Enhancement of CURB65 score with proadrenomedullin (CURB65-A) for outcome prediction in lower respiratory tract infections: Derivation of a clinical algorithm

Proadrenomedullin (ProADM) confers additional prognostic information to established clinical risk scores in lower respiratory tract infections (LRTI). We aimed to derive a practical algorithm combining the CURB65 score with ProADM-levels in patients with community-acquired pneumonia (CAP) and non-CAP-LRTI

Bei Eintritt den Austritt bereits im Blick : der PACD am Kantonsspital Aarau

Die Erfassung und Bewertung des «biopsychosozialen Risikos» ermöglicht es, bereits frühzeitigerkennen und entscheiden zu können, ob ein Patient nach einem stationären Aufenthalt aufUnterstützung in einer post-akuten Institution zu Hause angewiesen sein wird. Das KantonsspitalAarau setzt dafür das Einschätzungsinstrument «Post-acute-care-discharge» (PACD) ein

Verbessert eine pflegegeleitete Versorgung die Selbstpflegefähigkeiten? Eine quasi‐experimentelle Studie

Hintergrund: Die Zunahme von betagten und multimorbiden Patienten erhöht die Anforderungen an Behandlungs- und Prozessabläufe in Akutkrankenhäusern. Seit 2010 bietet das Kantonsspital Aarau (KSA) mit der pflegegeleiteten Versorgung (NLC-KSA) eine innovative Dienstleistung an. Mit den fünf NLC-KSA Pflegeschwerpunkten erhalten Patienten eine individuelle, regelgeleitete Pflege, zur Erhöhung ihrer Selbstständigkeit, Alltags- und Selbstpflegekompe- tenzen. Ziele: Diese Studie beschreibt die demographischen und pflegerischen Merkmale von NLC-KSA Patienten sowie die Unterschiede in den Alltags- und Selbstpflegekompetenzen zwischen NLC-KSA Versorgung und der üblichen Versorgung im Akutkrankenhaus. Methode: Es handelt sich um eine Studie mit quasi-experimen- tellem Design. Aus 1917 Patienten der Kontrollgruppe und 54 Patienten der NLC-KSA Gruppe konnten durch Propensity Score Matching je 45 Patienten pro Gruppe zugeordnet werden. Ergebnisse: Die NLC-KSA Patienten waren älter als die medizinischen Patienten der Gesamtgruppe (Median 78 vs. 70 Jahre). Außerdem hatten sie mehr Einschränkungen hinsichtlich ihrer Alltags- und Selbstpflegekompetenzen (Median Selbstpflegeindex 29 vs. 37) und traten bereits mit erhöhten biopsychosozialen Risiken (Median PACD 12 vs. 6) in das Krankenhaus ein. Im Vergleich zur Kontrollgruppe zeigten NLC-KSA Patienten, die bis zur Hälfte der Gesamtaufenthaltsdauer in NLC-KSA Versorgung waren (n=30), signifikante Ver- besserungen des Selbstpflegeindex (B=4,513, p=0,004) und der Bewegungsfähigkeiten vom Eintritt bis zum Austritt (B=1,055, p=0,038). Schlussfolgerungen: Da es sich bei den NLC-KSA betreuten Patienten um ältere, vulnerable Patienten handelte, profitierten diese insbesondere von einem intensiveren Aufbautraining, der Unterstützung ihres Selbstmanagements und der gezielten Austrittsvorbereitung

Biomarkers from distinct biological pathways improve early risk stratification in medical emergency patients: the multinational, prospective, observational TRIAGE study

INTRODUCTION: Early risk stratification in the emergency department (ED) is vital to reduce time to effective treatment in high-risk patients and to improve patient flow. Yet, there is a lack of investigations evaluating the incremental usefulness of multiple biomarkers measured upon admission from distinct biological pathways for predicting fatal outcome and high initial treatment urgency in unselected ED patients in a multicenter and multinational setting. METHOD: We included consecutive, adult, medical patients seeking ED care into this observational, cohort study in Switzerland, France and the USA. We recorded initial clinical parameters and batch-measured prognostic biomarkers of inflammation (pro-adrenomedullin [ProADM]), stress (copeptin) and infection (procalcitonin). RESULTS: During a 30-day follow-up, 331 of 7132 (4.6 %) participants reached the primary endpoint of death within 30 days. In logistic regression models adjusted for conventional risk factors available at ED admission, all three biomarkers strongly predicted the risk of death (AUC 0.83, 0.78 and 0.75), ICU admission (AUC 0.67, 0.69 and 0.62) and high initial triage priority (0.67, 0.66 and 0.58). For the prediction of death, ProADM significantly improved regression models including (a) clinical information available at ED admission (AUC increase from 0.79 to 0.84), (b) full clinical information at ED discharge (AUC increase from 0.85 to 0.88), and (c) triage information (AUC increase from 0.67 to 0.83) (p <0.01 for each comparison). Similarly, ProADM also improved clinical models for prediction of ICU admission and high initial treatment urgency. Results were robust in regard to predefined patient subgroups by center, main diagnosis, presenting symptoms, age and gender. CONCLUSIONS: Combination of clinical information with results of blood biomarkers measured upon ED admission allows early and more adequate risk stratification in individual unselected medical ED patients. A randomized trial is needed to answer the question whether biomarker-guided initial patient triage reduces time to initial treatment of high-risk patients in the ED and thereby improves patient flow and clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT01768494 . Registered January 9, 2013.status: publishe

Biomarker-enhanced triage in respiratory infections: a proof-of-concept feasibility trial

Concerns about inadequate performance and complexity limit routine use of clinical risk scores in lower respiratory tract infections. Our aim was to study feasibility and effects of adding the biomarker proadrenomedullin (proADM) to the confusion, urea90 mmHg (systolic) or ≤60 mmHg (diastolic), age≥65 years (CURB-65) score on triage decisions and length of stay. In a randomised controlled proof-of-concept intervention trial, triage and discharge decisions were made for adults with lower respiratory tract infection according to interprofessional assessment using medical and nursing risk scores either without (control group) or with (proADM group) knowledge of proADM values, measured on admission, and on days 3 and 6. An adjusted generalised linear model was calculated to investigate the effect of our intervention. On initial presentation the algorithms were overruled in 123 (39.3%) of the cases. Mean length of stay tended to be shorter in the proADM (n=154, 6.3 days) compared with the control group (n=159, 6.8 days; adjusted regression coefficient -0.19, 95% CI -0.41-0.04; p=0.1). This trend was robust in subgroup analyses and for overall length of stay within 90 days (7.2 versus 7.9 days; adjusted regression coefficient -0.18, 95% CI -0.40-0.05; p=0.13). There were no differences in adverse outcomes or readmission. Logistic obstacles and overruling are major challenges to implement biomarker-enhanced algorithms in clinical settings and need to be addressed to shorten length of stay

Effectiveness of Proadrenomedullin Enhanced CURB65 Score Algorithm in Patients with Community-Acquired Pneumonia in “Real Life”, an Observational Quality Control Survey

Background: An intervention trial found a trend for shorter length of stay (LOS) in patients with community-acquired pneumonia (CAP) when the CURB65 score was combined with the prognostic biomarker proadrenomedullin (ProADM) (CURB65-A). However, the efficacy and safety of CURB65-A in real life situations remains unclear. Methods: From September, 2011, until April, 2012, we performed a post-study prospective observational quality control survey at the cantonal Hospital of Aarau, Switzerland of consecutive adults with CAP. The primary endpoint was length of stay (LOS) during the index hospitalization and within 30 days. We compared the results with two well-defined historic cohorts of CAP patients hospitalized in the same hospital with the use of multivariate regression, namely 83 patients in the observation study without ProADM (OPTIMA I) and the 169 patients in the intervention study (OPTIMA II RCT). Results: A total of 89 patients with confirmed CAP were included. As compared to patients with CURB65 only observed in the OPTIMA I study, adjusted regression analysis showed a significant shorter initial LOS (7.5 vs. 10.4 days; −2.32; 95% CI, −4.51 to −0.13; p = 0.04) when CURB65-A was used in clinical routine. No significant differences were found for LOS within 30 days. There were no significant differences in safety outcomes in regard to mortality and ICU admission between the cohorts. Conclusion: This post-study survey provides evidence that the use of ProADM in combination with CURB65 (CURB65-A) in “real life” situations reduces initial LOS compared to the CURB65 score alone without apparent negative effects on patient safety