Commentary on selected new evidence

Commentary on selected new evidence

With advice from topic experts we selected 1 study for further commentary.

Care on the general ward following transfer

We selected the systematic review by Niven DJ et al. (2014) for a full commentary because they assessed the impact of critical care transition programmes on people discharged from an Intensive Care Unit (ICU) to general wards. This is one of the main areas of the acutely ill patient care included in NICE guideline CG50.

What the guideline recommends

CG50 recommends that people being transferred from critical care to ward should have a formal structured handover supported by a written plan. The critical care area team and the ward team should take a shared responsibility for the care of the person being transferred. The receiving ward team (with support from critical care if required) needs to ensure that they can deliver the agreed plan. NICE guideline CG50 also includes a list of items that a formal structured handover of care should include:

  • a summary of critical care stay, including diagnosis and treatment

  • a monitoring and investigation plan

  • a plan for ongoing treatment, including drugs and therapies, nutrition plan, infection status and any agreed limitations of treatment

  • physical and rehabilitation needs

  • psychological and emotional needs

  • specific communication or language needs.

NICE guideline CG50 also includes a research recommendation about the clinical and cost effectiveness of a transfer facilitator for people transferred from critical care to a general ward.

Methods

The systematic review by Niven DJ et al. (2014) assessed the impact of critical care transition programmes on the risk of ICU readmission or death following ICU discharge. Rapid response teams, medical emergency teams, critical care outreach teams, or ICU nurse liaison programmes were included as part of the critical care transition programmes definition.

Two authors independently selected studies for inclusion. They included controlled studies that compared critical care transition programmes to standard care in adults admitted to an ICU. Only studies that reported an ICU readmission rate (rates of readmission following ICU discharge during the hospital stay) were included.

Data extraction was carried out in duplicate, including information about general characteristics of the study (type of study, year, setting, and country), population, intervention, comparators and important outcomes of interest (hospital death and ICU readmission rates). They assessed the risk of bias of each included study using Cochrane Collaboration criteria for controlled studies.

The authors performed a meta‑analysis for the risk of ICU readmission associated with a critical care transition programme and another for the risk of in‑hospital mortality. They used fixed‑effect and random‑effects models to calculate pooled risk ratios (95% confidence intervals) and assessed the statistical heterogeneity using Cochran's Q and I2 statistics. Potential sources of heterogeneity were explored. A risk assessment for publication bias was also carried out using a funnel plot and Begg test.

Results

Nine before‑and‑after studies covering 16,433 people discharged from the ICU to general wards were included in the systematic review. One of these included studies did not provide the number of people discharged from ICU to wards. The authors contacted the original investigators to request missing data but they were not able to provide them. This study was excluded from meta‑analysis.

All of the included studies were assessed as being at high risk of bias due to the lack of randomisation, allocation concealment and blinding. The authors did not detect risk of publication bias.

Four studies were carried out in the UK, three in Australia, one in New Zealand and one in Canada. Six studies were conducted in medical and surgical ICU, two in surgical ICU and one in medical ICU.

All studies but one described the team composition. All the teams included ICU nurses. Apart from nurses four studies also included ICU physicians, and one study also included a respiratory therapists. People discharged from ICU were followed‑up for 48 hours or until clinically stable.

Critical care transition programmes were associated with a significant reduction in the risk of ICU readmissions (relative risk [RR] 0.87, 95% confidence interval [CI] 0.76 to 0.99, 8 studies, n=16,433) but it was not associated with a reduction of the risk of in‑hospital mortality compared to standard care following ICU discharge (RR 0.84, 95% CI 0.66 to 1.05, 3 studies, number of patients not reported).

Although the results were not heterogeneous, the authors performed stratified analyses to assess the impact of patient or program characteristics on the risk of ICU readmission. The characteristics explored included: transition program structure, ICU physician presence within the team, duration of follow‑up, and lack of data about population age or APACHE II score within the studies. They reported that the factors explored showed similar results.

Other comparisons as per example early (less than 48 hours) compared to late readmissions (more than 48 hours), closed compared to open ICUs, or the impact of the changes in the patient's goals of care on the ICU readmission were not possible due lack or inconsistencies in reporting.

Strengths and limitations

Strengths
  • The study was relevant to the scope of NICE guideline CG50 and showed that critical care transition programmes might have a role on the risk reduction of ICU readmission in high‑risk populations.

  • The authors did a comprehensive literature search on MEDLINE, EMBASE, CENTRAL, CINAHL, and two clinical trial registries (including unpublished studies) without language restrictions.

  • Selection of studies for inclusion and data extraction were carried out in duplicate. In addition, a list of the included studies and their main characteristics was included, although characteristics of the controls were missing.

  • The quality of the studies was assessed and reported but it was not clear if it was done by two reviewers.

  • Appropriate methods were used to combine the results and explore sources of heterogeneity and publication bias.

Limitations
  • Although the results of the study showed that people discharged from ICU may benefit from the intervention in terms of risk reduction of ICU readmission, the differences found between the groups compared were borderline. The clinical relevance of these findings needs to be established.

  • The review did not include all important outcomes such as patient satisfaction.

  • The authors discussed how the poor quality of the evidence found affected their conclusions. It was not clear in the paper if the studies included were controlled before‑after studies. Their lack of randomization, blinding or control group makes it difficult to attribute the differences observed to the intervention assessed. These results are based on studies with high risk of bias and need be interpreted with caution.

  • The main characteristics of the critical care transition programmes that could lead to an improvement of patient important outcomes after an ICU discharge remain uncertain (for example team composition, type of follow‑up and frequency of follow‑up).

Impact on guideline

This systematic review supports NICE guideline CG50 recommendations. Critical care transition programmes could have a role in the improvement of important outcomes of people transferred from ICU to general wards, but more research is needed in the area.


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