Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial.

BACKGROUND: In France, for patients aged 75 or older, it has been estimated that the hospital readmission rate within 30 days is 14 %, a quarter being avoidable. Some evidence suggests that interventions "bridging" the transition from hospital to home and involving a designated professional (usually nurses) are the most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a care transition program from hospital to home for elderly admitted to short-stay units. METHODS: This is a multicentre, stepped-wedge cluster randomised trial. The program will be implemented at three times of the transition: 1) during the patient's stay in hospital: development of a discharge plan, creation of a transitional care file, and notification of the primary care physician about inpatient care and hospital discharge by the transition nurse; 2) on the day of discharge: meeting between the transition nurse and the patient to review the follow-up recommendations; and 3) for 4 weeks after discharge: follow-up by the transition nurse. The primary outcome is the 30-day unscheduled hospital readmission or emergency visit rate after the index hospital discharge. The patients enrolled will be aged 75 or older, hospitalized in an acute care geriatric unit, and at risk of hospital readmission or an emergency visit after returning home. In all, 630 patients will be included over a 14-month period. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. DISCUSSION: Our study makes it possible to evaluate the specific effect of a bridging intervention involving a designated professional intervening before, during, and after hospital discharge. The strengths of the study design are methodological and practical. It permits the estimation of the intervention effect using between- and within-cluster comparisons; the study of the fluctuations in unscheduled hospital readmission or emergency visit rates; the participation of all clusters in the intervention condition; the implementation of the intervention in each cluster successively. TRIAL REGISTRATION: This study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02421133 ). Registered 9 March 2015.

A five-step protocol for withholding and withdrawing of life support in an emergency department: an observational study.

OBJECTIVE: The objective of the study was to describe a five-step protocol for withholding and withdrawing of life support (WH/WDLS) in an emergency department (ED) for terminally ill patients. DESIGN AND SETTING: An observational study was conducted in ED of a general hospital. PATIENTS: A total of 98 patients were admitted over a 1-year period. INTERVENTIONS: The healthcare team chose a pattern of treatment limitation on the basis of a five-step protocol for every patient, which comprised five groups: group 1: there was no limitation of care, group 2: do not resuscitate order was followed, group 3: administration of therapies without treating an acute organ failure, group 4: active withdrawal of all therapies except mechanical ventilation and group 5: active withdrawal of mechanical ventilation. All the patients received comfort care. The opinions of the patients and their families were collected. MEASUREMENTS AND RESULTS: Ninety-eight patients were included in the study (1.5% of admissions). Mean age was 82+/-13 years. An acute organ failure was observed at admission in 80 patients. Severe chronic disease was noted in 93 patients. Among the 98 patients, there were 14 patients in group 2, 65 in group 3, six in group 4 and 13 in group 5. The time interval between admission and WH/WDLS decision was 117+/-77 min and ED stay was 239+/-136 min. The outcome was death in ED (n=21), admission to a medical ward (n=71) or an intensive care unit (n=six). On day 30, 16 patients were still alive. CONCLUSION: This five-step protocol could improve collaboration in the WH/WDLS decision-making process, while facilitating dialogue and transmission of information between staff and families.