The InterACT (Intervention for Appropriate Care and Treatment) study: working with clinical teams in hospitals to trial a feedback loop approach to promoting appropriate care and treatment for elderly patients at the end-of-life.

Intervention

Intervention code Behaviour

The study intervention involves a prospective feedback loop to clinical teams, based on the outcomes of a twice-weekly patient record review process using the Criteria for Screening and Triaging to Appropriate aLternative Care (CriSTAL) tool and the Supportive and Palliative Care Indicators Tool (SPICT). The feedback provided to the clinical teams (the CriSTAL status and SPICT score) is intended to act firstly as a flag for the clinical team to review patient care activities and pathways, and to .... The study intervention involves a prospective feedback loop to clinical teams, based on the outcomes of a twice-weekly patient record review process using the Criteria for Screening and Triaging to Appropriate aLternative Care (CriSTAL) tool and the Supportive and Palliative Care Indicators Tool (SPICT). The feedback provided to the clinical teams (the CriSTAL status and SPICT score) is intended to act firstly as a flag for the clinical team to review patient care activities and pathways, and to stimulate a tailored clinical response to promote appropriate patient care and treatment outcomes. The study will be implemented in three acute Queensland hospitals. All hospitals commence the study at the same time point, and all complete a four-week site preparation and clinical team recruitment phase. Hospital 1 then sequentially completes a 16 week usual exposure phase, a four-week intervention establishment phase and a 34-week intervention exposure phase; Hospital 2, a 25-week usual exposure phase, a four-week establishment phase and a 25-week intervention exposure phase; and Hospital 3, a 34-week usual exposure phase, a four-week establishment phase and a 16-week intervention exposure phase. The four-week intervention establishment phase will be used to prepare for the implementation of the feedback loop intervention, and tailor it to ensure it is feasible at each site and reflects local context and workflows. In this phase the the project team, study team, hospital executive advisory group and enrolled clinical teams will work together to: - attend information sessions about the study, the tools being used, the background and evidence for non-beneficial treatment including risk factors and the range of options for responding to screened patients. these will be delivered by the project team. Number and duration will be tailored to reflect hospital requirements; will minimally include a 30 minute introduction session and a 30 minute evidence and rationale session. - decide the process for the study team to provide the patient level screening outcomes to the clinical teams: - pilot the proposed feedback mechanisms for one week with each clinical team, in the intervention establishment phase. - decide the preferred clinical team responses to feedback. This will require agreement on how each clinical team will respond to feedback about the screening outcomes and the hospital inputs that will be provided to support this. Clinician response plans could include, but will not be limited to, palliative care referral, multidisciplinary team review, advance care planning consultation, and patient/carer meetings. The record review will be performed by a trained auditor, employed as a Registered Nurse at the participating hospital and not part of the participating clinical team. A member of the study team will provide direct feedback to a nominated clinical team member of the outcomes of each record review. The study team will conduct a process evaluation to assess adherence and fidelity and support implementation. The record review will occur throughout the usual exposure, intervention establishment and intervention exposure phases, with the feedback of the screening scores to clinical teams and a tailored clinical response part of the intervention phase only. There are three participant populations across the study: 1: Clinical teams - who will be enrolled in the study and participate in the feedback loop intervention 2: Patients 75 years and older, admitted under enrolled clinical teams 3: Members of the enrolled clinical teams, executive advisory group, site study team - who will be invited to participate in semi-structured interviews in the intervention establishment, intervention exposure and post-trial phases.
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Comparison

Control group Active

This is a stepped-wedge study design where each hospital and clinical team will act as their own control. Patient record review will occur throughout the study with the feedback loop and associated clinical response occurring in the intervention exposure phase. The length of the usual exposure and intervention exposure phases will be randomly allocated as per the stepped-wedge design for periods of 16, 25 or 34 weeks each. During the usual exposure and intervention establishment phases all usual .... This is a stepped-wedge study design where each hospital and clinical team will act as their own control. Patient record review will occur throughout the study with the feedback loop and associated clinical response occurring in the intervention exposure phase. The length of the usual exposure and intervention exposure phases will be randomly allocated as per the stepped-wedge design for periods of 16, 25 or 34 weeks each. During the usual exposure and intervention establishment phases all usual care will be provided by the clinical teams. Usual care in this case means the medical care that is typically provided by the clinical teams at the participating hospitals as part of their employment. To check for potential seasonality or other confounders we will collect historical and comparator data about patient admission rates to the Intensive Care Unit (ICU) and length of hospital stay. These data will be collected for all patients 75 years and older admitted to TPCH, RBWH, GCUH in non-enrolled clinical teams, and three comparator hospitals, for 2 years prior to week 1 as well as for the trial period of the study.
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Outcomes

Outcome: Proportion of patients with one or more Intensive Care Unit (ICU) admission. This will be assessed via data linkage to patient medical records.
Timepoint: These data will be collected twice; once in week 1 of the usual exposure phase for the 2 years prior to day 1 of the usual exposure phase (historical data set), and once after week 58 (the end of all the trial phases).