Hospital in

the Home
Version 5

Clinical Indicator User Manual

ACHS Performance and

Endorsed by:
Outcomes Service
5 Macarthur Street
ULTIMO NSW 2007
Phone: (02) 9281 9955
Fax: (02) 9211 9633
The Australian Council on Healthcare Standards E-mail: pos@achs.org.au
Website: http://www.achs.org.au
 The data collected with this User Manual are to be reported and
submitted to ACHS using the ACHS Performance Indicator Reporting Tool (PIRT) at
https://pirt.achs.org.au/login.aspx

The Hospital in the Home Working Party is led by A/Prof Mary O’Reilly
Version 5 of this set of clinical indicators was first released for data collection in July 2016

Participating Colleges, Societies and Associations

Hospital in the Home Society Australasia http://www.hithsociety.org.au/

Australian Private Hospitals Association http://www.apha.org/

© Copyright by The Australian Council on Healthcare Standards 2015

All rights reserved. No part of this document may be reproduced, stored in a retrieval system or
transmitted in any form or by any means electronic, or mechanical, or by photocopying, recording or
otherwise without the prior written permission of the copyright owner.

Last updated 02/02/2016

Contents Hospital in the Home version 5

CONTENTS

CONTENTS............................................................................................................................................. 2

WORKING PARTY MEMBERS .............................................................................................................. 3

FOREWORD ........................................................................................................................................... 4

STRATIFICATION VARIABLES ............................................................................................................ 5

HITH AREA 1: Patient safety, selection, communication and care co-ordination ......................... 6
Rationale ................................................................................................................................................................. 6
Reporting periods .................................................................................................................................................... 6
Inclusions ................................................................................................................................................................ 6
Exclusions ............................................................................................................................................................... 6
Data cleaning rules ................................................................................................................................................. 6
Definitions of terms ................................................................................................................................................. 7
CI 1.1: Unexpected clinical telephone calls – adult/paediatric patient ..................................................................... 8
CI 1.2: Unexpected clinical telephone calls – neonatal patient ............................................................................... 8
CI 1.3: Unexpected administrative telephone calls – adult/paediatric patient.......................................................... 8
CI 1.4: Unexpected administrative telephone calls – neonatal patient .................................................................... 8
CI 1.5: Unscheduled clinical assessment – adult/paediatric patient ........................................................................ 8
CI 1.6: Unscheduled clinical assessment – neonatal patient .................................................................................. 9
Background ............................................................................................................................................................. 9

HITH AREA 2: Service interruption ................................................................................................... 11

Rationale ............................................................................................................................................................... 11
Reporting periods .................................................................................................................................................. 11
Inclusions .............................................................................................................................................................. 11
Exclusions ............................................................................................................................................................. 11
Data cleaning rules ............................................................................................................................................... 11
Definition of terms ................................................................................................................................................. 11
CI 2.1: Unplanned return to hospital – adult/paediatric patient .............................................................................. 12
CI 2.2: Unplanned return to hospital – neonatal patient ........................................................................................ 12
CI 2.3: Unplanned return to hospital within 24 hours – adult/paediatric patient..................................................... 12
CI 2.4: Unplanned return to hospital within 24 hours – neonatal patient ............................................................... 12
Background ........................................................................................................................................................... 13

HITH AREA 3: Unexpected deaths .................................................................................................... 14

Rationale ............................................................................................................................................................... 14
Reporting periods .................................................................................................................................................. 14
Inclusions .............................................................................................................................................................. 14
Exclusions ............................................................................................................................................................. 14
Data cleaning rules ............................................................................................................................................... 14
Definition of terms ................................................................................................................................................. 14
CI 3.1: Unexpected deaths during HITH admission – adult/paediatric patient ...................................................... 15
CI 3.2: Unexpected deaths during HITH admission – neonatal patient ................................................................. 15
Background ........................................................................................................................................................... 15

APPENDICES ...................................................................................................................................... A1
APPENDIX 1: ICD-10-AM Codes applicable to the Hospital in the Home indicator set ........................................ A1
APPENDIX 2: NSQHS Standards / EQuIPNational and these clinical indicators .................................................. A2
APPENDIX 3: Changes to the user manual from the previous version .................................................................A3

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Working Party Members Hospital in the Home version 5

WORKING PARTY MEMBERS

HOSPITAL IN THE HOME SOCIETY AUSTRALASIA

A/Prof Mary O’Reilly Vice President, HITH Society Australasia

(Chair) Executive Clinical Director, Ambulatory and Community Services &
Director, Infectious Diseases and Infection Prevention & Control,
Eastern Health, VIC

Barbara Farrelly President, HITH Society Australasia

Advanced Clinical Service Coordinator,
Southern Adelaide Local Health Network, SA
Dr James Pollard Clinical Director, Hospital in the Home,
Barwon Health, VIC

Michelle Horsnell Nurse Manager, Hospital in the Home Unit,

Cabrini Health, VIC

Amanda Trist Senior Occupational Therapist, Post Acute Care Service,

Prince of Wales Hospital, NSW

AUSTRALIAN PRIVATE HOSPITALS ASSOCIATION

Dr James McDonald Medical Director, Hospital in the Home Unit,

Cabrini Health, VIC

CLINICIAN
Unit Head, Hospital in the Home,
A/Prof Michael Montalto
Royal Melbourne Hospital, VIC
Senior Consultant, Hospital in the Home,
Epworth Richmond, VIC

CONSUMER REPRESENTATIVE

Janney Wale Consumer

UNIVERSITY OF NEWCASTLE

Stephen Hancock Statistician, Health Services Research Group,

University of Newcastle, NSW

AUSTRALIAN COUNCIL ON HEALTHCARE STANDARDS

Linda O’Connor Executive Director, Customer Services and Development

Myu Nathan Manager, Performance and Outcomes Service

Laura Hutchinson Project Officer, Performance and Outcomes Service

Dr Brian Collopy Clinical Advisor, Performance and Outcomes Service

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Foreword Hospital in the Home version 5

FOREWORD

Hospital in the Home (HITH) is now a well established component of our health care system.
Current studies confirm HITH provides safe, well accepted care with equivalent and possibly
improved patient outcomes, improved patient satisfaction and enhanced utilisation of bed
based services. It is important to ensure that HITH services continue to provide safe, high
quality care and benchmarking using national indicators is one mode of assurance. The
HITH Clinical Indicators, Version 5, aligning with the Australian Commission for Safety and
Quality in Health Care Standards, are designed to facilitate review and benchmarking and
therefore improve patient outcomes.
The HITH Clinical Indicators have been updated with multidisciplinary and consumer input to
reflect the changing arena in HITH care and to ensure they remain current and relevant.
Changes include modification of denominators from the number of HITH patients to HITH
occupied bed days to align with bed based services and better reflect activity. In consultation
with the paediatric sector, patient categorisation has been updated to separate
adult/paediatric HITH services from neonatal HITH services reflecting the different casemix
in these services.
Unplanned phone calls have been separated into clinical and administrative calls, accepting
that the clinical calls are an essential part of managing the deteriorating patient while
administrative calls should be low.
Review of unplanned HITH service interruption is considered essential in ensuring quality
care. While a low rate of service interruption is considered desirable it is accepted that rates
will depend on both casemix and level of care provided by the HITH service. Review of
unplanned service interruption to HITH care, both early and late, including assessment of
preventable and not preventable service interruption, can be used to support service
improvement in assessment and care choices and management of deteriorating patients.
The aim of the HITH Clinical Indicators, Version 5, is to further improve safety and quality of
HITH care.

A/Prof Mary O’Reilly

Chair, Hospital in the Home Working Party
Hospital in the Home Society Australasia

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Stratification variables Hospital in the Home version 5

STRATIFICATION VARIABLES

The ACHS, in collaboration with relevant professional colleges, associations and specialty
societies, has developed the following stratification variables to enable ‘like’ organisations to
be grouped for the purpose of comparison.
Four levels of comparison are available:
 An individual organisation’s data compared to ALL organisations that submit data for
a particular indicator
 Each individual organisation’s data compared to all other organisations submitting
data within the same sector, that is, public or private
 Within the Australasian Clinical Indicator Report (published annually), data are
compared by state, public/private and on a metropolitan/non-metropolitan basis.
These historical data are accessible from the ‘Retrospective ACIR data in full’ tab via
the following link on the ACHS website: http://www.achs.org.au/publications-
resources/australasian-clinical-indicator-report/
 An individual organisation’s data results compared to other organisations classified
according to defined stratification variables for the indicator set. The criteria used to
stratify an indicator set are based on the factors that the Working Party believes may
impact how different healthcare organisations perform.
Organisations interested to see their data stratified against additional variables should
contact POS (pos@achs.org.au) to request the additional reports.

Hospital in the Home stratification variables

All organisations are stratified into public / private categories and whether the Hospital in the
Home service treats:
 Adult patients only
 Paediatric patients only
 Neonatal patients only
 Combination of adult, paediatric and/or neonatal patients

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Area 1: Patient safety, selection, communication and care co-ordination

HITH AREA 1: Patient safety, selection, communication

and care co-ordination

Rationale
The admission of a patient into a Hospital in the Home (HITH) service involves the complex
interplay of patient safety, selection, communication and care co-ordination. The clinical
indicators included within this area reflect how the HITH service manages these elements.

(See Background for more information)

Reporting periods

1 January – 30 June 1 July – 31 December

Inclusions
For the purpose of CIs 1.1 – 1.2:
 All unexpected patient calls that include a clinical question or both a clinical and an
administrative question are to be INCLUDED in the numerator of CIs 1.1 – 1.2.
For the purpose of CIs 1.3 – 1.4:
 All unexpected patient calls that are not of a clinical nature are to be INCLUDED in
the numerator of CIs 1.3 – 1.4.

Exclusions
For the purpose of CIs 1.1, 1.3 and 1.5:
 Patients participating in the Geriatric Evaluation and Management (GEM) Program
are to be EXCLUDED.
 Patients who are accessing accommodation in a Medi-Hotel are to be EXCLUDED.
For the purpose of CIs 1.5 – 1.6:
 HITH patients who present to the Emergency Department or hospital ward are to be
EXCLUDED from the numerator of CIs 1.5 – 1.6.

Data cleaning rules

 The denominator figures for CIs 1.1, 1.3, 1.5, 2.1 and 2.3 should be the SAME, as
they share the same definition.
 The denominator figures for CIs 1.2, 1.4, 1.6, 2.2 and 2.4 should be the SAME, as
they share the same definition.

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Area 1: Patient safety, selection, communication and care co-ordination

Definitions of terms

For the purpose of CIs 1.1 – 1.6:

Adult refers to a patient whose age is 18 years or older.
Paediatric refers to a patient whose age is from 29 days to 17 years and 364 days.
Neonatal refers to a patient whose age is 28 days or younger.
HITH patients are those who, without the provision of HITH programs, would require
inpatient care by the nature of their medical condition or social circumstances. The National
Health Data Dictionary Version 16 describes HITH as “provision of care to hospital admitted
patients in their place of residence as a substitute for hospital accommodation. Place of
residence may be permanent or temporary”.
Patient bed-days should be inclusive of multiday and day stays.

For the purpose of CIs 1.1 – 1.2:

An unexpected clinical telephone call refers to a call received by the HITH service from a
patient regarding a clinical matter, when the patient was not specifically asked to telephone
about a given problem.
Occasionally, HITH staff may request that an individual patient telephone in certain specific
circumstances, for example if a particular symptom has not settled in a given time. That is an
example of an expected telephone call. Patients admitted to HITH services are usually
encouraged to telephone if they perceive any problem or concern related to their current
condition. Therefore this clinical indicator can be used for monitoring the number of patients
making clinical calls rather than being recommended as a high or low desirable rate. For
data capturing purposes, a clinical question should be deemed as superseding an
administrative question.

For the purpose of CIs 1.3 – 1.4:

An unexpected administrative telephone call refers to a call received by the HITH service
from a patient regarding an administrative matter, such as confirming an appointment time.

For the purpose of CIs 1.5 – 1.6:

An unscheduled clinical assessment refers to an assessment that would not ordinarily
have been required in order to deliver routine care. Reasons for an unscheduled clinical
assessment may include nausea and vomiting, new symptoms, equipment failure, pump
alarm, discharge from wounds and/or pain.

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Area 1: Patient safety, selection, communication and care co-ordination

Indicator(s) within this Area

CI 1.1: Unexpected clinical telephone calls – adult/paediatric patient

Number of unexpected clinical telephone calls made by adult/paediatric HITH patients or
Numerator
on their behalf, during the 6 month reporting period.
Number of adult/paediatric HITH patient bed-days within the HITH program, during the 6
Denominator
month reporting period.
Desirable rate: High  Low  Not specified 
Indicator type: Structure  Process  Outcome 

CI 1.2: Unexpected clinical telephone calls – neonatal patient

Number of unexpected clinical telephone calls made on behalf of neonatal HITH patients,
Numerator
during the 6 month reporting period.
Number of neonatal HITH patient bed-days within the HITH program, during the 6 month
Denominator
reporting period.
Desirable rate: High  Low  Not specified 
Indicator type: Structure  Process  Outcome 

CI 1.3: Unexpected administrative telephone calls – adult/paediatric patient

Number of unexpected administrative telephone calls made by adult/paediatric HITH
Numerator
patients or on their behalf, during the 6 month reporting period.
Number of adult/paediatric HITH patient bed-days within the HITH program, during the 6
Denominator
month reporting period.
Desirable rate: High  Low  Not specified 
Indicator type: Structure  Process  Outcome 

CI 1.4: Unexpected administrative telephone calls – neonatal patient

Number of unexpected administrative telephone calls made on behalf of neonatal HITH
Numerator
patients, during the 6 month reporting period.
Number of neonatal HITH patient bed-days within the HITH program, during the 6 month
Denominator
reporting period.
Desirable rate: High  Low  Not specified 
Indicator type: Structure  Process  Outcome 

CI 1.5: Unscheduled clinical assessment – adult/paediatric patient

Number of unscheduled clinical assessments of adult/paediatric HITH patients, during
Numerator
the 6 month reporting period.
Number of adult/paediatric HITH patient bed-days within the HITH program, during the 6
Denominator
month reporting period.
Desirable rate: High  Low  Not specified 
Indicator type: Structure  Process  Outcome 

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Area 1: Patient safety, selection, communication and care co-ordination

CI 1.6: Unscheduled clinical assessment – neonatal patient

Number of unscheduled clinical assessments of neonatal HITH patients, during the 6
Numerator
month reporting period.
Number of neonatal HITH patient bed-days within the HITH program, during the 6 month
Denominator
reporting period.
Desirable rate: High  Low  Not specified 
Indicator type: Structure  Process  Outcome 

Background
Hospital in the Home (HITH) refers to the delivery of acute care in the patient’s place of
residence as a substitute for being in hospital.1, 2 Most Australian states and territories have
HITH programs,3 with some services specialising in paediatric and neonatal patient care.
The general principles of HITH relating to patient care, care setting and medical
management apply to services providing care to paediatric and neonatal patients. 4 In 2013-
14 approximately 545,000 days of HITH care were reported (approximately 6% of these
days were attributed to private facilities) for approximately 93,000 separations, with an
average length of stay within HITH being 8.2 days.3 HITH facilitates the avoidance of
admission to hospital or the reduction of the length of stay in hospital if admission cannot be
avoided.1, 2, 5 The feature of providing a direct substitution for admitted acute care delineates
HITH from other community-based services.2 The most common conditions and treatments
delivered by HITH are intravenous antibiotic therapy for cellulitis, genitourinary tract or
respiratory tract infection, anticoagulant therapy, complex wound care, and chemotherapy.6
Appropriate recognition and response to a deteriorating patient is an important attribute of a
high quality HITH service. Unexpected clinical telephone calls and unscheduled clinical
assessments are two elements of an important escalation process adopted by HITH
services.
HITH services allow the faster movement of patients through hospital beds and reduce long
waiting lists, without creating additional costs to the health care system.7 From a patient
perspective, HITH can increase their independence, reduce disruption to their family and
create a sense of autonomy over their treatment.6, 7 The accumulation of factors such as
these has led to some patients reporting that they believe their recovery time was faster in
HITH compared to the anticipated recovery time had they stayed in hospital-based care.6
However, the literature has warned about the consequences of carers who may not fully
understand the commitment and responsibilities associated with caring for a patient admitted
to a HITH service.7, 8 Therefore, a patient’s physical condition needs to be considered
together with the patient’s home environment and social situation when determining a
patient’s suitability for HITH services.7 Furthermore, paediatric and neonatal patients have
the additional requirement that a guardian must be available and present during all treatment
interventions.9
HITH services involve a structured admission of patients who are regarded as inpatients of
the health service.2, 10-12 Patient selection is a critical factor to the safety, efficacy, and cost-
effectiveness of HITH programs.13 A clear set of admission criteria should ensure that HITH
is truly a substitute rather than an add-on to inpatient care, and also ensure only patients
who are appropriately selected are accepted into the program (in terms of factors such as
clinical stability, home environment and social support).2 A patient’s care needs should be
comprehensively assessed during patient selection and throughout admission in a HITH
service.9 HITH staff are responsible for the assessment, treatment and monitoring of HITH
patients.2, 10, 11 HITH staff should appropriately establish a management plan that includes
structured visits.10 Usually a member of the HITH team visits the patient at least once a
day.14 However in some circumstances, the patient may be requested to come to the
hospital to receive a component of the treatment or for further investigation or review.15

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Area 1: Patient safety, selection, communication and care co-ordination

References
1. Viney R, Haas M, Shanahan M and Cameron I. Assessing the value of hospital-in-the-home: lessons from
Australia. Journal of Health Services Research & Policy 2001; 6(3): 133-138.
2. Haas M, Shanahan M, Viney R and Cameron I. Consultancy to progress Hospital in the Home care provision :
final report. Canberra; Commonwealth of Australia; 1999.
3. AIHW. Admitted patient care 2013-14: Australian hospital statistics. Health services series no 60 Cat no HSE
156. Canberra: AIHW; 2015.
4. Ministry of Health New South Wales (NSW). NSW Hospital in the Home (HITH) Guideline. Document Number
GL2013_006. NSW Government; 2013.
5. Caplan GA, Sulaiman NS, Mangin DA et al. A meta-analysis of “hospital in the home”. Medical Journal of
Australia 2012; 197(9): 512-519.
6. Department of Human Services. Review of HITH programs: qualitative research with patients. Melbourne:
DLA Phillips Fox; 2009.
7. Duke M and Street A. Tensions and constraints for nurses in hospital-in-the-home programmes. International
Journal of Nursing Practice 2005; 11(5): 221-227.
8. Duke M and Street A. The impetus for the development of Hospital in the Home (HITH) programs: A literature
review. Contemporary Nurse 2003; 14(3): 227-239.
9. Department of Health. Hospital in the Home (HITH) Guideline. Document Number QH-GDL-379:2014.
Queensland Government; 2014.
10. Lui B, Tran A and Montalto M. Treatment of patients with pulmonary embolism entirely in hospital in the
home. Australian Family Physician 2007; 36(5): 381-384.
11. Montalto M, Lui B, Mullins A and Woodmason K. Medically-managed Hospital in the Home: 7 year study of
mortality and unplanned interruption. Australian Health Review 2010; 34(3): 269-275.
12. Sartain SA, Maxwell MJ, Todd PJ et al. Randomised controlled trial comparing an acute paediatric hospital at
home scheme with conventional hospital care. Archives of Disease in Childhood 2002; 87(5): 371-375.
13. Hunt GE, O'hara-Aarons M, O'connor N and Cleary M. Why are some patients admitted to psychiatric
hospital while others are not? A study assessing risk during the admission interview and relationship to outcome.
International Journal of Mental Health Nursing 2012; 21(2): 145-153.
14. Department of Human Services. Literature review and background analysis - hospital in the home.
Melbourne: DLA Phillips Fox; 2009.
15. Department of Health and Human Services. Hospital in the Home. State Government of Victoria. Accessed
from http://www.health.vic.gov.au/hith/index.htm on 14/09/2015.

ACHS CI User Manual Page 10 of 21

Area 2: Service interruption

HITH AREA 2: Service interruption

Rationale

Unplanned return to hospital or presentation at the Emergency Department (ED) during a

patient’s Hospital in the Home (HITH) treatment may have clinical implications and broader
implications on the health care system. It is important for HITH services to monitor their
patient selection process and examine the return of patients to hospital or the ED that are
preventable compared to those that are non-preventable, as they denote different quality in
care. In non-preventable situations, a return to hospital or ED may demonstrate a safe level
of care through the implementation of an appropriate escalation process for that HITH
service and its patients.

(See Background for more information)

Reporting periods

1 January – 30 June 1 July – 31 December

Inclusions
 Patients who attend the hospital or the ED for clinical review are to be INCLUDED in
the numerator of CIs 2.1 – 2.4.

Exclusions
 Patients who return to hospital for investigations or a planned outpatient appointment
are to be EXCLUDED from the numerator of CIs 2.1 – 2.4.
For the purpose of CIs 2.1 and 2.3:
 Patients participating in the Geriatric Evaluation and Management (GEM) Program
are to be EXCLUDED.
 Patients who are accessing accommodation in a Medi-Hotel are to be EXCLUDED.

Data cleaning rules

 The denominator figures for CIs 1.1, 1.3, 1.5, 2.1 and 2.3 should be the SAME, as
they share the same definition.
 The denominator figures for CIs 1.2, 1.4, 1.6, 2.2 and 2.4 should be the SAME, as
they share the same definition.

Definition of terms

For the purpose of CIs 2.1 – 2.4:

Adult refers to a patient whose age is 18 years or older.
Paediatric refers to a patient whose age is from 29 days to 17 years and 364 days.
Neonatal refers to a patient whose age is 28 days or younger.

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Area 2: Service interruption

HITH patients are those who, without the provision of HITH programs, would require
inpatient care by the nature of their medical or social condition. The National Health Data
Dictionary Version 16 describes HITH as “provision of care to hospital admitted patients in
their place of residence as a substitute for hospital accommodation. Place of residence may
be permanent or temporary”.
Patient bed-days should be inclusive of multiday and day stays.
An unplanned return to hospital refers to an unexpected requirement to transfer the
patient back to hospital or ED during a HITH admission. An example is a patient with
osteomyelitis returning to hospital with chest pain for investigation.

Indicator(s) within this Area

CI 2.1: Unplanned return to hospital – adult/paediatric patient

Number of adult/paediatric HITH patients having an unplanned return to hospital, during
Numerator
the 6 month reporting period.
Number of adult/paediatric HITH patient bed-days within the HITH program, during the 6
Denominator
month reporting period.
Desirable rate: High  Low  Not specified 
Indicator type: Structure  Process  Outcome 

CI 2.2: Unplanned return to hospital – neonatal patient

Number of neonatal HITH patients having an unplanned return to hospital, during the 6
Numerator
month reporting period.
Number of neonatal HITH patient bed-days within the HITH program, during the 6 month
Denominator
reporting period.
Desirable rate: High  Low  Not specified 
Indicator type: Structure  Process  Outcome 

CI 2.3: Unplanned return to hospital within 24 hours – adult/paediatric patient

Number of adult/paediatric HITH patients having an unplanned return to hospital within
Numerator
24 hours of HITH admission, during the 6 month reporting period.
Number of adult/paediatric HITH patient bed-days within the HITH program, during the 6
Denominator
month reporting period.
Desirable rate: High  Low  Not specified 
Indicator type: Structure  Process  Outcome 

CI 2.4: Unplanned return to hospital within 24 hours – neonatal patient

Number of neonatal HITH patients having an unplanned return to hospital within 24 hours
Numerator
of HITH admission, during the 6 month reporting period.
Number of neonatal HITH patient bed-days within the HITH program, during the 6 month
Denominator
reporting period.
Desirable rate: High  Low  Not specified 
Indicator type: Structure  Process  Outcome 

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Area 2: Service interruption

Background
A recent Australian-based study found the rate of completed care, without interruption, for
HITH patients was as high as 95.8%.1 Factors that were associated with service interruption
include patients who were older, referred from inpatient wards, and patients who were
treated with intravenous antibiotics.1 Unplanned interruption to HITH service provision may
reveal difficulties in establishing suitable eligibility criteria, in determining the appropriate
care choice, in conducting comprehensive assessment at admission, and potentially
misdiagnosing the condition or its severity.2 An unexpected interruption to care is an
undesirable outcome for patients and hospitals and should be monitored accordingly. 1
However, unexpected interruption to a HITH service does not necessarily reflect deficits in
the service but rather may be the best outcome for a patient and a sign of a vigilant HITH
program.1, 2 A patient may experience an unexpected and unavoidable complication of
treatment or the clinical condition. In those instances an unexpected interruption to the HITH
service would be the most suitable provision of care.2
HITH services should have clearly established processes in place to manage emergencies,
adverse events and other patient complications.3 The CIs within this area should be highly
associated with the Australian Commission on Safety and Quality in Health Care’s Standard
9, as they show a clear response to the deteriorating patient.4 Whilst a low rate of HITH
service interruption may be desirable, it is largely dependent on casemix and the service’s
model of care. For example, the incorporation of a medical model into HITH services,
whereby a doctor is directly involved in providing home care, may reduce hospital review
and admission rates.5 Additionally a patient returning to hospital within 24 hours of HITH
admission may reflect an inappropriate admission to the service. However, there is a range
of mitigating circumstances that may contribute to an increased number of service
interruptions within 24 hours. Firstly, some HITH services participate in ‘trialling’ patients in
the HITH program as a way of determining a patient’s suitability. Secondly, dependant on
the HITH model of care being implemented, a HITH service may take high risk patients with
the understanding that return to hospital may occur. Thirdly, carer anxiety can be a
significant factor in the decision for a patient to return to hospital. These components show
that there can be a broad range of factors impacting upon the unexpected return to hospital
for some HITH patients.

References
1. Montalto M, Lui B, Mullins A and Woodmason K. Medically-managed Hospital in the Home: 7 year study of
mortality and unplanned interruption. Australian Health Review 2010; 34(3): 269-275.
2. Montalto M, Portelli R and Collopy B. Measuring the quality of hospital in the home care: a clinical indicator
approach. International Journal for Quality in Health Care 1999; 11(5): 413-418.
3. Department of Health. Hospital in the Home (HITH) Guideline. Document Number QH-GDL-379:2014.
Queensland Government; 2014.
4. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health
Service Standards. Sydney NSW; ACSQHC. Accessed from
http://www.safetyandquality.gov.au/publications/national-safety-and-quality-health-service-standards/ on
21/09/15.
5. Tran A and Taylor DM. Medical model for hospital in the home: effects on patient management. Australian
Health Review 2009; 33(3): 494-501.

ACHS CI User Manual Page 13 of 21

Area 3: Unexpected deaths

HITH AREA 3: Unexpected deaths

Rationale

The clinical indicator within this area monitors the unexpected death of patients who have
been admitted to a Hospital in the Home (HITH) program.

(See Background for more information)

Reporting periods

1 January – 30 June 1 July – 31 December

Inclusions
 As per numerator and denominator.

Exclusions
 Patients who are undergoing planned end of life care are to be EXCLUDED.
For the purpose of CI 3.1:
 Patients participating in the Geriatric Evaluation and Management (GEM) Program
are to be EXCLUDED.
 Patients who are accessing accommodation in a Medi-Hotel are to be EXCLUDED.

Data cleaning rules

 Nil

Definition of terms
For the purpose of CIs 3.1 – 3.2:
Adult refers to a patient whose age is 18 years or older.
Paediatric refers to a patient whose age is from 29 days to 17 years and 364 days.
Neonatal refers to a patient whose age is 28 days or younger.
HITH patients are those who, without the provision of HITH programs, would require
inpatient care by the nature of their medical or social condition. The National Health Data
Dictionary Version 16 describes HITH as “provision of care to hospital admitted patients in
their place of residence as a substitute for hospital accommodation. Place of residence may
be permanent or temporary”.
Patient bed-days should be inclusive of multiday and day stays.
An unexpected death refers to a patient who was not expected to die at the time of
admission. All deaths within a HITH service necessitate a review, and determining whether
the death was expected or unexpected would require a retrospective application of the
definition during the case review.

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Area 3: Unexpected deaths

Indicator(s) within this Area

CI 3.1: Unexpected deaths during HITH admission – adult/paediatric patient

Number of unexpected deaths of adult/paediatric HITH patients, during the 6 month
Numerator
reporting period.

Number of adult/paediatric HITH patient bed-days within the HITH program, during the 6
Denominator
month reporting period.
Desirable rate: High  Low   Not specified 
Indicator type: Structure  Process  Outcome 

CI 3.2: Unexpected deaths during HITH admission – neonatal patient

Number of unexpected deaths of neonatal HITH patients, during the 6 month reporting
Numerator
period.

Number of neonatal HITH patient bed-days within the HITH program, during the 6 month
Denominator
reporting period.
Desirable rate: High  Low   Not specified 
Indicator type: Structure  Process  Outcome 

Background
HITH provides service to acutely unwell patients in an environment with a reduced level of
supervision compared to that in a hospital. Therefore, given the nature of the service, there
are inherent risks associated with the service which must be assessed and reduced to avoid
adverse events such as unexpected death.1 HITH services will have clearly established
processes to ensure the early recognition and appropriate management of patients who are
clinically deteriorating. Furthermore, it is recommended that patients and carers are provided
with education and written information regarding the signs and symptoms of deterioration.2
The spectrum of clinical conditions treated within HITH services is broadening.3 The
treatment, model of care and level of service that can be provided will differ between HITH
programs, therefore the type of patient selected may vary between services. 4 The
appropriate selection of patients influences the safety and quality of HITH programs,
therefore patients, their situation and environment, should be assessed using set criteria.5
The process of selecting appropriate patients should adhere to local policies and
procedures.6 Additionally, at the other end of the spectrum, HITH healthcare professionals
should direct patients who do not require the level of care provided by HITH to more
appropriate community-based services.7
It has been shown that mortality outcomes are not significantly different between HITH and
hospital-based care,8 and the mortality rates and adverse events as a result of HITH
management are low.9, 10 Studies have also indicated that there is a higher rate of adverse
events when elderly patients receive hospital-based care compared to home-based care.5
However, this can be difficult to conclude when confounding factors such as health status
and measurement sensitivity are considered.5 Whilst there are unexpected deaths among
HITH patients, such as those with unexpected complications, the rate should be very low.
The use of clinical indicators will facilitate the monitoring of these adverse events and
improve services.6 In the event of a patient death whilst within the HITH program, a HITH
service will have to comply with the broader organisational processes for reviewing the
case.11

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Area 3: Unexpected deaths

References
1. Montalto M, Lui B, Mullins A and Woodmason K. Medically-managed Hospital in the Home: 7 year study of
mortality and unplanned interruption. Australian Health Review 2010; 34(3): 269-275.
2. Ministry of Health New South Wales (NSW). NSW Hospital in the Home (HITH) Guideline. Document Number
GL2013_006. NSW Government; 2013.
3. Montalto M. The 500-bed hospital that isn't there: the Victorian Department of Health review of the Hospital in
the Home program. Medical Journal of Australia 2010; 193(10): 598-601.
4. Shepperd S, Doll H, Angus Robert M et al. Hospital at home admission avoidance. Cochrane Database of
Systematic Reviews 2008(4): Accessed from
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007491/abstract on 21/09/2015.
5. Department of Human Services. Literature review and background analysis - hospital in the home. Melbourne:
DLA Phillips Fox; 2009.
6. Department of Health. Hospital in the Home Guidelines. Melbourne, Australia; State Government of Victoria;
2011.
7. Department of Health. Report on evaluation of Hospital in the Home Programs. Melbourne: DLA Phillips Fox;
2009.
8. Aimonino Ricauda N, Tibaldi V, Leff B et al. Substitutive “Hospital at Home” Versus Inpatient Care for Elderly
Patients with Exacerbations of Chronic Obstructive Pulmonary Disease: A Prospective Randomized, Controlled
Trial. Journal of the American Geriatrics Society 2008; 56(3): 493-500.
9. Tran A and Taylor DM. Medical model for hospital in the home: effects on patient management. Australian
Health Review 2009; 33(3): 494-501.
10. Liu AL and Taylor DM. Adverse events and complications among patients admitted to hospital in the home
directly from the emergency department. Emergency Medicine 2002; 14(4): 400-405.
11. Department of Health. Hospital in the Home (HITH) Guideline. Document Number QH-GDL-379:2014.
Queensland Government; 2014.

ACHS CI User Manual Page 16 of 21

Appendices

APPENDICES

APPENDIX 1: ICD-10-AM Codes applicable to the Hospital in the Home

indicator set

HITH AREA 1: Patient safety, selection, communication and care co-ordination

No ICD-10-AM codes identified.

HITH AREA 2: Service interruption

No ICD-10-AM codes identified.

HITH AREA 3: Unexpected deaths

No ICD-10-AM codes identified.

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Appendices

APPENDIX 2: NSQHS Standards / EQuIPNational and these clinical indicators

The use of clinical indicators by healthcare organisations supports quality oversight and
provides a foundation for quality improvement within the organisation and its departments.
The monitoring of clinical indicators and an organisation’s response to the data remain an
important option for presenting evidence to demonstrate performance against criteria in the
NSQHS Standards and EQuIPNational.
Actions from EQuIPNational (including NSQHS Standards, where applicable) that may be
evidenced with these Hospital in the Home CIs are outlined in the appendix.

STANDARD 1: GOVERNANCE FOR SAFETY AND QUALITY IN HEALTH SERVICE

ORGANISATIONS

Criterion: Governance and quality improvement systems

Action 1.2.1 Relevant CIs from this set:

Regular reports on safety and quality indicators and ALL HITH CIs
other safety and quality performance data are
monitored by the executive level of governance.

Action 1.2.2 Relevant CIs from this set:

Action is taken to improve the safety and quality of ALL HITH CIs
patient care.

Action 1.5.2 Relevant CIs from this set:

Actions are taken to minimise risks to patient safety ALL HITH CIs
and quality of care.

Action 1.6.1 Relevant CIs from this set:

An organisation-wide quality management system is ALL HITH CIs
used and regularly monitored.

Action 1.6.2 Relevant CIs from this set:

Actions are taken to maximise patient quality of care. ALL HITH CIs

Criterion: Clinical practice

Action 1.8.3 Relevant CIs from this set:

Systems exist to escalate the level of care when HITH CI 1.1: Unexpected clinical telephone
there is an unexpected deterioration in health status. calls – adult/paediatric patient
HITH CI 1.2: Unexpected clinical telephone
calls – neonatal patient

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Appendices

STANDARD 9: RECOGNISING AND RESPONDING TO CLINICAL DETERIORATION IN ACUTE

HEALTH CARE

Criterion: Establishing recognition and response systems

Action 9.2.2 Relevant CIs from this set:

Deaths or cardiac arrests for a patient without an HITH CI 3.1: Unexpected deaths during HITH
agreed treatment-limiting order (such as not for admission – adult/paediatric patient
resuscitation or do not resuscitate) are reviewed to
HITH CI 3.2: Unexpected deaths during HITH
identify the use of the recognition and response
admission – neonatal patient
systems, and any failures in these systems.

Criterion: Recognising clinical deterioration and escalating care

Action 9.4.1 Relevant CIs from this set:

Mechanisms are in place to escalate care and call HITH CI 1.1: Unexpected clinical telephone
for emergency assistance. calls – adult/paediatric patient
HITH CI 1.2: Unexpected clinical telephone
calls – neonatal patient

Criterion: Communicating with patients and carers

Action 9.7.1 Relevant CIs from this set:

Information is provided to patients, families and HITH CI 1.1: Unexpected clinical telephone
carers in a format that is understood and meaningful. calls – adult/paediatric patient
The information should include:
HITH CI 1.2: Unexpected clinical telephone
 the importance of communicating concerns calls – neonatal patient
and signs/symptoms of deterioration, which
are relevant to the patient’s condition, to the
clinical workforce.
 local systems for responding to clinical
deterioration, including how they can raise
concerns about potential deterioration.

Action 9.9.1
Mechanisms are in place for a patient, family
member or carer to initiate an escalation of care
response.

Action 9.9.2
Information about the system for family escalation of
care is provided to patients, families and carers.

Action 9.9.3
The performance and effectiveness of the system for
family escalation of care is periodically reviewed.

Action 9.9.4
Action is taken to improve the system performance
for family escalation of care.

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Appendices

STANDARD 11: SERVICE DELIVERY

Criterion: Appropriate and effective care

Action 11.5.1 Relevant indicators from this CI set:

The organisation ensures appropriate and effective ALL HITH CIs
care through:
 processes used to assess the
appropriateness of care
 an evaluation of the appropriateness of
services provided
 the involvement of clinicians, managers and
consumers / patients in the evaluation of
care and services.

STANDARD 14: INFORMATION MANAGEMENT

Criterion: Collection, use and storage of information

Action 14.6.1 Relevant CIs from this set:

Monitoring and analysis of clinical and non-clinical ALL HITH CIs
data and information occurs to ensure:
 accuracy, integrity and completeness
 the timeliness of information and reports
 that the needs of the organisation are met
and improvements are made as required.

Action 14.7.1 Relevant CIs from this set:

The organisation uses data from external databases ALL HITH CIs
and registers for:
 research
 development
 improvement activities
 education
 corporate and clinical decision making
 improvement of care and services.

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Appendices

APPENDIX 3: Changes to the user manual from the previous version

The Hospital in the Home Working Party convened on 18 September 2015, and following a
series of consultations, the revised set of Hospital in the Home Clinical Indicators (CIs)
version 5 was completed.
The eight CIs in the previous Hospital in the Home set v4 were organised into three areas:
1. Patient safety and selection
2. Program interruption
3. Unexpected deaths

Hospital in the Home version 5

In version 5, the eight Hospital in the Home CIs have been revised into three areas. Working
Party members decided to update existing areas so that they were current, relevant and
collectable.
The major changes to the ACHS Hospital in the Home set version 5 are:
The denominator for these CIs have been changed from the number of HITH patients to
HITH patient bed-days to be more reflective of the service provided. These revised CIs now
capture data on adult/paediatric and neonatal HITH patients separately to provide more
meaningful benchmarking data to participating HITH services.
HITH AREA 1: Patient safety, selection, communication and care co-ordination - Revised
The Working Party has changed the title of this area to reflect the multifaceted nature of
service provision. The previous CI on the number of unexpected telephone calls has been
revised and separated into two CIs to reflect the nature of the call (clinical and/or
administrative). The previous CI on unscheduled staff callouts has been refined to capture
unscheduled clinical assessments.
HITH AREA 2: Service interruption - Revised
The Working Party has changed the title of this area as they felt it was the service rather the
HITH program that was being interrupted. The CIs on unplanned return to the hospital have
been revised so that HITH services can examine and differentiate between those cases that
are preventable and those non-preventable cases where a return to hospital or presentation
to the Emergency Department demonstrates a safe level of care through the implementation
of an escalation process.
HITH AREA 3: Unexpected deaths - Revised
The Working Party revised the CIs in this area to monitor the unexpected death of a patient
admitted to a HITH program. It was decided that end of life care patients be excluded from
these CIs as they would skew the data for HITH services providing palliative care.

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The Australian Council on Healthcare Standards