Pilot studies

PhD Study: Investigation of internal transitions of elderly patients with multimorbidity in hospital (between wards, departments, and hospitals) for the development of a prototype AI-based digital information page.

The study is conducted by Matilde Skødstrup Axelsen, nurse, MSc in Nursing, PhD student at the Department of Cardiology, Zealand University Hospital Roskilde, and the Institute of Regional Health Research, University of Southern Denmark.

Title of the PhD Project: Internal Transitions in the Cardiology Department – Experiences and Perceptions of Elderly Patients, Relatives, and Nurses in a Cardiological Context.

Studies: The project runs over three years (2024-2027) and consists of three sub-studies:

– Study 1, April-June 2024: Observational study of internal transitions of elderly patients with cardiovascular and multimorbidity diseases, including informal interviews with healthcare professionals, patients, and relatives.
– The aim is to explore clinical nursing practices related to internal transitions of elderly patients (≥65 years) in the Cardiology Department, focusing on organisational and nursing workflows as well as nurses’ approach to documentation, communication, and interaction with patients, relatives, and healthcare staff.

– Study 2, April-October 2025: Interviews with elderly patients.
– The aim is to explore the experiences of elderly patients (≥65 years) with cardiovascular and multimorbidity diseases during hospitalisation, with a particular focus on internal transitions in the Cardiology Department.

– Study 3, March 2026: Focus group interviews with nurses.
– The aim is to explore nurses’ experiences of internal transitions in the Cardiology Department related to elderly patients (≥65 years) with cardiovascular and multimorbidity diseases, with a focus on:
a) Communication between patients, relatives, and nurses.
b) Communication and documentation between nurses and other healthcare professionals.

Results: The studies will contribute research-based knowledge that will:
– Be translated into a set of recommendations for clinical practice to optimise patient safety during internal transitions in hospitals.
– Be used to develop a new digital patient information page for the Health Platform using artificial intelligence. The solution aims to ensure clear accessibility to relevant patient data/information for healthcare professionals. For this, collaboration is established with the IT company IQVIA.

PhD Study: Development and Testing of a Model to Predict Acute Readmissions in Elderly Patients Over 65 with Multiple Conditions

The study is being conducted by Nanna Selmer, a nurse, MSc in Nursing, and PhD candidate at the Department of Medicine, Zealand University Hospital Køge, and the Institute of Regional Health Research at the University of Southern Denmark.

Title of the PhD project: Development and Testing of a Prediction Model for Acute Readmissions in Elderly Medical Patients with Multiple Conditions – The REMIND Model.

Studies: The project runs over three years (2023–2026) and consists of four sub-studies:

Study 1 (October 2023–September 2024): A systematic review aimed at identifying existing prediction models, with the goal of finding tested predictors that may lead to 30-day readmission in elderly patients with multiple conditions.

The aim of this study is to identify predictors through evidence-based prediction models, which will be tested in Study 2.
Study 2 (June 2024–May 2025): A cohort study (a health science study conducted on a well-defined group of individuals) to collect clinical patient data, as well as relevant predictors in elderly patients with multiple conditions, to contribute to the development of a prediction model.

Study 3-4 (June 2025–January 2026): A cross-sectional study in which the prediction model will be tested on elderly medical patients aged 65 and over in the hospital, followed by evaluation by clinical nurses through focus group interviews. This stage will ensure the evaluation of the model’s usability and relevance in practice, after which it will be adapted to function effectively in the hospital setting.

Outcomes:

The results aim to help identify (including the use of socioeconomic factors) which elderly patients over 65 with multiple conditions are at high risk of readmission within 30 days. This will enable us to intervene and develop appropriate interventions where necessary. Additionally, we will gain broader insights into predictors that can assist in forecasting the risk of readmission. The development of the prediction model will utilise artificial intelligence in collaboration with the IT company IQVIA.

In the Build-a-Care model, a checklist is being developed for discharge nurses, outlining a series of practical actions aimed at ensuring a safe patient discharge.

Purpose: To develop, implement, and test the feasibility of the Build-a-Care model, which specifies the roles and tasks of discharge nurses. Additionally, it aims to strengthen their coordination of complex transitions between hospital departments and municipal care for elderly patients with multiple chronic conditions.

The project is led by research leader and professor of clinical nursing Connie Berthelsen, Department of Medicine, Zealand University Hospital Køge, and the University of Southern Denmark’s Institute of Regional Health Research. The project is conducted in collaboration with Postdoc Birgitte Lerbæk, Aalborg University Hospital, and Associate Professor Cedric Mabire, Lausanne University, Switzerland.

Studies: The project will be carried out through two studies between March 2024 and October 2026:

Study 1 (March–December 2024): Based on existing knowledge, current practices, and the experience of discharge nurses, a checklist will be developed, covering practical actions crucial to a safe and efficient patient discharge. For example, ensuring contact with relatives and identifying any need for assistive devices. The checklist will be created using knowledge from a regional Delphi survey (a structured collection of expert knowledge from various disciplines and fields). The checklist will serve as a guideline to ensure that the discharge process carried out by nurses is comprehensive and well-structured. As the add-on solution is developed, it will be presented in an easy and accessible format.

Study 2 (April 2025–May 2026): The checklist will be implemented in the Department of Medicine at Zealand University Hospital Køge and tested by discharge nurses for its practical usefulness. Discharge nurses will be trained in using the checklist (theoretically and practically) to trial and implement it in practice. Observations of the nurses’ practice will be conducted, and due to their expertise, they will also be interviewed.

If you are interested in learning more about the Build-a-Care model, please contact Connie Berthelsen at cobe@regionsjaelland.dk .