Safety of hospital in the home

To the Editor: We note with interest the studies published in the Journal by Richards et al and Ong et al.1,2 The authors conclude that treating pneumonia and pulmonary emboli in an ambulatory setting is safe for selected patients. However, this represents a large change in the conditions traditionally treated on this basis, from conditions that are associated with a very low mortality (such as cellulitis) to a subgroup of patients with potentially serious infections that are identified as being of low risk. We feel that safety is of prime importance in hospital-in-the-home programs because of limited or delayed access to acute medical care, and that both studies were underpowered to define this endpoint.

Both studies incorrectly quote previous work that suggests that the groups they have identified have mortality rates of up to 5% (for pulmonary emboli) and up to 9.2% (for mild to moderate pneumonia). Published data suggest that the mortality of mild pneumonia (with CURB-65 scores ≤ 2) is in the range 1.7%–3%,3,4 and that mortality from treated sub-massive pulmonary emboli is in the range 1.0%–1.3% within the first week.5 These rates, although seemingly small, are still much higher than that associated with the treatment of soft tissue infections on ambulatory care programs. Recurrent pulmonary embolus, in particular, may be sudden and unexpected. Although admission to hospital may not necessarily prevent these deaths, the additional trauma of a death at home, particularly soon after transfer to ambulatory care, may carry a higher significance in the minds of patients, their families and the public than a death in hospital.

We acknowledge that benefits for patients in ambulatory treatment programs need to be balanced against potential adverse outcomes. However, if these conditions are to be treated where access to medical attention may be delayed, it is imperative that informed consent be obtained from patients (including an awareness of the possibility of death), a mechanism be available for patients to summon urgent attention at any time, and patients and health care providers be aware that readmission to the hospital may be necessary in the event of clinical deterioration.