INTERCARE 护士主导模式对减少养老院转移的积极影响：一项非随机阶梯式楔形设计。
Positive effect of the INTERCARE nurse-led model on reducing nursing home transfers: A nonrandomized stepped-wedge design.
机构信息
Department of Public Health, Faculty of Medicine, Institute of Nursing Science, University of Basel, Basel, Switzerland.
Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Leuven, Belgium.
出版信息
J Am Geriatr Soc. 2022 May;70(5):1546-1557. doi: 10.1111/jgs.17677. Epub 2022 Feb 5.
BACKGROUND
Unplanned nursing home (NH) transfers are burdensome for residents and costly for health systems. Innovative nurse-led models of care focusing on improving in-house geriatric expertise are needed to decrease unplanned transfers. The aim was to test the clinical effectiveness of a comprehensive, contextually adapted geriatric nurse-led model of care (INTERCARE) in reducing unplanned transfers from NHs to hospitals.
METHODS
A multicenter nonrandomized stepped-wedge design within a hybrid type-2 effectiveness-implementation study was implemented in 11 NHs in German-speaking Switzerland. The first NH enrolled in June 2018 and the last in November 2019. The study lasted 18 months, with a baseline period of 3 months for each NH. Inclusion criteria were 60 or more long-term care beds and 0.8 or more hospitalizations per 1'000 resident care days. Nine hundred and forty two long-term NH residents were included between June 2018 and January 2020 with informed consent. Short-term residents were excluded. The primary outcome was unplanned hospitalizations. A fully anonymized dataset of overall transfers of all NH residents served as validation. Analysis was performed with segmented mixed regression modeling.
RESULTS
Three hundred and three unplanned and 64 planned hospitalizations occurred. During the baseline period, unplanned transfers increased over time (β = 0.52), after which the trend significantly changed by a similar but opposite amount (β = -0.52; p = 0.0001), resulting in a flattening of the average transfer rate throughout the postimplementation period (β + β ≈ 0). Controlling for age, gender, and cognitive performance did not affect these trends. The validation set showed a similar flattening trend.
CONCLUSION
A complex intervention with six evidence-based components demonstrated effectiveness in significantly reducing unplanned transfers of NH residents to hospitals. INTERCARE's success was driven by registered nurses in expanded roles and the use of tools for clinical decision-making.
背景
非计划性的养老院（NH）转院对居民来说是负担，对医疗系统来说也是昂贵的。需要创新的以护士为主导的护理模式，专注于提高内部老年专业知识，以减少非计划性转院。目的是测试全面、适应背景的以护士为主导的老年护理模式（INTERCARE）在减少 NH 向医院非计划性转院方面的临床效果。
方法
在瑞士德语区的 11 家 NH 中实施了一项多中心非随机阶梯式楔形设计的混合 2 型有效性实施研究。第一家 NH 于 2018 年 6 月开始入组，最后一家于 2019 年 11 月入组。研究持续 18 个月，每个 NH 有 3 个月的基线期。纳入标准为 60 张或以上的长期护理床位和每 1000 名居民护理日 0.8 次或以上的住院治疗。2018 年 6 月至 2020 年 1 月间，共有 942 名长期 NH 居民在知情同意的情况下入组。短期居民被排除在外。主要结局为非计划性住院治疗。所有 NH 居民的整体转院的完全匿名数据集作为验证。分析采用分段混合回归模型进行。
结果
共发生 303 次非计划性和 64 次计划性住院治疗。在基线期内，非计划性转院随时间推移而增加（β = 0.52），此后该趋势显著发生类似但相反的变化（β = -0.52；p = 0.0001），导致整个实施后期间的平均转院率趋于平稳（β + β ≈ 0）。控制年龄、性别和认知表现并没有影响这些趋势。验证集也显示出类似的平稳趋势。
结论
一项具有六项循证组成部分的复杂干预措施，在显著减少 NH 居民向医院的非计划性转院方面显示出有效性。INTERCARE 的成功得益于扩展角色的注册护士和使用临床决策工具。
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