Short summary

In frail older multimorbid citizens, early recognition of disease symptoms is challenging and delays treatment initiation. This project aims to enhance home-based early diagnosis by using Point Of Care Technology (POCT) to prevent acute admissions and adverse outcomes.

Rationale

Background Lower respiratory tract infections are one of the most common causes of acute hospitalization among older adults worldwide as well as in Denmark. Acute hospitalization due to Community Acquired Pneumonia (CAP) occurred in about 34,000 Danes aged 65+y in 2018. Acutely admitted frail older adults are especially at risk of poorer outcomes, i.e. higher mortality, increased hospital use, and functional decline, following their high level of comorbidities, low functional level, cognitive impairment, and complications during hospital stay. Comorbidities and lower functional level have negative impact on the prognosis of pneumonia, and pneumonia is a very common cause of death after admission. Diagnosing acutely ill older patients is challenged by the atypical presentation of symptoms, especially when it comes to pneumonia. Due to ageing-related physiological changes, e.g. coughing is a less prominent symptom, and many older patients display only small increases in temperature despite fulminant infection. Delirium, falls, and rapid decline in physical functions may be proxy symptoms for infections. Focused Lung Ultrasound Scan (FLUS) During the last couple of decades ultrasound has become a diagnostic tool of pneumonia in the emergency departments, intensive care units and in primary care. In the hands of a trained health professional FLUS is an accurate tool in diagnosing pneumonia. FLUS has a high sensitivity and specificity compared to X-ray, with CT thorax scan as golden standard. In a Danish randomized controlled trial FLUS showed significantly increased diagnostic validity among admitted patients, especially in older patients. An Italian study comparing FLUS with chest-x-ray in hospitalized 80+y found a similar high sensitivity and specificity as in younger patients, but even higher in patients with high dependency and functional decline, which matches the profile of home care receiving older Danes. In-hospital FLUS is thus valid for diagnosing CAP, but there is no knowledge about its validity when used acutely in a home-setting. An ongoing research project explores the value of PCPs using FLUS in their practice. The demographic challenge The population of older adults is increasing in Europe and other high-income countries. Projection of the number of 80+y old Danes, i.e. the most vulnerable and frequently acutely admitted age group, will increase by 100% to 548.280 persons in 25 years. Primary and secondary health care systems are confronted by the demographic change, which is further challenged by fewer people in the workforce and reduction of hospital beds. Based on the notion that early treatment prevents more severe disease development, and subsequent complications in other organs ('Domino-effect') it is imperative to recognize and diagnose acute disease in older adults as soon as possible to avoid acute hospitalization, functional loss and premature death. Acute municipal home care function To increase the early recognition it has been enforced to all Danish municipalities to establish an acute municipal home care function, most commonly by introducing 'acute community nurses' (ACN). The ACNs are trained in in-home assessment of an older person, in whom the usual home carer has observed and recognized the subtle symptoms of possible acute health deterioration. The assessment includes Point-of-Care-Technology (POCT) of objective vital status parameters and - when appropriate - on-site biochemical analyses, e.g. CRP and electrolytes. Together with relevant medical information all results are communicated to the primary care physician (PCP), who thus receives clinical objective information qualifying diagnosis and medical decision-making. Adding FLUS may increase diagnostic accuracy when respiratory infection is suspected but has yet not been introduced as an in-home POCT. Study Objectives The overall aim is to investigate whether POCT, incl. FLUS, can be used in a home-setting to increase the in-home diagnostic accuracy of pneumonia in older adults, thereby qualifying primary care physician's decision on treatment earlier on and reduce hospital admission in frail older adults. Hypothesis • Focused Lung Ultrasound Scan (FLUS) has an acceptable diagnostic accuracy as a Point of Care Technology in an in-home setting for the diagnosis of pneumonia among older adults aged 65+ years • Trained ACNs can diagnose a pneumonia diagnosis with FLUS • In-home FLUS, carried out by trained ACNs, supports PCPs' medical diagnosis and treatment decision and can prevent acute hospital admission due to pneumonia among older adults.

Description of the cohort

The study participants are acutely ill older adults above 64 years of age. The study participants must be referred to the acute community team in the municipality by the municipal home care or the Primary Care Physician (PCP) due to a suspicion of emerging acute illness, and at least one symptom: dyspnea, chest pain, fever, coughing, or functional decline. The study will be conducted in the participants' own home or nursing care facility.

Data and biological material

Eligible participants undergo a systematic screening and examination program, which include referral diagnosis, symptoms of infection, Barthel 20 (activities of daily living), and clinical examination of vital signs (blood pressure, pulse, saturation, respiratory frequency, and temperature). POCT for analyses on blood (C-reactive protein, leukocytes, electrolytes, hemoglobin and creatinine), oral swab (for coronavirus and influenza), and urine samples will be carried out as well. A focused lung ultrasound scan (FLUS) will also be carried out during the visit. FLUS examination follows a standardized protocol. Conclusive findings are noted by the PhD-student. All FLUS examinations will be stored digitally. Blinded assessment of stored FLUS examinations is carried out by a FLUS specialist. Consequences of the FLUS will also be noted (admission, antibiotics, home visit by PCP, involvement of ED doctors etc). Blood-samples, oral swabs, and urine samples will be analysed shortly after collection. All samples are destroyed same day as collected - after analysis - hence, no research biobank will be established during this study. To assess co-morbidity, disability, need of primary home care, admission status, deaths, and medical history several data sources will be applied for permission to access. The participant must prior to accessing the data sources give their informed written consent and thereby their accept on accessing the data sources. Besides participants, the Regional Committees on Health Research Ethics for Southern Denmark and the Data Health Data Authority will be applied for permission to access following data sources: The Danish Health Data Authority, The Danish Medical Chart (Fælles Medicin Kort; FMK), The Electronic Municipal Care Records (EOJ - Elektronisk Omsorgsjournal), and The Electronic Patient Journal (EPJ).

Collaborating researchers and departments

Dept. of Respiratory Medicine, Odense University Hospital

• Christian B Laursen, MD, PhD, Professor, Head of Research

Dept. of Microbiology, Odense University Hospital

• Flemming S. Rosenvinge, MD,

Research Unit of General Practice, Dept. of Public Health, University of Southern Denmark

• Dorte Ejg Jarbøl, MD, PhD, Professor