Webster, Leah W.

ABSTRACT Hospital‐at‐Home (HaH) programs provide acute care in patients' homes, reducing hospitalization and improving patient experience. While crucial in traditional settings, antimicrobial stewardship (AMS) in HaH programs remains understudied. This manuscript explores the potential benefits of AMS in HaH and the role of infectious diseases (ID) pharmacists in optimizing antimicrobial therapy. Key challenges in implementing AMS in HaH include medication delivery logistics, treatment regimen adjustments, and unique administration techniques. ID pharmacists can address these challenges by providing expertise in antimicrobial selection, dosing, and duration, as well as identifying opportunities for de‐escalation and intravenous (IV) to oral conversions. By integrating AMS into HaH programs, health care systems can improve patient outcomes, reduce antimicrobial resistance, and optimize resource utilization. Further research and training programs are needed to fully realize the potential of AMS in this emerging model of care.

Abstract Background Outcomes of patients with acute pyelonephritis (AP) treated in a hospital-at-home setting have not been comprehensively evaluated in the United States. Methods We performed a multicenter, retrospective cohort study of adults diagnosed with and managed for AP in Mayo Clinic's Advanced Care at Home (ACH) program between July 2020 and January 2025. Collected data included demographics, Charlson Comorbidity Index (CCI), genitourinary comorbidities, severity of illness (SOI), and risk of mortality (ROM) scores, as well as pyelonephritis-related complications. Outcomes included length of stay (LOS), escalation of care, and 30-day postdischarge emergency department (ED) visits, readmissions, and mortality. Results A total of 165 patients met inclusion criteria. Median age was 67 years; SOI scores were moderate in 33.3%, major in 52.1%, and extreme in 8.5%. ROM scores were moderate in 30.3%, major in 38.2%, and extreme in 6.7%. Median CCI score was 5, and all patients had preexisting genitourinary conditions. On admission, 30.9% met sepsis criteria, acute kidney injury was present in 47.3%, and bacteremia developed in 33.3%. Median LOS in the ACH program was 3.1 days. Only 4.8% required escalation to a brick-and-mortar hospital. Readmission occurred in 17.0%, and 4.8% had ED visits. No in-program deaths occurred. Conclusions This multicenter retrospective study shows that AP, including cases with high illness severity and complex comorbidities, can be managed safely and effectively in a hospital-at-home setting with careful patient selection and robust infrastructure to support timely escalation when needed.

Hepatic hydrothorax (HH) is a rare but serious complication of end-stage liver disease that is often refractory to conventional medical and procedural management. This case report describes a 75-year-old woman with HH secondary to cirrhosis from metabolic-associated steatotic liver disease. Her clinical course was marked by recurrent hospitalizations, refractory right-sided pleural effusion, and multiple unsuccessful interventions including diuretics, serial thoracenteses, an indwelling pleural catheter, and chemical pleurodesis. Notably, the persistence of pleural fluid despite resolution of ascites ultimately led to the formation of a thoracic fistula, with pleural drainage volumes exceeding 4 L/day. Further invasive procedures, such as transjugular intrahepatic portosystemic shunt or liver transplantation, were declined by the patient. She was enrolled in Mayo Clinic’s hospital-at-home (HaH) program, where continuous intravenous octreotide was initiated at a dose of 25 mcg/h. This resulted in a significant reduction in pleural output—from over 4000 mL to less than 100 mL daily. After clinical stabilization, the patient transitioned to subcutaneous octreotide and remained clinically stable for over 6 months, with improved quality of life and no significant adverse effects. To our knowledge, this is the first reported case of continuous intravenous octreotide infusion for HH administered safely in a home-based acute care setting. This case underscores the potential therapeutic role of octreotide in managing refractory HH and highlights the feasibility of delivering complex cirrhosis-related care through a HaH model with multidisciplinary collaboration. Further research is warranted to assess the long-term efficacy, safety, and cost-effectiveness of octreotide in this context and to explore broader application in home hospital environments.

Abstract Purpose Hospital at home (HaH) program development, spurred by hospital congestion during the COVID-19 pandemic, is moving from a novel idea to a standard of inpatient practice. Understanding pharmacy’s clinical role in the HaH patient care team is exceedingly important as programs across the country continue to develop, implement, and expand. The purpose of this study is to describe how clinical pharmacy services are currently provided for home hospital patients and to explain the vital role of pharmacists within the HaH care team. Description A descriptive study was designed to evaluate pharmacy services provided for home hospital patients from January 1, 2023, to February 28, 2023. Prior to the study period, a focused group of pharmacists routinely active in HaH patient care met to define a standard process for documenting pharmacy services using an electronic documentation system (i-Vent) within the EHR. During the study period, a total of 221 patients were admitted to home hospital at either site representing 3,258 inpatient medication orders with 2,997 medication administrations. Pharmacists signed 903 progress notes and documented 561 interventions across all types. The top 3 pharmacy intervention types were drug administration change (37%), medication reconciliation (29%), and antimicrobial stewardship (15%). Each of the top 3 types were further evaluated by subtype. Conclusion Documented pharmacy services encompassed a variety of intervention types. The overwhelming majority of patients admitted to the program received pharmacy consultative services, demonstrating how pivotal pharmacists are to the operational success of these programs and clinical care of HaH patients. More research is needed to expose pharmacy potential and facilitate growth for pharmacists practicing in HaH programs.

Home hospital programs continue to grow across the United States. There are limited studies around the process of patient selection and successful acquisition from the emergency department. The article describes how an interdisciplinary team used quality improvement methodology to significantly increase the number of admissions directly from the emergency department to the Advanced Care at Home program.