Evidence-based intervention to reduce avoidable hospital admissions in care home residents (the Better Health in Residents in Care Homes (BHiRCH) study): protocol for a pilot cluster randomised trial

Background People with advanced dementia who live and die in nursing homes experience variable quality of life, care and dying. There is a need to identify appropriate, cost-effective interventions that facilitate high-quality end-of-life care provision. Objectives To establish the feasibility and acceptability to staff and family of conducting a cluster randomised controlled trial of the Namaste Care intervention for people with advanced dementia in nursing homes. Design The study had three phases: (1) realist review and (2) intervention refinement to inform the design of (3) a feasibility cluster randomised controlled trial with a process evaluation and economic analysis. Clusters (nursing homes) were randomised in a 3 : 1 ratio to intervention or control (usual care). The nature of the intervention meant that blinding was not possible. Setting Nursing homes in England providing care for people with dementia. Participants Residents with advanced dementia (assessed as having a Functional Assessment Staging Test score of 6 or 7), their informal carers and nursing home staff. Intervention Namaste Care is a complex group intervention that provides structured personalised care in a dedicated space, focusing on enhancements to the physical environment, comfort management and sensory engagement. Main outcome measures The two contender primary outcome measures were Comfort Assessment in Dying – End of Life Care in Dementia for quality of dying (dementia) and Quality of Life in Late Stage Dementia for quality of life. The secondary outcomes were as follows: person with dementia, sleep/activity (actigraphy), neuropsychiatric symptoms, agitation and pain; informal carers, satisfaction with care at the end of life; staff members, person-centred care assessment, satisfaction with care at the end of life and readiness for change; and other data – health economic outcomes, medication/service use and intervention activity. Results Phase 1 (realist review; 86 papers) identified that a key intervention component was the activities enabling the development of moments of connection. In phase 2, refinement of the intervention enabled the production of a user-friendly 16-page A4 booklet. In phase 3, eight nursing homes were recruited. Two homes withdrew before the intervention commenced; four intervention and two control homes completed the study. Residents with advanced dementia (n = 32) were recruited in intervention (n = 18) and control (n = 14) homes. Informal carers (total, n = 12: intervention, n = 5; control, n = 7) and 97 staff from eight sites (intervention, n = 75; control, n = 22) were recruited over a 6-month period. Recruitment is feasible. Completion rates of the primary outcome questionnaires were high at baseline (100%) and at 4 weeks (96.8%). The Quality of Life in Late Stage Dementia was more responsive to change over 24 weeks. Even where economic data were missing, these could be collected in a full trial. The intervention was acceptable; the dose varied depending on the staffing and physical environment of each care home. Staff and informal carers reported changes for the person with dementia in two ways: increased social engagement and greater calm. No adverse events related to the intervention were reported. Conclusions A subsequent definitive trial is feasible if there are amendments to the recruitment process, outcome measure choice and intervention specification. Future work In a full trial, consideration is needed of the appropriate outcome measure that is sensitive to different participant responses, and of clear implementation principles for this person-centred intervention in a nursing home context. Trial registration Current Controlled Trials ISRCTN14948133. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 6. See the NIHR Journals Library website for further project information.

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“…This supports similar results observed in previous studies with similar populations. [170][171][172]…”

Section: Actigraphymentioning

confidence: 99%

A group intervention to improve quality of life for people with advanced dementia living in care homes: the Namaste feasibility cluster RCT

Froggatt

Best

Bunn

et al. 2020

Health Technol Assess

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“…Thus, timing of data collection differs from our protocol. 20 Implementation support This was developed consistent with the PARiHS framework to ensure implementation matched individual contexts. It was important for Practice Development Champions (PDCs) to decide on how they approached this, given the philosophy of quality collaboratives and 'champions' in place.…”

Section: Interventionmentioning

confidence: 99%

Pilot cluster randomised trial of an evidence-based intervention to reduce avoidable hospital admissions in nursing home residents (Better Health in Residents of Care Homes with Nursing—BHiRCH-NH Study)

et al. 2020

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ObjectivesTo pilot a complex intervention to support healthcare and improve early detection and treatment for common health conditions experienced by nursing home (NH) residents.DesignPilot cluster randomised controlled trial.Setting14 NHs (7 intervention, 7 control) in London and West Yorkshire.ParticipantsNH residents, their family carers and staff.InterventionComplex intervention to support healthcare and improve early detection and treatment of urinary tract and respiratory infections, chronic heart failure and dehydration, comprising: (1) ‘Stop and Watch (S&W)’ early warning tool for changes in physical health, (2) condition-specific care pathway and (3) Situation, Background, Assessment and Recommendation tool to enhance communication with primary care. Implementation was supported by Practice Development Champions, a Practice Development Support Group and regular telephone coaching with external facilitators.Outcome measuresData on NH (quality ratings, size, ownership), residents, family carers and staff demographics during the month prior to intervention and subsequently, numbers of admissions, accident and emergency visits, and unscheduled general practitioner visits monthly for 6 months during intervention. We collected data on how the intervention was used, healthcare resource use and quality of life data for economic evaluation. We assessed recruitment and retention, and whether a full trial was warranted.ResultsWe recruited 14 NHs, 148 staff, 95 family carers and 245 residents. We retained the majority of participants recruited (95%). 15% of residents had an unplanned hospital admission for one of the four study conditions. We were able to collect sufficient questionnaire data (all over 96% complete). No NH implemented intervention tools as planned. Only 16 S&W forms and 8 care pathways were completed. There was no evidence of harm.ConclusionsRecruitment, retention and data collection processes were effective but the intervention not implemented. A full trial is not warranted.Trial registration numberISRCTN74109734 (https://doi.org/10.1186/ISRCTN74109734).Original protocolBMJ Open. 2019;9(5):e026510. doi:10.1136/bmjopen-2018-026510.

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“…INTERACT focusses on managing acute changes in residents' condition using [18]: We worked with stakeholders including staff and our (family) Carer Reference Panel (CRP), to develop and adapt the INTERACT communication and care pathway tools for use in the UK [29] (paper in preparation). We did not include ACP tools in our version of INTERACT because this is already a separate area of focus in many UK nursing homes.…”

Section: Intervention Developmentmentioning

confidence: 99%

“…For intervention details see Sampson et al (2019) [29]. The pilot trial ran for 10 months between November 2017 and August 2018.…”

Section: Interventionmentioning

confidence: 99%

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A pilot cluster randomised trial of an evidence-based intervention to reduce avoidable hospital admissions in nursing home residents (Better Health in Residents of Care Homes with Nursing - BHiRCH-NH study)

Sampson¹,

Feast

Blighe

et al. 2020

Preprint

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Background: Nursing home residents are often frail and most have complex healthcare needs. Hospitalisation is distressing to the person, their family and nursing home staff and costly for health services. Early detection of changes in residents’ health may reduce admissions. Our aim was to pilot a complex intervention with implementation support to improve early detection and treatment for four common Ambulatory Care Sensitive Conditions (ACSCs); urinary tract and respiratory infections, chronic heart failure and dehydration. Methods: Pilot cluster randomised controlled trial in 14 nursing homes (7 intervention, 7 control). The intervention involved 1) “stop and watch (S&W)” early warning tool for changes in physical health, 2) condition- specific care pathways and 3) Situation, Background, Assessment and Recommendation (SBAR) to structure communication with primary care. of Intervention implementation was supported by Practice Development Champions (PDCs) in the care home, a Practice Development Support Group (PDSG) and regular telephone coaching with external facilitators. We collected data on nursing homes (quality ratings, size, ownership), residents, their family carers and staff demographics during the month prior to intervention and subsequently, numbers of admissions, accident and emergency visits and unscheduled GP visits monthly for 6 months during the intervention period. We collected data on how the intervention was used, healthcare resource use and quality of life data for economic evaluation. We assessed participant recruitment and retention and whether a full trial was warranted. Results: We recruited 14 nursing homes, 148 staff, 95 family carers and 245 residents. One nursing home closed prior to the intervention starting and another withdrew during the data collection phase. We retained the majority of participants recruited (95%). 15% of residents had an unplanned hospital admission for one of the four study conditions during follow-up. We were able to collect sufficient data on study questionnaires (all were over 96% complete). No home implemented intervention tools as planned. Only 16 S&W forms and 8 Care Pathways were completed. There was no evidence that the intervention was harmful.Conclusions: Study recruitment, retention, data collection and processes were effective but the intervention was not implemented in practice, therefore a full trial is not warranted. Trial registration: ISRCTN74109734 (registered 6/11/2017) https://doi.org/10.1186/ISRCTN74109734

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Evidence-based intervention to reduce avoidable hospital admissions in care home residents (the Better Health in Residents in Care Homes (BHiRCH) study): protocol for a pilot cluster randomised trial

Cited by 13 publications

References 31 publications

A group intervention to improve quality of life for people with advanced dementia living in care homes: the Namaste feasibility cluster RCT

A group intervention to improve quality of life for people with advanced dementia living in care homes: the Namaste feasibility cluster RCT

Pilot cluster randomised trial of an evidence-based intervention to reduce avoidable hospital admissions in nursing home residents (Better Health in Residents of Care Homes with Nursing—BHiRCH-NH Study)

A pilot cluster randomised trial of an evidence-based intervention to reduce avoidable hospital admissions in nursing home residents (Better Health in Residents of Care Homes with Nursing - BHiRCH-NH study)

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