Comparing nurse-led with standard care for post-acute medical patients : a randomised controlled trial
This study was carried out in the context of increased pressure on acute medical beds, increasing demand for alternatives to acute medical care and the need to reduce junior doctors' working hours. Nurse-led in-patient care has been advocated as a response to these pressures that also has the potential to improve patient outcomes. However, evidence to support the safety and effectiveness of this model of care was limited and came from Nursing Development Units, making it difficult to predict how well the model of care would perform in routine NHS practice. The nurse-led in-patient service was compared with standard care on the acute wards via a randomised controlled trial. Recruitment for the trial took 17.5 months. Key outcomes were length of stay following randomisation, discharge destination and change in physical functioning. Secondary outcomes were mortality, re-admissions within thirty days of discharge, falls, complications of hospitalisation. The process of care was explored by comparing medical reviews, therapy reviews, changes to medication and numbers of tests and investigations during the trial period. The nurse-led service did not demonstrate any improvement in outcomes, but substantially increased the length of stay in the treatment arm of the trial. The apparently higher rate of therapy reviews and rates of some complications were diminished when these outcomes were controlled for length of stay. Daily rates of medical reviews, medical investigations and changes to medications were lower for the treatment arm of the trial. The findings of this study do not support the limited benefit reported in previous studies. The widespread introduction of this model of care cannot, therefore, be advocated on the basis of improved outcomes for post-acute patients. However, the nurse-led intervention was not shown to be worse than standard care and may result in organisational benefits, such as reduced medical input. From the poor outcomes observed in this study, it would appear that neither nurse-led nor standard care is meeting the needs of this patient group. Further research is needed to identify and evaluate appropriate nursing interventions for post-acute medical patients.