Increasing epidemic surge capacity with home-based hospital care.

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VOL 52: MAY • MAI 2006 Canadian Family Physician•Le Médecin de famille canadien

563 Editorials

Increasing epidemic surge capacity with home-based hospital care

William Hogg,

MD, CCFP, FCFP

Jacques Lemelin,

MD, CCFP, FCFP

Patricia Huston,

MD, MPH

Simone Dahrouge,

MSC

T

he 2003 severe acute respiratory syndrome (SARS) epidemic and the current threat of pandemic inﬂu- enza underscore the need for an effective health care system response to outbreaks of respiratory infec- tions. During the Toronto, Ont, outbreak of SARS in 2003, 225 cases were diagnosed and 100 times more were quarantined for infection control. Toronto Public Health authorities identiﬁed taking surge-capacity measures as a critical step in responding to such disease threats.¹

In a health crisis of the magnitude predicted for an inﬂuenza pandemic, the demand for acute hospital services will outstrip supply. In Ottawa, Ont, as elsewhere in Canada, the number of acute care hospital beds has decreased over the last 20 years, despite a growing population. Hospital-in-the-home programs can provide substantial capacity relief in the face of a pandemic.

The Canadian Pandemic Influenza Plan estimates that as many as 25% to 35% of Canadians could be infected by pandemic inﬂuenza and become ill over a 6- to 12-week period.² Based on the Plan’s projections, in a city such as Ottawa, with an approximate population of 750 000, roughly 200 000 persons would become ill during the pandemic—approximately 22 000 a week.

The Plan estimates that about 1% of patients who con- tract the infection would require hospitalization, or 220 patients a week in Ottawa. Hospitals, which currently run at capacity, would need to cancel elective surgery to accommodate this need. Based on the Toronto expe- rience, this practice would, at best, allow admission of 100 additional patients weekly. If we expect the length of stay in hospital to be approximately 1 week, capacity for another 100 to 120 patients would be needed weekly until the pandemic subsided.

Providing surge capacity in response to infectious disease outbreaks or other health emergencies is chal- lenging. It would not be possible to build the required number of new beds in a timely fashion. Health authorities have considered management of patients in tempo- rary non-traditional health care settings for the duration of a pandemic. Although this might be feasible, it has its own set of challenges.² Ideal surge capacity entails immediate medical response for such outbreaks, while effectively controlling spread of infection. We propose that a partial solution could be provided by home-based hospital care. The Ottawa model, called Home-Based Intermediate Care (HBIC), is designed to substitute intermediate-level hospital care with care in the home.

In a pandemic, the home-based program would not nec- essarily be looking after patients with pandemic inﬂu- enza who had complex respiratory management needs.

Rather, it would allow some patients who need hospital- level care, but not 24-hour supervision, to be managed in their homes. These patients could receive comparable levels of care in their homes, thereby making hospital beds available for victims of the pandemic.

Internationally, a range of hospital-substitution mod- els, managed by hospitals or community institutions to deliver care that otherwise could be provided only by admission to hospital, have been assessed and suc- cessfully implemented.³ These programs are preferred, in general, by patients and their caregivers, and have demonstrated comparable or better health outcomes for most patient groups than hospital care has.^3-6 Since the introduction of hospital-at-home services into Australian public hospitals during the 1990s,^7,8 demand continues to grow, with services expanding to treat more patients and more conditions. While, to date, hospital-at-home services have not always been less expensive than inpatient care,³ these programs have demonstrated cost effectiveness for a range of clinical conditions.^9-12

The HBIC Program is an acute hospital–substitution pilot project recently completed in Ottawa that has the potential to provide emergency preparedness for vari- ous types of health disasters. Aligned with the Ontario Family Health Network initiative, the HBIC project pairs nurse practitioners with family physicians who admit patients to the family medicine ward of the Ottawa Hospital (Civic Campus).

The nurse practitioners work collaboratively with the admitting family physicians so that full nursing and medical coverage are provided to patients in their homes, with the support of a portable laboratory that allows a variety of blood tests to be performed at point of care.

While the development of home-based hospital programs reﬂects the growing international trend to establish intermediate-care programs for an aging population with chronic conditions,¹³ it presents a way to provide tem- porary acute hospital care that can be rapidly deployed in times of disaster. At this time, the Ottawa-based program personnel comprise 1.5 full-time–equivalent nurse practitioners and can accommodate 3 patients concur- rently. The service could be readily expanded to accommodate at least 15 patients, and thereby help increase surge capacity for acute need. No building is necessary, as

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Canadian Family Physician•Le Médecin de famille canadien VOL 52: MAY • MAI 2006

Editorials

patients are cared for in their own homes and in relative isolation to help prevent the spread of illness. Existing nursing staff could be supplemented to manage the extra work for the short period of the epidemic. If similar programs were implemented through all 4 acute care hospitals in Ottawa, as many as 60 patients could receive needed hospital-level care in the event of an acute health emergency. In this way, based on Ottawa’s estimated requirements for surge capacity, approximately 50% of the outstanding projected need could be met by hospital- in-the-home programs.

Canada requires concrete, realizable strategies to respond to such health emergencies as infectious disease outbreaks. The health care system must be able to implement these strategies within reasonable time frames. This means that processes, if they are new, must be pilot-tested, and the necessary infrastructure must be in place and ready to respond to a surge in need. Staff must have the necessary training; the network coor- dinating the response must be established and opera- tional. Home-Based Intermediate Care could present such a solution. Policies and procedures, communica- tion structure, support measures, and other aspects of providing care in the home could quickly become oper- ational and would require only expansion. Like other planned measures for increases in health care services, HBIC would need to bring into service a part of the medical work force not otherwise committed to disaster relief.

Home-Based Intermediate Care is one way to enhance the health system response to another outbreak of SARS or a strain of inﬂuenza not well covered by vaccine. There is already sufﬁcient evidence that such programs should be established as permanent services in acute care hospitals,¹⁴ maintaining low, but nevertheless important, hospital-substitution activity levels, and be ready to respond to a surge in need for hospital services.

Dr Hogg is a Professor and Director of Research in the Department of Family Medicine at the University of Ottawa; Dr Lemelin is a Professor in the Department of

Family Medicine at the University of Ottawa; Dr Huston is Associate Medical Ofﬁcer of Health and Manager of Surveillance, Emerging Issues in the Education and Research Division at Ottawa Public Health; and Ms Dahrouge is Research Manager at the Élisabeth Bruyère Research Institute, all in Ottawa, Ont.

Correspondence to: Dr William Hogg, Director, CT Lamont Centre, Élisabeth Bruyère Research Institute, 43 Bruyère St, Room 706B, Ottawa, ON K1N 5C8; telephone 613 562-4262; fax 613 562-6099; e-mail whogg@uottawa.ca The opinions expressed in editorials are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

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