Response to: Beyond Benchmarking: Learning From Hospital at Home Escalations

To the Editors,

We thank Amith for his letter.¹

We agree with Amith that the purpose, or value, of the escalation review extends far beyond any numerical comparison. The rate itself is intended only as a starting point for the measurement of quality processes, staffing, patient assessment, HaH model design and responsiveness, or clinical severity indicators, in HaH.

He raises several issues worthy of consideration. With regard to the definition of unplanned escalation, in the SWISH study² we used an overnight stay in BAM for 2 reasons: firstly, because such a stay is recorded by most hospital systems which facilitates easier and more consistent data capture between institutions; and secondly because an overnight stay would exclude most presentations that are only for investigations or relatively brief observations, which may or may not have been through an Emergency department.

Further approaches to delineate escalations to add what we may learn include distinguishing whether they occur early or late during the HaH admission, and whether the escalation was foreseen at transfer to HaH.

His audit framework deserves attention, especially in the domain of assessing preventability (or non-preventability), although that preventability will be setting and time specific. For example, it could be further classified into clinical decision making, capability building (e.g. access to services like blood transfusion without escalation), operational limitations, or preference by the BAM management team.

We hope that every HaH team will apply unplanned escalation, and the derivatives we have described, in ways that usefully address comparative models and operations in HaH. Benchmarking is a pointless exercise without agreed and common outcomes. We hope we have given HaH clinicians and planners a common nomenclature with which to start that conversation, as Amith has proposed.

Stephanie Q Ko, Michael Montalto and David Levine, on behalf of SWISH authors

Conflict of Interest

There are no conflicts of interest to disclose.

Corresponding Author:

Stephanie Q Ko, stephanie_ko@nuhs.edu.sg
NUHS
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