P-441: The cardiac care bridge: a randomized controlled trial of a nurse coordinated transitional intervention in high risk older cardiac patients

摘要

Background: After hospitalization for cardiac disease, older patients are at high risk of readmission and death. The Cardiac Care Bridge (CCB) transitional care program examines if unplanned hospital readmission and mortality can be reduced. Methods: The CCB program was a Dutch multicenter randomized clinical trial in high-risk cardiac patients >70 years and hospitalized > 48 h. Patients at high risk of functional loss and/or whom experienced an unplanned hospitalization in the 6 months before index hospitalization, were eligible. The intervention included a comprehensive geriatric assessment), an integrated care plan, a face-to-face handover with the community care registered nurse (CCRN) and four home visits. The CCRNs collaborated with physiotherapists who performed home-based cardiac rehabilitation and with a pharmacist in medication management. The primary outcome is first all-cause unplanned readmission or mortality within 6 months. Results: In total, 306 patients were included. The mean age was 82 years, 57% had a diagnosis of heart failure on admission and > 90% was acutely hospitalized. Nearly 50% experienced a hospital admission and have fallen at least once in the previous 6 months. Furthermore, 31% was cognitive impaired (MMSE < 24), 39% had impairment in daily functioning (Katz-6) and 31% was at risk of malnutrition (SNAQ). Follow-up data is currently collected until March 2020. The study design, intervention, baseline data and results of the intervention process evaluation will be presented. Key conclusions: This study will provide new knowledge on the effectiveness of a nurse coordinated, multidisciplinary transitional care program in older high risk cardiac patients. Dutch Trial Register (NTR6316, April 6, 2017).