hospitalization was provided and optional overruling criteria prespecified. This overruling was virtual since the nurse-led unit (NLU) was not yet available and ...
Optimized Patient Transfer using an Innovative Multidisciplinary Assessment in the Kanton Aargau (OPTIMA I) – An observational survey in lower respiratory tract infections W. Albrich1, K. Rüegger1, F. Dusemund1, R. Bossart2, K. Regez2, U. Schild2, A. Conca2, P. Schuetz3, T. Sigrist4, A. Huber5, B. Reutlinger2, B. Müller1 1Medical
University Department of the University of Basel, Kantonsspital Aarau, Aarau, Switzerland 2Department of Nursing, Kantonsspital Aarau, Aarau, Switzerland 3Harvard School of Public Health, Boston, USA 4Department of Medicine, Kantonsspital Zug, Zug, Switzerland 5Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
Background Current medical scores have limited efficiency and safety profiles to assign the most appropriate treatment site to patients with lower respiratory tract infections (LRTIs). The addition of the biomarker proadrenomedullin (ProADM) significantly improved the prognostic value of clinical scores, while addition of other biomarkers did not lead to any further improvement. Herein, we describe an observational quality-control survey of our current triage process of patients with acute LRTIs. We aimed to identify the proportions of patients who would best be cared for at different levels of care based on an interdisciplinary risk assessment using clinical, biopsychosocial and functional scores and patient preferences with and without the addition of the biomarker ProADM.
Community-acquired lower respiratory tract infections (LRTIs) are the most prevalent, the most frequently fatal and the most cost-intensive infectious diseases in western countries. The initial site of care decision is arguably the single most important clinical decision made by physicians during the entire course of illness for patients with LRTI. It has a direct influence on the intensity of laboratory testing, microbiological evaluation, antibiotic therapy and cost of treatment. The estimated average cost of inpatient care for community-acquired pneumonia (CAP) in the USA is 8-20 times higher than for outpatient management.
Methods -Observational prospective quality control survey to evaluate the current triage practice for LRTI at -Assessment of medical stability daily based on current IDSA/ATS criteria the Kantonsspital Aarau, Switzerland -Psychosocial and functional assessments upon hospital admission (PACD, “post acute care discharge -All consecutive adults evaluated from 11/2009-04/2010 at ED for LRTIs score”), and during hospitalization (SPI=“Self-care index”) -If a patient remained hospitalized despite being medically stable, the main reason for ongoing -Novel combined risk score CURB65-A, consisting of CURB65 score and admission ProADM values hospitalization was provided and optional overruling criteria prespecified. classified patients into three medical risk categories: This overruling was virtual since the nurse-led unit (NLU) was not yet available and some triage options CURB65-A class I (low-risk, appropriate for treatment as an outpatient or in a non-acute medical facility): at times unavailable due to bed shortage. CURB65 score of 0-1 and ProADM ≤ 0.75 nmol/l CURB65-A class II (intermediate-risk, appropriate for short-term hospitalization for 48 hours): CURB65=2 -Primary endpoint: compare allocation to ideal virtual treatment sites based on algorithm with and ProADM ≤ 1.5 nmol/l actually allocated treatment sites CURB65-A class III (high-risk, requiring acute hospitalization): CURB65 ≥ 3 and/or ProADM ≥ 1.5 nmol/l -Secondary endpoints: correlation of biomarkers, clinical and functional scores with site of care decisions; determination of length of hospitalization before and after medical stability; identification of main reasons -Patients with low medical risk (CURB65-A class I) appropriate for care in non-acute medical institutions for discrepancy between actual and virtual treatment sites; and correlation of patient’s outcomes (adverse were further subgrouped into 3 biopsychosocial and functional risk categories (see fig. 1) events) with CURB65 and CURB65-A
Results 253 patients were included in this survey (mean age: 64.5 y; 56.1% male). ProADM was measured on presentation to the ED in the subgroup of 146 patients (mean age: 63.6 y; 58.2% male). Baseline characteristics of the two groups (with and without measurement of ProADM) were comparable. Overall, 96% of 253 patients were hospitalized. Among the 138 patients with available CURB65-A, 17.4% had a low medical risk (possible treatment in an outpatient or non-acute medical setting) 34.1% had an intermediate medical risk (short-hospitalization) 48.6% had a high medical risk (hospitalization)
Fewer patients were in a low CURB65-A class (I) than a low CURB65 class (0, 1) (17.4% vs. 44.6%, p
