A complex intervention to reduce avoidable hospital admissions in nursing homes: a research programme including the BHiRCH-NH pilot cluster RCT

Preventing urinary tract infection in older people living in care homes: the 'StOP UTI' realist synthesis

BACKGROUND

Urinary tract infection (UTI) is the most diagnosed infection in older people living in care homes.

OBJECTIVE

To identify interventions for recognising and preventing UTI in older people living in care homes in the UK and explain the mechanisms by which they work, for whom and under what circumstances.

METHODS

A realist synthesis of evidence was undertaken to develop programme theory underlying strategies to recognise and prevent UTI. A generic topic-based search of bibliographic databases was completed with further purposive searches to test and refine the programme theory in consultation with stakeholders.

RESULTS

56 articles were included in the review. Nine context-mechanism-outcome configurations were developed and arranged across three theory areas: (1) Strategies to support accurate recognition of UTI, (2) care strategies for residents to prevent UTI and (3) making best practice happen. Our programme theory explains how care staff can be enabled to recognise and prevent UTI when this is incorporated into care routines and activities that meet the fundamental care needs and preferences of residents. This is facilitated through active and visible leadership by care home managers and education that is contextualised to the work and role of care staff.

CONCLUSIONS

Care home staff have a vital role in preventing and recognising UTI in care home residents.Incorporating this into the fundamental care they provide can help them to adopt a proactive approach to preventing infection and avoiding unnecessary antibiotic use. This requires a context of care with a culture of personalisation and safety, promoted by commissioners, regulators and providers, where leadership and resources are committed to support preventative action by knowledgeable care staff.

Reducing unplanned hospital admissions from care homes: a systematic review

Background

Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost.

Objectives

Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings.

Data sources

We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. 'Grey' literature (January 2022) and citations were searched and reference lists were checked.

Methods

We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect.

Results

We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence.

Conclusions

Effective implementation of interventions at various stages of residents' care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation.

Limitations

Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible.

Future work

We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes.

Study registration

This study is registered as PROSPERO database CRD42021289418.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.

Evaluating the implementation fidelity to a successful nurse-led model (INTERCARE) which reduced nursing home unplanned hospitalisations

BACKGROUND

Implementation fidelity assesses the degree to which an intervention is delivered as it should be. Fidelity helps to determine if the outcome(s) of an intervention are attributed to the intervention itself or to a failure of its implementation. Little is known about how fidelity impacts the intended outcome(s) and what elements or moderators can affect the fidelity trajectory over time. We exemplify the meaning of implementation fidelity with INTERCARE, a nurse-led care model that was implemented in eleven Swiss nursing homes (NHs) and showed effectiveness in reducing unplanned hospital transfers. INTERCARE comprises six core elements, including advance care planning and tools to support inter- and interprofessional communication, which were introduced with carefully developed implementation strategies.

METHODS

A mixed-methods convergent/triangulation design was used to investigate the influence of implementation fidelity on unplanned transfers. A fidelity questionnaire measuring the degree of fidelity to INTERCARE's core components was fielded at four time points in the participating NHs. Two-monthly meetings were conducted with NHs (September 2018-January 2020) and structured notes were used to determine moderators affecting fidelity (e.g., participant responsiveness). We used the fidelity scores and generalized linear mixed models to analyze the quantitative data. The Framework method was used for the qualitative analysis. The quantitative and qualitative findings were integrated using triangulation.

RESULTS

A higher overall fidelity score showed a decreasing rate of unplanned hospital transfers post-intervention (OR: 0.65 (CI = 0.43-0.99), p = 0.047). A higher fidelity score to advance care planning was associated with lower unplanned transfers (OR = 0.24 (CI 0.13-0.44), p = < 0.001) and a lower fidelity score for communication tools (e.g., ISBAR) to higher rates in unplanned transfers (OR = 1.69 (CI 1.30-2.19), p = < 0.003). In-house physicians with a collaborative approach and staff's perceived need for nurses working in extended roles, were important moderators to achieve and sustain high fidelity.

CONCLUSION

Implementation fidelity is challenging to measure and report, especially in complex interventions, yet is crucial to better understand how such interventions may be tailored for scale-up. This study provides both a detailed description of how fidelity can be measured and which ingredients highly contributed to reducing unplanned NH transfers.

TRIAL REGISTRATION

The INTERCARE study was registered at clinicaltrials.gov Protocol Record NCT03590470.

Hospital transfer rates and advance care planning following a nursing home-targeted video-conference education series (Project ECHO): a prospective cohort study

Purpose

Nursing home staff manage increasingly complex patients yet struggle to access education. This study measured the impact of a novel education programme on emergency transfers from nursing homes.

Methods

In this prospective experimental cohort study, ten interactive sessions were provided to 20 nursing homes, using teleconferencing technology through the “Project ECHO” (Extension for Community Healthcare Outcomes) model. Details of all emergency hospital transfers were submitted by participating nursing homes 6 months before and 6 months from commencement of ECHO.

Results

Of 20 nursing homes, 13 submitted sufficient data for inclusion. In these 13, there were 260 emergency transfers over a year. There was no significant difference in the number of transfers before and after ECHO (137/260 pre-ECHO vs 123/260 post-ECHO, p = 0.62). Post-ECHO, it was 50% more likely that transfer wishes were discussed in advance of transfer (62 of 137 (45%) transferred pre-ECHO vs 82 of 123 (67%) post-ECHO, p < 0.001). There was a significant increase in compliance with resident wishes post-ECHO in that transferred residents were less likely to have a documented “Not for Transfer” wish (29/137 pre-ECHO (21%) vs 10/123 post-ECHO (8%), p < 0.001). Point prevalence surveys of residents demonstrated significant increases in “Do Not Resuscitate” orders; 286/589 (49%) residents pre-ECHO vs 386/594 (65%) post-ECHO, p < 0.001. Post-ECHO, pain was less frequently the primary cause for transfer (11/137 (8%) pre-ECHO vs 1/123 (0.8%) post-ECHO, p = 0.006).

Conclusion

ECHO did not affect rates of emergency hospital transfers but did increase advance care planning discussions ahead of hospital transfer by 50% and compliance with the results of those discussions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00624-6.

Aim

What effect does a novel education programme have on emergency hospital transfers of, and advance care planning decisions among, nursing home residents?

Findings

This education programme did not affect overall rates of emergency hospital transfer. It did increase advance care planning discussions, increase compliance with the results of these discussions and increase “DNR” orders among nursing home residents.

Message

Novel tele-education programmes have the potential to improve advance care planning discussions in nursing homes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00624-6.