Implementation evaluation of a comprehensive CARE record to reduce hospital-acquired complications: a mixed-methods pre-post study.

OBJECTIVES: To evaluate whether implementing the Comprehensive Assessment and Risk Evaluation (CARE) record, developed to operationalise Standard 5: Comprehensive Care of the Australian National Safety and Quality Health Service Standards was associated with improvements in patient safety and quality of care. A secondary objective was to explore staff and patient experiences of implementation. DESIGN: Mixed-methods pre-post evaluation combining quantitative analysis of routinely collected hospital data with staff surveys and patient interviews. SETTING: A metropolitan hospital network in Melbourne, Victoria, Australia PARTICIPANTS: Quantitative analysis included 88 041 admissions pre-implementation and 23 765 post implementation. Staff surveys were completed by 117 staff (84% nurses, 60% with >5 years at the service). Structured interviews were conducted with 39 patients (mean age 65.6 years, 64% male). INTERVENTION: The CARE record was a structured record embedding validated risk assessments (STRATIFY, Braden Scale, Malnutrition Screening Tool, Confusion Assessment Method/4 'A's Test, Broset Violence Checklist, Columbia-Suicide Severity Rating Scale) and care planning into routine workflows, to meet requirements of Standard 5. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were the incidence of falls and pressure injuries. Secondary outcomes were completion of the CARE record, staff and patient experiences, and documentation of other hospital-acquired complications (HACs) (delirium, malnutrition, violence and aggression, suicide and self-harm). Data were compared for two time periods: 1 January 2016 to 28 February 2019 (before CARE record implementation) and 1 March 2019 to 30 March 2020 (after CARE record implementation but before COVID-19). RESULTS: Post implementation, overall falls decreased (OR 0.85; 95% CI 0.78 to 0.93), though severe falls increased (OR 1.89; 95% CI 1.17 to 3.07). Pressure injuries decreased in coded data (OR 0.41; 95% CI 0.23 to 0.73) and incident reports (OR 0.79; 95% CI 0.68 to 0.92). Documentation of delirium (OR 2.02), malnutrition (OR 2.03), aggression/violence (OR 2.09) and suicide/self-harm (OR 1.92) increased. Half of the staff (50.4%) felt they knew more about patients, but 61.2% reported more time to admit patients. Communication between nursing and allied health improved (65.8%). Patients were generally satisfied, though 50% repeated information frequently and 20% felt unprepared for discharge. CONCLUSIONS: CARE record implementation, mandated by the Australian Commission on Safety and Quality in Health Care's Standard 5, was associated with fewer pressure injuries and overall falls (though there was an increase in falls resulting in serious injury), and greater documentation of other complications. Staff and patient experiences highlighted some benefits but also documentation time challenges. Findings provide lessons for the national implementation of Standard 5 and the need to balance structured processes with clinical judgement.