Adult’s Hospital at Home

The service is a One Bromley Local Care Partnership initiative. It is for patients with a working diagnosis only. Bromley Adult's Hospital at Home is a consultant-led multi-disciplinary team currently comprised of nurses, doctors, hospital and hospice consultants and other healthcare professionals from Princess Royal University Hospital, Bromley Healthcare, St Christopher’s and Bromley GP Alliance. It is based within Bromley Healthcare’s Urgent Community Response directorate.

The service provides acute-level assessment, treatment and monitoring in a patient’s own home/nursing home/care home, to prevent or shorten a hospital admission. It has expertise in acute respiratory, frailty exacerbation and urgent palliative care requiring response within 48 hours.

It is for patients who:

- are safe/appropriate to be at home and have a working diagnosis
- have an expected length of stay of up to 7 days (or 14 days for intravenous antibiotics)

The service takes clinical responsibility for the episode of care, except for longer courses of intravenous antibiotics as agreed between the service and individual hospital consultants.

It works with patients in their own environment, with their informal carers and others to confirm treatment plans. It utilises remote monitoring technology for vital signs and patient reported outcomes and has access to ECG, bladder scanner and blood monitoring at bed-side. Through close working with the PRUH Frailty Unit the service can arrange hospital level diagnostics (e.g. x-ray, CT scan) during the patient’s episode of care where a working diagnosis has already been made.

The service is relatively new and is constantly growing and adapting. It has a core offer but welcomes conversations about patients you think could benefit from its care for an acute medical issue.

For patients referred from hospital, please:

- Consent the patient for treatment at home
- Confirm that the patient can summon help in the event of deterioration (either self or via a carer)
- Double-check which address the patient will be going home to
- Ensure the referral has been accepted by the Hospital at Home team prior to discharging the patient – see “How do I refer” below
- The discharge summary is sent to Hospital at Home
- Patients have their medications prior to leaving hospital
- Patients have the Bromley Adult's Hospital at Home patient information leaflet

For patients referred from the community please:

- Consent the patient for treatment at home
- Confirm that the patient can summon help in the event of deterioration (either self or via a carer)
- Call to make the referral and confirm acceptance – see “How do I refer” below
- Patients have the Bromley Adult's Hospital at Home patient information leaflet

The service currently accepts patients aged 18+ with a Bromley GP referred by:

- GPs
- St Christopher’s Hospice
- Urgent Community Response – Rapid Response
- Princess Royal University Hospital

Other provides – please call 0208 315 8722 Option 1 in the first instance to discuss the patient requirements. The patient must have a working diagnosis to be referred to this service.

- Patient monitoring for change in medication/rescue pack
- Infection - initiation and continuation of IVAB OD, BD, TDS for

cellulitis
lower respiratory tract infection
urinary tract infection
other patients agreed with us and, as appropriate, Princess Royal University Hospital Microbiology team

- Decompensation of frailty

Frailty assessment and planning
Note - please do not refer for non-resolving delerium

- Heart failure

Decompensated chronic heart failure (fluid overload) requiring oral or intravenous diuretics

- Respiratory

Bronchiectasis
Covid-19
Exacerbation of COPD, pneumonia, LRTI or other respiratory conditions requiring remote monitoring of O2 sats
Nebuliser loan and wean
Intravenous Antibiotics
Note - patients with long-term oxygen therapy must be using their prescribed dose and within their target saturation range
Note - patients should not be referred due to asthma exacerbation

- Palliative

Urgent needs assessment to stabilise end of life patients at home (where beyond GP scope of practice)
Urgent symptom control beyond GP’s scope of practice and where unknown to St Christopher’s
Urgent support to patients and their families

- Dehydration

Requiring intravenous or subcutaneous fluids and/or blood monitoring
Oral rehydration protocols

- Diabetes

Monitoring control plan (insulin and blood glucose monitoring)

The service has this core offer but welcomes conversations about patients you think could benefit from its care.

View the PDF of typical presentations, exclusions and interventions

• Remote monitoring
• IVAB – up to TDS
• Assessment and planning, including frailty and palliative
• IV diuretics and monitoring fluid off load in HF
• Acute monitoring and support of patients in relation to Insulin and blood glucose monitoring
• Wound management
• Pain management
• Bladder and bowel monitoring
• Catheterisation
• Hydration protocol
• IV fluids
• Bloods monitoring (at bedside or via lab): renal function, infection markers
• Nebuliser therapy support and monitoring
• Medication review
• Syringe driver
• Prescribing
• Chest physio
• Bladder scans
• ECG

View the PDF of typical presentations, exclusions and interventions

View the Adult's Hospital at Home - Typical presentations, exclusions and interventions

Bromley Adult’s Hospital at Home generally has good capacity for remote patient monitoring, with readings requested from patients up to three times a day.

Patients we have seen to date on this pathway, and where the technology works well, include observations following changes to medication, diabetic plan monitoring, and as part of respiratory, heart failure and frailty care. Patients monitor up to three times a day.

The remote monitoring kits can monitor NEWS2 plus blood sugars, peak flow, weight and Kardia ECG (the latter not suitable for patients with heart implants). Patient health status questionnaires can also be requested.

Where patients are admitted to this pathway, equipment will be sent to patients at home and they will be telephoned by the service to be onboarded. The expected length of stay with the service should be up to 7 days.

Please refer in the usual way (020 8315 8722, Option 1, ask for Hospital at Home). The service inclusion and exclusion criteria apply.

8am to 8pm, 7 days a week. Outside of these hours patients should contact 111 or 999.

Referrals currently accepted Monday to Friday 9am to 5pm.

At the first visit, a risk assessment will be undertaken, observations taken, interventions administered and the patient record updated. Patients may also be issued with remote monitoring technology called Doccla.

At every subsequent visit, the patient will be reassessed, observations completed, interventions delivered and recorded on Bromley Healthcare’s electronic patient record (EMIS). Where a patient has remote monitoring technology the observations will be reviewed virtually by the clinical team. Readings that are missed or outside agreed parameters will be followed up by phone call, home visit, or escalation to hospital. Remote readings are also recorded in Bromley Healthcare’s electronic patient record (EMIS).

Patients are discussed in a multidisciplinary board round to ensure personalised care plans with appropriate escalation and de-escalation.

At the final visit, it will be confirmed that the patient is being discharged from the service. As appropriate, cannulas are removed by the team at the end of treatment. The team can re-site cannulas as needed. Longer lines such as a PICC line may require a hospital visit for removal which will be arranged by the team. The patient will be asked to send back the monitoring technology.

The patient’s GP will receive an electronic discharge notification via email, including any relevant information regarding onward referral and changes to medication.

Inclusion Criteria

• Aged 18+ and registered with Bromley GP
• Have working diagnosis
• Reviewed face to face in last 72 hours (includes video)
• Safe prior to Hospital at Home 1st visit (by 10am next day)
• Expected Length of Stay up to 7 days (14 days for IVAB)
• Patient can self-escalate via phone or carer
• Able to understand and consent to community treatment (or assessed in best interests)

Exclusion Criteria

• Immunocompromised/neutropenic
• Asthma – primary reason for referral
• Sepsis
• Non-resolving delirium
• Current intravenous drug or solvent misuse

GP Referrals

• Call 020 8315 8722 (Option 1) - request Hospital at Home
• Monday – Friday 9am to 5pm
• The triager will ask for a referral form available on the ROP for accepted referrals

St Christopher’s Hospice

• Self-triage against service criteria – liaising with palliative H@H clinician as required
• Hospital-based patient: Call H@H clinician to hand over
• Community patient: Create SystemOne E-workflow for internal referral to H@H Palliative

Urgent Community Response

• Liaise with Hospital at Home Triage via 020 8315 8722 (Option 1)

Bromley Healthcare Community Teams (e.g. District Nursing)

• Refer to Rapid Response in the first instance via 020 8315 8722 (Option 1)

Princess Royal University Hospital

• Use the referral form: Bromley Hospital at Home Referral Form and email as directed.

Other providers

• Liaise with Hospital at Home Triage via 020 8315 8722 (Option 1) in the first instance

In all cases consider whether an oral alternative would be suitable.

The services is for:

• Cellulitis
• Lower respiratory tract infection
• Urinary tract infection
• Other patients agreed with us and, as appropriate, Princess Royal University Hospital Microbiology Team

Hospital patients

Where stepping-down a patient from hospital, liaise with microbiology to ensure the minimal dosing regime and duration of antibiotics is prescribed.

A triager will call you back to confirm details of the referral and will ask for either:

• drug chart (ambulatory services) or
• electronic discharge summary (ward)

These should be emailed by the acute clinician to bromh.ucr@nhs.net copying in the patient’s consultant.

Please confirm acceptance to the service prior to discharge and that the patient leaves hospital with:

• Patient information leaflet
• Antibiotics
• Diluent
• Flushes
• Needles, syringes
• Giving sets and IV bags (if applicable)
• Sharps bin
• PICC/Midline dressings

The service has been set up for short courses of antibiotics (up to 14 days, up to TDS) however, if the service has capacity it may be able to take referrals for longer courses of antibiotics to support earlier discharges. This must be agreed in advance by triage and the team. Call in advance to check current capacity: 0208 315 8722. Longer courses require a named consultant who will perform reviews and advise on treatment plans e.g. diabetic foot team, orthopaedics. Remember teicoplanin for more than one week requires levels to be monitored.