Background Pandemics disrupt traditional health care operations by overwhelming system resource capacity but also create opportunities for care innovation. Objective To describe the development and rapid deployment of a virtual hospital program, Atrium Health hospital at home (AH-HaH), within a large health care system. Design Prospective case series. Setting Atrium Health, a large integrated health care organization in the southeastern United States. Patients 1477 patients diagnosed with coronavirus disease 2019 (COVID-19) from 23 March to 7 May 2020 who received care via AH-HaH. Intervention A virtual hospital model providing proactive home monitoring and hospital-level care through a virtual observation unit (VOU) and a virtual acute care unit (VACU) in the home setting for eligible patients with COVID-19. Measurements Patient demographic characteristics, comorbid conditions, treatments administered (intravenous fluids, antibiotics, supplemental oxygen, and respiratory medications), transfer to inpatient care, and hospital outcomes (length of stay, intensive care unit [ICU] admission, mechanical ventilation, and death) were collected from electronic health record data. Results 1477 patients received care in either the AH-HaH VOU or VACU or both settings, with a median length of stay of 11 days. Of these, 1293 (88%) patients received care in the VOU only, with 40 (3%) requiring inpatient hospitalization. Of these 40 patients, 16 (40%) spent time in the ICU, 7 (18%) required ventilator support, and 2 (5%) died during their hospital admission. In total, 184 (12%) patients were ever admitted to the VACU, during which 21 patients (11%) required intravenous fluids, 16 (9%) received antibiotics, 40 (22%) required respiratory inhaler or nebulizer treatments, 41 (22%) used supplemental oxygen, and 24 (13%) were admitted as an inpatient to a conventional hospital. Of these 24 patients, 10 (42%) required ICU admission, 1 (3%) required a ventilator, and none died during their hospital admission. Limitation Generalizability is limited to patients with a working telephone and the ability to comply with the monitoring protocols. Conclusion Virtual hospital programs have the potential to provide health systems with additional inpatient capacity during the COVID-19 pandemic and beyond. Primary funding source Atrium Health.

Insights From Rapid Deployment of a "Virtual Hospital" as Standard Care During the COVID-19 Pandemic.

Contemporary use of real-world data for clinical trial conduct in the United States: a scoping review.

Despite years of intense focus, inpatient and observation readmission rates remain high and largely unchanged. Hospitals have little, robust evidence to guide the selection of interventions effective at reducing 30-day readmissions in real-world settings. To evaluate if implementation of recent recommendations for hospital transition programs is effective at reducing 30-day readmissions in a population discharged to home and at high-risk for readmission. A non-blinded, pragmatic randomized controlled trial (
 Clinicaltrials.gov
 : NCT02763202) conducted at two hospitals in Charlotte, North Carolina. A total of 1876 adult patients, under the care of a hospitalist, and at high risk for readmissions. Random allocation to a Transition Services (TS) program (n = 935) that bridges inpatient, outpatient, and home settings, providing patients virtual and in-person access to a dedicated multidisciplinary team for 30-days, or usual care (n = 941). Thirty-day, unplanned, inpatient, or observation readmission rate. The 30-day readmission rate was 15.2% in the TS group and 16.3% in the usual care group (RR 0.93; 95% [CI, 0.76 to 1.15]; P = 0.52). There were no significant differences in readmissions at 60 and 90 days or in 30-day Emergency Department visit rates. Patients, who were referred to TS and readmitted, had less Intensive Care Unit admissions 15.5% vs. 26.8% (RR 0.74; 95% [CI, 0.59 to 0.93]; P = 0.02). An intervention inclusive of contemporary recommendations does not reduce a high-risk population’s 30-day readmission rate. The high crossover to usual care (74.8%) reflects the challenge of non-participation that is ubiquitous in the real-world implementation of population health interventions. ClinicalTrials.gov
 ; registration ID number: NCT02763202, URL: https://clinicaltrials.gov/ct2/show/NCT02763202

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Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): a Pragmatic Randomized Controlled Trial

Hospital mortality for patients with sepsis has recently declined, but sepsis survivors still suffer from significant long-term mortality and morbidity. There are limited data that support effective strategies to address post-discharge management of patients hospitalized with sepsis. The Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS) study is a pragmatic, randomized controlled trial at three hospitals within a single healthcare delivery system comparing clinical outcomes between sepsis survivors who receive usual care versus care delivered through the Sepsis Transition and Recovery (STAR) program. The STAR program includes a centrally located nurse navigator using telephone counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies for patients during hospitalization and the 30 days after hospital discharge, including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted through the Emergency Department with suspected infection (i.e., antibiotics initiated, bacterial cultures drawn) and deemed, by previously developed risk-stratification models, high risk for readmission or death are included. Eligible patients are randomly allocated 1:1 to either Arm 1, usual care or Arm 2, STAR. Planned enrollment is 708 patients during a 6-month period. The primary outcome is the composite of all-cause hospital readmissions and mortality assessed 30 days post discharge. Secondary outcomes include 30- and 90-day hospital readmissions, mortality, emergency department visits, acute care-free days alive, and acute care and total costs. This pragmatic evaluation provides the most comprehensive assessment to date of a strategy to improve delivery of recommended post-sepsis care. ClinicalTrials.gov, NCT03865602. Registered retrospectively on 6 March 2019.

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Structured, proactive care coordination versus usual care for Improving Morbidity during Post-Acute Care Transitions for Sepsis (IMPACTS): a pragmatic, randomized controlled trial

OBJECTIVES To test the effectiveness of a multicomponent care transition intervention targeted at hospitalized patients, aged 75 years and older, at high risk for hospital readmissions, return emergency department (ED) visits, and related complications. DESIGN Implementation as a quality improvement program with propensity-matched preintervention and concurrent comparison groups over a 12-month period. SETTING A 400-bed community teaching hospital. PARTICIPANTS Patients, aged 75 years and older, admitted to non-intensive care unit beds who met specific high-risk criteria. The intervention group included 202 patients, and the concurrent and preintervention comparison groups included 4142 and 4592 patients, respectively. MEASUREMENTS Primary outcomes were 30-day hospital readmissions and returns to the ED; 7-day readmissions and ED visits were secondary measures. RESULTS Among the 202 patients enrolled in the "Safe Transitions for At-Risk Patients" ("STAR") program, 37 (18.3%) were readmitted within 30 days, in contrast to 14.3% and 14.6% in the concurrent and preintervention comparison groups, respectively. Rates for 30-day return ED visits that did not result in hospitalization were 10.9% in the intervention group, and 7.2% and 7.9% in the comparison groups. STAR patients had greater 30-day ED use than patients in the preintervention comparison group (5.0 percentage points; 95% confidence interval = 0.8-9.3 percentage points; P = .020). Implementation challenges included suboptimal involvement of the participating hospital and post-acute care organizations and a relatively high proportion of patients who did not receive the intervention as planned, despite agreeing to participate before leaving the hospital. CONCLUSION A multicomponent care transitions intervention targeting high-risk patients, aged 75 years and older, admitted to a community teaching hospital was not effective in reducing 30- or 7-day readmissions or return ED visits. Our implementation experience offers many lessons for future programs for similar high-risk geriatric populations. J Am Geriatr Soc 67:2634-2642, 2019.

Evaluation of a Multicomponent Care Transitions Program for High-Risk Hospitalized Older Adults

Hospital readmissions remain highly prevalent despite being the target of policies and financial penalties. Evidence comparing the effectiveness and costs of interventions to reduce readmissions is lacking, leaving healthcare systems with little guidance on how to improve quality and avoid costly penalties. Effective interventions likely need to bridge inpatient and outpatient settings, incorporate information technology, and use dedicated providers. Such complex innovations will require rigorous evaluation. The framework of quality improvement research provides an approach that both improves care locally and contributes to closing the current knowledge gaps for readmissions. In this trial, we will study a comprehensive intervention that incorporates these recommendations into an integrated practice unit, called transition services, with an aim of reducing 30-day readmission rates. We describe a nonblinded, pragmatic, controlled trial with two parallel groups comprising an evaluation of the effect of referral to a provider-led integrated practice unit, inclusive of comprehensive multidisciplinary care, dedicated paramedicine providers, and virtual visits, on 30-day readmission rates for high-risk hospitalized patients. An automated risk-scoring system will randomly generate referrals to either transition services or usual care for 1520 hospitalized patients who score as high-risk for readmission. Transition services will then engage with patients in the hospital setting using a patient navigator and provide bridging outpatient services for the 30 days following discharge. All outcome data are retrieved electronically from administrative medical records. After reapplication of inclusion and exclusion criteria at the time of hospital discharge, analyses will follow the intention-to-treat principle such that patients will be analyzed on the basis of the referral group to which they were initially randomized. The hospital transition program under study is complex and integrates the latest recommendations for readmission reduction strategies. As healthcare systems innovate to address readmissions through such complex interventions, there is significant benefit for stakeholders to have a clear understanding of the potential reach, cost, and real-world effectiveness. The pragmatic methods described here provide a template for conducting quality improvement research that fits seamlessly into existing care delivery and improvement efforts, leading to better-informed strategic decisions and the investments necessary to transform care and value for patients. ClinicalTrials.gov, NCT02763202
 . Registered 3 March 2016 (retrospectively registered).

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Scott Rissmiller

Papers

Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): a Pragmatic Randomized Controlled Trial

Aiming to Improve Readmissions Through InteGrated Hospital Transitions (AIRTIGHT): study protocol for a randomized controlled trial.

Realizing a learning health system through process, rigor and culture change.