Implementing an intervention to facilitate early detection of deterioration in aged care residents: process evaluation of the EDDIE + trial

TL;DR

This study evaluated an intervention to help aged care staff detect resident deterioration early, finding it was well accepted but faced challenges like staff shortages and inconsistent implementation.

Contribution

The study provides insights into the implementation challenges and acceptability of a deterioration detection intervention in aged care settings.

Findings

Staff felt their knowledge and confidence improved despite no significant changes in hospital admission rates.

Workforce shortages and external factors like COVID-19 reduced the intervention's fidelity across aged care homes.

The intervention was accepted by staff but required systemic changes to address barriers like staffing issues.

Abstract

EDDIE + was a stepped wedge cluster randomised controlled trial with an embedded process evaluation in 11 residential aged care (RAC) homes in Queensland, Australia. The intervention aimed to upskill RAC staff to identify and manage deterioration to reduce unnecessary hospital transfer through education, decision support tools, diagnostic equipment and local facilitation. Main trial results indicated 46% of hospital admissions were due to falls and no significant improvements to outcome measures including hospital bed days were achieved. These findings were examined through a process evaluation.

A mixed methods approach guided by the i-PARIHS framework was used to assess fidelity, acceptability, mechanisms of impact and feasibility of implementation, including barriers and enablers. Semi-structured interviews, self-efficacy surveys, and project tracking documents were used. Qualitative data were coded to the i-PARIHS framework and quantitative data were analysed using linear mixed modelling.

Fidelity varied considerably due to workforce shortages including vacancy in the local clinical facilitator role, high workload, COVID-19, and other contextual factors. Differences in job and team-related staff self-efficacy before and after the introduction of EDDIE + were not statistically significant. However, inductive thematic analysis of the questionnaires indicated that staff felt their knowledge, skills, confidence and communication had increased.

The process evaluation indicates high acceptability of the EDDIE + intervention. However, fidelity and intended mechanisms of impact were mixed despite substantial pre-planning prior to implementation. For future studies, specific barriers in the RAC setting such as staffing and turnover may be unable to be adequately addressed without systemic change.

The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).

The online version contains supplementary material available at 10.1186/s13012-026-01484-5.

• The EDDIE+ intervention had high acceptability from RAC staff who felt their skills and confidence were increased.

• There were health system level and workforce level barriers such as staff shortages and COVID-19 that led to variation in fidelity and ability to deliver the EDDIE+ intervention across homes.

• Opportunities for RAC staff to upskill and reduce unnecessary hospital transfers through identification and response to deterioration remains a key priority in this setting.

The online version contains supplementary material available at 10.1186/s13012-026-01484-5.

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