Clinical trial NCT02543307: Effects of Nurse-led Patient Pathways
Official title: Quality and Process Improvement Using Nurse-led Patient Pathways in an Orthopedic Hospital
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Musculoskeletal Diseases
Keywords: Hip Replacement
Spinal Diseases
Rotator Cuff Reconstruction
Nursing
Nurse-led
Pathways
Patient Satisfaction
Quality of Nursing Care
Lead sponsor: Zurich University of Applied Sciences
Sponsor class: OTHER
Collaborators: name: Balgrist University Hospital
name: Ebnet-Foundation
name: Swiss Association Balgrist
First posted: 2015-09-07
Enrollment: 607
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: NON_RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: Objectives: This quasi-experimental pre-post-study investigated the effect of newly developed Nurse-led Patient Pathways (NPP) designed to improve patients', and health care professionals' as well as institutional outcomes.

Intervention: In the IG patients were cared for under the three newly developed NPP. NPP are characterized by four principles: evidence-based nursing, patient and family centered care, comprehensive discharge planning beyond hospital discharge and nurses' responsibility for patients' processes. The principles support and strengthen patient and family preferences as well as formalize nursing activities, and therefore contribute to process transparency in relation to other health care professionals.

Outcomes: Primary Outcomes were defined as quality of nursing care (nursing care index, NCI), and patient satisfaction (patient satisfaction with nursing care quality, PSNCQ). Secondary outcomes were defined as 1) nursing work environment (nursing work index revised, NWI-R; and nursing workplace quality, NWQ), and 2) institutional-related costs (length of hospital stay, LOS; nursing time and nursing costs). Additionally, nurses' and other health care professionals' experiences of intervention translation will be explored.

Detailed description: In Switzerland, the hospitalization rate of patients with musculoskeletal disorders has increased within the last decade. For example, recent data shows that Switzerland had the highest rate of hip replacement surgery in Europe. Due to the introduction of diagnosis related groups in Switzerland, there is increased pressure to reduce length of hospital stay and increase economic efficiency.

To achieve the required economic efficiency, there is a trend towards standardization of care delivery processes, often in the form of care pathways. The European Pathway Association has defined care pathways as a complex intervention. Pathways should incorporate evidence based care, best practices and patient expectations. As such, care pathways depend on communication and coordination between team members, patients and families, as well as defined roles and sequenced activities.

However, care pathways are often criticized for their organization-driven focus, the lack of a patient centered perspective or missing a holistic approach to care. Therefore, the Balgrist University Hospital and the Zurich University of Applied Sciences developed NPP to enhance patients', and health care professionals' as well as institutional outcomes.

Method: A quasi-experimental prospective study with a pre-post sample design will be conducted. Usual care will be given in the control group (Pre) and compared with a group of patients that were assigned to NPP (Post). The study will be conducted on the two largest orthopedic units at the Balgrist University Hospital, a highly specialized center in musculoskeletal care, located in the Canton of Zurich.

1. A convenience sample will be recruited, consisting of 558 surgical patients hospitalized for total hip arthroplasty, exploration and decompression of the spinal cord, and rotator cuff reconstruction. Demographic, clinical data as well as data to measure quality of nursing care, patient satisfaction, and costs will be obtained,
2. A sample of 38 nurses will be recruited, which are working on the two units. Demographic data and data to measure nursing work environment will be contained,
3. Additionally, a sample of 6 nurses and 5 other health care professionals' (directly involved in patients care) will be recruited to explore experiences of intervention translation within 2 focus group sessions.

The quantitative data analyses will be performed using statistical tests appropriate to the sample size, measurement level, distribution and the independence of variables. For group control appropriate tests for independent groups were used in respect to provision of necessary assumptions. Statistically significance was set on Alpha .05 with undirected hypothesis testing, if necessary correction for multiple testing will be included. Qualitative data analysis will be performed using content analysis.

We hypothesized that the NPP-group (post) will be experienced higher quality of nursing care and increased patient satisfaction, without an increase in health care costs. Secondary outcomes will be enhanced work environment for the nurses.

Eligibility criteria: 1. patients

   Inclusion Criteria:
   * surgical patients hospitalized for total hip arthroplasty, exploration and decompression of the spinal cord, and rotator cuff reconstruction,
   * age 18 years or older,
   * German speaking (oral and written),
   * consents to the use of patient data (chart review),
   * give informed consent (patient survey)

   Exclusion Criteria:
   * inclusion criteria will be not met
   * patients that had cognitive deficits such that they were unable to provide informed consent
2. nurses (survey and interview)

   Inclusion Criteria:
   * age 18 years or older,
   * works on one of the two study units
   * give informed consent

   Exclusion Criteria:

   - inclusion criteria will be not met
3. other health care professionals

Inclusion Criteria:

* directly involved in patients care
* give informed consent

Exclusion Criteria:

- inclusion criteria will be not met

Primary outcomes:
measure: Change in Nursing Care Index (NCI) between pre and post intervention group
timeFrame: Pre-data will be gathered over an eight month period for the control group. After a 4-month break for the implementation of the NPP, the 10-month post-data collection period for the NPP-group will be started.
measure: Change in Patient Satisfaction with Nursing Care Quality (PSNCQ) between pre and post intervention group
timeFrame: Pre-data will be gathered over an eight month period for the control group. After a 4-month break for the implementation of the NPP, the 10-month post-data collection period for the NPP-group will be started.
Secondary outcomes:
measure: Change in nursing work environment (nursing work index revised, NWI-R) between pre and post intervention group
timeFrame: Data will be gathered ones for the control group close before implementation of the NPP, and ones after 8 month of implementation of NPP.
measure: Change in nursing work environment (nursing workplace quality, NWQ) between pre and post intervention group
timeFrame: Data will be gathered ones for the control group close before implementation of the NPP, and ones after 8 month of implementation of NPP.
measure: Change in institutional-related costs (length of hospital stay, LOS; nursing time and nursing costs).
timeFrame: Pre-data will be gathered over an eight month period for the control group. After a 4-month break for the implementation of the NPP, the 10-month post-data collection period for the NPP-group will be started.
Other outcomes:
Locations:
city: Zurich
country: Switzerland
facility: Universitätsklinik Balgrist
Study officials:
affiliation: Zurich University of Applied Sciences
name: Lorenz Imhof, Prof Dr
role: PRINCIPAL_INVESTIGATOR
References: