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Evaluation of the Effectiveness of a Comprehensive Care Plan to Reduce Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2019-034121 on 20 July 2020. Downloaded from Evaluation of the effectiveness of a comprehensive care plan to reduce hospital acquired complications in an Australian hospital: protocol for a mixed- method preimplementation and postimplementation study Rebecca Leigh Jessup ,1,2 Mark Tacey,3,4 Maree Glynn,5 Michael Kirk,6 Liz McKeown5 To cite: Jessup RL, Tacey M, ABSTRACT Strengths and limitations of this study Glynn M, et al. Evaluation Introduction A new healthcare standard (Standard 5: of the effectiveness of a Comprehensive Care) has been introduced by the Australian ► A key strength of this study is the measurement of comprehensive care plan Commission on Safety and Quality in Healthcare. Standard to reduce hospital acquired both the clinical effectiveness and the cost effec- 5 advocates for organisational leadership to develop and complications in an Australian tiveness associated with implementing a compre- maintain systems and processes to deliver patient- centred hospital: protocol for a mixed- hensive care plan embedded in a hospital service in comprehensive care plans that include appropriate screening method preimplementation response to recent changes to the Australian National to identify and mitigate risks associated with hospitalisation. and postimplementation Safety and Quality Health Service Standards. study. BMJ Open The aim of this study is to evaluate the effectiveness and cost ► This comprehensive approach to evaluation uses a 2020;10:e034121. doi:10.1136/ effectiveness of a comprehensive care and risk evaluation mixed methods pre–post design to measure both bmjopen-2019-034121 (Comprehensive Assessment and Risk Evaluation (CARE)) the changes in the incidence of hospital acquired plan to reduce hospital acquired complications (HACs) in an ► Prepublication history and complications, impacts on patients and staff, and Australian hospital network. additional material for this the cost- effectiveness of the plan, relative to the http://bmjopen.bmj.com/ Methods and analysis This study will comprise a mixed- paper are available online. To benefit. view these files, please visit method pre and post implementation concurrent triangulation ► Limitations include that this study is being conduct- the journal online (http:// dx. doi. evaluation design. The primary clinical outcome will assess ed in only one hospital network, and results may not org/ 10. 1136/ bmjopen- 2019- the reduction of routinely reported HACs (pressure care be generalisable to other hospital services. 034121). and falls), selected based on the likely reliability of routinely ► As the study design is not experimental, this study collected data prior to implementation. Secondary clinical Received 16 September 2019 may be impacted by threats to internal validity. outcomes will include length of stay and activity- based Revised 20 May 2020 Accepted 02 June 2020 costing data for each episode, in- hospital mortality, expected and unplanned readmissions within 28 days, compliance on September 24, 2021 by guest. Protected copyright. with CARE plan completion and referrals for at risk patients, pressure from an ageing population,1 2 staff satisfaction, patient satisfaction and barriers and growth in chronic and preventable diseases,3 enablers to implementation. We expect that the incidence of increasing inflationary pressures and work- other HACs (malnutrition, delirium, violence and aggression, force shortages,4–8 and changing community and suicide and self- harm) may increase as routine methods expectations,9 10 there is a need for health- for assessing risk were not in place prior to implementation care providers to ensure that they provide of the CARE plan. We will therefore collect data on incidence of these HACs as tertiary outcomes. Our primary cost- effective care, which uses resources in the effectiveness outcome will be calculation of an incremental most efficient way to deliver the best possible © Author(s) (or their cost- effectiveness ratio. outcomes for patients. employer(s)) 2020. Re- use In 2018, the Australian Commission on permitted under CC BY-NC. No Ethics and dissemination Ethics approval has been commercial re- use. See rights received from Northern Health Low Risk Ethics Committee. Safety and Quality in Healthcare in collab- and permissions. Published by The results of this study will be published in peer- reviewed oration with Australian Government, states BMJ. journals and presented at conferences. and territories, the private sector, clinical For numbered affiliations see experts and patients and carers, launched end of article. INTRODUCTION their second edition of the National Safety 11 Correspondence to The provision of safe and appropriate health- and Quality Health Service Standards. Dr Rebecca Leigh Jessup; care is an ongoing challenge for health These standards aim to protect patients rebecca. jessup@ nh. org. au service providers. In the face of increasing from harm and improve the quality-of- care Jessup RL, et al. BMJ Open 2020;10:e034121. doi:10.1136/bmjopen-2019-034121 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-034121 on 20 July 2020. Downloaded from provision. They form the basis through which health for as part of earlier standard requirements and are the services are assessed to achieve accreditation, with the most reliably coded HACs. aim of ensuring that all Australian health services have Aim 2 is to conduct a cost- effectiveness study deter- appropriate systems in place to minimise the risk of harm mining the value of implementing the Comprehensive and ensure quality care delivery. Assessment and Risk Evaluation (CARE) plan relative to As part of the latest standards, a new standard has been the costs. introduced, Standard 5: Comprehensive Care11 (the Stan- dard). The standard advocates for organisational leader- ship to develop and maintain systems and processes to METHODS deliver patient- centred comprehensive care plans. The Study design standard includes a minimising patient harm criterion This study will comprise a mixed- method preimplemen- that advocates for appropriate screening to identify and tation and postimplementation concurrent triangula- mitigate risks associated with hospitalisation, specifically tion evaluation design. Routinely collected data will be the six hospital- acquired complications (HACs) of falls, used to evaluate the effectiveness of the CARE plan in pressure injury, delirium, malnutrition, violence and reducing the incidence of HACs. Audits and surveys will aggression, and suicide and self- harm. collect further quantitative and qualitative information to Falls are common in acute care, affecting an estimated fill the gaps of current routinely collected data sources, 12 13 2% of hospital stays, with around 25% resulting in including measuring time and resources required to 13 injury and 2% resulting in fractures. Pressure ulcers implement and use the CARE record, patient and staff prevalence in hospitals creates a significant financial satisfaction with the CARE plan, and auditing compliance burden to the health system. Studies have estimated that with completion of each component of the plan. To assess the cost of treating pressures ulcers per patient per day the cost effectiveness of the CARE plan, we will calculate 14 range from €2.65 to €87.57 ($A4.28 to $A141.39) and an incremental cost- effectiveness ratio to provide a ratio that the care of patients with pressure ulcers accounts of extra cost (staffing and resource use) per extra unit of 15 16 for between 1.9% and 4% of healthcare expenditure. health effect (reduction in HACs). Delirium impacts an estimated 3%–29% of hospitalised inpatients, with affected patients 2.6 times more likely Study population to die during an admission.17 18 Malnutrition is esti- Northern Health (NH) is the major provider of acute, mated to affect up to 40% of hospitalised individuals subacute and ambulatory specialist services in Melbourne’s and is often poorly documented.19 Malnutrition may be north and provides a comprehensive range of primary, present on admission or develop during a patient stay, secondary and tertiary healthcare services. The hospital but it is almost always associated with longer lengths of network consists of a 410-bed acute hospital (including http://bmjopen.bmj.com/ hospital stay and has been associated with a 31%–55% mental health, intensive care unit, special care nursery increase in hospital costs when compared with well- and short stay), two subacute hospital sites with 134 and nourished patients.20 Often malnourished patients, 87 beds, and an outpatient, day procedure site. The NH and/ or patients with delirium, are also at much higher catchment is located in one of Australia’s fasting growing risk of other HACs including falls21–23 and pressure areas, with the population projected to grow from 350 injury.24 25 000 in 2016 to more than 570 000 by 2031.30 Residents Occupational violence is common in healthcare settings originate from more than 184 countries and speak more and includes verbal and physical abuse. The number of than 106 languages, with the top five languages spoken on September 24, 2021 by guest. Protected copyright. Code Grey (emergency management response for a non- after English being Arabic, Italian, Assyrian, Turkish and armed act of aggression) responses in inner metropolitan Greek. Residents in the NH catchment have lower levels health services in Melbourne in 2015–2016 was 763426; of income, educational
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