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Discharge Planning in Emergency Department for Frail Older With AHF

Not Applicable
Conditions
Acute Heart Failure
Frail Elderly Syndrome
Interventions
Other: Multilevel Guided Discharge Planning
Other: Standard of care
Registration Number
NCT03696875
Lead Sponsor
F. Javier Martin Sanchez
Brief Summary

Objectives: To demonstrate the efficacy of care transition holistic intervention (Multilevel Guided Discharge Planning, MGDP) in reducing 30-day adverse outcomes among frail older patients with acute heart failure (AHF) discharged from Emergency Departments (EDs) and to validate the results of MGDP in real life.

Method: Investigators will select frail patients ≥70 years with primary diagnosis of AHF discharged from EDs. The intervention will consist of MGDP implementation: 1) checklist that includes clinical recommendations and resources activations; 2) scheduling of early visit with the specialist; 3) communication with primary care; 4) providing a written instruction sheet to patient or caregiver. Phase 1: matched-pair cluster randomized clinical trial. EDs were randomly allocated to intervention (n = 10) or control (n = 10) group. Investigators will compare the outcomes between intervention and control groups. Phase 2: a quasi-experimental study. The 20 EDs will carry out the intervention. Investigators will compare the outcomes between phase 1 and phase 2 of intervention group and between phase 1 and phase 2 of control group. The main outcome is a 30-day composite endpoint (ED revisit or hospital admission for AHF and cardiovascular death) after being discharged.

Detailed Description

Not available

Recruitment & Eligibility

Status
UNKNOWN
Sex
All
Target Recruitment
1260
Inclusion Criteria
  • Age ≥70 years.
  • Diagnosis of descompensated chronic heart failure.
  • Screening for frailty positive (ISAR ≥ 2).
  • Planned discharge home from Emergency Department (included observation and short stay unit).
  • Written informed consent provided by the patient or proxy.
Exclusion Criteria
  • De novo (new onset) acute heart failure (AHF).
  • Severe episode of acute heart failure (≥9th decile of MEESSI-AHF Score).
  • Uncorrected clinically significant primary valvular disease.
  • Acute coronary syndrome currently or within 30 days prior to enrolment.
  • Surgery or implanted device within 30 days prior to enrolment.
  • Significant arrhythmias.
  • Uncorrected systolic blood pressure < 100 mmHg, O2 saturation baseline < 92%, heart rate < 60 or >110 bpm, serum sodium < 130 mmol/l, serum potassium >5,5 mmol/l or hemoglobin <9 g/dL prior to enrolment.
  • Planned treatment with vasoactive therapies, ventricular assist device, heart surgery or transplant within 6 months.
  • End stage renal disease.
  • Severe disability.
  • Difficulty intervention due to significant dementia, active delirium or psychiatric disorder.
  • Condition with a life expectancy <1 year.
  • Length of stay in Emergency Department ≥96 hours.
  • Discharged to facility care.
  • Inability of outpatient follow-up.

Study & Design

Study Type
INTERVENTIONAL
Study Design
PARALLEL
Arm && Interventions
GroupInterventionDescription
Multilevel Guided Discharge PlanningMultilevel Guided Discharge Planning-
Standard of careStandard of care-
Primary Outcome Measures
NameTimeMethod
30-day emergency revisit or hospital admission for acute heart failure or cardiovascular mortality rate after dischargeat 30 days post-discharge

The proportion of patients who have emergency revisit or hospital admission for acute heart failure or cardiovascular mortality within 30 days after discharge

Secondary Outcome Measures
NameTimeMethod
Acute heart failure hospitalisation rateat 30 days post-discharge

The proportion of patients who have hospitalisation for acute heart failure within 30 days after discharge

All-cause mortality rateat 30 days post-discharge

The proportion of patients who have all-cause mortality within 30 days after discharge

Functional impairment (assessed by self-reported Barthel index)Change from baseline to 30 days post-discharge

Barthel index measures the subject's capacity to perform ten activities of daily living (feeding, bathing, grooming, dressing, bowel and bladder control, toileting, chair transfer, ambulation and stair climbing). The sum score ranges from 0 (totally dependent) to 100 (totally independent).

Cardiovascular mortality rateat 30 days post-discharge

The proportion of patients who have cardiovascular mortality within 30 days after discharge

Satisfaction of patient or caregiver about transition of care (assessed by Care Transitions Measure questionnaire)Within 30 days after discharge

CTM questionnaire assesses the quality of care transitions, with lower scores indicating a poorer quality transition, and higher scores indicating a better transition.

Quality of live of patients (assessed by EuroQol-5D)Within 30 days after discharge

EQ-5D measures of health-related quality of life. The descriptive system comprises 5 dimensions (mobility, self care, usual activities, pain/discomfort, anxiety/depression) and each dimension has 5 levels (no problems, slight problems, moderate problems, severe problems, and extreme problems). The EQ VAS records the respondent's self-rated health on a 20 cm vertical, visual analogue scale with endpoints labelled 'the best health you can imagine' and 'the worst health you can imagine'.

All-cause emergency revisit rateat 30 days post-discharge

The proportion of patients who have ED revisit for all causes within 30 days after discharge

Cardiovascular hospitalisation rateat 30 days post-discharge

The proportion of patients who have hospitalisation for cardiovascular events within 30 days after discharge

Free-hospitalization survivalat 30 days post-discharge

Number of days alive out of the hospital

Acute heart failure emergency revisit rateat 30 days post-discharge

The proportion of patients who have ED revisit for acute heart failure within 30 days after discharge

Cardiovascular emergency revisit rateat 30 days post-discharge

The proportion of patients who have ED revisit for cardiovascular event within 30 days after discharge

All-cause hospitalisation rateat 30 days post-discharge

The proportion of patients who have an hospitalisation for all causes within 30 days after discharge

Pharmacological adherence (assessed by Morisky Medication Adherence Scale)Within 30 days after discharge

The four-item MGLS measures pharmacological adherence. The score ranges from 0 (perfect adherence) to 4 (some level of non-adherence).

Trial Locations

Locations (1)

Hospital Clinico San Carlos

🇪🇸

Madrid, Spain

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