A randomised controlled trial: comparing nurse-led with standard care for post-acute medical patients

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Description/Abstract

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.