Interprofessional discharge planning to reduce hospital length of stay – a quality improvement study
| ISRCTN | ISRCTN83274049 |
|---|---|
| DOI | https://doi.org/10.1186/ISRCTN83274049 |
| Secondary identifying numbers | 407440_167376 |
- Submission date
- 21/03/2022
- Registration date
- 22/03/2022
- Last edited
- 29/09/2022
- Recruitment status
- No longer recruiting
- Overall study status
- Completed
- Condition category
- Other
Plain English summary of protocol
Background and study aims
Health care costs in Switzerland are high and rising also due to an aging population with multiple illnesses. In-hospital treatment is a key contributor to the current cost explosion. In view of the expected demographic evolution, resource allocation becomes a national priority. There is a lack of evidence-based tools to improve the integrative inter-professional in-hospital care and the transition process in real-life of an emergency and acute care hospital setting. Also, there is no reference standard for quality benchmarking in Switzerland which is mandatory to compare the quality of different institutions.
To address these issues, we propose a pragmatic multicenter quality improvement study to explore the effect of an inter-professional discharge planning tool (“In-HospiTOOL”) on length of stay and other patient outcomes. This tool combining several patient discharge measures was developed at our institution in an intensive multi-professional collaboration for the past ten years. For external multicenter validation of this tool, we will prospectively include consecutive polymorbid (with more than one illlness) medical patients upon admission to the medical ward. Because patient-level randomization is not feasible for an intervention that focuses on the process of care, we will use a quasi-experimental approach and compare outcomes before and after hospital-wide implementation of the management tool. We will use time-trend analysis to compare the length of stay before and after tool implementation. Data from other Swiss hospitals from the Swiss Federal Office of Health (Bundesamt für Gesundheit, BAG) serve as a control population. We target the inclusion of 45`000 patients over an 24-month period in at least five Swiss hospitals. The trial will inform us whether the “In-HospiTOOL” improves inter-professional team work and thereby reduces length of stay without negatively impacting subjective and objective markers of patient outcomes. The large amount of patient data collected within this trial will enable comparison of transition processes within different hospitals and establish a benchmarking for patient care quality. Our trial synergizes funds, national networks and, thus, will likely become a milestone in the current public healthcare discussions.
Who can participate?
Medical acute care units in Switzerland.
What does the study involve?
A department-wide implementation of the In-HospiTOOL.
What are the possible benefits and risks of participating?
Clinical trials that are embedded into usual care (“comprehensive effectiveness research”) have the potential to yield outcomes of great relevance to the institutions where they are performed and at the same time to yield information that may be generalizable to the health care system at large.
Health care costs in Switzerland are high and rising due to the aging, polymorbid population. Scientific evidence regarding performance, safety and cost-effectiveness of specific integrative multi-professional care models tailored to the Swiss health care system is largely lacking. The “In-HospiTOOL” is an integrative multi-professional inpatient management tool that enables a better understanding of the multifaceted health care processes and will close this gap. Through a standardized but at the same time individualized approach, it will improve the inter-professional management of patients from ED admission to hospital discharge to home or a nursing care facility. This will translate into optimized transparency, resource use, patient outcome and satisfaction, functional status, and overall hospital costs. We expect that the results of the In-HospiTOOL-study will be widely, directly and rapidly applied – and indeed, will contribute to a new standard of (inter-)national health care.
In addition to the main interventional trial, gathering of data from around ~45,000 patients from 7 Swiss hospitals will help to establish a national-wide framework involving important stakeholders of the Swiss health care system. Networking is a prerequisite for improving sustainable patient-centered health care delivery with an optimal resource allocation. This will lead to a more efficient patient flow with decreased risk for hospital-associated adverse outcomes. Also, the large dataset will allow comparing different outcomes of different patient populations across different hospitals with each individual health care strategy. We will also be open to sharing our data with other national health care researchers for secondary analyses. In addition, health insurance and policy authorities will largely profit from these data to conceptualize new reimbursement strategies in the polymorbid inpatient setting.
Such embedded comparative effectiveness research relies on the engagement of care providers and health care systems as active partners in defining the objectives of the research rather than as passive consumers of its product. This pragmatic research will enforce rethinking and redefining traditional ethical and regulatory standards (including informed consent and engagement in research) in this paradigm of low risk.
Where is the study run from?
Kantonsspital Aarau, University Hospital Basel, Kantonsspital Baden, Kantonsspital Muensterlingen, Spital Interlaken, Spital Muri, Spital Zofingen (Switzerland)
When is the study starting and how long is it expected to run for?
November 2016 to March 2019
Who is funding the study?
Swiss National Science Foundation (SNSF, National Research Program, NRP 74), 407440_167376), the research council (Grant 3071410.000.086) and the “Wissenschaft & Weiterbildung” (W&W) Fonds (140.000.495) of the Kantonsspital Aarau AG, the “Hugo und Elsa Isner Foundation” of the Argovian Department of Health and Social Affairs, Funds from the “Argovia Professur” of the Medical Faculty of the University of Basel.
Who is the main contact?
Prof. Dr. Beat Mueller, beat.mueller@ksa.ch
Contact information
Scientific
Tellstrasse 25
Aarau
5001
Switzerland
 ORCID ID |
0000-0002-7549-5648 |
|---|---|
| Phone | +41 62 838 9735 |
| alexander.kutz@ksa.ch |
Study information
| Study design | Interventional non randomized study |
|---|---|
| Primary study design | Interventional |
| Secondary study design | Non randomised study |
| Study setting(s) | Hospital |
| Study type | Other |
| Participant information sheet | 41398 PIS.pdf |
| Scientific title | Integrative Hospital Treatment in Older patients to benchmark and improve Outcome and Length of stay – the In-HospiTOOL study |
| Study acronym | In-HospiTOOL |
| Study objectives | There is a lack of evidence-based tools for management of polymorbid medical patients throughout the in-hospital stay with transition to post-acute care institutions. We propose a trial that will close this gap by studying the effects of the “In-HospiTOOL” on resource use including length of stay, inter-professional collaboration, and at the same time will give transparent information on outcome data and barriers to transition across several Swiss hospitals. We hypothesize that implementing the “In-HospiTOOL” in a nationwide multicenter setting will significantly shorten length of stay without compromising patient outcomes and functional independence. Tight inter-professional collaboration enabled through an electronical communication platform and identification of the delaying factors in the patient flow will result in decreased waiting times contributing to the shortening of length of stay. |
| Ethics approval(s) | As a quality improvement study, the institutional review board (IRB) of Northwestern Switzerland approved the study and waived the need for individual informed consent by formulating a declaration of no objection (approved on 21/11/2016 - EKNZ BASEC PB_2017–00449). Eligible patients will be informed by clinical staff and an information flyer about their study participation within 24 hours after hospital admission. |
| Health condition(s) or problem(s) studied | Improving discharge planning in medical inpatients |
| Intervention | The In-HospiTOOL will be implemented among intervention hospitals and is a bundled patient management tool with specific items including a first medical assessment in the emergency room, a daily (re-) assessment by physicians, nurses, and social workers on medical ward, and provision of discharge relevant information in addition to typical discharge planning services provided by physicians and nurses. The tool is developed based on a sounding board consensus involving national stakeholders from the healthcare, information technology, and governmental sectors. Control hospitals were following their individual discharge planning strategies. Before starting the intervention phase, participating hospitals will be asked to designate at least one physician, one nurse, and one social worker as local team leaders. The team leaders will be instructed in procedural details of the study and then disseminated this information among their colleagues. Training of team leaders will be accomplished through onsite visits or phone conferences at least every month. After approval and project support by hospital administrations, team leaders at each site will be asked to lead the project locally. To guarantee a standardized education of the local staff, we provided a teaching video to all study sites, where the appropriate usage of In-HospiTOOL is meticulously described (https://youtu.be/bNyRPucs-FQ, video available in German only). In February 2018, In-HospiTOOL will be implemented amongst the seven intervention hospitals. In addition, a local supervisor closely monitors tool fidelity and intervened to improve alignment with the key principles and study goals, if appropriate. From August 2017 until February 2019 local interview teams will conduct 30-day phone interviews in order to receive information on patient-reported outcomes before and during the study intervention. |
| Intervention type | Other |
| Primary outcome measure | Length of stay (LOS), defined as days spent in the hospital during the index hospitalization. The index hospitalization includes all readmissions into the index hospital within 18 days after discharge from the index hospital if the main reason for rehospitalization is related to the main diagnosis from the index hospitalization. According to the SwissDRG definition, every readmission into the same hospital after 18 days from discharge or any readmission into another hospital will be defined as a new index hospitalization. Thus, a single patient may have more than one index admission during the study period. LOS that crosses from one study phase to another or that goes past the study end date will be attributed to the study phase applicable during hospital admission. |
| Secondary outcome measures | 1. All-cause hospital readmission within 30 days after discharge measured using patient records. Regarding hospital readmission, both planned and emergency readmissions will be included in the analysis. 2. All-cause in-hospital mortality, and facility discharge (i.e. long-term care facility, convalescent home, or rehabilitation clinic) measured using patient records. Out-of-hospital mortality data will be not available in the claims dataset. |
| Overall study start date | 21/11/2016 |
| Completion date | 02/03/2019 |
Eligibility
| Participant type(s) | Patient |
|---|---|
| Age group | Adult |
| Lower age limit | 18 Years |
| Sex | Both |
| Target number of participants | 45000 |
| Total final enrolment | 54695 |
| Key inclusion criteria | Medical patients aged ≥18 years with at least two diagnoses in need of acute treatment |
| Key exclusion criteria | 1. Patients treated in an intensive care unit (ICU) only 2. Patients with outlier hospitalization stays longer than 100 days |
| Date of first enrolment | 01/02/2017 |
| Date of final enrolment | 31/01/2019 |
Locations
Countries of recruitment
- Switzerland
Study participating centres
Aarau
5001
Switzerland
Baden
5404
Switzerland
Basel
4031
Switzerland
Muensterlingen
8596
Switzerland
Unterseen
3800
Switzerland
Muri
5630
Switzerland
Zofingen
4800
Switzerland
Sponsor information
Hospital/treatment centre
Tellstrasse 25
Aarau
5001
Switzerland
| Phone | +41 62 838 41 41 |
|---|---|
| beat.mueller@ksa.ch | |
| Website | http://www.ksa.ch |
Funders
Funder type
Charity
Private sector organisation / Trusts, charities, foundations (both public and private)
- Alternative name(s)
- Schweizerischer Nationalfonds, Swiss National Science Foundation, Fonds National Suisse de la Recherche Scientifique, Fondo Nazionale Svizzero per la Ricerca Scientifica, Fonds National Suisse, Fondo Nazionale Svizzero, Schweizerische Nationalfonds, SNF, SNSF, FNS
- Location
- Switzerland
Government organisation / Other non-profit organizations
- Alternative name(s)
- Research Council of Aarau Cantonal Hospital, Research Council of Cantonal Hospital Aarau, Research Council of the Kantonsspital Aarau
- Location
- Switzerland
No information available
No information available
No information available
Results and Publications
| Intention to publish date | 01/04/2022 |
|---|---|
| Individual participant data (IPD) Intention to share | Yes |
| IPD sharing plan summary | Available on request |
| Publication and dissemination plan | The main study manuscript is planned to be published in a high-impact peer-reviewed journal. |
| IPD sharing plan | Available upon request. kutz.alexander@gmail.com |
Study outputs
| Output type | Details | Date created | Date added | Peer reviewed? | Patient-facing? |
|---|---|---|---|---|---|
| Participant information sheet | in German | 22/03/2022 | No | Yes | |
| Protocol article | 23/04/2019 | 22/03/2022 | Yes | No | |
| Results article | 01/09/2022 | 29/09/2022 | Yes | No |
Additional files
- 41398 PIS.pdf
- in German
Editorial Notes
29/09/2022: Publication reference added.
22/03/2022: Trial's existence confirmed by the institutional review board (IRB) of Northwestern Switzerland .
