Life In The Slower Lane

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

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Full Title (verbatim and exact):

“Pilot cluster randomised trial of an evidence-based intervention to reduce avoidable hospital admissions in nursing home residents (Better Health in Residents of Care Homes with Nursing—BHiRCH-NH Study)”

Sampson EL, Feast A, Blighe A, et al.

BMJ Open (2020); 10:e040732

DOI: https://doi.org/10.1136/bmjopen-2020-040732

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Type of Article:

Pilot cluster randomised controlled trial (RCT)

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PICO Analysis:

Population:

• 245 residents from 14 nursing homes (NHs) in London and West Yorkshire, UK
• Median age: 86; high dependency and frailty
• Residents targeted for early detection and intervention for four ambulatory care sensitive conditions (ACSCs):
  • Respiratory infection
  • Urinary tract infection (UTI)
  • Dehydration
  • Congestive heart failure (CHF) 

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Intervention:

BHiRCH-NH intervention – a multicomponent package adapted from the US INTERACT program, comprising:

1. Stop and Watch tool: Early warning signs checklist used by care staff
2. Condition-specific care pathways: Two-step clinical assessment for the four ACSCs
3. SBAR communication tool: Structured format for contacting primary care 

Implementation support included:

• Training workshops for Practice Development Champions (PDCs)
• Project handbooks and support groups
• Monthly telephone coaching 

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Comparator:

• Treatment as usual (TAU): Standard NHS and general practice care in the participating homes without structured intervention tools

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Outcome:

1. Person-centred outcomes:

• Not directly reported as primary outcomes
• Secondary data included:
  • EQ-5D-5L for resident quality of life (self/proxy)
  • Barthel Index for functional status
  • No adverse events attributable to intervention reported 

2. Process outcomes:

• Primary feasibility findings:
  • Only 16 Stop and Watch tools and 8 care pathways were used across 5 intervention homes
  • Limited implementation fidelity; staff reported barriers due to time pressures and complexity
  • Implementation strategy (including PDCs and support groups) was ineffective in practice 

3. Health system outcomes:

• Hospital admissions for ACSCs over 6 months:
  • Low overall incidence (only 15% had ACSC-related hospitalisation)
  • ACSC admissions deemed an unreliable proxy for avoidable hospitalisation due to poor record completeness 
• Health economic findings:
  • Slight QALY gain in the intervention group (mean QALY diff. = 0.016)
  • Mean incremental cost per QALY = £12,633
  • Probability of cost-effectiveness at £20,000/QALY = 65%
  • However, given the intervention was not implemented, these findings are not robust enough to justify a full trial 

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Summary Conclusion:

This pilot cluster RCT of the BHiRCH-NH intervention demonstrated good recruitment and retention of homes and participants, but the intervention itself was not implemented in practice. Staff did not engage with the tools, and documentation was sparse. As a result, hospital admission outcomes could not be meaningfully assessed, and the intervention cannot currently be recommended for further trial without substantial redesign. The study contributes valuable insights into the challenges of introducing complex care tools in UK nursing homes, especially under conditions of staff burden and variable infrastructure.

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