Meet Emma (Cane) Onelli who has been nursing since 1998, so 23 years! She is from Hobart, Tasmania and her nursing background is 20 year of Emergency Nursing and the last 6 in HITH (Hospital in the Home) as well as casual in ED. She is kept busy with a hubby and 2 girls aged 9 and 11. She actually met her Italian husband while nursing on a Cruise ship in the US, he’s a Ships Engineer!

After 20 years of ED nursing and even nursing on a cruise ship, why did you transition to Hospital in the home?

I needed a more family-friendly job and I was not coping with a bit of bullying. I’d come from an amazing ED (Royal Hobart Hospital) and went to an ED as a Clinical Nurse and had a bit of bullying going on that I wasn’t used to. Someone told me they were starting a new job in a HITH program so I asked if there were jobs going…..

Would you recommend nursing to young people?

Yes absolutely. This career has enabled me to work around Australia, overseas, work from home. I’ve done Emergency Nursing, Telephone Triage, HITH nursing, casual pool, remote nursing, indigenous health, cruise-ship nursing. Not many careers would enable this. And for great pay and to be so emotionally rewarding.

What is HITH nursing?

HITH’s obvious main goal is hospital avoidance. All the studies show people recover quicker in their own beds, with their own food and their own bugs. We are like a virtual ward with a bed capacity of 36 pts. We work alongside a HITH team at the hospital with a Reg, Consultant, Clinical Nurses and a Pharmacist. Our company is a national company contracted by Qld Health to provide HITH.

What are the main types of presentations you see and what is your role in their care?

We primarily do IV antibiotics for infections such as bacteraemia, post-op wound infections, cellulitis, pneumonia, we do warfarin titration, heart failure medication titrations, IV fluids for hyperemesis pts, wound care, teach parents to use spo2 monitors to do overnight sleep studies on kids at home, support pts with new stomas, provide support for newly diagnosed diabetics and heaps more.

As a Clinical Nurse what are your day to day roles/responsibilities?

I’m a Clinical Nurse. I do go on the road and see pts but most of my shifts are in the office dealing with the hospital HITH team, doctors, pharmacy, aged care facilities etc co-ordinating the care of HITH pts, trouble-shooting clinical issues and scheduling pts for the next day (my biggest nightmare as HITH pts often still want to work, go out for lunches, attend weddings etc !)

Can you tell us about the skills and knowledge required to work Hospital In The Home?

ED nurses are great HITH nurses as we are all rounders and are used to dealing with changes and having to think on our feet. ED nurses are, however, terrible at wound care! We usually slap on a wet gauze and leave the ward to deal with it, so for me wound care was tricky to begin with. Medication management, acute care and wound care are our main skillset, so any nursing background including those, is good.  

It’s difficult when you’re in someone’s home and they have an anaphylaxis episode or other complication and there is no oxygen, suction, resus trolley or MET team to call on.

Acute care and some wound care knowledge is fantastic in our role.

What are some common misconceptions about HITH nursing?

That’s it’s boring community nursing with mostly wound care and you don’t really need skills to do it.

You see a lot of alcohol related problems in HITH nursing. Can you reflect on this and tell us the impact?

I did a speech with the Tasmanian Police Commissioner to the news media on the effects of alcohol on the ED. Something like 20% of ED presentations involve alcohol. I personally see it as a huge cultural issue in Australia. The load on the ED because of it – car accidents, rapes, domestic violence, unwanted pregnancies, assaults is mind-blowing. It’s one of the reasons I hardly drink.

Tell us about your passion for hospital avoidance/prevention and why it’s so important?

When I first started in HITH I was told a hospital bed costs $3000/day, which factors in the CEO, the cleaners, the caterers, wardies, nurses, allied health teams etc etc, whereas a HITH pt costs about $500/day, so that’s a massive reason to use HITH, aside from the quicker recoveries of pts in their own homes.

It makes my cringe when I see how many pts come to ED that could be treated at home, or by their GP, or Aged Care Residents who could be kept at home and seen there instead.

Self Neglect

We see a lot of pts who self-neglect, mostly due to drugs and alcohol and poor social circumstances. We also see a lot of diabetics who don’t look after their Diabetes very well. There is a huge case for a bigger role in Primary Health Care to take the load of the hospital system. For a while we ran a Respiratory Program where we called COPD pts every day and got their vitals from them and did an assessment, we were often able to avoid them calling an ambulance or self-presenting to an ED.  

What advice or recommendations for nurses looking to get into HITH nursing?

I’d recommend HITH to any nurses, however, if you’re in the beginning years of your career, it would be better to consolidate your skills first as you are working more autonomously in a HITH position.

Safety and HITH Nursing

Sometimes it’s downright terrible going into peoples homes. Some live in mansions and others live in complete squalor, some live at the end of corrugated dirt roads. It’s very sad to see how some people live and you can see why they get recurrent infections.

We have a 24/7 security company we can call on if we are worried about entering a pts house, we also have panic alarms and an app that allows us to put in the pts address, what time we are going there and what time we will be leaving, then if we don’t check back in, to the app in a certain timeframe, they ring a primary contact, then police. We always call our pts first before we come. All our pts have to sign that they are agreeing to HITH and being home, providing a safe environment etc, before they are discharged from the hospital

What have been you main career highlights?

I loved my ED job that I used to have but I especially loved the year of Cruise-ship nursing I did in the US. It was an amazing experience and where I met my husband. If people ask me if I’ve done remote nursing I say yes, because there’s not much more remote than being on a cruise-ship in the middle of the ocean!

You can’t call an ambulance or the Flying Doctors! We could only call the US Coastguard if things were that bad. One time we had to bag a pt for 3 hours as we raced to shore as our ventilator broke down, which was hard going between 3 of us!

I’ve delivered a baby in ED and been there for countless sudden deaths, those experiences have helped to shape the clinician that I am today. I try very hard to maintain empathy and not become apathetic.

I was working in ED one shift and had a 65 year old with chest pain. He was scanned, seen by cardiothoracics and vascular, who all said they couldn’t do anything for his ballooning aorta and that he would die within 12 hours. This is the one case that will live with me forever. He told me he was not ready to die. What do you say to someone in that situation when you take them up to the Medical Ward, hand them over to the ward nurse and leave? It was horrendous. I went home and cried more than I have ever cried. He died 11 hours in.

What’s next for your career?

I still really miss ED, as I only do casual shifts there now. I’d love to maybe go back one day as the kids are older but I’m pretty sure it won’t be the same anyway. At the moment I’m really happy in my job. Our company has also got a contract to provide all NSW positive COVID cases with a phone call each day to do an assessment, so I am just starting that role also.

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