Optimized patient transfer using an innovative multidisciplinary assessment in the Kanton Aargau (OPTIMA I): an observational survey in lower respiratory tract infections

BACKGROUND: Current medical scores have limited efficiency and safety profiles to enable assignment to the most appropriate treatment site in patients with lower respiratory tract infections (LRTIs). We describe our current triage practice and assess the potential of a combination of CURB65 with proadrenomedullin (ProADM) levels for triage decisions. METHODS: Consecutive patients with LRTIs presenting to our emergency department were prospectively followed and retrospectively classified according to CURB65 and ProADM levels (CURB65-A). Low medical risk patients were further subgrouped according to biopsychosocial and functional risks. We compared the proportion of patients virtually allocated to triage sites with actual triage decisions and assessed the added impact of ProADM in a subgroup. RESULTS: Overall, 93% of 146 patients were hospitalised. Among the 138 patients with available CURB65-A, 17.4% had a low medical risk indicating possible treatment in an outpatient or non-acute medical setting; 34.1% had an intermediate medical risk (short-hospitalisation); and 48.6% had a high medical risk (hospitalisation). Fewer patients were in a low CURB65-A class (I) than a low CURB65 class (0,1) (17.4% vs. 46.3%, p >0.001). Mean length of hospitalisation was 9.8 days including 3.6 days after reaching medical stability. In 60.3% of patients, hospitalisation was prolonged after medical stability mainly for medical reasons. CONCLUSIONS: Current rates of hospitalisation are high in patients with LRTI and length of stay frequently extended beyond time of medical stabilization. The lower proportion of patients reclassified as low risk by adding ProADM to the CURB65 score might improve confidence in the triage algorithm

The potential impact of biomarker-guided triage decisions for patients with urinary tract infections

Objectives: Current guidelines provide limited evidence as to which patients with urinary tract infection (UTI) require hospitalisation. We evaluated the currently used triage routine and tested whether a set of criteria including biomarkers like proadrenomedullin (proADM) and urea have the potential to improve triage decisions. Methods: Consecutive adults with UTI presenting to our emergency department (ED) were recruited and followed for 30days. We defined three virtual triage algorithms, which included either guideline-based clinical criteria, optimised admission proADM or urea levels in addition to a set of clinical criteria. We compared actual treatment sites and observed adverse events based on the physician judgment with the proportion of patients assigned to treatment sites according to the three virtual algorithms. Adverse outcome was defined as transfer to the intensive care unit (ICU), death, recurrence of UTI or rehospitalisation for any reason. Results: We recruited 127 patients (age 61.8±20.8 years; 73.2% females) and analysed the data of 123 patients with a final diagnosis of UTI. Of these 123 patients, 27 (22.0%) were treated as outpatients. Virtual triage based only on clinical signs would have treated only 22 (17.9%) patients as outpatients, with higher proportions of outpatients equally in both biomarker groups (29.3%; p=0.02). There were no significant differences in adverse events between outpatients according to the clinical (4.5%), proADM (2.8%) or urea groups (2.8%). The mean length of stay was 6.6days, including 2.2days after reaching medical stability. Conclusions: Adding biomarkers to clinical criteria has the potential to improve risk-based triage without impairing safety. Current rates of admission and length of stay could be shortened in patients with UT

Evaluation of the Rapid Immunoassay Determine HIV 1/2 for Detection of Antibodies to Human Immunodeficiency Virus Types 1 and 2

We evaluated the reliability of a rapid human immunodeficiency virus type 1 test for quick clinical decision making, such as in needle-stick accidents. The test was evaluated with 1,160 patients. It proved to be a simple and useful test with 99.6% specificity and 99.4% sensitivity. One patient with late-stage AIDS had a false-negative result

Postexpositiebehandeling tegen HIV buiten het ziekenhuis in Amsterdam, januari-december 2000

The Infectious Diseases Department of the Amsterdam Public Health Service regularly sees people who have possibly been exposed to human body fluids infected with hepatitis B virus (HBV), hepatitis C virus (HCV) or human immunodeficiency virus (HIV), as a result of incidents in either a non-hospital-related occupation or during their leisure time. Until January 2000, people reporting possible exposure were referred to hospitals for HIV post-exposure prophylaxis (HIV-PEP), whereas for HBV and HCV, the tracing of the infection source and the follow-up took place at the Public Health Service clinic. Since the introduction of a new protocol in January 2000, the Public Health Service as well as a hospital can establish an indication for HIV-PEP and prescribe it. In 2000, 322 persons reported to the Public Health Service. The source was tested in 194 incidents and an HIV test was carried out on 104 occasions. In 19 cases HIV antibodies were found or the source was known to be HIV positive. A total of 50 people were prescribed HIV-PEP; 16 times after a needle-stick accident, 22 times after a sexual accident, 6 times after a bite-wound and 6 times after direct exposure to human blood. The sources of 30 PEP recipients could be tested and after this 16 recipients could stop with the treatment due to a negative HIV test. In 4 cases PEP treatment was stopped following a review of the indication. Therefore, 30 people had an indication to complete the PEP treatment. Of these, more than 80% reported side effects and 3 people had to withdraw from the treatment at an early stage because of this. The implementation of the protocol has resulted in less confusion because the follow-up now takes place at one location. Compared to other studies, the average time between exposure and treatment is shorter and compliance is good. In the period up to 15 May 2001, no seroconversions had been observe

The potential impact of biomarker-guided triage decisions for patients with urinary tract infections

OBJECTIVES: Current guidelines provide limited evidence as to which patients with urinary tract infection (UTI) require hospitalisation. We evaluated the currently used triage routine and tested whether a set of criteria including biomarkers like proadrenomedullin (proADM) and urea have the potential to improve triage decisions. METHODS: Consecutive adults with UTI presenting to our emergency department (ED) were recruited and followed for 30 days. We defined three virtual triage algorithms, which included either guideline-based clinical criteria, optimised admission proADM or urea levels in addition to a set of clinical criteria. We compared actual treatment sites and observed adverse events based on the physician judgment with the proportion of patients assigned to treatment sites according to the three virtual algorithms. Adverse outcome was defined as transfer to the intensive care unit (ICU), death, recurrence of UTI or rehospitalisation for any reason. RESULTS: We recruited 127 patients (age 61.8 +/- 20.8 years; 73.2 % females) and analysed the data of 123 patients with a final diagnosis of UTI. Of these 123 patients, 27 (22.0 %) were treated as outpatients. Virtual triage based only on clinical signs would have treated only 22 (17.9 %) patients as outpatients, with higher proportions of outpatients equally in both biomarker groups (29.3 %; p = 0.02). There were no significant differences in adverse events between outpatients according to the clinical (4.5 %), proADM (2.8 %) or urea groups (2.8 %). The mean length of stay was 6.6 days, including 2.2 days after reaching medical stability. CONCLUSIONS: Adding biomarkers to clinical criteria has the potential to improve risk-based triage without impairing safety. Current rates of admission and length of stay could be shortened in patients with UTI

Cotrimoxazole is effective as primary prophylaxis for toxoplasmic encephalitis in HIV-infected patients: a case control study

In a case-control study, prophylaxis with cotrimoxazole for toxoplasmic encephalitis (TE) in HIV-infected patients was evaluated. Cotrimoxazole had been given as PCP prophylaxis. 20 patients with TE were identified and 72 matching control cases were found. All patients had IgG-antibodies to Toxoplasma gondii and CD4+ T-cell counts 70% of the observation time, and that the 1-y incidence was 0% in the control group vs. 41% in those patients without sufficient cotrimoxazole use. The conclusion is that cotrimoxazole is effective as primary prophylaxis for TE, even in a dose of 480 mg dail

Multidisciplinary Assessment to Personalize Length of Stay in Acute Decompensated Heart Failure (OPTIMA II ADHF)

BACKGROUND: Acute decompensated heart failure (ADHF) causes a substantial burden for health care systems. Data to rationally define the need for hospitalization or the appropriate length of stay (LOS) is limited. Our aim was to personalize length of stay in patients admitted to hospital for acute decompensated heart failure. METHODS: Consecutive patients with ADHF presenting to our emergency department were prospectively followed. We daily conducted a multidisciplinary risk assessment and compared proposed with actually observed triage decisions. RESULTS: At presentation, all patients required hospitalization. Median LOS was 11 days including 1 day after reaching medical stability. In 42.7% of patients, hospitalization was prolonged after medical stability mainly for nursing and organizational reasons. Within 30 days of enrollment, 7 (9.3%) patients were rehospitalized, 3 of them for persisting or relapsing heart failure. CONCLUSIONS: There appears to be potential to shorten inhospital stay in patients with ADHF mainly by providing post discharge ambulatory nursing care in order to improve resource utilization and to diminish "hospitalization-associated disability"

Optimized Patient Transfer through Innovative Multidisciplinary Assessment: Project Description of Phase I

Introduction: OPTIMA is a multi-professional quality management and research project, conducted at the Cantonal Hospital of Aarau (KSA), Switzerland in cooperation with post-acute care institutions from November 2009 until December 2012. Objective: The goal of this study was to optimize patient care pathways and to provide patient-centered, cost- effective care that is conform with the introduction of the Diagnosis Related Groups (DRG) in 2012. Methods: The “Post-Acute Care Discharge Scores” (PACD) was applied to assess the risk for transfer to post- acute care facilities in 240 patients suffering from lower respiratory tract infections during the rst phase of the study (OPTIMA I) from October 2009 until April 2010. In order to assess the patients’ self-care ability, the “Self-Care Index” (SPI) tool was applied on admission and during the course of inpatient treatment. Results: The PACD predicted that 55% of patients (N=202) were at medium to high risk of requiring post-acute care. According to the SPI, 38% of patients (N=217) showed reduced ability to care for themselves. The discharge of 69% of medically stable patients (N=43) was postponed due to shortage of beds in post-acute care facilities. Correspondingly, 62% of the medically stable patients (N=141) could imagine receiving post-acute care in a “Nurse- led Unit” (NLU). Despite being medically stable, one third of the patients (N=124) was not ready to return to their homes because they felt too weak or insecure to cope with everyday life. Conclusion: Using standardized tools to predict patients at risk for transfer to post-acute care facilities and reduced self-care abilities and the continuous evaluation of medical stability are all methods that could be applied to enhance interdisciplinary care and optimize discharge management. Furthermore, setting up NLU is expected to unburden the occupancy of acute care beds by a considerable amount of patients who are in need of post-acute care

OPTIMA-Optimierter Patienten-Transfer durch innovatives multidisziplinäres Assessment: Projektbeschreibung der Phase I

Im Rahmen eines multiprofessionellen Qualitätsmanagement- und Forschungsprojektes wird im Zeitraum von November 2009 bis Dezember 2012 am Kantonsspital Aarau unter Beteiligung nachsorgender Institutionen die interdisziplinäre OPTIMA-Studie durchgeführt. OPTIMA steht für �Optimierter Patienten-Transfer durch innovatives multidisziplinäres Assessment�. Ziel der Studie ist neben der Optimierung von Patientenpfaden die Gewährleistung einer patientenzentrierten und gleichzeitig kosteneffizienten Behandlung und Betreuung hinsichtlich der bevorstehenden Einführung von Fallpauschalen (DRG) in der Schweiz in 2012