Introduction
Methods
Data sources and searches
Study selection
Data extraction
Quality assessment
Data synthesis and analysis
Results
Search results
Characteristics of included studies
Study/year (references) | Setting | (Participants, n) | Intervention vs. control | Results | ||||
---|---|---|---|---|---|---|---|---|
Intervention | Control | Outcome | Intervention | Control |
p value | |||
Garcea et al. [39] | Patients discharged from a ITU or HDU in a general hospital (UK) | 833 | 547 | Outreach service vs. usual care | ICU readmission rate (%) | 9.5 | 9.0 | NR |
Readmissions critical care mortality, % (CI) | 22.8 (−2.4 to –30.3) | 36.7 | NR | |||||
Readmissions in-hospital mortality, % (CI) | 32.6 (−1.4 to 33.5) | 49.6 | NR | |||||
Readmissions 30-day mortality, % (CI) | 32.6 (2.8–37.6) | 53.1 | NR | |||||
Total critical care mortality (%) | 9.3 | 14.3 | NR | |||||
Total in-hospital mortality (%) | 4.8 | 9.8 | NR | |||||
Chaboyer et al. [40] | Patients discharged from a 13 bed ICU in tertiary referral hospital (Australia) | 85 | 101 | Liaison nurse vs. usual care | Discharge delay of >2 h (%) | 22.4 | 49.0 | <0.001 |
Discharge delay of >4 h (%) | 14.1 | 29.0 | <0.001 | |||||
Discharge delay of >2 h, OR (95 % CI) | 1.0 | 3.3 (1.7–6.2) | <0.001 | |||||
Discharge delay of >4 h, OR (95 % CI) | 1.0 | 2.5 (1.2–5.2) | <0.05 | |||||
Caffin et al. [41] | Patients discharged from a pediatric ICU in an tertiary hospital (Australia) | 1,388 | 1,487 | Liaison nurse vs. usual care | Unplanned readmission rate, % (95 % CI) | 4.8 (3.8–6.1) | 5.4 (4.3–6.7) | 0.5 |
Zeigler et al. [42] | Patients admitted to the surgical or medical ICU and receiving SUP in a 766-bed community-teaching hospital (USA) | 61 | 53 | Medication reconciliation vs. usual care | Incidence of prolonged SUP upon ICU discharge (%) | 79 | 85 | 0.39 |
Incidence of prolonged SUP upon surgical ICU discharge (%) | 87 | 88 | 1.00 | |||||
Incidence of prolonged SUP upon medical ICU discharge | 71 | 81 | 0.351 | |||||
Eliott et al. [43] | Patients admitted to a 12-bed general medical-surgical ICU in a 348-bed metropolitan university teaching hospital (Australia) | 943 | 835 | Liaison nurse vs. usual care | Admission: ICU, median LOS, days (range) | 2.1 (0–68) | 2.2 (0–86) | 0.07 |
Admission: ICU, mean step-down LOS, days (SD)a
| 37 (15.5) | 71 (14.2) | <0.001 | |||||
Admission: median hospital LOS, day (range) | 11.5 (0.4–68) | 12.0 (0.2–230) | 0.16 | |||||
Admission: ICU mortality (%) | 14 | 15 | 0.69 | |||||
Admission: hospital mortality (%) | 22 | 23 | 0.78 | |||||
Readmissions: median ICU LOS, days (range) | 3.0 (0.3–41) | 4.0 (0.3–86) | 0.89 | |||||
Readmissions: mean step-down LOS, days (SD) | NR | NR | NR | |||||
Readmissions: median hospital LOS, days (range) | 35 (6–174) | 39 (8–139) | 0.59 | |||||
Readmissions: ICU mortality (%) | 16 | 18 | 0.79 | |||||
Readmissions: hospital mortality (%) | 26 | 35 | 0.30 | |||||
Endacott et al. [44] | Patients discharged from ICU in a 220-bed regional hospital (Australia) | 187 | 201 | Liaison nurse vs. usual care | Rate of transfer to higher care (%) | 23.0 | 13.9 | 0.0114 |
Crude odds of transfer to higher care (95 % CI) | 1.88 (1.14–3.09) | 1.00 | 0.014 | |||||
Adjusted odds of transfer to higher care (95 % CI) | 1.82 (1.07–3.09) | 1.00 | 0.028 | |||||
Rate of surgical procedure required, % | 26.2 | 15.9 | 0.022 | |||||
Crude odds of surgical procedure required (95 % CI) | 1.85 (1.09–3.12) | 1.00 | 0.022 | |||||
Adjusted odds of surgical procedure required (95 % CI) | 2.11 (1.24–3.58) | 1.00 | 0.006 | |||||
Rate of unexpected death, % | 3.2 | 3.5 | 0.881 | |||||
Crude odds of unexpected death (95% CI) | 0.92 (0.30–2.79) | 1.00 | 0.881 | |||||
Williams et al. [45] | Discharges from 22-bed general tertiary-referral unit in a metropolitan teaching hospital (Australia) | 295 | NR | Discharge plan vs. usual care | AE fluid management (%) | 7 | 47 | NR |
AE respiratory problems (%) | 16 | 24 | NR | |||||
Probably preventable AEs (%) | 16 | 53 | <0.001 | |||||
Definitely preventable AEs (%) | 26 | 12 | <0.001 | |||||
Williams et al. [46] | Patients discharged from ICUs in 3 tertiary-referral hospitals (Australia) | 1,435 | 1,566 | Outreach service vs. usual care | Median ICU LOS (days) | 1.8 | 1.9 | 0.57 |
Median LOS admission ICU until hospital discharge (days) | 10.1 | 9.8 | 0.86 | |||||
Hospital mortality (%) | 5.4 | 5.5 | 0.86 | |||||
Readmissions (%) | 5.4 | 5.6 | 0.83 | |||||
Palma et al. [47] | All healthcare professionals working in a 74-bed neonatal ICU in a 304-bed academic hospital (US) | 46 | 54 | Neonatal-specific electronic handoff tool vs. Microsoft Access-based handoff tool | Perceived accuracy of sign-out document: very accurate (%) | 37 | 13 | 0.0025c
|
Perceived accuracy of sign-out document: somewhat accurate (%) | 54 | 64 | ||||||
Perceived accuracy of sign-out document: somewhat inaccurate (%) | 9 | 22 | ||||||
Perceived accuracy of sign-out document: very inaccurate (%) | 0 | 0 | ||||||
Medlock et al. [48] | Patients treated in a 30-bed mixed medical-surgical closed format ICU in an academic hospital (the Netherlands) | 4,951 | 1,872 | Policy change and electronic decision support and reminders for writing ICU discharge letters vs. usual care | ICU LOS (days) | 1.9 | 1.9 | 0.36 |
Mortality (NR) | 17.81 | 17.47 | 0.74 | |||||
Initial discharge letter formally completed at time of discharge (%)% | 96.6 | 11.4 | NR | |||||
Initial discharge letter for deceased patients completed at time of discharge (%) | 99.7 | 71.6 | NR | |||||
Time to finalize initial discharge letter, median no. days (IQR) | 4 (2–9) | 23 (9–41) | <0.0001 | |||||
Chaboyer et al. [49] | Patients discharged from a 12-bed general ICU in a 580-bed metropolitan hospital (Australia) | 786 | 1,001 | Redesigned discharge process vs. four-step discharge process | Average delay time, h | 1.0 | 4.6 | NR |
Patient mortality in wards after ICU discharge (%) | 3.21b
| 3.21b
| NR | |||||
Readmission rate of ≤ 72 h (%) | 2.01b
| 2.01b
| NR |
Study/year (references) | Intervention | Outcome types | |||
---|---|---|---|---|---|
Use of carea
| Continuity of careb
| Mortalityc
| Adverse eventsd
| ||
Garcea et al. [39] | Outreach service | ✓ | ✓ | ||
Chaboyer et al. [40] | Liaison nurse | ✓e
| |||
Caffin et al. [41] | Liaison nurse | ✓ | |||
Zeigler et al. [42] | Medication reconciliation | ✓ | |||
Eliott et al. [43] | Liaison nurse | ✓e
| ✓ | ||
Endacott et al. [44] | Liaison nurse | ✓e
| ✓ | ||
Williams et al. [45] | Discharge plan | ✓e
| |||
Williams et al. [46] | Outreach service | ✓ | ✓ | ||
Palma et al. [47] | Neonatal-specific electronic handoff tool | ✓e
| |||
Medlock et al. [48] | ICU discharge letter policy change and electronic decision support | ✓ | ✓e
| ✓ | |
Chaboyer et al. [49] | Redesigned discharge process | ✓ | ✓ | ✓ | |
Total | 9 | 4 | 7 | 1 |
Methodological quality
Classification and effects of interventions
Study/year (reference) | Intervention | Relevant actions | Key players | Classification | Implementation activities | Significant effects | ||
---|---|---|---|---|---|---|---|---|
Information | Coordination | Communication | ||||||
Garcea et al. [39] | Outreach service | The outreach team consists of two senior grade nurses and a consultant nurse specialist, and a consultant intensivist acts as lead clinician; follow-up of discharges on at least a daily basis; acts as liaison between ward-based staff and critical care intensivists; ward staff are encouraged to refer any patients of concern directly to the outreach team for review | Outreach team, ward staff | ✓ | ✓ | Experienced nurses | No | |
Chaboyer et al. [40] | Liaison nurse | Assessment of patients for transfer to the ward, with major focus being the coordination of ICU patient transfer and liaison with ward staff; communicating with ward staff; assessing ward staff skill-mix and resources; assessing bed status; providing clinical support, resources and education to ward nurses | Liaison nurse, ICU staff, ward staff | ✓ | ✓ | Role development using literature review and focus groups interviews | Yes | |
Caffin et al. [41] | Liaison nurse | Follow-up of patients discharged from PICU within the last 48 h; advanced nurse consultancy and education; improve communication between PICU staff and staff on the wards | Liaison nurse, ICU staff, ward staff | ✓ | ✓ | Role development using existing guidelines; experienced and post-graduate nurse | No | |
Zeigler et al. [42] | Medication reconciliation | Medication profiles are printed and reviewed by the primary physician; existing medications are ordered to be either discontinued or resumed | Primary physician | ✓ | Educational sessions; web-based training module; presentations; one-on-one communication | No | ||
Eliott et al. [43] | Liaison nurse | Communicating with ward staff and providing support and bedside education as required | Liaison nurse, ward staff | ✓ | Experienced nurses | Yes | ||
Endacott et al. [44] | Liaison nurse | Post discharge visit to patient involving clinical assessment and chart review; support and informal education to staff | Liaison nurse, ward staff | ✓ | Experienced nurse with specialist critical care qualification; additional training for liaison nurse to standardize intervention | Yes | ||
Williams et al. [45] | Discharge plan | The discharge plan is a multidisciplinary form used as a tool to facilitate the handover and provide information on ongoing care needs; nursing information includes a summary of the patient’s stay in the ICU, social history, status, and care that the patient is receiving on discharge; checklist that includes whether the handover to the specialty team is documented, fluid or completed, and discharge summery written in the medical record | ICU staff, ward staff | ✓ | Intervention development by users; education for ICU and ward staff | Yes | ||
Williams et al. [46] | Outreach service | Assessment before discharge from ICU; follow-up visits by critical care nursing specialists, who review and assess patients before and after ICU discharge; education and clinical support of general care staff; protocol for processes undertaken at bedside and actions taken in response | Outreach team, ward staff | ✓ | ✓ | Job description and selection criteria used in recruitment; 2-week orientation period for outreach nurses; newsletter, personal communication and education sessions to inform hospital staff about study | No | |
Palma et al. [47] | Neonatal-specific electronic handoff tool | Printed neonatal sign-out document; neonatal sign-out data entry form; sign-out document is organized by bed location and is populated automatically; patient description, a systems-based summary of active medical issues and ongoing care, a to-do list are entered as free text on sign-out entry form | ICU staff, ward staff | ✓ | Instructions of handoff tool were emailed to users; training for pediatric residents; informal instructional sessions were provided to staff | Yes | ||
Medlock et al. [48] | ICU discharge letter Policy change and electronic decision support | A letter as a transfer note; a copy of the completed initial letter goes with the patient at the time of ICU discharge; assignment of responsibility is an automatic process; provision of decision support, through automatic copying of important content from the patient record to the letter | ICU medical staff | ✓ | ✓ | ✓ | New software was developed by users; consensus about the software was reached among clinicians by round table discussion; the software was tested and integrated in existing data management system | Yes |
Chaboyer et al. [49] | Redesigned discharge process | Handover sheet was used to guide phone handover and face-to-face handover, and as documentation for ward staff to record information and provide a basis for future reference by ward staff; notification by ward staff of a specific time they could receive the patient; a daily ‘ICU discharge alert sheet’ summarizing all likely patient discharges | ICU staff, ward staff | ✓ | ✓ | ✓ | Appointing a well-known and respected nursing leader as a change agent; handover sheet developed by ward charge nurses; education by change agent for staff; poster, bedside summary as memory aids and to facilitate face-to-face handover; ongoing support for ICU and ward staff; nursing leaders from ICU and ward endorsed new process | No |