OVER the past two decades, there has been a paradigm shift in the approach to treating selected patients outside of the hospital setting due to increased awareness that inpatient admission carries the risk of hospital-acquired infections (here and here) and is associated with higher costs. The negative impacts of hospital admission on quality of life and family disruption are particularly true for children. Given the choice, many children and caregivers would choose treatment outside of the hospital setting (here and here), an important factor underpinning true patient-centred care.
Several alternative settings to inpatient admission have been described, such as ambulatory units, daily visits to the emergency department (ED) and medical care in the patient’s home.
Where this shift in care has had the most traction in children is with the use of outpatient intravenous (IV) antibiotics (here and here). Previous studies have shown that home or ambulatory treatment for cystic fibrosis, appendicitis and cellulitis are feasible and preferred by patients (here and here). While most clinicians accept that home is psychologically better for children and family functioning, the lack of evidence for efficacy and safety in high quality studies is frequently cited as the underlying reason for their reluctance to manage children outside the hospital environment, without the reassurance of 24-hour monitoring.
Although this practice initially began in the 1970s as an option for prolonged courses of IV antibiotic administration for cystic fibrosis, 50 years later, the standard of care for children needing IV antibiotics remains admission to hospital. This is particularly true for children with acute infections such as cellulitis and urinary tract infections who are usually otherwise healthy. There have been no randomised trials of the efficacy of home versus hospital management in acute infections in children. Without the gold standard of randomised evidence, it is often hard to implement change.
Recently, a randomised controlled trial was conducted through the Murdoch Children’s Research Institute with 188 children who presented to the ED at the Royal Children’s Hospital Melbourne (RCH) with moderate to severe cellulitis. This was the first trial to randomise children with an acute infection, to IV ceftriaxone once a day at home or IV flucloxacillin every 6 hours in hospital. For patients randomly allocated to home treatment, the RCH Hospital-in-the-Home Department provided once-daily nursing visits to the patient’s home to administer antibiotics, as well as a daily in-person or teleconference medical review. This study was a landmark study in terms of attempting to address for the first time the efficacy of an alternative to inpatient admission, completely avoiding a hospital stay.
The results clearly showed that there was no difference in treatment failure between management at home and in hospital. Adverse events such as vomiting and diarrhoea occurred less at home than in hospital, while the proportion of those with complications was no different between the treatment locations. Other disadvantages to hospital treatment were repeat insertions of the IV cannula, a distressing procedure for all involved, and longer duration in ED waiting for a hospital bed. The only outcome that did not favour home treatment was that length of stay under medical care was half a day longer, but this was entirely in their own home.
Perhaps the most interesting aspect of this trial was how well it was received by families, reflected by their willingness to participate in a trial where the location of their child’s care would effectively be determined by the toss of a coin. In addition, a parent survey, reported in the original study, showed that of those treated at home, 97% of families would prefer home treatment again. Unsurprisingly, parents reported that disruption to parental and child routine was more likely to occur in hospital than at home.
Another major finding reported in the original study was the cost saving to the health care institution associated with hospital and home treatment. At the hospital where the trial was conducted, the average cost of treating a patient with moderate to severe cellulitis at home is $530 per day compared with the cost of an inpatient bed on a medical ward which is $1297 per day. The total cost for the 93 patients treated at home was $136 042 compared with $246 430 for the 95 patients treated in hospital, a cost difference of $110 388. Extrapolating these data to other settings across the whole of Australia would reflect substantial cost savings. With a conservative estimate that a similar proportion of paediatric attendances is due to the same infection across Australia (although it is likely to be higher in tropical northern regions), this equates to 2415 children attending ED with this infection per year who would be eligible for IV treatment at home. Based on this assumption, the cost savings across Australia would therefore be $4 368 735 just for cellulitis. If this model of care were used for other conditions such as urinary tract infections, febrile neutropenia, and even infections not needing antibiotics but needing nursing observations (such as gastroenteritis and bronchiolitis), then savings would rapidly accrue.
The RCH trial is a game-changer for moderate to severe cellulitis, because it provides the much-needed robust evidence that ambulatory/home treatment is as good as hospital treatment and is associated with better quality of life, while reducing costs. Although the RCH has the largest paediatric Hospital-in-the-Home Department in Australia, these findings should be applicable to other ambulatory programs. If an acute admission avoidance pathway exists at their institution, clinicians need to have a well considered rationale for admitting children to hospital and exposing them to the risks of hospital-acquired infections, adverse events, and reducing the quality of life for the child and family. At institutions where such a pathway does not exist, these results should provide the evidence to advocate for resourcing this type of care.
This trial and the outcomes investigated embraced the true meaning of patient-centred care, advocating for better quality of life for children and their families, with the results showing that efficacy and safety of treatment were not compromised. In addition to IV antibiotics, other forms of treatment can be delivered in an ambulatory setting such as chemotherapy or rehydration. Further research is urgently needed and welcomed in other types of infections and medical conditions.
Since location of treatment is a dichotomous decision, we recommend that this should be in the form of randomised controlled trials to provide the robustness of evidence required to persuade clinicians to change their practice.
Associate Professor Penelope Bryant is a Paediatric Infectious Diseases physician, Lead of the Hospital-in-the-Home Department, and Clinical Paediatrics research group leader at the Royal Children’s Hospital Melbourne, Murdoch Children’s Research Institute and University of Melbourne. She is a Clinician-Scientist Fellow whose goal is collaborative research in antibiotic use and antibiotic resistance in children, which includes research into delivering health services under the Hospital-in-the-Home model.
Dr Laila Ibrahim is a post-doctoral researcher and clinician at the Murdoch Children’s Research Institute and the Royal Children’s Hospital Melbourne. Her current research is focused on avoiding unnecessary hospitalisation from the emergency department through clinical risk scores, and investigating the efficacy and safety for treatment at home through high quality randomised controlled trials.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.