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LR21 / Effectiveness of the nursing led units (NLU)for post acute intermediate care (CRM)

Romania




Type of Patient Safety Practice
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Handover
Patient safety theme the SCP/clinical risk management practice is aimed at
CRM practice: effectiveness of nursing-led inpatient units (NLUs) in preparing patients for discharge from hospital (comparing with usual post-acute care managed and planned by hospital doctors as leaders of the multi-disciplinary team).
Objective of the CRM practice
The intention was to compare the effectiveness in nursing-led inpatient units (NLUs), where post-acute intermediate care is given to prepare patients for discharge from hospital with the usual post-acute care units, managed and planned by hospital doctors as leaders of the multi-disciplinary team [p.108;1]. Evidence for other forms of inpatient intermediate care is scant or non-existent. The evidence is certainly far stronger for the NLU than for intermediate care in care homes (Ward et al., 2003). However, generalization from this evidence for the development of new services must be made with caution [p.114; p.115; 1].
Short description of the CRM practice, including any references for further information
The description of the practice is not very detailed. The NLU is defined as an institutional setting (i.e. not in the patient’s home) where nurses assume the care management function (including admission and discharge decisions) and team leadership that is usually vested in doctors for the majority of patients (Griffiths and Wilson-Barnett, 1998). All offered non specialist rehabilitation in a nurse-managed environment and placed emphasis on the therapeutic activities of nurses (as opposed to purely ‘maintenance care’) In general, care on the NLU was described as more patient centered than in comparison units with systems of nursing work such as primary nursing. Descriptions of the NLU typically described attempts to make the environment and living experience of the patients more ‘homely’ and therapeutic. The mechanisms for achieving this varied considerably and included staff abandoning traditional nursing uniforms, patients attending communal meals and recreational therapy. In general, overall nurse staffing for the NLU (including qualified and unqualified staff) was described to be at an equivalent level to that on control wards [p.110;1]. The methodology and results of the study are extended: Review methods: The Cochrane Library, Effective Practice and Organization of Care specialist register, Medline, Cinahl, Embase, British Nursing Index and the HMIC databases were searched for all available dates up to mid-2003. The science and social science citation indices were searched for papers that cited key works. Authors of papers were asked to identify additional research. Statistical meta-analysis on the results of controlled trials was performed. Sensitivity analyses were conducted to determine the impact of methodological quality on conclusions.[p.109;1]. Eligible study types were randomized controlled trials (RCT), controlled clinical trials (CCT), controlled before and after studies and interrupted time-series designs. The criteria for entry into the review were those of the Cochrane EPOC group and studies were assessed against methodological and quality criteria relevant to each study design (2003). Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Seven studies were conducted in the UK and two in the USA. Eight studies were randomized controlled trials and one quasi random (Hall et al., 1975). Validity assessment for studies A quality score was derived from the EPOC checklist (Bero et al., 2004) based on the number of quality criteria that were met. There are seven criteria for RCTs and CCTs. In addition to the EPOC criteria, use of intention to treat analysis was rated, since selective attrition from the nurse-led group due to medical instability is a major potential source of bias. . A quality score from 7 (best) to 0 (worst) was awarded. Quality of studies was variable. No study met all the 7 quality criteria and scores ranged from 2 to 6. Outcomes considered were mortality, institutionalization after discharge, functional status early readmission, length of inpatient stay and cost. Participants considered for inclusion in the review were post-acute adult patients who are assessed as eligible for nurse-managed care in a NLU where inpatient medically led care is the alternative. Although most often it is considered as a care option for older people, the model of care is not age related and hence inclusion was not limited by age provided the service was for adult (18+) patients. In all the cases where detail is given the mean age of the patient population was over 70 years. A degree of medical stability was an implicit or explicit criterion for admission in all cases and although most units attempted to define additional criteria they were generally subjective. Patients who had been admitted with a range of medical/surgical problems were treated although conditions commonly associated with functional limitation in the short or long-term such as stroke, falls and orthopedic conditions were frequent. Three studies recruited only patients with specific conditions (stroke, hip fracture and heart disease). The majority of patients spent the majority of their stay in either the NLU or acute units. Some control group patients experiencing usual care were transferred from acute care to traditional rehabilitation or community hospital settings in most studies. Such facilities were not widely used by patients from the NLU. Wherever possible the index admission was determined from entry into the study (or admission to hospital) until the patient has made the transition to their intended permanent place of residence (be it home or institution). Results: There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care (OR 1.10, 95% CI 0.56–2.16). The NLU was associated with reduced odds of discharge to institutional care (OR 0.44 95% CI 0.22–0.89), better functional status at discharge (SMD 0.37, 95% CI 0.20–0.54) and reduced odds of early readmission (OR 0.52 95% CI 0.34–0.80). Length of stay until discharge home was increased by 5.13 days (WMD) (95% CI–0.5–10.76 days). At longest follow up (3–6 months) there was no statistically significant difference in the proportion of patients in institutional care (OR 0.97, 95% CI 0.60–1.58). The results were not generally sensitive to study quality. The NLU successfully functions as a form of intermediate care, and so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term.[p.107; p.108;p109; 1].
Innovator of the SCP, country of origin
UK and USA NLU was part of wider nursing practice development initiatives typified by the nursing development unit concept in some UK units. A number of models for providing inpatient intermediate care have been suggested. The most commonly identified services in the UK include nursing-led inpatient units (NLUs), nursing home beds and community (‘cottage’) hospitals (Department of Health, 2002). In the US sub-acute and transitional/progressive care services (Griffiths, 1997; von Sternberg et al., 1997), generally based on skilled nursing facilities, have been developed and cover a similar spectrum of care settings [p.112; 1]
Involved health care staff
Nurse staffing for the NLU (including qualified and unqualified staff) was described to be at an equivalent level to that on control wards. Where, reported there was generally a high level of involvement from physiotherapy, occupational therapy and social work, although, where comparative data were, available this did not differ greatly from usual care [ p.109;1].
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
UK – NLUs ; USA – sub-acute and transitional/progressive care services [p.108; 1]. Despite the heterogeneity of the original reason for hospital admission, these services have a number of features in common. All described a service for patients following acute admission and explicitly or implicitly described a recovery trajectory from medical to nursing need as part of their rationale
Summary of evidence for effectiveness, including references
Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Studies quality was variable. There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care. The NLU was associated with reduced odds of discharge to institutional care, better functional status at discharge and reduced odds of early readmission. Length of stay until discharge home was increased by 5.13. At longest follow up (3–6 months) there was no statistically significant difference in the proportion of patients in institutional care (P. Griffiths, 2004). The results were not generally sensitive to study quality. The NLU successfully functions as a form of intermediate care; so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term. 1.) Despite the apparent heterogeneity of patient groups, settings and implementation of NLU the pattern of results is consistent for most studies on most outcomes. 2.) There is no evidence of adverse effects in terms of mortality to longer follow up but the confidence intervals are wide and the pattern of results is consistently unfavorable to the NLU for inpatient mortality. Although this could be a product of increased length of stay or sampling error it is not possible to be confident that early mortality is not increased by the NLU. 3.) Patients discharged from the NLUs were more independent in terms of functional status. There is evidence that patients were less likely to be discharged to institutional care from the NLU and less likely to experience early readmission. 4.) However, there is no evidence that benefit is maintained over the medium to long term as there is no difference in the numbers in institutional care by the end of follow up (typically six months). It may be that patients are better at point of discharge from the NLU simply because they have stayed longer. 5.) Avoidance of institutionalization in the short term alone is less clearly advantageous and service users would best determine the value of this. 6.) Issues of cost effectiveness are complicated by health care financing systems. In the US, some post-acute stays in skilled nursing facilities are reimbursable by Medicare in addition to fixed payments based on DRGs for the initial stay. In the UK additional funding has been made available specifically to provide intermediate care [p.113; p.114;1].
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
1.) Description of the context for which the practice was designed explained for USA and UK settings 2.) Guidance on implementation: summary description 3.) Generalizability: more evidence are required 4. )Process and results: summary information on process; results are detailed: It was observed that the similarity between the NLU and usual hospital care is more striking than the differences (Griffiths, 2002), certainly in terms of measurable attributes of care process. Ultimately, the rhetoric of ‘therapeutic nursing’ and ‘intermediate care’ may simply reduce to attempts to create environments and mechanisms to deliver high quality nursing care to patients who might be deprived of it when the need for specialist medical supervision has diminished. Trends to early discharge from acute units and increasing acuity among the general medical and surgical inpatient population make it challenging, and possibly undesirable, to deliver non-specialist rehabilitative nursing care in acute settings. Nonetheless, the key determinants of quality in patient experience for the NLU may be precisely the same as for any other inpatient nursing setting. The NLU is one of a range of possible services in which additional resources could be invested. Despite the consistency of results, the services described as NLUs are complex and diverse and attention must be given to the detailed implementation in local circumstances. Certainly the effectiveness of NLUs should not be assumed when developing new services. The majority of evidence for NLU derives from what are best described as demonstration units and in all cases there was additional preparation for staff either in terms of advanced qualification for some or all practitioners, specific skills training or wider programs of practice development. The NLU, as evaluated, does not necessarily entail a net reduction in resource use and evidence from the UK suggests that total resource use in the inpatient setting is increased. Rather the NLU involves an alteration in the way resources are used and an alteration in composition of the healthcare team. Since costs are largely determined by local circumstances, it would be unwise to draw too general a conclusion. The economic basis of sub-acute units in the USA in particular is complex since payments to the provider for the initial acute hospitalization may be fixed under prospective payment systems, while substitution of an acute care stay for some of the inpatient period can generate additional revenues. Hence, even the more costly option in terms of resources used by the facility might in fact generate more revenue to the provider.
Summary of available information on feasibility, including references
More evidence from well-conducted trials is required to fully determine safety in the NLU compared to usual hospitalization. More evidence is required identifying criteria for suitability for NLU (as opposed to other forms of intermediate care) and to determine the cost effectiveness of the NLU relative to other forms of intermediate care. In determining cost effectiveness, it will be important to recognize that any service that sits at a boundary between different service providers is in danger of generating perverse incentives with the solution to the equation for cost effectiveness varying according to which provider’s perspective is taken. However, if decisions are to be made regarding the merit of investing in NLUs in order to gain (for example) a short-term delay in admission to a nursing home, a wider consideration of both client and care giver perspectives on the matter is required.
Existing implementation tools, including references
No tools available for the practice itself.
Potential for/description of patient involvement in the CRM practice, including references
Three studies reported measures of patient satisfaction, two used the Newcastle satisfaction with nursing scale (Griffiths et al., 2000, 2001) and one a patient services checklist (Pearson et al., 1988b). In all cases response fell below 80%. Patients experiencing the NLU were more satisfied than those experiencing usual care (SMD 0.22, 95% CI_0.03 to 0.46) although the result does not quite achieve significance. No individual studies achieved significance but in all cases outcomes For the NLU were favorable. The perspective of service users has not been fully considered as yet, although in addition to the weak but positive evidence on satisfaction presented here there has been some qualitative research, which gave a broadly favorable view of the NLU (Wiles et al., 2003) [p.113;1].
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] Griffiths, Peter; Edwards, Margaret; Forbes, Angus; Harris, Ruth(2005):Post-acute intermediate care in nursing-led units, a systematic review of effectiveness International Journal of Nursing Studies 42;p. 107–116 References [2].Bero, L., Grilli, R., Grimshaw, J., Mowatt, G., Oxman, A.,Zwarenstein, M., 2004. Cochrane Effective Practice and Organization of Care Group. In: The Cochrane Library, Issue 1. Wiley, Chichester, UK. [3].Griffiths, P., 1997. In search of therapeutic nursing: subacute care. Nursing Times 93 (26), 54–55. Griffiths, P., 1998. Evaluation of a nursing-led in-patient unit. PhD Thesis. King’s College, University of London. [4].Griffiths, P., 2002. Nursing-led in-patient units for intermediate care: a survey of multidisciplinary discharge planning practice. Journal of Clinical Nursing 11 (3), 322–330. P. Griffiths et al. / International Journal of Nursing Studies 42 (2005) 107–116 115 [5].Griffiths, P., Evans, A., 1995. Evaluating a Nursing Led In-Patient Service: An Interim Report. King’s Fund Centre, London. [6].Griffiths, P., Wilson-Barnett, J., 2000. Influences on length of stay in intermediate care: lessons from the nursing-led inpatient unit studies. International Journal of Nursing Studies 37 (3), 245–255. [7].Griffiths, P., Wilson-Barnett, J., Richardson, G., Harris, R., Miller, F., Spilsbury, K., 2000. The effectiveness of intermediate care in a nursing-led in-patient unit. International Journal of Nursing Studies 37 (2), 153–161. [8].Griffiths, P., Harris, R., Richardson, G., Hallett, N., Heard, S., Wilson-Barnett, J., 2001. Substitution of a nursing-led inpatient unit for acute services: randomized controlled trial of outcomes and cost of nursing-led intermediate care. Age and Ageing 2001 (30), 483–488. [9].Hall, L., Alfons, G., Rifkin, E., Levine, H., 1975. Final Report: Longitudinal Effects of an Experimental Nursing Process. Loeb Center for Nursing and Rehabilitation, Bronx, New York. [10].Pearson, A., Durant, I., Punton, S., 1988b. The feasibility and effectiveness of nursing beds. Nursing Times 84 (47), 48–50. [11].Von Sternberg, T., Hepburn, K., Cibuzar, P., Convery, L., Dokken, B., Haefemeyer, J., Rettke, S., Ripley, J., Vosenau, V., Rothe, P., Schurle, D., Won-Savage, R., 1997. Posthospital sub-acute care:an example of a managed care model. Journal of American Geriatric Society 45 (1), 87–91. [12].Ward, D., Severs, M., Dean, T., Brooks, N., 2003. Care home versus hospital and own home environments for rehabilitation of older people (Cochrane Review). In: The Cochrane Library. Update Software, Oxford. [13].Wiles, R., Postle, K., Steiner, A., Walsh, B., 2003. Nurse-led intermediate care:patients’ perceptions. International Journal of Nursing Studies 40 (1), 61–71.
Reviewer
Dr Carmen Angheluta and Dr T. Ciolompea National School of Public Health and Management, Romania
Organisation
National School of Public Health and Management, Romania
Any additional information on the CRM (e.g. implementation barriers and drivers)
description of concrete national or regional experience in practice
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Anne Bebek cicicocuk Bebek, Çocuk, Genç
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