Hospital-Level Care at Home for Acutely Ill Adults: a Qualitative Evaluation of a Randomized Controlled Trial.

BACKGROUND: Substitutive hospital-level care in a patient's home ("home hospital") has been shown to lower cost, utilization, and readmission compared to traditional hospital care. However, patients' perspectives to help explain how and why interventions like home hospital accomplish many of these results are lacking. OBJECTIVE: Elucidate and explain patient perceptions of home hospital versus traditional hospital care to better describe the different perceptions of care in both settings. DESIGN: Qualitative evaluation of a randomized controlled trial. PARTICIPANTS: 36 hospitalized patients (19 home; 17 control). INTERVENTION: Traditional hospital ("control") versus home hospital ("home"), including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing. APPROACH: We conducted a thematic content analysis of semi-structured interviews. Team members developed a coding structure through a multiphase approach, utilizing a constant comparative method. KEY RESULTS: Themes clustered around 3 domains: clinician factors, factors promoting healing, and systems factors. Clinician factors were similar in both groups; both described beneficial interactions with clinical staff; however, home patients identified greater continuity of care. For factors promoting healing, home patients described a locus of control surrounding their sleep, activity, and environmental comfort that control patients lacked. For systems factors, home patients experienced more efficient processes and logistics, particularly around admission and technology use, while both noted difficulty with discharge planning. CONCLUSIONS: Compared to control patients, home patients had better experiences with their care team, had more experiences promoting healing such as better sleep and physical activity, and had better experiences with systems factors such as the admission processes. Potential explanations include continuity of care, the power and familiarity of the home, and streamlined logistics. Future improvements include enhanced care transitions and ensuring digital interfaces are usable. TRIAL REGISTRATION: NCT03203759.

Burnout Among Staff in a Home Hospital Pilot.

BACKGROUND: Burnout affects large portions of the healthcare workforce and is associated with increased medical errors, decreased patient experience and adherence, loss of professionalism, and decreased productivity. Little data exists on how novel clinical care settings might impact burnout. We studied the experience and burnout of staff involved in a home hospital pilot, where acutely ill patients were cared for at home as a substitute for traditional hospitalization. METHODS: We analyzed evaluations completed by home hospital staff (physicians, registered nurses, and research assistants) at the conclusion of a 2-month pilot program. Our primary outcome was burnout evaluated by the Mini Z Burnout Survey. Secondary outcomes included overall job satisfaction, work environment, workload, and team evaluation measured on a 5-point Likert scale. RESULTS: Eight of nine (89%) staff completed evaluations. Seven of eight (88%) staff had no symptoms of burnout; one (13%) was under stress but did not feel burned out. Median overall satisfaction with home hospital was 4.5/5.0 (interquartile range (IQR), 1.0). Most staff (6/8; 75%) "strongly agreed" that their professional values were well-aligned with the program. Three of six (50%) "entirely" or "very much" preferred home hospital to their standard clinical setting. Six of eight (75%) staff felt that their opinions were "entirely" heard; four of eight (50%) felt the team "entirely" valued each of its participants. CONCLUSIONS: Novel clinical care settings like home hospital may lead to low staff burnout, high job satisfaction, and a healthy work environment. Further study is warranted.

Thermodynamic insights into 2-thiouridine-enhanced RNA hybridization.

Nucleobase modifications dramatically alter nucleic acid structure and thermodynamics. 2-thiouridine (s(2)U) is a modified nucleobase found in tRNAs and known to stabilize U:A base pairs and destabilize U:G wobble pairs. The recently reported crystal structures of s(2)U-containing RNA duplexes do not entirely explain the mechanisms responsible for the stabilizing effect of s(2)U or whether this effect is entropic or enthalpic in origin. We present here thermodynamic evaluations of duplex formation using ITC and UV thermal denaturation with RNA duplexes containing internal s(2)U:A and s(2)U:U pairs and their native counterparts. These results indicate that s(2)U stabilizes both duplexes. The stabilizing effect is entropic in origin and likely results from the s(2)U-induced preorganization of the single-stranded RNA prior to hybridization. The same preorganizing effect is likely responsible for structurally resolving the s(2)U:U pair-containing duplex into a single conformation with a well-defined H-bond geometry. We also evaluate the effect of s(2)U on single strand conformation using UV- and CD-monitored thermal denaturation and on nucleoside conformation using (1)H NMR spectroscopy, MD and umbrella sampling. These results provide insights into the effects that nucleobase modification has on RNA structure and thermodynamics and inform efforts toward improving both ribozyme-catalyzed and nonenzymatic RNA copying.