Background
Older patients near the end of life in an acute hospital setting are at risk of experiencing non-beneficial treatments. The Intervention for Appropriate Care and Treatment (InterACT) trial involved three large tertiary hospitals in Queensland and used two screening tools to establish a risk profile for older patients nearing the end of life. 

 

Aim
The aim was to trial a prospective feedback loop to increase clinician awareness of their patient’s risk profile and to measure the impact this had on care review activity timing and occurrence. 

Methods
All patients 75 years and older admitted under fourteen enrolled clinical teams in three hospitals were screened twice weekly. Over 7,000 patients were screened, with 60% identified as ‘at-risk’ of receiving non-beneficial treatment. During the intervention phase, clinical teams were notified of any patients ‘at-risk. Medical notes of each ‘at-risk’ patient were reviewed for evidence of three care review outcomes: clinician-led care review discussion; palliative care referrals; and review of care directive measures in both the usual care and intervention periods. 

 

Results
There were no observed improvements in the three care review outcomes. In two hospitals the probability of reviews of care directive measures reduced by 0.08 and 0.14. In one hospital the number of clinician-led care review discussions reduced by 0.20. Minimal change was seen in the number of palliative care referrals between the usual care and intervention periods (probability changes under 0.05). 

Conclusion
While it was hypothesised that increased awareness of a patient’s risk profile would increase clinician led care review activities, this did not occur. Health system challenges (e.g. COVID-19) and variability in implementation processes between the study sites may have contributed to the failure of the nudge intervention to improve care of hospitalised older people in a complex clinical environment. 

Results published at https://doi.org/10.1186/s12877-022-03554-x