Life In The Slower Lane

Here is the standardised PICO analysis for the fourteenth uploaded article:

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Full Title

Evaluating the implementation fidelity to a successful nurse-led model (INTERCARE) which reduced nursing home unplanned hospitalisations

Authors: Raphaëlle A. Guerbaai et al.

Journal: BMC Health Services Research, 2023; 23:138

DOI: 10.1186/s12913-023-09146-8

Type of Study

Mixed-methods convergent design evaluating implementation fidelity of a complex nurse-led intervention in 11 Swiss nursing homes

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PICO Summary

Population (P)

• Residents of Swiss nursing homes (n = 11 facilities)
• Institutional staff including nurses, INTERCARE nurses, and physicians
• Focus on those at risk of unplanned hospital transfers

Intervention (I)

• INTERCARE: A nurse-led model of care targeting reduction of unplanned hospitalisations.It includes six core components:
  1. Interprofessional collaboration
  2. A trained INTERCARE nurse
  3. Comprehensive geriatric assessment (CGA)
  4. Use of evidence-based tools (STOP&WATCH, ISBAR)
  5. Advance care planning (ACP)
  6. Data-driven quality improvement

Implementation support included training, coaching, structured meetings, and feedback mechanisms over a 6–18 month implementation period.

Comparison (C)

• No formal control group; variation in fidelity scores across facilities and time served as the basis for comparison
• Compared facilities with high vs. low fidelity scores and examined impact on unplanned hospitalisation rates

Outcomes (O)

Health system outcomes:

• Primary: Reduction in unplanned hospital transfers
  • High overall fidelity was associated with significantly reduced transfers (OR: 0.65, 95% CI: 0.43–0.99, p = 0.047)
  • High fidelity to ACP was strongly associated with reduced transfers (OR: 0.24, 95% CI: 0.13–0.44, p < 0.001)
  • Low fidelity to STOP&WATCH was associated with increased transfers (OR: 1.69, p < 0.003)

Process outcomes:

• Implementation fidelity varied across components and over time:
  • High and sustained fidelity: INTERCARE nurse role, ISBAR tool, data-driven quality improvement
  • Low or declining fidelity: STOP&WATCH and CGA (not followed through in practice)
  • Gradually increasing fidelity: Advance care planning (from moderate to high by study end)

Moderators of fidelity (qualitative themes):

• Context: Physician engagement (responsible in-house vs. multiple external GPs), pre-existing structures
• Participant responsiveness: Perceived need and staff engagement with tools and roles
• Implementation strategies: Visibility, champions, structured feedback loops
• Quality of delivery: Clarity of roles, follow-up processes, and team integration of tools

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Findings Summary

• The INTERCARE model effectively reduced unplanned hospitalisations when implemented with high fidelity.
• Advance care planning and structured communication tools (ISBAR, STOP&WATCH) were critical components linked to reduced transfers.
• Implementation fidelity was dynamic—affected by leadership support, team responsiveness, staff turnover, and presence of responsible physicians.
• Nurse-led models with dedicated training, coaching, and embedded interdisciplinary processes can be scaled if fidelity is maintained.

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