in complicated ways requiring multiple drug levels.

So low molecular weight heparin and antibiotic change... antibiotic development has certainly led the way, and in fact the drug companies have deliberately had home based care in mind. The development of secure venous access devices... we certainly use peripheral lines... but certain... but the introduction of picc lines which are long lines which can remain inside you for long periods of time and give us secure venous access have made a tremendous difference in the ability to give people intravenous anything at home, and along with that goes the development of innovative pumps, both mechanical and non-mechanical, which again allow the infusion of different compounds at different frequencies at different periods over an entire day and they, together, go hand in hand with our capacity to expand the conditions that we treat at home.

And finally, and probably most excitingly, it really is portable diagnostics. These are the most disruptive of technologies and I think that we’re going to see much more from them due to miniaturisation and portability, and anything that’s miniaturised or portable is music to my ears because it means that we can use those technologies to our advantage.  My most exciting and most recent acquisition has been my x-ray department... this is my x-ray department... and the ability to digitally transmit x-ray images has been around for 10 years, every x-ray department now does it, but in some way I think well so what?  It doesn’t... hasn’t actually changed the way they work, but what it’s done for me is it’s meant I can now take an x-ray machine out to a nursing home, do a chest x ray, transmit the image quickly, immediately without any other processing required, and get a report back within hours, and that changes our capacity to address acute illnesses in a variety of different settings... and that’s been wonderful for me.

I won’t spend a lot of time on patients. Suffice to say we’ve heard about the development of chronic disease, we know that our population is aging, and we know that we’re turning once lethal conditions into conditions that require patients presence in the hospital on a frequent basis.  Hospitals are no nicer than they ever were, they seem to be glorified extensions of car parks or food courts... at least where I come from... they’re further distant from patients homes, they’re still cold, they’re still impersonal, and occasionally they’re still dangerous.  You know, there’s lots of studies describing the danger of hospitals to patient groups, and sometimes I don’t  necessarily buy into the criticism of hospitals because hospitals are dealing with a population who when they first present are at the beginning of what sometimes is a slippery slope, and often you can’t do much about it, but the point is that people are presenting older, more frail and will be more disrupted by the hospitalisation itself rather than the condition that led to it.

Bruce Leff this morning talked a little bit about evidence and evidence as a factor contributing to Hospital in the Home, and certainly all health services suffer from the evidence burden, but unfortunately the more complex the health service intervention and the system the more difficult the task, and Hospital in the Home is actually a complex intervention. Globally, as a small emerging clinical entity, we’ve struggled to find funds to be able to undertake good clinical research even though journals are quite happy to publish it, and as Bruce described this morning there has been a systematic review of substitutive Hospital in the Home.  It had 10 studies... that’s not a huge number... but the other thing is there is not a single study from the United States and you sort of think well there aren’t many systematic reviews with not a single study from the United States, and that kind of tells you something about perhaps the state of research and where it could be improved, but their outcomes showed what we know clinically and that is that we aim to achieve equivalent outcomes of care, and the meta analysis, such as it was, suggested that... that care was essentially equivalent in terms of mortality, that there was not much difference in re-admissions, and that people were happier with Hospital in the Home.

But when you drill down a little more, as I’ve done here, and I’ve described for you the medical input in those 10 studies of so called substitutive Hospital in the Home... so this was a paper looking at a specific sub-set of Hospital in the Home... the sub-set that we should all be interested in... even within that group you’ll see on the right where I’ve described the medical input, and there’s several so called Hospital in the Home services with no medical input... or at least none described... but none, some where the hospital provided input, and some where it’s been a combination of a co-operative or general practitioners.

So what does that do for us? It poses special difficulties because Hospital in the Homes are expensive to set up and quite difficult to maintain, so when randomised trials come along we suffer from particular burdens.  One is that there’s no standard definition... I gave you mine, but that’s not necessarily everyone’s definition... and certainly the models, even if you accept that definition, the models of care, which I’ll address in a sec, can vary quite a lot, and particularly if you enter things like OPAT into the mix, and other post discharge services, and the RCTs in that, the systematic review were quite small.  Often people do them as the first thing they do... let’s set up a Hospital in the Home, you must study it, so let’s start off with a randomised trial that doesn’t necessarily tell you what the Hospital in the Home will be doing in five years time or 10 years time and how it does it.  There’s a mixture of conditions and a mixture of treatments, so you’ve got a randomised trial with Hospital in the Home versus hospital, but in the Hospital in the Home arm you’re giving different treatments to the hospital arm that doesn’t make a lot of sense because you’ve got other variables involved and so it’s not... you’re not just testing the Hospital in the Home as the outcome.  Essentially what we aim to do in Hospital in the Home is to deliver the same care that the patient would have in hospital, and therefore the main outcome of interest if we are going to deliver the same care to the same group of patients with the same level of severity should be safety, essentially.

So there are different models of Hospital in the Home and I’m going to talk about the bottom one a lot later on, but there are others. No medical care really involves self care, the administration of treatment to a patient themselves with some supervision by the hospital.  Two and three are very similar.  Colloquially I guess they’re now called OPAT... Outpatient Antibiotic Therapy... but essentially they’re outpatient models of care where the patients have some input from the hospital, usually just nursing care and the medications are provided, but that’s about it.  They’re not provided with any other ongoing care.  The usual community care means it’s left to the patient’s usual General Practitioner or District Nurses to deliver care, and then finally there’s the clinical unit model which is a medically intense hospital linked model of Hospital in the Home.  They’re different.  I’m a little disappointed that OPAT seems to have gained some ground in the United Kingdom, and certainly in the most recent paper that I could find in any journal or note, referred specifically to OPAT.  And the reason I’m disappointed I guess is that there are issues with non-medical Hospital in the Home.  They come down to these essentially, that by virtue of the lack of supervision they tend to be low equity and low substitutions index type services.  The emphasis is on efficiency.  It tends to reinforce that Inpatient Outpatient gap that I described, so I guess my point is conceptually what I want the hospitals to do is to say this is about us, this is about how we will be different institutions in the future, but if we still call something that cares to a patient outside the hospital as Outpatient and we can’t conceive it in any other way, then it means they haven’t addressed the nature of the beast that we’re talking about, which is changing Inpatient care.  There’s a tendency to be out of mind when you’re out of sight, so governance again suffers.  There’s low thresholds for returns to hospital, and certainly some of the independent studies of OPAT are showing very high return rates to hospital with extensions of length of stay.  And finally the thing that we don’t often hear about is the burden on patients. Some patients will accept any alternative to get out of hospital, so unfortunately you’re not going to get a big section on me talking about patient satisfaction because there are people who want out and you will often find that no matter what service provision you offer them, if they’re out of the place they’re happy.  So they’re all factors that I guess have existed for some time and all have come to influence the reason for and the way we administer care at home... the Hospital in the Home care.

Now I want to move onto the experience in Victoria specifically because we have a significant amount of experience, and I’ve been involved in the area since 1993, I was lucky to have, you know, a literature review published way before there was any service. You will notice that... if you ever read it... it’s got an odd mix of naivety and enthusiasm which I still exhibit today, but even in my naivety when I wrote the line... the last line of the extract... it seems inevitable that for a select number of conditions in a select group of patients, home hospital services will become a reality in this county.  That was just a straight lie!  Because I’d been to almost every CEO of the major public hospitals in 1992/93 and those that knew about it couldn’t have cared less, and those that didn’t know about it didn’t want to know about it.  There was certainly no interest at all in providing acute care to patients at home in 1993.  So I was as surprised as anyone else within a year of the publication of that paper that I was able to hang up my own shingle and set up a Hospital in the Home service.  The speed of that introduction was quite dizzying.  I hope that you gain from that experience because at the time it... things moved very, very quickly.  And so I’m going to give you the benefit of at least 20 years of retrospectivity and certainly got a chance to write a paper 17 years after my first paper describing what the outcome of that rapid introduction did.

To go briefly for you policy makers, as I said before ’94 there was no Hospital in the Home activity. All those indirect incentives I talked about... the technologies were emerging, the patients were not enjoying hospital care and the pressure on to state... they were all there but there was no Hospital in the Home.  What happened in 1994 in my state is the Victorian Government, in its infinite wisdom, initiated a Hospital in the Home policy whereby Hospital in the Home was reimbursed at the acute hospital inpatient rate and it was uncapped initially, so whereas hospitals have caps even in a case payment model, Hospital in the Home was exempt from that cap.  So what it said from the very beginning was that in my state Hospital in the Home would be a hospital centred inpatient programme, and that it will earn acute inpatient reimbursement.  That ensured some early success and it was evaluated in ’99... I won’t talk much about that evaluation, but it was very positive and activity was moving along at a rapid rate.  Unfortunately the department didn’t specify a preferred model or even any minimum inputs, and really the state had started the programme and was happy to leave it to the hospitals.  What happened was that almost all the activity in the country in terms of Hospital in the Home came from Victoria and it grew very quickly to $110 million per annum in reimbursements annually within 10 years of starting the programme.  That caused concern because that growth in expenditure was probably beyond what people were imagining, and the Department of Health were concerned enough to remind hospitals what the intent of the programme was, and essentially it was about ensuring that the substitution remained at the core of the mission of Hospital in the Home. So along with reminding hospitals about that, they undertook some audits and they undertook a full evaluation, and in that full evaluation what they found was that by 08/09 more than 5% of all multi day admissions in the Victorian hospital sector were being delivered in Hospital in the Home.  That significant amount of acute inpatient work.  It’s 32,000 inpatient episodes, it’s the equivalent of a 500 bed hospital.  It’s a lot of activity that otherwise would not have occurred in the system.  The pattern of that activity was unusual in that in fact by the time they had done the evaluation there had been some warnings and activity was actually trailing down, so that 5.3% was not the peak of activity, it was less than the peak because there’d been efforts by the Government to make... to rationalise the definition of Hospital in the Home. So by the time it got to 08/09 the numbers were in fact decreasing if anything.  What that meant was that there’d been some gaming in the system and the department had undertaken their role in minimising that gaming, and so when some of that gaming was removed we were down to a 5.5% rate of growth.

The commonest bed days... here’s a list of the things that have... have changed, and I mean what you see there are some community acquired infections, some serious long term infections, you see some acute venous thromboembolism, and they’re the things that have changed forever in the Victorian hospital sector. Those things Hospital in the Home has made a significant impact in the way people treat them.  Now you’ll also notice that there are some DIGs there that don’t seem to make sense, like other, and other again... that comes up a couple of times... and you might wonder what sleep apnoea is doing there, and I wonder exactly the same thing.  But again, where you’ve got a big bucket of money and a lot of significant incentives, hospitals were awakened to the potential of Hospital in the Home, but some hospitals were tempted by the lure of uncapped reimbursement with little evaluation, but where they did get involved properly it’s make a significant difference.  So a quarter of all patients admitted with skin and soft tissue infections come to Hospital in the Home, about half of the DVTs come to Hospital in the Home.  An increase in those would have a significant impact on activity through the whole Hospital in the Home sector, and now our rate is up to 6% of all multi day admissions and that’s primarily because where the Government does have money to fund expansion they will contract it preferentially to Hospital in the Home, so the department will say we have X Dollars to purchase X DIGs from your hospital, but we specify that that happens in Hospital in the Home.  The tendering for that work happens through a Hospital in the Home service.

So what have the hospitals done with some of that benefit? It’s reasonable to say that it hasn’t all been positive in the sense that re-investment of hospitals back into Hospital in the Home hasn’t been at a rate where it should be, so we have earned the hospital income that they have then used in most instances to plug holes in other parts of the dam, and that’s I guess expected and reasonable.  But one area where they should re-invest is in the area of employing doctors, and you see from that table... and this is self reported data from Victorian hospitals in 2012 that there are fewer medical EFTs employed in Hospital in the Home than there are Administrative Assistants, and that limits the service and that needs to change.

Why does it need to change? If we’re going to summarise what we found in Victoria for you, let’s go down the pro’s list.  There’s been dramatic measurable growth by keeping the service within the hospital system, the CEOs, the Exec Directors can see exactly what it is they’re getting for their money, it’s in their system, they know how many admissions and how much it costs them. So unlike other admission avoidance programmes or admission prevention programmes or continuing care programmes who can make claims that are sometimes difficult to substantiate in the hospital, in this setting the hospital knows exactly what it is that they’ve got for the programme. It’s been a very low capital cost so the growth in Hospital in the Home can occur at a lower capital cost.  The models have meant that they can be flexibly applied across different conditions, the hospitals themselves who are the gatekeepers for this sort of stuff are engaged whereas before they weren’t, it’s financially competitive and if it’s not the hospitals won’t be interested.  We have access to both hospital and non hospital technology which is wonderful, the hospital badges gives Hospital in the Home credibility that otherwise it would not have and that credibility is important in gaining patient consent, and in gaining consultant consent and consultant buy in, and the patient benefits are obvious.  On the other side, well activity is not always substitution and people need to keep a close eye on that.  The hospitals have had little incentive to re-invest back into Hospital in the Home.  Sometimes the models have been the lowest common denominator.  Hospital in the Home was born into a clinical vacuum, there was no speciality called Hospital in the Home which was clambering for Hospital in the Home.  Unfortunately the policy led the practice and that’s been a problem.  There’s been some gaming, specific Hospital in the Home technology being slow, there have been some governance gaps, and that results in some threats to patient safety.

I’m just very briefly going to touch on probably the most important paper written on Hospital in the Home in the last 12 months in my country. It was written by a medical defence lawyer unfortunately, and because you’re all thinking already gee how does this guy manage that sort of stuff and not get himself into trouble... and this didn’t happen to me by the way... how does this system manage these patients and not get themselves into trouble?  And this was an unfortunate case, a 17 year old young man who died in Hospital in the Home after the family made several requests of the unit for help.  The coroner made a couple of statements, the first was Hospital in the Home did not have the same level of attendant care and observation as being an inpatient which should therefore be the basis for earlier and lower thresholds of escalation, and the other thing the coroner said was that there was obvious confusion within the household about the appropriate point of contact if any concerns arose, and that confusion seemed to exist in the hospital as well as in the patient.

Well in response to that the first is for the task of Hospital in the Home to increase the level of supervision in every way it possibly can using every means it possibly can, including the provision of 24 hour on call, 24 hour visiting medical services, so it’s not enough to just accept oh well we don’t provide as much attendant care to that, and the second is that the governance will follow the money and if Hospital in the Home is being paid in patient rates to look after people then the governance in the eyes of the law will follow that money, and so it’s the hospital who has to take responsibility for these patients.

How do I run Hospital in the Home in my small institution? Since 2004 we run a medical clinical unit.  I guess the best way to describe my unit is that it looks like every other unit in my hospital and probably most of the general medical units in your hospital too.  We have consultants, we have registrars, we have a resident, we have our own nursing staff, we have a process of care that says you have to refer a patient to us, we go and assess the patient, then we transfer their care, we look after them and then they’re discharged.  We write the discharge summary and that’s the end of the episode.  We look after our patients all the time, 24 hours a day, 7 days a week, and in fact the care is normally transferred from the inpatient unit... if they didn’t come to us directly from emergency, they’re transferred to our care, so the day to day care comes from us.  Our nursing staff are our own, and in doing this what we aim to do is to increase the severity and increase the component of the total admission that can be spent on Hospital in the Home.

So what do we do? We do about a thousand admissions a year which is about an occupancy of 23 which is creeping up as time passes.  We get about a third of our patients directly to us, we get about a third from the medicals wards, and a third from emergency.  We have unplanned returns to hospital which I’ll touch briefly on later, and since we’ve moved into the care of very unwell patients who live in nursing homes we’ve had some deaths, whereas previously we did not have deaths.  So this is the division of medicine and community care which is the division I report to that has the general medical units and MU1 is the professorial medical unit, down to MU4, a couple of other speciality medical units, infectious diseases are not in our division so I haven’t got their numbers, but the point of this picture is to show you that we’re contributing in order of 15% of the work of the general medical division in our hospital.  So again it’s not an insignificant peripheral niche, it’s becoming part of the day to day set up of the way the hospital expects it will manage certain conditions in certain patients in the hospital.  And again, to further illustrate to you perhaps those of you that are the clinicians, the kind of work we do this is an actual handover on a specific day last year.  It was a busy day so I’ll admit that, but nevertheless a typical day.  And if we run down the next three slides... and I’m not going to read them all out... but just cast your eyes down and you’ll see significant long term infections, you’ll see sepsis, NH refers to nursing homes, some acute venous thromboembolism, exacerbation of heart failure, and the kind of interventions are on the right.  So intravenous antibiotics, low molecular weight heparin and intravenous diuretics.  Again in patients who have... not just this problem, but we manage the entire patient while they’re with us.  So there are a couple of community acquired infections, some serious long term infections, infected prostheses, multi drug resistant organisms that cause us to give complicated drug regimes.  And so by the use of the technology and the use of the system, people who need combinations like intravenous meropenem and vancomycin for serious hospital acquired infections, be they culture positive or culture negative, can be managed, so that this is a person having about eight infusions through the day through two different pumps and we’re capable of doing that by virtue of the way we’re organised... and I’ve seen a lot of red legs in my life... a lot of DVTs, a lot of red eyes.

Again, to look at it by speciality, we have an impact on every speciality in the hospital, every medical speciality in the hospital, and certainly infectious diseases are our biggest client where we’re making significant impact on the way infectious disease of all kinds is managed in our hospital, but also clinical haematology, cardiology, haematology oncology has certainly been interested in expanding the work that we can offer and the care that we can offer to their patients, particularly around stem cell transplantation, be it pre-stem cell transplantation or post-stem cell transplantation with both routine post-stem cell and complications of post-stem cell transplantation. Diabetes has been mentioned and the management of patients with complications... serious complications of diabetes is certainly an important part of what we do.  Respiratory, immunology, palliative care to a certain extent, and geriatrics of course which is a complication for all of the above, where older people who develop the kind of conditions that we’ve mentioned in one through eight are an important comorbidity to everything we do.

We bring people back. We also don’t bring people back, we go out and address a lot of problems, but we certainly bring people back.  Now I don’t apologise for bringing people back.  In fact what I say to my registrars is it’s very important to bring people back at the right time so that those issues are addressed before they deteriorate further.  So the pulmonary embolism you see up there was a young man who had an infected ACL repair, woke up one morning with a little breathlessness, nurse who visited noticed, my registrar went out and we bought the patient back in on a suspicion of a PE, he had a PE, it was treated, he came back to us.  Had we not then again we’re not addressing our contract in terms of governance and caring for the whole of that patient in an acute episode, and these things that you see up there happened to all our acute patients, they happen in your hospitals all the time, even to the most straightforward well diagnosed patient, they will still get the kind of problems that you see up there, so our challenge is to manage those problems on a day to day basis.  Someone asked this morning about the growth and are we doing things more now... are we doing different things now than we did five years ago, and certainly the growth in nursing home acquired pneumonia and all nursing home acquired sepsis has really been astounding, has been driving our activity, and it has a high level of substitution and it also provides a high level of benefit to the patients who don’t have to be bundled into an ambulance and transported to the hospital.  And nursing home pneumonia is the commonest reason for non-trauma hospital presentation from nursing homes, it has a very high mortality and it forms a significant burden of care for the hospitals, and what we’ve been able to do in Hospital in the Home is through the use of mobile x-ray and through re-engineering our programme somewhat we’ve been able to look after these people at home.  The nursing homes do no more than they were doing before, they don’t have anything to do with the acute care, they do the personal care, the attendant care.  We do the acute care, and we’ve been able to show equivalent outcomes to those patients who are transferred to hospital and managed in hospital.  We don’t have time to go into that in  any more detail.

So as we come close to the end I want you to think about admission and hospital admission, and I’ve come up with four levers if you like in terms of disease differentiation, disease severity, technology and patient issues. And I guess what I want to do is suggest that there’s an equation for which the answer equals hospital admission, but that if we can further flesh out those factors in an equation that provides them with a Hospital in the Home admission then we might all be able to understand a little more clearly what the inputs into admission are, and what the inputs into a traditional hospital admission need to be versus a Hospital in the Home admission. So, for example, there’s a third way that perhaps we hadn’t thought of before and it’s very difficult because while hospitals continue to think of their work in terms of inpatient and outpatient and playing within that nomenclature, that they’ll never arrive at thinking about another way, which is to look at how Hospital in the Home can be constructed and what the variables are that make it possible.  So if inpatient care has a high intensity and outpatient care is a low intensity, then there is a place for a medium intensity of care.  Similarly on-site care which distinguishes inpatients from outpatients are... Hospital in the Home is not, again, all hours care we associate with inpatient care, but in fact it can be administered just as safely through a Hospital in the Home model of care.  It’s really about having our hospitals think more critically about what the inputs are into their intellectual property, what it is that they own and they can do, and how it can be re-thought in terms of Hospital in the Home.

So the future? I don’t know the future.  Google knows the future so I’ll ask them.  We already had this analogy raised this morning, I’m going to raise it again.  This is Copenhagen in 1952, this is what happens when smart people say that person dying of respiratory polio, we have an operating theatre, we reintubate people, why don’t be intubate that person even though they don’t need an operation?  And that, as you know, is the beginning of intensive care in the world.  It could never have continued the way it started with medical students bagging patients with respiratory paralysis and polio 24 hours a day, 7 days a week, so what happened?  What happened was technologies grew around that particular clinical scenario, so the technologies were attracted to the concept of really thinking about how in that case particularly acute care was administered.  So mechanical ventilation, the use of inotropes, enteral nutrition, cooling, pacing... these are things that we now all take for granted, but they’re essentially technologies that are gathered around a particular way that care was delivered, and I guess what I’m proposing is that Hospital in the Home is the same, that we will have technologies that will gather around Hospital in the Home and that we will have staff and units that exist not so much because of the condition that’s being managed, the fact that pneumonia or the fact they have heart disease, but because they are in a place that requires specific staff requirements and specific technologies which is the way ICU... the way ICU exists and grows.

The UK? I’m not here to tell you anything really about yourselves, but I did look up... I always like to look for low hanging fruit when I’m trying to put proposals to people, I went to the hscic.gov.uk site to look at admissions, I found some low hanging fruit there. Phlebitis and thrombophlebitis for as I could interpret it from the other DIGs that refers to DVT. There’s a lot of skin and soft tissue infection that’s floating around UK hospitals, there’s a lot of pneumonia, some endocarditis, abscesses, urinary tract infections etc.  I found about half a million admissions that seem to fit the target group for Hospital in the Home.  There were some that I couldn’t find, so I’m going to round it up to 600,000 admissions.  That 600,000 admissions of which if we took a proportion of that that was conservative and said, I don’t know, 10%?  That’s a significant number of admissions I would have thought.  Often people are looking for silver bullets in reform and interventions, and I just think 10% of 600,000 is a good place to start rather than aiming too high and failing.  So whether or not this translates to the UK system, I’m sure people will tell me.

But thank you for your attention.

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