Implementation of a Strategy to Prevent Hospital Admission in Nursing Home Residents: Protocol of a Quasi-experimental Study
试验速览
- 阶段
- 不适用
- 状态
- 终止
- 入组人数
- 13
- 试验地点
- 1
- 主要终点
- Hospitalization rate
研究概览
简要总结
Elderly patients residing in nursing homes are particularly at risk of experiencing urgent medical problems needing admission to the Emergency Department (ED). This circumstance contributes to ED overcrowding, increases the risk of ward admission of elderly patients, and puts them at an even higher risk of hospitalization-related adverse events. The study hypothesis is that a complex intervention, delivered directly in nursing homes by hospital physicians in case of urgent medical problems, would contribute to reduce hospitalization of older nursing home residents.
The intervention consists in a hospital-based "multidisciplinary mobile unit" (MMU), composed of a hospital specialist and a resident in emergency-urgency medicine who are coordinated by a senior physician serving as "flow manager". The team is active on work days, 8 am to 6 pm, and is activated by general practitioners of nursing homes, in case of urgent medical needs of one of the residents. The activation is made by a phone call to the "flow manager", who triages the clinical needs of the case. The output of the phone consultation may include therapeutic advice provided by phone, immediate on-site visit by the MMU team (specialist and resident), scheduled visit by the MMU team, or direct admission to the hospital unit where MMU is based, avoiding ED visits. The MMU team is provided with a portable ultrasound system, an essential set of drugs and medical devices useful in a urgency setting (central venous lines, nasogastric tubes, rectal tubes, bladder catheters). During on-site visits, the MMU team performs diagnosis, stabilization and therapeutic advice, with the mission of avoiding ED visits and hospital admissions whenever possible.
The MMU intervention is already active in two nursing homes, since December 2018. The aim of this prospective, pragmatic, multicenter, quasi-experimental study (sequential design with two cohorts) is to test the effects of the implementation of the MMU care model in terms of reduction of unplanned hospitalization rates (primary outcomes), mortality, health service use and costs (secondary outcomes).
Two nursing homes (i.e., the ones who already benefit from the intervention) will serve as study group, and two nursing homes with similar geographical location will serve as control group. All residents of the participating nursing homes will be eligible for study inclusion. The study will last for 18 months, and a number of 338 residents is planned for inclusion.
详细描述
The study is based in the University Hospital of Parma, which has a catchment area of more than 400,000 inhabitants, of whom 22.3% is over 65 years old. It provides the only Emergency service of the district, and it ranks fourth in Italy by number of ED visits (yearly average of over 110,000). The average admission rate of the adult ED population is 18%, of which 65% concern people older than 65.
In the last two decades, the University Hospital of Parma has implemented several innovative initiatives to manage the hospital flow of frail multimorbid patients and their complex needs. These initiatives included bed management to avoid "bed-blockers", physician accountability for the discharge process, and creation of a dedicated hospital unit, organized by intensity of care to anticipate the needs of these patients preserving high performance indices. This unit, called Internal Medicine and Critical Subacute Care Unit, performs over 3,500 urgent admissions of frail multimorbid elderly patients per year, with an average length of stay that in 30% of cases is lower than 3 days.
Participating nursing homes are public facilities which ensure the presence of nursing staff 24 hours a day and of a physician at least 4 hours a day (high-intensity care facilities). The possible role of distance to the hospital is considered by including in each group one nursing home located next to the hospital and one located >5 km of distance.
This study follows a multimethod approach, based on the MRC framework for developing and evaluating complex interventions, including the development, feasibility assessment, and evaluation phases.
- Development of the intervention First, the different types of approaches reported in the literature, described above, were considered. The "prevention approach", interventions conducted in nursing homes, was chosen as the most suitable strategy to integrate the hospital's organizational model already in place, as it can target both hospitalization rates and ED overcrowding, allowing to intervene before the person accesses the hospital.
研究设计
- 研究类型
- Observational
- 观察模型
- Other
- 时间视角
- Prospective
入排标准
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •All residents of the participating nursing homes, regardless of age, gender or clinical conditions
排除标准
- •Unwillingness to sign informed consent form (patient him/herself or legal representatives)
结局指标
主要结局
Hospitalization rate
时间窗: 1 year
Calculated as all unplanned admissions divided per the sum of the person-time of the at-risk population (days of stay at the nursing home)
次要结局
- Cost analysis(1 year)
- Crude all-cause death(1 year)
- Hospital mortality rate(1 year)
- Length of hospital stay(1 year)
- Adverse events or complications(1 year)
研究者
Tiziana Meschi
Head of Geriatric-Rehabilitation Department
Azienda Ospedaliero-Universitaria di Parma