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Calcitonin Gene derived peptides for an Optimized Patient Transfer using an Innovative Multidisciplinary Assessment in the Canton Aargau (OPTIMA II)

Research Project
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01.04.2011
 - 31.03.2014

Community-acquired lower respiratory tract infections (LRTIs) include acute bronchitis, acute exacerbations of chronic obstructive pulmonary disease and pneumonia (CAP). They are among the most frequent causes of hospitalization1 and direct treatment costs amount to $15 billion in the USA2. Inpatient care of CAP is 8 to 20 times more expensive 3, 4 and carries a higher risk of nosocomial infections including Clostridium difficile-associated diarrhea5 than outpatient treatment. Many patients prefer outpatient treatment6. Nevertheless, despite a low-risk according to clinical severity scores, many patients are hospitalized for medical comorbidities and psychosocial reasons4, 7. Admission rates and length of stay are affected by a variety of medical, functional, psychosocial factors including patient and relatives preferences4, 7-9. In our multicentre ProHOSP study, compliance with the procalcitonin (PCT)-guided antibiotic algorithm was 90%10. Importantly, only half of the patients in the low medical risk groups as determined by PSI are treated as outpatients despite high intensity implementation10, 11. Regardless of low observed risk for adverse events, fear of medical complications was the dominant motive for hospitalization similarly among physicians, nurses, patients and relatives 12. This malcompliance may be due among others to the static behavior of the CAP severity scores during the course of the disease, the considerable variability in outcome within a given risk category and poor memorizability13. Intervention bundles reduce hospitalization rate and length of stay particularly in low-risk patients, and decrease antibiotic use and overall costs while achieving similar quality of life and patient outcomes in CAP14, 15. To assess nursing-related risk of patients, functional and frailty scores of varying complexity were developed. The ?Selbstpflegeindex? (SPI=self care index) is a simple and commonly used nursing and geriatric tool to assess functional dependence in activities of daily life. A score of <32 points indicates a risk for post-acute care deficit16. As a 5-variable scoring system the post-acute care discharge score (PACD) facilitates discharge planning17. A ?8 point score on day 3 of hospitalization was accurate (AUC: 0.82) to predict discharge to a post-acute care facility. Similarly, 5 items were independently associated with discharge to post-acute care if assessed on day 1 of admission. Nurse led units (NLU) are defined as institutional settings, typically within acute care hospitals, which provide independent specialized nursing service for post-acute care patients, who need predominantly nursing care. They constitute a possible model of care for patients with low medical yet high nursing risk18, 19 and are characterized and operationalized by five factors: 1) In-patient environment offering active treatment; 2) case mix based on nursing needs; 3) nursing leadership of the (multidisciplinary) clinical team; 4) nursing conceptualized as the predominant active therapy; 5) nurses? authority to admit and discharge patients18, 19. There are indications that post-acute care patients cared for in NLUs have a better functional status and a greater psychological well-being at discharge, are more often discharged home than to another institution and are less often readmitted early to the hospital than patients receiving usual care. There are also indications that these patients are more satisfied with the provided service19-21. Biomarkers are objective, dynamic, easily measurable and lack the need for memorizing complex algorithms. PCT-guided antibiotic therapy was shown in 11 randomized controlled trials (5 performed by our group)10, 22-25 to safely reduce antibiotic exposure in LRTIs by up to 75%26-28 and has been successfully implemented into clinical routine29. Unfortunately, CRP, PCT or other routinely measured markers have at best a moderate prognostic utility in LRTI 30-33.

Publications

Widmer, Daniel et al. (2014) ‘Effectiveness of Proadrenomedullin Enhanced CURB65 Score Algorithm in Patients with Community-Acquired Pneumonia in ‘Real Life’, an Observational Quality Control Survey’, Journal of Clinical Medicine, 3(1), pp. 267–79. Available at: https://doi.org/10.3390/jcm3010267.

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Albrich, Werner C. et al. (2013) ‘Biomarker-enhanced triage in respiratory infections: a proof-of-concept feasibility trial’, European Respiratory Journal, 42(4), pp. 1064–75. Available at: https://doi.org/10.1183/09031936.00113612.

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Conca, Antoinette et al. (2013) ‘Bei Eintritt den Austritt bereits im Blick : der PACD am Kantonsspital Aarau’, Krankenpflege, 106(1), pp. 20–23. Available at: https://www.sbk.ch/publikationen/zeitschrift-krankenpflege.html.

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Jensen, Jens-Ulrik (2013) ‘Biomarker-guided clinical decisions: for patients, health economists or neither?’, The European respiratory journal, pp. 895–897. Available at: https://doi.org/10.1183/09031936.00024813.

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Kolditz, Martin, Ewig, Santiago and Höffken, Gert (2013) ‘Management-based risk prediction in community-acquired pneumonia by scores and biomarkers’, The European respiratory journal, 41(4), pp. 974–84. Available at: https://doi.org/10.1183/09031936.00104412.

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Krueger, Stefan and Frechen, Dirk (2012) ‘Another brick in the wall: adrenomedullin and prognosis in community-acquired pneumonia’, The European respiratory journal, pp. 1060–1061. Available at: https://doi.org/10.1183/09031936.00179911.

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Members (1)

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Beat Müller

Principal Investigator