Issue 9 / 17 March 2014

ANDREW Gilmore was 17 years old when he was injured by a knee to the abdomen while playing football in May 2009.

What happened next was the subject of a Victorian Coroner’s report.

After 2 days in hospital, a repeat computed tomography (CT) revealed a pancreatic transection so he underwent a distal pancreatectomy. On the fifth postoperative day, fluid from one of the drains showed an amylase level of 7500 indicating a pancreatic fistula, so this drain was left in.

After an uneventful postoperative course Mr Gilmore was sent home on the eighth postoperative day under the care of a hospital in the home (HITH) service for management of his drainage tube, with a plan to leave the drain in pending a clinic review for a repeat drain tube amylase level.

Mr Gilmore was visited daily by HITH nurses at his home, which was just over 30 km from the Alfred Hospital in Melbourne. On the first visit he was stable, and alternate sutures were removed as planned, but he developed bleeding and discharge from the wound site in the evening, so his mother phoned the ward where he had been an inpatient, as suggested by a card provided prior to discharge.

On the second and third days he woke with pain and vomited. The family and the HITH nurse spoke to a variety of doctors and other staff at the hospital but, it would seem, never the same person twice. It seemed the HITH nurse and various hospital staff were not aware of all the phone calls.

The advice was generally to continue with oral treatment at home, but come into hospital if things didn’t improve. Although initially waking with pain on the second day and vomiting after taking analgesia there were no other indications “anything was awry”, but his condition worsened again on the third day.

After three phone calls on the morning of the third day, 2 hours after waking with pain, Mr Gilmore collapsed and, despite the best efforts of the ambulance paramedics, died. The autopsy showed 1400 mL of intra-abdominal blood with no bleeding site. Cause of death was listed as intra-abdominal haemorrhage.

At the inquest expert witnesses felt that earlier review in hospital on the third day at home would have been preferred, for what was described as an unusual complication. The Coroner’s report noted that “even if you’re in hospital it’s going to be a close call”.

The Coroner concluded that treatment in HITH should have an earlier and lower threshold of escalation to a consultant. In this case, a lack of clarity within the household and the treating team as to who was the appropriate person to convey their concerns was a major concern.

The Coroner recommended that all operations of the HITH program be reviewed to improve communication between HITH staff, the patient and the family; and amend the escalation procedure to ensure immediate escalation to the consultant or readmission to hospital for any new, recurrent or escalating pain or where concerns are expressed by the patient or family.

In this case, the pain in the morning of the second day at home was felt, in retrospect, to be a sentinel event, indicating a small intra-abdominal bleed.

There is no doubt that what happened to this young man was a tragedy, although it is not possible to say with certainty that it was avoidable.

Some may think that HITH treatment is less safe than treatment in hospital. However, recent meta-analyses show that HITH treatment is actually safer than corresponding in-hospital treatment. A Cochrane review of admission-substitution HITH found a 23% non-statistically significant reduction in mortality with HITH treatment at 3 months and a 38% reduction at 6 months, although none of the 10 included studies were in post-surgical patients. A standard meta-analysis, which did include studies of post-surgical patients, found a 19% reduction in mortality for patients treated in HITH compared to those randomly allocated to inhospital treatment, with a number needed to treat to prevent one death of 50.

However, for HITH to be safe and provide appropriate treatment it is essential for the patient and his or her family to be a part of the team. This means that education and information specific to the condition should be provided so they know what to look out for, as well as 24-hour contact phone numbers.

Ideally, this will be written information but for more unusual conditions, like traumatic pancreatic resection, this may not be feasible.

It is even more vital for the HITH service staff to acquaint themselves with the different aspects of unusual or particular conditions with which they are not familiar. It also means that the hospital and HITH teams must be familiar with each other’s staff and roles to facilitate easy communication and education.

There is no doubt that this is much more difficult where a patient is a tertiary referral from a distant hospital, as in this case, so the local HITH team may not be in regular communication with the surgical unit.

It is likely that video communication will, in the near future, improve this aspect of care, perhaps with the completion of the National Broadband Network.

There is no doubt that sick hospital-level patients are safely cared for in HITH and patients clearly prefer HITH treatment over inhospital therapy.

However, safe HITH treatment sometimes means a timely return to hospital.
 

Associate Professor Gideon Caplan is a geriatrician based at the Prince of Wales Clinical School, University of NSW, involved in Hospital in the Home research.

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