Implementation of a complex intervention to improve hospital discharge: process evaluation of a cluster randomised controlled trial

Abstract

ObjectivesTo study the implementation of a cluster randomised controlled effectiveness-implementation hybrid trial testing the effectiveness of a medication review at hospital discharge combined with a communication stimulus between hospital physicians (HPs) and general practitioners (GPs) on rehospitalisation of multimorbid older patients.DesignExtension of Grant’s mixed method process evaluation framework to trials with multilevel clustering.SettingGeneral internal medicine wards in Swiss hospitals.ParticipantsConvenience samples of 15 chief physicians (of 21 hospitals participating in the effectiveness trial), 60 (74) senior HPs, 65 (164) junior HPs and 187 (411) GPs.Implementation strategyTwo-hour teaching sessions for senior HPs on a patient-centred, checklist-guided discharge routine.Process evaluation componentsData collection on recruitment, delivery and response from chief physicians (semistructured interviews), senior HPs, junior HPs, GPs (surveys) and patients (via HPs). Quantitative data were summarised using descriptive statistics, and interviews analysed using thematic analysis.Outcome measuresIntervention dose (quantitative), implementation fidelity (qualitative), feasibility and acceptability, facilitators and barriers, implementation support strategies.ResultsRecruitment of hospitals was laborious but successful, with 21 hospitals recruited. Minimal workload and a perceived benefit for the clinic were crucial factors for participation. Intervention dose was high (95% of checklist activities carried out), but intervention fidelity was limited (discharge letters) or unknown (medication review). Recruitment and retention of patients was challenging, partly due to patient characteristics (old, frail) and the COVID-19 pandemic: Only 612 of the anticipated 2100 patients were recruited, and 31% were lost to follow-up within the first month after discharge. The intervention was deemed feasible and helpful by HPs, and the relevance of the topic appreciated by both HPs and GPs.ConclusionsThe results from this evaluation will support interpretation of the findings of the effectiveness study and may inform researchers and policy makers who aim at improving hospital discharge.Trial registration numberISRCTN18427377.

Medication Review and Enhanced Information Transfer at Discharge of Older Patients with Polypharmacy: a Cluster-Randomized Controlled Trial in Swiss Hospitals

“…The flexible implementation of our study minimally disrupted hospital routines, 28 but possibly at the expense of a weaker intervention 54 that generated no incremental benefit in hospitals with already well-organized discharge procedures including routine HP-PCP communication, critical medication review, and a high awareness of polypharmacy and deprescribing.…”

“…Implementation outcomes were collected in parallel to the core study and evaluated according to an adapted framework 28 for process evaluation studies. 35…”

“…That being said, follow-up surveys among PCPs confirmed that they often and readily adopted changes to their patients' long-term medication without further consultation with HPs. 28…”

How to fall into a new routine: factors influencing the implementation of an admission and discharge programme in hospitals and general practices

“…In addition, they point to the importance of training to raise awareness of the interventions and their benefits for the stakeholders involved [12]. In relation to cross-sectoral innovations, discharge planning or care transitions, several studies have found that the following factors are crucial for implementation: Clarity of roles and responsibilities [13,14], evidence base and perceived benefits, although it often takes time for these benefits to become visible/ recognisable [14][15][16], champions or leaders who commit to the innovation over a long period of time and stick with it even when others stop [14,15,17], low additional workload due to the innovation [16] and high additional workload for study-related activities such as obtaining informed consent from study participants [14]. Resources have both been described as constraining (when there is not enough staff or time) [16], but lack of resources can also facilitate change when staff recognise that they need to find a way to work more efficiently [17].…”

How To Fall Into A New Routine: Factors Influencing The Implementation Of An Admission And Discharge Program In Hospitals And General Practices

“…Furthermore, they point out the relevance of trainings to raise awareness about the interventions and point out its bene ts to the actors involved [12]. Regarding cross-sectoral innovations, discharge planning or care transitions, there are several studies that found determinants to implementation to be: clarity about roles and responsibilities [13,14], evidence base and perceived bene t, even though it often takes time for this bene t to be visible/ perceivable [14][15][16], having champions or leaders who commit to the innovation over a long time and stick with it even when others stop doing so [14,15,17], only little additional workload by the innovation [16], and high additional workload for study-related measures such as getting informed consent by study participants [14]. Resources were reported as both constraining (if there is not enough staff or time) [16], but lack of resources can also facilitate change if people recognise that they have to nd a way to work more e ciently [17].…”