Life In The Slower Lane

Here is the structured PICO analysis for the twenty-ninth article you uploaded:

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Full Title (verbatim and exact):

“Improving care for residents in long term care facilities experiencing an acute change in health status”

Munene A, Lang E, Ewa V, et al.

BMC Health Services Research (2020); 20:1075

DOI: https://doi.org/10.1186/s12913-020-05919-7

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Type of Article:

Study protocol for a quasi-experimental stepped-wedge implementation trial

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PICO Analysis:

Population:

• Residents of 38 long-term care (LTC) facilities in the Calgary zone of Alberta Health Services (AHS), Canada
• Participants are older adults (age >65), typically long-stay residents, vulnerable to acute deterioration due to frailty and multiple chronic conditions (e.g., CHF, UTI, pneumonia) 

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Intervention:

A standardised LTC–ED care and referral pathway combined with use of INTERACT® tools, including:

1. INTERACT® “Stop and Watch” early warning tool (for health care aides)
2. Change in Condition cards (for nurses)
3. Pathway-based referral structure involving:
   • RAAPID (Referral, Access, Advice, Placement, Information & Destination) call centre for urgent care coordination
   • Consultation with LTC and ED physicians to determine best care site (e.g., on-site vs hospital transfer)
   • Community paramedicine options (e.g., IV therapy, facilitated imaging) 

The intervention is supported by:

• Staff training
• Implementation coaching
• Barrier assessment using the Theoretical Domains Framework (TDF)
• Resident/family engagement via advisory groups 

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Comparator:

• Usual care prior to implementation
• Each LTC facility serves as its own control in a stepped-wedge rollout, providing baseline data before receiving the intervention

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Outcome:

1. Person-centred outcomes:

• Resident/family-reported experience of care via modified OPTICS tool (Older Persons’ Transitions in Care Success) within 72 hours of ED visit or community paramedic care
• Concordance of treatment with goals of care
• Safety reviews for any ED transfer within 72h of community paramedicine visit 

2. Process outcomes:

• Primary outcome: Change in rate of ED transfers per 1000 resident days before and after pathway implementation
• Secondary outcomes:
  • Change in hospitalisation rate
  • Proportion of residents managed in place via community paramedicine
  • RAAPID call volume and triage appropriateness
  • Dashboard feedback loop using Tableau software for real-time monitoring of outcomes 

3. Health system outcomes:

• Comparative cost analysis of:
  • ED visits
  • Hospitalisations
  • Community paramedicine
  • Physician fees and program implementation
• Expected return on investment calculation
• Reduction in iatrogenic harms, cognitive and functional decline linked to unnecessary hospital transfers 

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Summary Conclusion:

This study outlines a large-scale, rigorously designed stepped-wedge implementation trial aiming to reduce unnecessary emergency transfers from LTC by embedding a patient-centred, structured pathway supported by INTERACT® tools, real-time clinical coordination (RAAPID), and enhanced use of community paramedicine. The evaluation uses mixed methods, capturing both system-level efficiency and resident-centred quality of care. The model is scalable, leverages existing infrastructure, and responds directly to pressing issues in LTC during and beyond the COVID-19 pandemic.

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