A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 840
- 试验地点
- 1
- 主要终点
- Readmission rate
研究概览
简要总结
To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH
详细描述
Hospital with high readmission rate is view as having lower quality of care High readmission rate is view as wasteful healthcare spending
Primary Aim:
To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH
Secondary Aim:
To find out if a transitional care model can reduce the number of visits to the emergency department in SGH To find out the quality of our transitional care model by using a care transition measure (CTM-15)
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Health Services Research
- 盲法
- Single (Outcomes Assessor)
入排标准
- 年龄范围
- 21 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •More than 1 admission in the last 90 days
排除标准
- •Subject is a non-resident
- •Subject has no local home address
- •Subject is from a long-term care facility during index admission
- •Subject is unable to participate in telephone surveillance
- •Subject is discharged before takeover
- •Subject has impaired decision making capacity without surrogate decision maker
- •Subject is pending or currently in critical care unit
- •Subject or caregiver is mentally unstable
- •Subject is haemodynamically unstable
- •Subject requires acute inpatient respiratory support
- •Subject requires acute inpatient dialysis support
- •Subject pending surgical intervention
- •Subject pending transfer to other specialist discipline
- •Primary team consultant declined to participate in this research
研究组 & 干预措施
Intervention'
Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge
Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge
Intervention after discharge:
Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients
干预措施: a transitional care model (Other)
Control'
Patients receive usual standard of care from the internal medicine team
干预措施: Control (Other)
结局指标
主要结局
Readmission rate
时间窗: 30 days after index discharge
A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Readmission rate is calculated by dividing the total number of admission by the total number of patients
次要结局
- Readmission rate(up to 180 days after index discharge)
- Specialist Outpatient Clinic visits(Up to 180 days after index discharge)
- Quality of transitional care using a validated care transition measure (CTM-15) tool(90 days after index discharge)
- Emergency department attendance rate(Up to 180 days after index discharge)
- Time to first readmission(Up to 90 days after index discharge)