HOME FIRST (Home Followed - up with Infection Respiratory Support Team) is an early supported discharge scheme. It will enable patients with lower respiratory tract infection (LRTI) to be provided with high quality safe, effective, efficient patient centred care, tailored to their needs in their own home; aiming to improve the overall experience of the service user, improve patient outcomes and reduce hospital length of stay whilst simultaneously reducing admission rates, an area of major strategic importance to the NHS.
A randomised interventional clinical care pathway study of early supported discharge (termed 'HOME FIRST') versus standard hospital care for patients hospitalised with LRTI. HOME FIRST will provide co-ordinated multidisciplinary team (MDT) care, provision of 24hr emergency telephone cover, access to fully trained respiratory study nurse(s) and study doctor(s). The HOME FIRST MDT consists of: * Study doctors (trained respiratory physicians - consultants and senior SpRs) * Highly trained respiratory specialist nursing staff * Close links with a physiotherapist (mobility and respiratory) * Home help provision (temporary assistance with ADLs by carers) which may include occupational therapy or social worker involvement (HOME FIRST has fast access to meals-on-wheels) * Close links with pharmacy for rapid dispensing of discharge medication. Patients hospitalised with LRTI at the Royal Liverpool and Broadgreen (RLBUHT) Teaching Hospitals between October 2012 and April 2014 will be approached. Patients (or the next of kin if the patient is unable to give informed consent) will be offered participation in the study if they fit the strict inclusion/exclusion criteria. They will be then be randomised to receive HOME FIRST or standard hospital care (SHC). The investigators will aim to recruit 25 patients to each arm of the study. Patients randomised to HOME FIRST care will initially receive up to twice daily respiratory specialist nurse visits for the first 48 hours. After this time period, the frequency and duration of visits will depend on clinical need. The study nurse will establish the need for the involvement of other MDT team members. Laboratory tests will be performed as clinically indicated at the discretion of the study team. Venepuncture will be performed by fully trained research staff for clinical purposes as needed in the HOME FIRST limb: as for those patients in the SHC limb frequency of venepuncture depends on clinical assessment of need by their regular medical team. Patients randomised to standard hospital care (SHC) - All management and discharge decisions will be made by the patient's usual hospital team. Clinical tests will be performed at the discretion of the medical team. If any significant or concerning clinical issues are noted during study team's visits, the usual medical team will be alerted. All patients will be discussed at a weekly case-note MDT meeting. All patients will be followed-up on discharge in the 'Respiratory Infection' out-patient clinic (in the patient's own home if necessary) at 6 weeks, with a repeat chest X-ray if needed.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
NONE
Enrollment
26
HOMEFIRST patients receive monitoring and review of; vital signs, symptoms, mental state, nutrition and hydration, urine output, skin turgor and integrity, mobility, coping ability, medication concordance, smoking and nutrition and hydration. Individualised verbal and written self-management plans, a list of symptoms (including red flag symptoms) to prompt contact with the study team and a 24hr emergency contact number are provided. Clinical bloods and other investigations will be taken/requested as necessary. Questionnaires will be completed as follows; SF-12 - at recruitment and 6 weeks, CAP-SYM - at recruitment and 6 weeks. Satisfaction questionnaires are conducted over the telephone at 2 wks by an independent assessor. As part of usual clinical practice patients will have bloods and radiology requested as required.
No research investigations will occur except for questionnaires; as part of usual clinical practice patients will have bloods and radiology requested as desired by their usual clinical team. SF-12 (physical and mental function) \[performed twice in total\] - at recruitment (day 0) and 6 weeks CAP-SYM \[performed 3 times in total\] - at recruitment day 0 (twice including day minus 30) and 6 weeks Patient (and carer/consultee) satisfaction - conducted over the telephone at 2 wks by an independent assessor.
Royal Liverpool And Broadgreen University Hospital
Liverpool, Merseyside, United Kingdom
Time to recovery
Our primary endpoint is time to recovery. This is assessed by our simple 'RECRTI' (functional RECovery from Respiratory Tract Infection) questionnaire (non-validated) which is completed at 6 weeks Patients (or consultees) will be asked at recruitment to define their/the patient's best exercise capacity in the last 3 months e.g chair to bed with 1, unlimited exercise tolerance etc At the 6 week out-patient appointment they will be asked 4 simple questions: (marked on a likert-type scale in days and weeks): 1. When (if at all) did your sleep return to normal? 2. When (if at all) did your diet/appetite return to normal? 3. When (if at all) did your (pre-defined) exercise capacity return to normal? 4. When (if at all) did your capacity to work or socialise (delete as appropriate) return to normal? With regards to the primary outcome of time to recovery, this is a non-inferiority trial.
Time frame: Six weeks
30-day mortality
We will assess safety i.e. ensure there is no increase in mortality in the HOME FIRST limb.
Time frame: up to 6 weeks after recruitment
30-day hospital readmission rates
We will assess safety i.e. ensure there is no delayed recovery, no pneumonia (or non-pneumonia) complications resulting in hospital admission in the HOME FIRST arm.
Time frame: up to 6 weeks after recruitment
Patient satisfaction using a validated satisfaction questionnaire
A validated patient satisfaction will be conducted at 2 weeks by an independent assessor.
Time frame: at 2 weeks post recruitment
Carer (NOK) satisfaction using a validated satisfaction questionnaire
A validated carer/consultee satisfaction will be conducted at 2 weeks by an independent assessor.
Time frame: at 2 weeks post recruitment
Length of stay in hospital
Length of hospital stay will be calculated.
Time frame: Participants will be followed for the duration of hospital stay, this may be 1 day to 1 year
Functional status as assessed by SF-12 validated questionnaire
Functional status (physical and mental) and quality of life (QOL) questionnaire will be completed to assess recovery / post respiratory infection.
Time frame: up to 6 weeks after recruitment
Pneumonia score as assessed by CAP-SYM validated questionnaire
The questionnaire will be completed to assess recovery / post respiratory infection
Time frame: up to 6 weeks after recruitment
Combined total length of stay (days) - hospital and home first
Total length of stay - combined will be calculated
Time frame: Participants will be followed for the duration of hospital stay and their HOME FIRST stay, the latter can range from 1 - 5 days
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