Breaking the mould

No place like home

Having shown excellent results from a trial treating children with cellulitis, the researchers set their sights on other conditions that could also benefit from home treatment.

One of those diseases is bronchiectasis, a lung condition that brought a seven year old boy called Leroy to hospital at Christmas time.

Bronchiectasis would normally require a lengthy stay in hospital for antibiotics. In Leroy's case, it would have meant being in hospital for Christmas, a hard ask for a seven year old.

With hospital in the home treatment, Leroy was back in his own bed and waiting for Santa on Christmas Eve.

Instead of up to two weeks away from his family, Leroy had daily visits by a nurse to administer antibiotics and a physiotherapist to help with his breathing. A second physio appointment by teleconference allowed further observation and advice.

As a result, he enjoyed Christmas and the new year at home with mum Amy, dad Simon and sister Violet, playing with their dogs and new toys while welcoming visits from relatives and neighbours. He also got to enjoy home-cooked food.

"The fact that the team came to us made it so much easier," Amy says. "Leroy was really happy being at home. He was more comfortable, for sure. It worked beautifully for us!"

Despite brighter décor and better treatments, hospital remains a daunting place for children.

Besides feeling unwell, they miss family, friends, home and maybe even school. For parents, it means enormous stress and worry, missing work, and higher costs in terms of fuel, parking, meals and more.

Imagine, then, if kids could be successfully treated at home – possibly with even better results.

Moving treatment from hospital to home is happening for more children thanks to a world-first trial developed by MCRI researchers and their colleagues at The Royal Children's Hospital (RCH).

Hospital-in-the-Home

'Hospital-in-the-Home' is a well-established option for patient care after hospital admission. But our researchers wanted to know if we could skip hospital admission altogether and send children home to complete their care after coming into the emergency department.

The project compared the outcomes of 188 children aged six months to 18 years who presented at hospital with the common, and sometimes painful, bacterial skin infection cellulitis. Cellulitis treatment often means a hospital admission to receive intravenous (IV) antibiotics.

Following parental consent into the randomised control trial, a coin toss decided whether the children would receive IV antibiotics in hospital, or at home, with daily staff visits.

The Melbourne Children's campus offered a unique location for this MCRI-led study, given our co-location, shared facilities and close ties with the RCH.

Surprising results

When the results of the trial into skipping the hospital portion of treatment came in, researchers were astounded.

Treatment was successful for 98 per cent of children at home, compared to 93 per cent in hospital.

Home treatment also saved money for families and hospitals. The hospital saved almost $1500 per patient. For families, at home treatment cost an average of $400 less than a hospital stay.

Hospital-in-the-Home medical lead, Associate Professor Penelope Bryant, describes it as "an amazing result that we didn't expect".

"Doctors need to be confident that sending a child home for IV antibiotics directly from emergency is effective and safe," she says.

"For the first time we have truly shown that is the case; and by avoiding hospital admission altogether, children also avoid risks such as hospital-acquired resistant infections."

Clinician-researcher Dr Laila Ibrahim led the project for her doctorate, with senior authors and investigators Penelope and Paediatric Emergency Medicine Professor Franz Babl. "My dream is that almost every child, once medically stable, should be treated at home," says Laila.

The results were featured on the cover of the prestigious journal, The Lancet Infectious Diseases. They showed that children treated at home had better outcomes in a range of areas, including adverse events, patient satisfaction and parental and child quality of life.

Further research

Hospital-in-the-Home is now standard care for children presenting to RCH with cellulitis requiring IV antibiotics. It is also part of the RCH Paediatric Clinical Practice Guidelines, which guide hospitals on the east coast of Australia.

More studies are planned or underway for appendicitis, urinary tract infections and bronchiolitis, and patients with autism spectrum disorder are now being treated at home where possible.

Better together

The power of PREDICT to improve health for children

The Hospital-in-the-Home project is an example of the work that can be done through PREDICT – the Paediatric Research in Emergency Departments International Collaborative.

PREDICT has successfully coordinated paediatric emergency research since it was founded in 2004. In 2019, it received funding for a five-year Paediatric Emergency Medicine Centre of Research Excellence (PEM-CRE) from the National Health and Medical Research Council of Australia.

PREDICT was born out of recognition that the role of Emergency Departments (EDs) as the hospital's 'front door' puts them in a unique position. EDs can initiate research into the wide range of acute care issues that bring children and their families to hospital, including those who end up being successfully treated under Hospital-in-the-Home. The PEMCRE will further that work.

Paediatric Emergency Medicine Professor and Vice-Chair of PREDICT Franz Babl says: "PREDICT will provide an improved evidence base for emergency care in children and a platform for emergency and paediatric researchers from all specialties to conduct acute care research."