Poly-stakeholders integrated care for chronic patients in acute phases

Not Applicable

• Conditions: I50; J44; J18; N10; A46; Heart failure; Other chronic obstructive pulmonary disease; Pneumonia, organism unspecified; Acute tubulo-interstitial nephritis; Erysipelas

• Registration Number: DRKS00014645
• Lead Sponsor: niversitätsklinikum Bonn - Studienzentrale SZB - Institut für klinische Chemie und klinische Pharmakologie

Brief Summary

Not available

Detailed Description

Not available

Study Timeline

• Study Start: 2018-05-07
• Study Completion: 2018-11-08
• Last Update Posted: 19 August 2024

Recruitment & Eligibility

• Status: Complete
• Sex: All
• Target Recruitment: 7

Inclusion Criteria

• Age = 65 years
• Living in the area of coverage
• Patients with the ability to follow study instructions and likely to attend and complete all required visits
• Written informed consent
Social:
• Supported by either a nursing service or an informal carer living in the same household
• Appropiate Housing Conditions
• Informal carer available (at least by telephone) all day
• Having social needs, defined as
• Barber at least 2 answers in the affirmative + Any Barthel-Score OR
• Barthel-Score between 80 and 95 + Barber at least 1 answer in the affirmative OR
• Barthel-Score 75 or less + any Barber
Medical:
COPD exacerbation (without indication for in-patient treatment according to the GP)
• physician-diagnosed COPD (defined as FEV1/ FVC <70%)
• new exertional dyspnea or worsening of existing exertional dyspnea
• necessity of a systemic therapy with antibiotics and/or corticosteroids
Decompensated heart failure (without indication for in-patient treatment according to the GP)
• physician-diagnosed heart failure (all functional classes)
• At least one of the following symptoms
o new exertional dyspnea or worsening of existing exertional dyspnea
o new peripheral oedema or worsening of existing oedema
o increase in weight of = 2 kg within 5 days or less
• necessity of new medication with a (additional) diuretic or modification (increase) of an existing diuretic therapy
Pneumonia (without indication for in-patient treatment according to the GP)
• Suspected pneumonia by the GP PLUS at least one of the following
o Corresponding auscultation of the lung
o Elevated CRP
o Corresponding Chest-x-ray
• At least two points in the Charlson Comorbidity Index (CCI)
Pyelonephritis (without indication for in-patient treatment according to the GP)
• Suspected pyelonephritis by the GP PLUS at least one of the following:
o Elevated CRP
o Corresponding urine test strip
o Corresponding ultrasound
• At least two points in the Charlson Comorbidity Index (CCI)
Erysipel (without indication for in-patient treatment according to the GP)
• Suspected erysipel by the GP
• At least two points in the Charlson Comorbidity Index (CCI)

Exclusion Criteria

• Patients not able to give consent
• Necessity of hospitalization according to the appraisal of the GP
• Severe dyspnea
• Oxygen saturation < 90% (if measured)
• Rapid progression of symptoms
• Clouding of conscioussness
• Central cyanosis
• Uncertain diagnosis
• Hypotension, defined as systolic blood pressure < 100 mmHg
• Pulmonary oedema
• New or hemodynamic relevant arrhythmias (including new atrial fibrillation)
• Patients without legal capacity who is unable to understand the nature, scope, significance and consequences of this clinical trial
• Patients with implanted pacemaker or ICD-system
• Patients with severe mental retardation, psychiatrical disorders or other cognitive impairment resulting in incapability to adequately estimate the risks and benefits of study participitation (e.g. advanced dementia)
• Patient lacks suitability for Polycare in estimation of the local Polycare-Team (consisting of staff of SZB and IfH of the UKB)

Study & Design

• Study Type: interventional
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
Evaluation of the ICT system with the System Usability Score (SUS)