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Background: Different severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia phenotypes were described that match with different lung compliance and level of oxygenation, thus requiring a personalized ventilator setting. The burden of so many patients and the lack of intensive care unit (ICU) beds often force physicians to choose non-invasive ventilation (NIV) as the first approach, even if no consent has still been reached to discriminate whether it is safer to choose straightforward intubation, paralysis, and protective ventilation. Under such conditions, electrical impedance tomography (EIT), a non-invasive bedside tool to monitor lung ventilation and perfusion defects, could be useful to assess the response of patients to NIV and choose rapidly the right ventilatory strategy.Objective: The rationale behind this study is that derecruitment is a more efficient measure of positive end expiratory pressure (PEEP)-dependency of patients than recruitment. We hypothesized that patients who derecruit significantly when PEEP is reduced are the ones that do not need early intubation while small end-expiratory lung volume (ΔEELV) variations after a single step of PEEP de-escalation could be predictive of NIV failure.Materials and Methods: Consecutive patients admitted to ICU with confirmed SARS-CoV-2 pneumonia ventilated in NIV were enrolled. Exclusion criteria were former intubation or NIV lasting > 72 h. A trial of continuos positive airway pressure (CPAP) 12 was applied in every patient for at least 15 min, followed by the second period of CPAP 6, either in the supine or prone position. Besides standard monitoring, ventilation of patients was assessed by EIT, and end-expiratory lung impedance (ΔEELI) (%) was calculated as the difference in EELI between CPAP12 and CPAP6. Tidal volume (Vt), Ve, respiratory rate (RR), and FiO2 were recorded, and ABGs were measured. Data were analyzed offline using the dedicated software. The decision to intubate or continue NIV was in charge of treating physicians, independently from study results. Outcomes of patients in terms of intubation rate and ICU mortality were recorded.Results: We enrolled 10 male patients, with a mean age of 67 years. Six patients (60%) were successfully treated by NIV until ICU discharge (Group S), and four patients failed NIV and were intubated and switched to MV (Group F). All these patients died in ICU. During the supine CPAP decremental trial, all patients experienced an increase in RR and Ve. ΔEELI was < 40% in Group F and > 50% in Group S. In the prone trial, ΔEELI was > 50% in all patients, while RR decreased in Group S and remained unchanged in Group F.Conclusion: ΔEELI < 40% after a single PEEP de-escalation step in supine position seems to be a good predictor of poor recruitment and CPAP failure.

BackgroundThe prevalence of malnutrition in older persons depends on the healthcare setting. In recent years, hospital-based case management programs (CM Programs) targeting individuals in the community with chronic multimorbidity and high use of hospital resources (admissions or emergency visits) have been developed in many countries to reduce the need for complex health care. The objective of this study was to assess the prevalence of risk of malnutrition, using the Short Form of the Mini-Nutritional assessment, of community dwelling patients included in a chronic CM Program. Factors associated with malnutrition risk were also explored.MethodsPatients included in a hospital-based integrated CM Program for older persons at high risk for hospital readmission after an index admission were studied. MNA-SF was used at program inclusion to assess the risk of malnutrition. An array of factors potentially associated with malnutrition were explored (including feeding route, use of dental prosthesis, dysphagia, consistency of foods, specific therapeutic diets, use of oral nutritional supplements, polypharmacy, falls, and other diseases and geriatric syndromes).Results791 participants were included, mean age 79.8years, 50.1% females. Risk of malnutrition was present in 44.9%. Participants at risk of malnutrition were more frequently female, had a lower BMI, were less likely to be fed orally and used more nutritional supplements. They also had a higher prevalence of dysphagia, needing changes in food consistency or using specific therapeutic diets, and had dementia or cancer more frequently. They also showed a higher need for palliative care.ConclusionsRisk of malnutrition in patients included in a CM Program is higher than in non-selected community dwelling older individuals. This information may help inform screening policies in similar populations at risk of hospital readmission.

Background: The last WHO definition of palliative care (PC) recognizes the integration of early PC in the course of illness and in conjunction with other therapies that are intended to treat disease as the way to provide optimal care. There is wide literature highlighting the benefits of early implementation of PC in oncological patients and there is a growing recognition of PC as an integral aspect of cancer treatment with the establishment of a range of specific guidelines concerning palliative cancer care. Nevertheless, these advances are not developed to the same extent in the approach of non-oncological chronic conditions. In this regard, patients of non-cancer diseases are rarely offered these services and even when they are admitted to a PC unit they are typically closer to death and have a lower functional level than those with cancer. It is important to highlight this situation as the great majority of adults in need of PC die from non-oncological diseases – such as cardiovascular diseases, chronic respiratory diseases or diabetes – accounting a higher percentage than those with cancer. Aims and objectives: INADVANCE project (funded under the H2020 Programme) seeks an earlier, integrated and more effective implementation of PC to adequately address the needs of non-oncological chronic patients. Thus, this workshop is focused on early PC among patients with chronic conditions. This analysis will be encouraged by presenting the current state of early PC among this profile of patients, some experiences in their management at different healthcare systems. Finally, at the end of the workshop a common discussion between all presenters and attendants will be performed in order to analyze main barriers and facilitators to organize and implement PC services addressed to chronic complex patients. Format: A 90-minutes workshop session will be organized in order to achieve the aforementioned objectives. Two people from INADVANCE project will be in charge of organizing and running the workshop with the participation of the following speakers in these topics: “Introduction” (5min): outline of the main objectives and structure of the session (Ascension Donate). “Early PC for patients with complex chronic conditions” (10min): presentation of INADVANCE project, the current state of the art of PC services among non-oncological chronic conditions, how to identify patients in need of PC (Ascension Donate). “Experiences in the provision of PC among non-oncological conditions” (40min): five presentations of local experiences (Soledad Gimenez, Vania Dimitrova, Panagiotis Bamidis, Adriano Fernandes & Gordon Linklater). Time for questions. “Barriers and facilitators to effectively implement PC” (30min): open discussion with speakers and attendants to the workshop (Soledad Gimenez). For this session several materials will be arranged, such as a boards, markers or post-it. “Sum up” (5min): main conclusions (Ascension Donate). Target audience: People interested in PC, care and management of chronic conditions at clinical and organizational level. Learnings: Workshop participants will learn about differences in the provision of integrated PC between cancer vs. non-cancer diseases, real experiences improving the PC of chronic complex conditions and challenges for future improvement.

In the past few years, healthcare systems have been facing a growing demand related to the high prevalence of chronic diseases. Case management programs have emerged as an integrated care approach for the management of chronic disease. Nevertheless, there is little scientific evidence on the impact of using a case management program for patients with complex multimorbidity regarding hospital resource utilisation. We evaluated an integrated case management intervention set up by community-based care at outpatient clinics with nurse case managers from a telemedicine unit. The hypothesis to be tested was whether improved continuity of care resulting from the integration of community-based and hospital services reduced the use of hospital resources amongst patients with complex multimorbidity. A retrospective cohort study was performed using a sample of 714 adult patients admitted to the program between January 2012 and January 2015. We found a significant decrease in the number of emergency room visits, unplanned hospitalizations, and length of stay, and an expected increase in the home care hospital-based episodes. These results support the hypothesis that case management interventions can reduce the use of unplanned hospital admissions when applied to patients with complex multimorbidity.

Introduction: Los programas de gestion de casos (GC) surgieron como un nuevo enfoque en la atencion de personas con problemas de salud complejos con el objetivo de mejorar la calidad de vida y de procurar por la eficiencia en el uso de recursos. Theory/methods: Desde 2010, en el Departament de Salud Valencia-LaFe se desarrolla la GC sobre dos grupos de poblacion: pacientes con cronicidad compleja y con necesidades paliativas (oncologicos y no oncologicos). En ambos casos, la atencion se caracteriza por desarrollar intervenciones de seguimiento programado y continuo, y por la posibilidad de proporcionar atencion avanzada en domicilio ante la identificacion temprana de necesidades y exacerbaciones. La sinergia entre el equipo de atencion primaria, las enfermeras de GC y la unidad de hospitalizacion a domicilio es clave para evitar ingresos y reducir las estancias hospitalarias. En este estudio se describen los resultados de ambos programas de GC y se evalua el impacto en el consumo de recursos hospitalarios a traves del analisis de los casos atendidos entre 2014 y 2017. Results: En el programa de GC de cronicidad fueron atendidos 1063 pacientes. El seguimiento promedio fue de 510,8 dias. La tasa mensual de contactos telefonicos programados por paciente fue de 1,7. Las llamadas a demanda fueron un 7,9% del total. En comparacion con el ano previo a la inclusion en GC, el riesgo de estancias hospitalarias urgentes disminuyo un 49% (RR: 0,51) y el de episodios en urgencias hospitalarias un 32% (RR: 0,68). Con respecto a la atencion en la UHD, la probabilidad de ingreso se incremento (RR: 1,35) y se redujo la de estancias (RR 0,54). En el programa de GC de necesidades paliativas 1.097 pacientes fueron incluidos. El seguimiento promedio fue de 219,5 dias. La tasa mensual de llamadas por paciente fue de 4,2. Las llamadas a demanda fueron un 17,6% del total. En comparacion con el ano previo a la inclusion en GC, el riesgo de estancias hospitalarias urgentes disminuyo un 31% (RR: 0,69) y el de episodios en urgencias hospitalarias un 27% (RR: 0,73). Con respecto a la atencion en la UHD, la probabilidad de ingreso se incremento 6 veces (RR: 6,74) y 2 veces la de estancias (RR: 2,39). El 75,5% de los fallecimientos fueron en el domicilio. Discussions: La diferencia en la estancia media en el programa se asocia al pronostico de vida de cada grupo de pacientes. Con respecto a las necesidades de atencion requeridas, se refleja del analisis es el aumento de las necesidades de atencion al final de la vida y el impacto positivo en ambos grupos de pacientes. Conclusions: La integracion de alternativas a la hospitalizacion convencional, como es la UHD, en los programas de GC es fundamental en la atencion de descompensaciones en el domicilio y reduce la probabilidad de consumo de recursos hospitalarios. Limitations: Limitaciones relacionadas con los analisis quasiexperimentales. Suggestion for future research: Analizar los motivos de atencion Analizar la relacion entre el momento de la demanda y la cobertura asistencial ofrecida, especialmente en horario nocturno.

We present data on the prevalence of dysphagia in a population followed-up by a hospital at home unit after acute hospitalization. A total of 440 consecutive patients were studied. The presence of dysphagia before and after the acute episode and its association with age and comorbidity were evaluated. The patients underwent a domiciliary nutritional intervention and clinical evaluation at 1 month was performed. The prevalence of dysphagia during the acute hospitalization phase and follow-up by the hospital at home unit was 31.8% (95% confidence interval [CI], 27.6-36.4%), which was significantly higher than that before admission: 23.0% (95% CI, 19.5-26.5%); p 0.05). Mortality during the first month was 12.0%. The detection methods and specific treatments adopted did not prevent dysphagia in a high percentage of patients (8%) during follow-up. In conclusion, dysphagia is a frequent problem in units attending the elderly population with neurological comorbidity. This disorder increases with recent hospitalization and requires specific interventions after discharge.

Introduction : In the past few years, healthcare systems are facing a growing demand related to high prevalence of chronic diseases. Case Management (CM) programs have emerged as a new approach for the management of chronic disease focused on improving individual’s health and serving social needs. Nevertheless, there is no great scientific evidence about the impact on healthcare of using generic CM program for high-complexity chronic patients. Methodology : We evaluated a CM model based on a reengineering care process that has aligned the health care levels implied, providing the attention from a patient centred perspective and promoting the patient empowerment through education and self-care. A retrospective cohort study has been carried out using a sample of 714 adult chronic patients admitted at the Valencia-La Fe Health Department Chronic CM program between January 2012 and January 2015. Results : The results of the one-tailed matched Wilcoxon’s hypothesis test (α=5%), show statistically significant differences for the rate of unplanned admissions and for the rate of emergency room (ER) visits. The rate of admissions in Hospital at Home (HaH) did not show a significant difference. The results showed statistically significant differences for the rate of unplanned hospitalization Length of Stay (LoS) and for HaH. The results of the RR of admission show that the risk of unplanned admission decreases to a 58.4%, and the risk of visits to the ER decreases to a 73.5%. However, the HaH admission relative risk increases in 50.2%. Discussion : The positive results can be based on two facts. Firstly, the proactive character of the intervention through Primary Health scheduled intervention; and secondly, the support of the CM nurses from the Telemedicine Unit and the advanced care at home, developed by the HaH unit when needed. Self-management educational interventions have positive effects on hospital consumption, such as hospital admission. Two studies evaluated a home-based educational intervention on patients with heart failure achieving fewer emergency department visits and unplanned readmissions, improving quality of life and reducing mortality. We may expect that the induction program in our model empowers patients for self-care interventions and early identification of risk situations. Additionally, the close follow-up of patients and families by primary healthcare team could explain our results. The possibility of scheduled home visits and/or consultations performed by general practitioner, staff nurse and community case manager nurse facilitates the accessibility to medical attention. This may explain the relationship between complex chronic CM and the decrease of Hospital admissions, LoS and ER visits. Our model had also the support of the Telemedicine unit led by case manager nurses. Their aim is to promote self-care, early risk identification and an appropriate management of sources when social and clinical needs appear. Studies reflect that the benefit of telephone follow-up is observed regardless of home visits and consultations, concluding that a positive effect could exist between the role of the telemedicine unit and the results. Also, the increase in the number of HaH admissions once the patient is included in the program is a good indicator of appropriate use of Hospital-based home care as an alternative to conventional hospitalization. From the institutional perspective, we can estimate a global bed savings per year. We expect to save around 5 days of a bed per patient. Taking into account that we manage around 243 patients per year in the CM intervention, this may imply a number of around 1,215 bed savings per year. Conclusion : Our CM intervention has a significant hospital resource savings in average with a positive impact on patient admissions and LoS. We suggest that policies and strategies should keep promoting CM interventions both for healthcare network for patients and families and for research. Whether the CM intervention is profitable for reducing the use of hospital resources for other clinical profiles is still a question under study. It seems clear that the CM intervention reduces hospital resources, which of course leads to economic savings. However, the CM intervention also entails new economic costs that should be analyzed. A future step is to carry out a cost-effectiveness analysis to compare if the CM intervention implies economic savings apart from the observed hospital resources savings. The adoption of this type of intervention to a different health center may require a careful implementation according to the characteristics of chronic patients. In elderly patients, the assessment of social environment is an aspect of relevance as well as the cultural aspects and organizational issues.

Summary Background and objectives Noninvasive home mechanical ventilation (HMV) has been shown to be beneficial for certain forms of respiratory failure, improving symptoms and quality of life. Adaptation and follow-up are usually conducted within the hospital framework. Our objective was to verify whether the same results could be obtained in the patient's home by the Home Hospitalization Unit. Methods This was a prospective study of patients with stable restrictive ventilatory disorders, who met the criteria to receive HMV. They underwent hospital adaptation (group 1) or ambulatory adaptation (group 2) based on geographical area. The following tests were performed throughout the follow-up: Borg scale, respiratory function, arterial blood gases, nocturnal pulse oximetry, a health survey questionnaire (SF-36), and initially, the Barthel index. Adaptation and follow-up were performed identically in both groups in accordance with the adaptation and follow-up protocol of our hospital. Independent and intergroup comparisons were made for both groups. Results Forty-two patients (21 at hospital and 21 at home) were included. No initial differences were found between the two groups. Improvements were noted on the Borg scale and for nocturnal pulse oximetry within the groups, with no differences between them. No improvement in pulmonary function was observed in either group. Arterial blood gases improved in both groups, but the ambulatory group recorded significantly higher values (PO 2 , P = 0.033; P CO 2 , P = 0.020). Most domains of the SF-36 questionnaire improved in both groups, although some intergroup differences were noted. Conclusions HMV improved arterial blood gases and quality of life in patients with restrictive ventilatory disorders. Arterial blood gases were better in the ambulatory group and the quality of life was similar in both groups.