Hospital in the Home Delivery of Supportive Care for Autologous Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

Introduction: High dose therapy with Autologous Stem Cell Transplantation (ASCT) has traditionally been performed as an inpatient procedure. However, with improvements in care and patient selection it is possible to safely deliver conditioning chemotherapy and supportive care in an Daytherapy setting (Kodad SG et al., 2019). While deemed an "outpatient procedure" this method is often delivered on large day units which requires the patient to attend daily, often only spending overnight at home.

To reduce these daily visits the Clinical Haematology Department of Peter MacCallum and Royal Melbourne Hospital (CHD) in collaboration with the Hospital in the Home department (HIHD) at Royal Melbourne Hospital developed an innovative program to safely deliver supportive care for Myeloma Patients undergoing ASCT at home (HIH-ASCT).

The HIHD is an acute inpatient unit that exists as a "virtual" inpatient ward. Patients are reviewed daily by a HIHD Doctor with twice daily visits by a HIHD Nurse for administration of supportive care measures (e.g. intravenous electrolyte and fluid replacement) in the comfort of their home. Here we report on the safety outcomes of our HIH-ASCT program, specifically patient complications and outcomes.

Methods: A retrospective case note audit identified 54 consecutive HIH-ASCT patients who received HIH-ASCT for Myeloma between 2018 and 2021 under HIHD. Patients were eligible for our HIH-ASCT program if they had Myeloma requiring ASCT; an ECOG ≤1; had not been admitted to ICU previously; lived within 30 minutes drive of the hospital; had a safe home environment (for both the patient and visiting staff) and a carer who could stay with them throughout their HIH-ASCT. While undertaking HIH-ASCT patients did not receive prophylactic antibiotics and they were not routinely given GCSF to minimise the risk of engraftment fevers.

Results: Of those treated as HIH-ASCT patients the median age was 60 years (range 33-72). 39% patients were female (n=21) and 61% male (n=33). Underlying disease groups included IgA (n=8; 15%), IgG (n=35; 64%), IgM (n=1; 2%), Light Chain (n=9; 17%) and Oligosecretory (n=1; 2%). 43% had High-risk Cytogenetics. ASCT-1 (n=48; 88%), ASCT-2 (n=5; 9%) and one patient underwent a ASCT-Tandem (both under HIHD). Conditioning regimes included Melphalan200 (n=37; 68%), Velcade-Melphan200 (n=13; 23%) and Carfilzomib-Melphalan200 (n=5; 9%). The average stem dose was 3.80 x10 ⁶/kg (range 2.14-8.4). Median time to Neutrophil engraftment was 12 days (range = 10-21) and Platelet engraftment 12 days (range = 8-18).

The total number of bed days saved through the HIH-ASCT program was 466, with a median length of stay (LOS) under the HIHD team of 9 days (Range = 3-14). In addition, 3 patients were not readmitted to the hospital (6%) and were discharged directly from the HIHD team. The most common reason for readmission was fever (n=43; 80%), of which only 11 were culture positive, and diarrhoea (n=44; 81%). Only 1 patient required intensive care support. There were no deaths. The median LOS as an inpatient once readmitted was 6 days (range = 2-27). In regards to cost savings, an acute inpatient bed under the CHD is approximately $1300 USD versus $900 USD per day for a HIHD bed. This equated to a potential cost saving for the CHD of approximately $186000 USD.

Conclusion: The delivery of supportive care for patients undergoing HIH-ASCT in is both safe and effective with comparable outcomes for what would be expected for an inpatient cohort. It resulted in a median of 9 bed days saved per patient (total number of bed days saved = 466). This is important as it allowed our department to increase bed capacity across the unit without the associated costs of building a new ward. In addition, during our COVID-19 outbreaks the HIH-ASCT program has allowed us to continue to deliver optimal patient care, while minimising the infection risk for our patients. More recently we have introduced remote monitoring (e.g. temperature, heart rate, blood pressure and oxygen saturations) with video reviews with the aim of increasing the capacity of our HIHD and further improving the HIH-ASCT experience for our patients.