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

Abstract Background: 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. The main trial results indicate that the expected changes in outcomes were not achieved, which is examined through this process evaluation.Methods: 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.Results: Fidelity varied considerably due to the considerable impacts of workforce shortages including vacancy in the 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 self-efficacy questionnaires indicated that staff felt their knowledge, skills, confidence and communication had increased.Conclusions: The process evaluation indicates good acceptability of the EDDIE + intervention. However, fidelity and intended mechanisms of impact were mixed due to a combination of contextual barriers, exacerbated by workforce shortages and COVID-19. Despite substantial pre-planning prior to implementation, specific barriers in the RAC setting such as staffing and turnover may be unable to be adequately addressed without system change.Trial registration: The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).