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Bohingamu Mudiyanselage S, Considine J, Hutchinson AM, Mitchell I, Mohebbi M, Watts JJ, Bucknall TK. An economic evaluation of the Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) clinical trial. Resuscitation 2024; 201:110272. [PMID: 38866230 DOI: 10.1016/j.resuscitation.2024.110272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/26/2024] [Accepted: 06/05/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Early recognition and response to clinical deterioration reduce the frequency of in-hospital cardiac arrests, mortality, and unplanned intensive care unit (ICU) admissions. This study aimed to investigate the impact of the Prioritising Responses Of Nurses To deteriorating patient Observations (PRONTO) intervention on hospital costs and patient length of stay (LOS). METHOD The PRONTO cluster randomised control trial was conducted to improve nurses' responses to patients with abnormal vital signs. Hospital data were collected pre-intervention (T0) at 6 months (T1) and 12 months (T2) post-intervention. The economic evaluation involved a cost-consequence analysis from the hospital's perspective. Generalised estimating equations were used to estimate the parameters for regression models of the difference in costs and LOS between study groups and time points. RESULTS Hospital admission data for 6065 patients (intervention group, 3102; control group, 2963) were collected from four hospitals for T0, T1 and T2. The intervention cost was 69.61 A$ per admitted patient, including the additional intervention training for nurses and associated labour costs. The results showed cost savings and a shorter LOS in the intervention group between T0 - T1 and T0 - T2 (cost differences T0 - T1: -364 (95% CI -3,782; 3049) A$ and T0 - T2: -1,710 (95% CI -5,162; 1,742) A$; and LOS differences T0 - T1: -1.10 (95% CI -2.44; 0.24) days and T0 & T2: -2.18 (95% CI -3.53; -0.82) days). CONCLUSION The results of the economic analysis demonstrated that the PRONTO intervention improved nurses' responses to patients with abnormal vital signs and significantly reduced hospital LOS by two days at 12 months in the intervention group compared to baseline. From the hospital's perspective, savings from reduced hospitalisations offset the costs of implementing PRONTO.
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Affiliation(s)
- Shalika Bohingamu Mudiyanselage
- School of Health and Social Development, Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia.
| | - Julie Considine
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, Eastern Health, Box Hill, Victoria, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia; Barwon Health, Geelong, Victoria, Australia
| | - Imogen Mitchell
- Australian National University College of Health and Medicine, Canberra, Australian Capital Territory, Australia; Research and Academic Partnerships, Canberra Health Services, Canberra, Australian Capital Territory, Australia
| | - Mohammadreza Mohebbi
- Faculty of Health, Biostatistics Unit, Deakin University, Geelong, Victoria, Australia
| | - Jennifer J Watts
- School of Health and Social Development, Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Tracey K Bucknall
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia; Alfred Health, Melbourne, Victoria, Australia
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Douglas C, Alexeev S, Middleton S, Gardner G, Kelly P, McInnes E, Rihari-Thomas J, Windsor C, Morton RL. Transforming nursing assessment in acute hospitals: A cluster randomised controlled trial of an evidence-based nursing core assessment (the ENCORE trial). Int J Nurs Stud 2024; 151:104690. [PMID: 38237324 DOI: 10.1016/j.ijnurstu.2024.104690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Patient safety is threatened when early signs of clinical deterioration are missed or not acted upon. This research began as a clinical-academic partnership established around a shared concern of nursing physical assessment practices on general wards and delayed recognition of clinical deterioration. The outcome was the development of a complex intervention facilitated at the ward level for proactive nursing surveillance. METHODS The evidence-based nursing core assessment (ENCORE) trial was a pragmatic cluster-randomised controlled trial. We hypothesised that ward intervention would reduce the incidence of patient rescue events (medical emergency team activations) and serious adverse events. We randomised 29 general wards in a 1:2 allocation, across 5 Australian hospitals to intervention (n = 10) and usual care wards (n = 19). Skilled facilitation over 12 months enabled practitioner-led, ward-level practice change for proactive nursing surveillance. The primary outcome was the rate of medical emergency team activations and secondary outcomes were unplanned intensive care unit admissions, on-ward resuscitations, and unexpected deaths. Outcomes were prospectively collected for 6 months following the initial 6 months of implementation. Analysis was at the patient level using generalised linear mixed models to account for clustering by ward. RESULTS We analysed 29,385 patient admissions to intervention (n = 11,792) and control (n = 17,593) wards. Adjusted models for overall effects suggested the intervention increased the rate of medical emergency team activations (adjusted incidence rate ratio 1.314; 95 % confidence interval 0.975, 1.773), although the confidence interval was compatible with a marginal decrease to a substantial increase in rate. Confidence intervals for secondary outcomes included a range of plausible effects from benefit to harm. However, considerable heterogeneity was observed in intervention effects by patient comorbidity. Among patients with few comorbid conditions in the intervention arm there was a lower medical emergency team activation rate and decreased odds of unexpected death. Among patients with multimorbidity in the intervention arm there were higher rates of medical emergency team activation and intensive care unit admissions. CONCLUSION Trial outcomes have refined our assumptions about the impact of the ENCORE intervention. The intervention appears to have protective effects for patients with low complexity where frontline teams can respond locally. It also appears to have redistributed medical emergency team activations and unplanned intensive care unit admissions, mobilising higher rates of rescue for patients with multimorbidity. TRIAL REGISTRATION NUMBER ACTRN12618001903279 (Date of registration: 22/11/2018; First participant recruited: 01/02/2019).
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Affiliation(s)
- Clint Douglas
- School of Nursing, Queensland University of Technology (QUT), Kelvin Grove, QLD 4059, Australia; Office of Nursing and Midwifery Services, Metro North Hospital and Health Service, Herston, QLD 4006, Australia.
| | - Sergey Alexeev
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2015, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Glenn Gardner
- School of Nursing, Queensland University of Technology (QUT), Kelvin Grove, QLD 4059, Australia
| | - Patrick Kelly
- The University of Sydney, Faculty of Medicine and Health, Sydney School of Public Health, Camperdown, NSW 2006, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | | | - Carol Windsor
- School of Nursing, Queensland University of Technology (QUT), Kelvin Grove, QLD 4059, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2015, Australia
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