Rural Home Hospital: Proof of Concept

Exclusion Criteria

• •Acute delirium, as determined by the Confusion Assessment Method
• •Cannot establish peripheral access (or access requires ultrasound guidance, unless ultrasound guidance is available)
• •Secondary condition: active non-melanoma/prostate cancer, end-stage renal disease, acute myocardial infarction, acute cerebral vascular accident, acute hemorrhage
• •Primary diagnosis requires controlled substances
• •Cannot independently ambulate to bedside commode
• •As deemed by on-call MD, patient likely to require any of the following procedures that have not already occurred: computed tomography, magnetic resonance imaging, endoscopic procedure, blood transfusion, cardiac stress test, or surgery
• •For pneumonia: Most recent CURB65 \> 3: new confusion, BUN \> 19mg/dL, respiratory rate\>=30/min, systolic blood pressure\<90mmHg, Age\>=65 (\<14% 30-day mortality); Most recent SMRTCO \> 2: systolic blood pressure \< 90mmHg (2pts), multilobar CXR involvement (1pt), respiratory rate \>= 30/min, heart rate \>= 125, new confusion, oxygen saturation \<= 90% (\<10% chance of intensive respiratory or vasopressor support); Absence of clear infiltrate on imaging; Cavitary lesion on imaging; Pulmonary effusion of unknown etiology; O2 saturation \< 90% despite 5L O2
• •For heart failure: Has a left ventricular assist device; GWTG-HF17 (\>10% in-hospital mortality) or ADHERE18 (high risk or intermediate risk 1)\*; Severe pulmonary hypertension
• •For complicated urinary tract infection: Absence of pyuria; Most recent qSOFA \> 1 (SBP≤100 mmHg, RR≥22, GCS\<15 \[any AMS\]) (if sepsis, \>10% mortality)
• •For other infection: Most recent qSOFA \> 1 (SBP≤100 mmHg, RR≥22, GCS\<15 \[any AMS\]) (if sepsis, \>10% mortality)
• •For COPD: BAP-65 score \> 3 (BUN\>25, altered mental status, HR\>109, age\>65) (\<13% chance in-hospital mortality): exercise caution
• •For asthma: Peak expiratory flow \< 50% of normal: exercise caution
• •For diabetes and its complications: Requires IV insulin
• •For hypertensive urgency: Systolic blood pressure \> 190 mmHg; Evidence of end-organ damage; for example, acute kidney injury, focal neurologic deficits, myocardial infarction
• •For atrial fibrillation with rapid ventricular response: Likely to require cardioversion; New atrial fibrillation with rapid ventricular response; Unstable blood pressure, respiratory rate, or oxygenation; Despite IV beta and/or calcium channel blockade in the emergency department, HR remains \> 125 and SBP remains different than baseline; Less than 1 hour of time has elapsed with HR \< 125 and SBP similar or higher than baseline
• •For patients with end-stage renal disease on peritoneal dialysis: Peritoneal catheter malfunction; Requires temporary hemodialysis
• •Home hospital census is full (maximum 3 patients at any time)
• •* GWTG-HF: AHA Get with the Guidelines: SBP, BUN, Na, Age, HR, Black race, COPD ADHERE: Acute decompensated heart failure national registry: BUN, creatinine, SBP
• •Non-english speaking
• •Undomiciled
• •No working heat (October-April), no working air conditioning if forecast \> 80°F (June-September), or no running water
• •On methadone requiring daily pickup of medication
• •in police custody
• •Resides in facility that provides on-site medical care (e.g., skilled nursing facility)
• •Domestic violence screen positive