Review question/objective

The purpose of this review is to synthesize the best available evidence regarding the impact that clinical interventions, carried out by unregistered healthcare workers (HCWs), have on readmissions for adult patients discharged in the previous 30 days from an acute setting to their usual place of residence.

The objective of the qualitative component of the review is to synthesize the best available evidence regarding the appropriateness of clinical interventions by unregistered HCWs and their impact on the patient pathway.

The objective of the quantitative component of the review is to synthesize the best available evidence regarding the effectiveness of clinical interventions prescribed by registered practitioners and carried out by community based unregistered HCWs on: a) premature readmission after discharge following an admission to an acute setting, and b) maintaining care in the usual place of residence.

Another objective of the quantitative component of the review is to synthesize the best available evidence regarding the incidence and causes of readmission in relation to unregistered HCWs interventions.

Background

Following the United Kingdom government impetus to provide Care Closer to Home nationally, there have been local moves to enhance domiciliary care. Policy developed by the UK Department of Health to enact this includes the closure of community hospital beds in some locations.3 Actions taken to continue care provision outside of community hospitals have inspired this systematic review.

The development of multi-disciplinary community based teams, known as Complex Care Teams (CCTs) in some parts of the United Kingdom, to support care closer to the homes of patients has led to extra remuneration funding and increased numbers of unregistered and registered healthcare professionals. Their remit includes prevention of primary admission to hospital and subsequent readmission. Enabling people with long-term and complex conditions to manage their lifestyle to the optimum level, following an acute admission, is at the forefront of the work of CCTs, as activity of daily living abilities (ADLs) are often compromized at this time.4

Admission and readmission to hospital has become an internationally recognized issue, in particular for the older person.5 Drivers for this include cost and the increasing older population numbers. While some admissions and readmissions are necessary to treat certain conditions, there is evidence that coordinated, community based integrated health and social care teams have a role to play in preventing readmissions that can be safely managed in the community.6 The latter is not always the cheaper option financially, but it is often the preferred option for patients and their families.7 The outcome measure most commonly used to benchmark readmission is 30-day readmission, i.e. readmission within 30 days of discharge.6

Many health care services consist of coordinators/administrators with therapists, nurses and social care teams. The general practitioner (GP), district nursing teams and other specialists, such as mental health teams, are included as appropriate. Within teams there are often unregistered HCWs working either in generic or discipline-specific roles under the guidance of the registered professionals. Many terms are used to identify the unregistered HCW, including health care assistants, community support workers, rehabilitation support workers, nurses' aides, community support workers and assistants in nursing.8 This has raised questions about the quality of care being delivered, particularly in the UK, where the Francis and Cavendish reports have brought the issue firmly into the public domain.9,10 Many UK National Health Service (NHS) Trusts have signed up to the code of conduct for unregistered HCWs as a way of beginning to address this area.11

The registered professional, of whatever discipline, assesses the patient and prescribes the program of care. This care will often include tasks needed for day-to-day support and care of the individual and may be delegated to the unregistered HCW. The HCW may be directly or indirectly supervised by the registered professional12. In situations where there has been an effort to "pull" a patient from an acute setting to their usual place of residence, this assessment and setting of goals may be undertaken by the professionally-registered practitioner within the acute setting which may generate other potential concerns. These include the prescribing practitioner not having line management responsibility for the unregistered HCW carrying out the care, or not having sufficient knowledge of the situation at the usual place of residence. Clinical governance, line management and accountability, competence maintenance and assessment all need to be considered and clarified to protect the patient, the registered practitioner and the unregistered HCW.13,14

Delegated tasks may include clinical interventions, for example, rehabilitation physiotherapy, occupational therapy, prescription and provision of equipment, venepuncture and wound care. While the registered professional carries the accountability, the unregistered HCW is delivering the treatment and monitoring the situation.

A preliminary search was undertaken for existing studies and reviews regarding the impact that clinical interventions carried out by unregistered HCWs have on readmissions.

The few primary research studies that exist provide evidence for prevention of readmission by the intervention of unregistered HCWs include one study that found that if these workers help create individual goals and care plans whilst the patient is in hospital followed by community follow up for a minimum of two weeks, the incidence of readmission was reduced.15 A pilot scheme in cardiac services found that the involvement of HCWs by another title appeared to be able to support patients and improve quality of care and reduce 30-day readmission rates.16

The one relevant systematic review relates to strategies appropriate for including unregistered healthcare workers in models of care;8 however it falls short of addressing the central focus for this review.

Issues to consider include firstly whether, following an acute admission, readmission rates are affected by the monitoring and support being largely given by the unregistered HCW as opposed to registered practitioners.

Secondly, it is imperative to ensure that the patient receives optimum care. This links with the first point and patient safety, as many of the interventions are undertaken by the unregistered workforce. It can be extended to examine whether the involvement of the therapeutic package of care is as good as the alternative (if available). An example would be to compare a stay in a community hospital with 24-hour nursing care and less therapy time versus domiciliary care with increased support. The patient may have had continuous monitoring by being an inpatient, as opposed to intermittent visits when in the community, both again by unregistered HCWs. Interpretation of monitoring and reporting to the registered staff would be vital, but any clinical intervention would potentially mean readmission to the acute services, as more advanced therapeutic procedures may not be available.

It is often stated that patients prefer to be cared for at home and that it is desirable for patients to take greater responsibility for their needs.7 However, it is not clear whether there are sufficient measures in place to ensure patient and family satisfaction with the shift toward community based care. In looking at the concept of the home, the term "usual place of residence" may be more pertinent. There is no definition for usual place of residence in the UK; however, it will be taken to mean it is the place where any individual spends most of his or her time, whether it is a house, or a nursing or residential home.

Inclusion criteria

Types of participants

The quantitative component of this review will consider studies that include health care assistants, community support workers and community rehabilitation workers, supporting the nursing, physiotherapy and occupational therapy professionals within the complex care teams. It will examine data, where available, where the primary caregiver is an unregistered member of the team.

The qualitative component of this review will consider studies that include patients aged 18 years and over who have been discharged from an acute health service in the previous 30 days and the unregistered HCW caring for them. Studies involving the registered workforce will also be included for comparison, encompassing those conducted in accident and emergency departments, medical and surgical assessment units, general or specialist wards, where the focus is on readmission rates and causes.

Studies will be excluded if patients (research participants) were: 1) discharged to destinations other than their usual place of residence; 2) in transition from acute care to their usual place of residence, for example, intermediate care; 3) discharged without the support of HCWs or Registered professionals; or 4) discharged with an existing package of care that is resuming at the same level as pre-admission.

Types of intervention(s)/phenomena of interest

The quantitative component of the review will consider studies that evaluate clinical interventions prescribed by registered practitioners and carried out by community based, unregistered HCWs.

The qualitative component of this review will consider studies that investigate patient journeys and experiences of care given by unregistered HCWs.

Types of outcomes

The quantitative component of the review will consider studies that include the following outcome measures: 30-day readmission rates for patients discharged from an acute setting to their usual place of residence and who have been cared for by unregistered HCWs and the causes of readmission in relation to unregistered HCWs interventions.

Types of studies

The quantitative component of the review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion.

The quantitative component of the review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion.

The qualitative component of the review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published after and including 2004 will be considered for inclusion in this review. The year 2004 was chosen to encompass the last ten years, which saw some significant changes in health care organization in the United Kingdom: the year previously had seen reorganization of the NHS with the publication of "NHS Reorganization: the Health and Social Care (Community Health and Standards) Act" and this was followed by plans being outlined for general practitioners to become involved in commissioning community services.17

The databases to be searched include:

AMED, British Nursing Index, CINAHL, EMBASE, HMIC, MEDLINE, Cochrane Library, JBI Database of Systematic Reviews and Implementation Reports.

The search for unpublished studies will include:

ProQuest dissertations and theses, also known as Dissertation Abstracts.

EThOS (British Library)

openthesis.

Initial keywords to be used will be:

The unregistered workforce, discharge from acute hospital, readmission following discharge from acute hospital, accountability, clinical interventions and clinical governance.

Assessment of methodological quality

Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Reviewers will appraise papers independently. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer (BK).

Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Authors of primary studies will be contacted for missing information or to clarify unclear data as necessary.

Data extraction

Quantitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.

Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.

Data synthesis

Quantitative papers will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different quantitative study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Qualitative research findings will, where possible be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.

Conflicts of interest

There are no conflicts of interest.

Acknowledgements

Mrs Alison Housley, Librarian, North Devon District Hospital, and her team for their support.

References