Here is the standardised PICO analysis for the fifty-first uploaded article:
Full Title
A complex intervention to reduce avoidable hospital admissions in nursing homes: a research programme including the BHiRCH-NH pilot cluster RCT
Authors: Murna Downs et al.
Journal: Programme Grants for Applied Research, 2021; 9(2)
DOI: 10.3310/pgfar09020
Type of Study
Multiphase mixed-methods implementation programme, culminating in a pilot cluster randomised controlled trial (RCT)
PICO Summary
Population (P)
- Residents of nursing homes (NHs) in the UK, aged ≥65, with multimorbidity and frailty
- Included staff (nurses, care assistants), family carers, and general practitioners
- 14 NHs were recruited; 245 residents, 148 staff, and 95 family carers participated
- Study focused on managing ambulatory care-sensitive conditions (ACSCs): UTI, respiratory infection, dehydration, and exacerbation of heart failure
Intervention (I)
BHiRCH-NH complex intervention, including:
- Stop and Watch (S&W) Early Warning Tool
- Condition-specific care pathways (for UTI, respiratory infections, etc.)
- SBAR (Situation-Background-Assessment-Recommendation) communication tool
- Knowledge and skills enhancement resources
- Structured involvement of family carers
- Supported by Practice Development Champions (PDCs) and implementation handbooks, monthly coaching calls, and practice development support groups
Comparison (C)
- Treatment as usual (TAU) in 7 control homes, with no structured intervention
- Comparison included care processes, hospitalisations, out-of-hours care, and staff/carer experience
Outcomes (O)
Primary outcomes:
- Feasibility of recruitment, retention, data collection
- Fidelity to intervention components
- Rates of hospitalisation for the 4 ACSCs
Key findings:
- Only 16 S&W forms and 8 care pathways were used across 6 months
- No improvement in hospitalisation rates
- Implementation fidelity was low: staff reported they were “already doing it,” but records showed little evidence
- Family carer involvement minimal, despite intention to include them in health change detection
- SBAR was better received, seen as useful in communicating with GPs
- PDCs found training helpful, but lacked time/resources to lead sustained implementation
- Staff cited competing demands, under-resourcing, and perceived redundancy of tools as barriers
Economic outcome:
- Limited cost-effectiveness due to lack of adoption of the intervention tools
- Cost analysis completed using QALYs and NHS/PSS data, but intervention unlikely to be sustainable without modification
Findings Summary
The BHiRCH-NH study developed and piloted a theoretically sound, multicomponent intervention to improve early detection and response to health deterioration in nursing home residents. Despite rigorous stakeholder engagement, the pilot trial failed to demonstrate effectiveness, primarily due to low engagement with the intervention and the perception among staff that they were already addressing these concerns informally.
The study concludes that:
- A definitive trial of the current intervention is not warranted
- Future efforts should target residential care homes without onsite nursing, where such tools may have more impact
- Implementation support must be simpler, better integrated, and context-sensitive
- Quality improvement methods may be better suited than RCTs for evaluating these interventions in real-world settings
Life In The Slower Lane 
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