Short summary

1,7 million people attend the Emergency departments (ED) yearly, 1,2 million are diagnosed and discharged without hospitalization. An increase is expected because of the growing population of elderly and people with chronic diseases along with less patient-related space in future hospitals. Therefore, it is highly important how the care is provided as it affects patients ability to understand health information for maintaining health after discharge and prevent revisits.The study aim to improve patient outcome through nurse assessment and person-centered care making patients confident in handling their everyday life after discharge within 24 hours. 

Rationale

Background:

The Danish health care system is moving towards the establishment of six new 'superhospitals' with less inpatient accommodation and an increased number of patients receiving outpatient or short stay care. In 2017 1,7 million people attended the Danish Emergency departments (ED), and from that number 1,2 million were diagnosed, treated and discharged without hospitalization. The number is expected to increase because of the new hospital organization and demographic changes. The care provided in ED's will influence patients experience of current stay but also affect their ability to understand and relate health information for maintaining their health as an outpatient. Studies describe that patients feel ED nurses seem to lose interest in the patient's life situation after the most acute treatment has been started. 30% of the patients attending the ED did not report that they were included in decision making process. Improving quality of care is to give patients a stronger voice and to identify the resource's they do or do not possess. To manage that in a short-term meeting requires ability to assess and engage with patients to meet their needs and tailor care. Research identified which outcomes of ED care patients value into 4 main outcomes; Understanding, Symptom Relief, Reassurance and Having a plan, but did not identify interventions to assess and tailor care of the valued outcomes, leaving problems unsolved. 

Aim:

The overall aim is to improve patient outcomes by nurse assessment and tailoring person-centred care for adults and relatives discharged from the ED < 24 hours. Intentions is to secure patients and their relatives experience best possible support in current life situation making them able to handle their everyday life after leaving the ED.

Context and research design:

The study is designed to uncover the diversity in acute settings, and to secure generalizability data will be collected at:

1) The ED, Odense University Hospital

2) The ED, Hospital of Southwest Jutland.

The research design is Participatory Design with the purpose of representing future end-users in designing an intervention strategy that create assessment and possibilities to tailor care.

Study I: Exploration of current practices and family unit needs

Methods:

Field observational studies: the observations are expected to bring observational perspectives into assessment of patient's needs and is carried out in both ED's.  Individual interviews: 20 patients and relatives equally collected from both sites will be interviewed within the first week after their emergency visit by telephone. 
Focus group interviews with nurses and physicians: 
4 focus groups interviews. The interactions between participants, can lead to informers contributing spontaneous and new ideas are created.

Study II: Designing and developing an intervention

Methods:

As method in study II three workshops will be conducted. During this process patients, relatives and healthcare professionals representing future end-users take an active part to predict possible obstacles or challenges with the prototype.

1) Design workshop with idea generation. Tools to facilitate could be 'personas'

2) Mock-up workshop, with the intention to create temporary prototype.

Relevant collaborators will be included e.g. IT software engineers.

3) A "laboratory" workshop testing the prototype in a clinical setting.

Study III: Testing in clinical practice

Methods: A pre- and posttest design without a control group using questionnaires to address both effectiveness and acceptability. 

At baseline the chosen questionnaire will be handed to 407 patients/caregivers based on a=0.050 and a power of 80 %, from that number a dropout of 30% is considered. We accept an increase of, yet undefined outcomes, with 10% improvement. Same number of patients will be included after implementing the intervention.

Endpoints: Primary endpoint will be if the patient-defined outcomes are improved by the intervention. Patients journals will be accessed to include re-visit rates as a secondary endpoint.

Description of the cohort

Inclusion criteria: 

Patients and relatives: Purposively sampling of patients:

> 18 years of age, Danish speaking, discharged < 24 hours with a medical or surgical diagnosis. Only relatives accepted by the patient are included. Sampling will ensure equally represented patients with first time visits along patients with multiple ED visits. 

Exclusion criteria: 

cognitive impairment, dying or patients with life threatening conditions. 

Variables:

gender, age, civil status, education level, length & frequency of stay, diagnosis, and family relation.

Healthcare professionals:

Nurses and physicians working at the ED >6 months will be included. Inclusion will be done purposively. Variables: gender, age, profession, years since educated, years of employment, educational level.

Data and biological material

Data on participant demography will be collected. See "rationale". 

Collaborating researchers and departments

Main supervisor:

Emergency Department, Odense University Hospital

• Professor Annmarie Touborg Lassen, MD, PhD, DM Sci 

Co supervisors: 

Department of Oncology, Odense University Hospital and University of Southern Denmark, Department of Clinical Research

• Associate professor Karin B. Dieperink, RN, MCN, PhD

Orthopaedic Surgery and traumatology, Odense University Hospital

University of Southern Denmark, Department of Clinical Research

• Charlotte Myhre Hansen, RN, PhD, PostDoc

University of Southern Denmark and Senior Lecturer, Griffith University Austalia 

• Adjunct Professor Elisabeth Coyne, RN, PhD

Department of Emergency Medicine, Hospital of Southwest Jutland

• Professor Mikkel Brabrand