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Intensive Care Medicine Jul 2018Discharge from an intensive care unit (ICU) out of hours is common. We undertook a systematic review and meta-analysis to explore the association between time of... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Discharge from an intensive care unit (ICU) out of hours is common. We undertook a systematic review and meta-analysis to explore the association between time of discharge and mortality/ICU readmission.
METHODS
We searched Medline, Embase, Web of Knowledge, CINAHL, the Cochrane Library and OpenGrey to June 2017. We included studies reporting in-hospital mortality and/or ICU readmission rates by ICU discharge "out-of-hours" and "in-hours". Inclusion was limited to patients aged ≥ 16 years discharged alive from a non-specialist ICU to a lower level of hospital care. Studies restricted to specific diseases were excluded. We assessed study quality using the Newcastle Ottowa Scale. We extracted published data, summarising using a random-effects meta-analysis.
RESULTS
Our searches identified 1961 studies. We included unadjusted data from 1,191,178 patients from 18 cohort studies (presenting data from 1994 to 2014). "Out of hours" had multiple definitions, beginning between 16:00 and 22:00 and ending between 05:59 and 09:00. Patients discharged out of hours had higher in-hospital mortality [relative risk (95% CI) 1.39 (1.24, 1.57) p < 0.0001] and readmission rates [1·30 (1.19, 1.42), p < 0.001] than patients discharged in hours. Heterogeneity was high (I 90.1% for mortality and 90.2% for readmission), resulting from differences in effect size rather than the presence of an effect.
CONCLUSIONS
Out-of-hours discharge from an ICU is strongly associated with both in-hospital death and ICU readmission. These effects persisted across all definitions of "out of hours" and across healthcare systems in different geographical locations. Whether these increases in mortality and readmission result from patient differences, differences in care, or a combination remains unclear.
Topics: After-Hours Care; Critical Care; Hospital Mortality; Humans; Intensive Care Units; Patient Discharge; Patient Readmission
PubMed: 29938369
DOI: 10.1007/s00134-018-5245-2 -
Journal of Rehabilitation Medicine Mar 2007Patients after stroke conventionally receive much of their rehabilitation in hospital. Services have been developed that offer patients an early discharge from hospital... (Comparative Study)
Comparative Study Review
Patients after stroke conventionally receive much of their rehabilitation in hospital. Services have been developed that offer patients an early discharge from hospital with more rehabilitation at home (early supported discharge). This paper sets out a systematic review of all randomized trials of early supported discharge services that included 12 trials (1659 patients). There was a reduced odds of death or dependency equivalent to 5 fewer adverse outcomes (95% confidence interval 1-10) for every 100 patients receiving an early supported discharge service (p = 0.04). Patients receiving early supported discharge services showed an 8 day reduction (p < 0.0001) in the length of hospital stay. The greatest benefits were seen in the trials evaluating a co-ordinated multidisciplinary early supported discharge team and with patients with mild-moderate disability. The experience of a trial from Stockholm is described in order to explore the potential mechanism of action of early supported discharge services. In conclusion, an illustrative case report is set out, indicating a typical patient pathway in an early supported discharge service.
Topics: Activities of Daily Living; Aged; Cost-Benefit Analysis; Critical Pathways; Early Ambulation; Evidence-Based Medicine; Female; Follow-Up Studies; Home Care Services; Humans; Length of Stay; Male; Patient Care Planning; Patient Discharge; Stroke; Stroke Rehabilitation; Treatment Outcome
PubMed: 17351690
DOI: 10.2340/16501977-0042 -
The American Journal of Emergency... May 2024Traumatic brain injury (TBI) results in 2.5 million emergency department (ED) visits per year in the US, with mild traumatic brain injury (mTBI) accounting for 90% of... (Review)
Review
INTRODUCTION
Traumatic brain injury (TBI) results in 2.5 million emergency department (ED) visits per year in the US, with mild traumatic brain injury (mTBI) accounting for 90% of cases. There is considerable evidence that many experience chronic symptoms months to years later. This population is rarely represented in interventional studies. Management of adult mTBI in the ED has remained unchanged, without consensus of therapeutic options. The aim of this review was to synthesize existing literature of patient-centered ED treatments for adults who sustain an mTBI, and to identify practices that may offer promise.
METHODS
A systematic review was conducted using the PubMed and Cochrane databases, while following PRISMA guidelines. Studies describing pediatric patients, moderate to severe TBI, or interventions outside the ED were excluded. Two reviewers independently performed title and abstract screening. A third blinded reviewer resolved discrepancies. The Mixed Methods Appraisal Tool (MMAT) was employed to assess the methodological quality of the studies.
RESULTS
Our search strategy generated 1002 unique titles. 95 articles were selected for full-text screening. The 26 articles chosen for full analysis were grouped into one of the following intervention categories: (1) predictive models for Post-Concussion Syndrome (PCS), (2) discharge instructions, (3) pharmaceutical treatment, (4) clinical protocols, and (5) functional assessment. Studies that implemented a predictive PCS model successfully identified patients at highest risk for PCS. Trials implementing discharge related interventions found the use of video discharge instructions, encouragement of daily light exercise or bed rest, and text messaging did not significantly reduce mTBI symptoms. The use of electronic clinical practice guidelines (eCPG) and longer leaves of absence from work following injury reduced symptoms. Ondansetron was shown to reduce nausea in mTBI patients. Studies implementing ED Observation Units found significant declines in inpatient admissions and length of hospital stay. The use of tablet-based tasks was found to be superior to many standard cognitive assessments.
CONCLUSION
Validated instruments are available to aid clinicians in identifying patients at risk for PCS or serious cognitive impairment. EDOU management and evidence-based modifications to discharge instructions may improve mTBI outcomes. Additional research is needed to establish the therapeutic value of medications and lifestyle changes for the treatment of mTBI in the ED.
Topics: Adult; Humans; Child; Brain Concussion; Post-Concussion Syndrome; Brain Injuries, Traumatic; Emergency Service, Hospital; Patient-Centered Care
PubMed: 38460465
DOI: 10.1016/j.ajem.2024.02.038 -
The American Journal of Emergency... Jan 2022The present study aimed to perform a systematic review and meta-analysis on the prevalence of one-year hospital readmissions and post-discharge all-cause mortality in... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The present study aimed to perform a systematic review and meta-analysis on the prevalence of one-year hospital readmissions and post-discharge all-cause mortality in recovered COVID-19 patients. Moreover, the country-level prevalence of the outcomes was investigated.
METHODS
An extensive search was performed in Medline (PubMed), Embase, Scopus, and Web of Science databases until the end of August 3rd, 2021. A manual search was also performed in Google and Google Scholar search engines. Cohort and cross-sectional studies were included. Two independent reviewers screened the papers, collected data, and assessed the risk of bias and level of evidence. Any disagreement was resolved through discussion.
RESULTS
91 articles were included. 48 studies examined hospital readmissions; nine studies assessed post-discharge all-cause mortality, and 34 studies examined both outcomes. Analyses showed that the prevalence of hospital readmissions during the first 30 days, 90 days, and one-year post-discharge were 8.97% (95% CI: 7.44, 10.50), 9.79% (95% CI: 8.37, 11.24), and 10.34% (95% CI: 8.92, 11.77), respectively. The prevalence of post-discharge all-cause mortality during the 30 days, 90 days and one-year post-discharge was 7.87% (95% CI: 2.78, 12.96), 7.63% (95% CI: 4.73, 10.53) and 7.51% (95% CI, 5.30, 9.72), respectively. 30-day hospital readmissions and post-discharge mortality were 8.97% and 7.87%, respectively. The highest prevalence of hospital readmissions was observed in Germany (15.5%), Greece (15.5%), UK (13.5%), Netherlands (11.7%), China (10.8%), USA (10.0%) and Sweden (9.9%). In addition, the highest prevalence of post-discharge all-cause mortality belonged to Italy (12.7%), the UK (11.8%), and Iran (9.2%). Sensitivity analysis showed that the prevalence of one-year hospital readmissions and post-discharge all-cause mortality in high-quality studies were 10.38% and 4.00%, respectively.
CONCLUSION
10.34% of recovered COVID-19 patients required hospital readmissions after discharge. Most cases of hospital readmissions and mortality appear to occur within 30 days after discharge. The one-year post-discharge all-cause mortality rate of COVID-19 patients is 7.87%, and the majority of patients' readmission and mortality happens within the first 30 days post-discharge. Therefore, a 30-day follow-up program and patient tracking system for discharged COVID-19 patients seems necessary.
Topics: COVID-19; Humans; Internationality; Mortality; Patient Discharge; Patient Readmission
PubMed: 34781153
DOI: 10.1016/j.ajem.2021.10.059 -
Clinical Nutrition (Edinburgh, Scotland) Jul 2023Malnutrition is a risk-factor for adverse postoperative outcomes. This systematic review and meta-analysis evaluated the impact of post-discharge oral nutritional... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Malnutrition is a risk-factor for adverse postoperative outcomes. This systematic review and meta-analysis evaluated the impact of post-discharge oral nutritional supplements (ONS) on outcomes in patients undergoing gastrointestinal surgery.
METHODS
The Medline and Embase databases were searched for randomised clinical trials in patients undergoing gastrointestinal surgery who had received ONS for at least two weeks after discharge from hospital. The primary endpoint was weight change. Secondary endpoints included quality of life, total lymphocyte count, total serum protein and serum albumin. Analysis was performed using RevMan5.4 software.
RESULTS
Fourteen studies with 2480 participants (1249 ONS/1231 controls) were included. Pooling of results revealed that a reduction in postoperative weight loss in patients taking ONS, when compared with control: overall weighted mean difference (WMD) -1.69 kg, 95% CI -2.98 to -0.41, P = 0.01. Serum albumin concentration was increased in the ONS group: WMD = 1.06 g/L, 95% CI 0.04 to 2.07, P = 0.04. Haemoglobin was also increased: WMD = 2.91 g/L, 95% CI 0.58 to 5.25, P = 0.01. Total serum protein, total lymphocyte count, total cholesterol and quality of life did not differ between the groups. Patient compliance was relatively poor across the studies and there was variability in the composition of ONS, volume consumed and surgical procedures performed.
CONCLUSIONS
There was a reduction in postoperative weight loss and an improvement in some biochemical parameters in patients receiving ONS after gastrointestinal surgery. Future RCTs with more consistent methodologies are needed to investigate the efficacy of ONS after discharge from hospital following gastrointestinal surgery.
Topics: Humans; Digestive System Surgical Procedures; Patient Discharge; Quality of Life; Aftercare; Malnutrition; Serum Albumin; Weight Loss; Dietary Supplements
PubMed: 37244753
DOI: 10.1016/j.clnu.2023.04.028 -
Nursing in Critical Care May 2022To develop a questionnaire to identify Intensive Care survivor needs at key transitions during the recovery process, and assess its validity and reliability in a group...
AIMS
To develop a questionnaire to identify Intensive Care survivor needs at key transitions during the recovery process, and assess its validity and reliability in a group of ICU survivors.
METHODS
Development of the Support Needs After ICU (SNAC) questionnaire was based on a systematic scoping review, and analysis of patient interviews (n = 22). Face and content validity were assessed by service users (n = 12) and an expert panel of healthcare professionals (n = 6). A pilot survey among 200 ICU survivors assessed recruitment at one of five different stages after ICU discharge [(1) in hospital, (2) < 6 weeks, (3) 7 weeks to 6 months, (4) 7 to 12 months, or (5) 12 to 24 months post-hospital discharge]; to assess reliability of the SNAC questionnaire; and to conduct exploratory data analysis. Reliability was determined using Cronbach's alpha for internal consistency; intraclass correlation coefficients for test-retest reliability. We explored correlations with sociodemographic variables using Pearson's correlation coefficient; differences between questionnaire scores and patient demographics using one-way ANOVA.
RESULTS
The SNAC questionnaire consisted of 32 items that assessed five categories of support needs (informational, emotional, instrumental [e.g. practical physical help, provision of equipment or training], appraisal [e.g. clinician feedback on recovery] and spiritual needs). ICU survivors were recruited from Northern Ireland, England and Scotland. From a total of 375 questionnaires distributed, 202 (54%) were returned. The questionnaire had high internal consistency (0.97) and high test-retest reliability (r = 0.8) with subcategories ranging from 0.3 to 0.9.
CONCLUSIONS
The SNAC questionnaire appears to be a comprehensive, valid, and reliable questionnaire. Further research will enable more robust examination of its properties e.g. factor analysis, and establish its utility in identifying whether patients' support needs evolve over time.
RELEVANCE TO CLINICAL PRACTICE
The SNAC questionnaire has the potential to be used to identify ICU survivors' needs and inform post-hospital support services.
Topics: Humans; Intensive Care Units; Psychometrics; Reproducibility of Results; Surveys and Questionnaires; Survivors
PubMed: 34387920
DOI: 10.1111/nicc.12695 -
Clinical Cardiology Feb 2022Conventionally, patients have been admitted overnight after atrial fibrillation (AF) catheter ablation. Several centers have recently adopted a same-day discharge (SDD)... (Meta-Analysis)
Meta-Analysis Review
Conventionally, patients have been admitted overnight after atrial fibrillation (AF) catheter ablation. Several centers have recently adopted a same-day discharge (SDD) protocol for patients undergoing AF catheter ablation. We aimed to systematically review the current evidence for the safety and efficacy of SDD after AF catheter ablation. A systematic search was performed in PubMed, Embase, Scopus, Web of Science, and the Cochrane library until August 21, 2021. The risk of bias was assessed with the "Methodological Index for Non-Randomized Studies" (MINORS). The pooled efficacy rate of SDD protocol (defined as the proportion of patients discharged the same day of ablation among the patients who were planned for SDD) was calculated. Meanwhile, pooled major complication rates and early readmission or emergency department (ED) visit rates were evaluated in successful and planned SDD groups separately. Overall, 12 observational studies consisting of 18,065 catheter ablations were included, among which 7320 (40.52%) were discharged the same-day after ablation. The pooled efficacy was 90.3% (95% confidence interval [CI] [82.7-96.0]). The major complication rates were 1.1% (95%CI [0.5-1.9]), and 0.7% (95% CI [0.0-3.1]) in planned SDD and successful SDD groups, respectively. In addition, readmission/ED visit rate were 3.0% (95%CI [0.9-6.1]), and 3.1% (95% CI [0.8-6.5]) in the same groups. There were no significant differences between planned SDD and overnight groups with respect to major complication rate (risk ratio = 0.70, 95%CI [0.35-1.42], p-value = .369). The available data indicates that SDD after AF ablation is safe and efficient. Further prospective and randomized studies are warranted to elucidate the safety of SDD after AF ablation and develop a standardized SDD protocol.
Topics: Atrial Fibrillation; Catheter Ablation; Humans; Patient Discharge; Treatment Outcome
PubMed: 35084049
DOI: 10.1002/clc.23778 -
Critical Care (London, England) Jun 2013The discharge of patients from the intensive care unit (ICU) to a hospital ward is a common transition of care that is associated with error and adverse events. Risk... (Review)
Review
INTRODUCTION
The discharge of patients from the intensive care unit (ICU) to a hospital ward is a common transition of care that is associated with error and adverse events. Risk stratification tools may help identify high-risk patients for targeted interventions, but it is unclear if proper tools have been developed.
METHODS
We searched Ovid EMBASE, Ovid MEDLINE, CINAHL, PUBMED and Cochrane Central Register of Controlled Trials from the earliest available date through March 2013, plus reference lists and citations of all studies included in the systematic review. Cohort studies were selected that described the derivation, validation or clinical impact of tools for predicting medical emergency team activation, ICU readmission or mortality following patient discharge from the ICU. Data were extracted on the study design, setting, population, sample size, tool (components, measurement properties) and outcomes.
RESULTS
The literature search identified 9,926 citations, of which eight studies describing eight tools met the inclusion criteria. Reported outcomes included ICU readmission (n=4 studies), hospital mortality (n=3 studies) and both ICU readmission and hospital mortality (n=1 studies). Seven of the tools were comprised of distinct measurable component variables, while one tool used subjective scoring of patient risk by intensive care physicians. The areas under receiver operator curves were reported for all studies and ranged from 0.66 to 0.92. A single study provided a direct comparative analysis between two tools. We did not find any studies evaluating the impact of risk prediction on processes and outcomes of care.
CONCLUSIONS
Eight risk stratification tools for predicting severe adverse events following patient discharge from ICU have been developed, but have undergone limited comparative evaluation. Although risk stratification tools may help clinician decision-making, further evaluation of the existing tools' effects on care is required prior to clinical implementation.
Topics: Controlled Clinical Trials as Topic; Hospital Mortality; Humans; Intensive Care Units; Mortality; Patient Discharge; Predictive Value of Tests; Risk Assessment
PubMed: 23718698
DOI: 10.1186/cc12747 -
Annals of Intensive Care Dec 2017Veno-venous extracorporeal membrane oxygenation (ECMO) for refractory acute respiratory distress syndrome (ARDS) is a rapidly expanding technique. We performed a... (Review)
Review
Veno-venous extracorporeal membrane oxygenation (ECMO) for refractory acute respiratory distress syndrome (ARDS) is a rapidly expanding technique. We performed a systematic review and meta-analysis of the most recent literature to analyse complications and hospital mortality associated with this technique. Using the PRISMA guidelines for systematic reviews and meta-analysis, MEDLINE and EMBASE were systematically searched for studies reporting complications and hospital mortality of adult patients receiving veno-venous ECMO for severe and refractory ARDS. Studies were screened for low bias risk and assessed for study size effect. Meta-analytic pooled estimation of study variables was performed using a weighted random effects model for study size. Models with potential moderators were explored using random effects meta-regression. Twelve studies fulfilled inclusion criteria, representing a population of 1042 patients with refractory ARDS. Pooled mortality at hospital discharge was 37.7% (CI 95% = 31.8-44.1; I = 74.2%). Adjusted mortality including one imputable missing study was 39.3% (CI 95% = 33.1-45.9). Meta-regression model combining patient age, year of study realization, mechanical ventilation (MV) days and prone positioning before veno-venous ECMO was associated with hospital mortality (p < 0.001; R = 0.80). Patient age (b = 0.053; p = 0.01) and maximum cannula size during treatment (b = -0.075; p = 0.008) were also independently associated with mortality. Studies reporting H1N1 patients presented inferior hospital mortality (24.8 vs 40.6%; p = 0.027). Complication rate was 40.2% (CI 95% = 25.8-56.5), being bleeding the most frequent 29.3% (CI 95% = 20.8-39.6). Mortality due to complications was 6.9% (CI 95% = 4.1-11.2). Mechanical complications were present in 10.9% of cases (CI 95% = 4.7-23.5), being oxygenator failure the most prevalent (12.8%; CI 95% = 7.1-21.7). Despite initial severity, significant portion of patients treated with veno-venous ECMO survive hospital discharge. Patient age, H1N1-ARDS and cannula size are independently associated with hospital mortality. Combined effect of patient age, year of study realization, MV days and prone positioning before veno-venous ECMO influence patient outcome, and although medical complications are frequent, their impact on mortality is limited.
PubMed: 28500585
DOI: 10.1186/s13613-017-0275-4 -
Journal of Public Health (Oxford,... Mar 2012Routinely collected data sets are increasingly used for research, financial reimbursement and health service planning. High quality data are necessary for reliable... (Review)
Review
INTRODUCTION
Routinely collected data sets are increasingly used for research, financial reimbursement and health service planning. High quality data are necessary for reliable analysis. This study aims to assess the published accuracy of routinely collected data sets in Great Britain.
METHODS
Systematic searches of the EMBASE, PUBMED, OVID and Cochrane databases were performed from 1989 to present using defined search terms. Included studies were those that compared routinely collected data sets with case or operative note review and those that compared routinely collected data with clinical registries.
RESULTS
Thirty-two studies were included. Twenty-five studies compared routinely collected data with case or operation notes. Seven studies compared routinely collected data with clinical registries. The overall median accuracy (routinely collected data sets versus case notes) was 83.2% (IQR: 67.3-92.1%). The median diagnostic accuracy was 80.3% (IQR: 63.3-94.1%) with a median procedure accuracy of 84.2% (IQR: 68.7-88.7%). There was considerable variation in accuracy rates between studies (50.5-97.8%). Since the 2002 introduction of Payment by Results, accuracy has improved in some respects, for example primary diagnoses accuracy has improved from 73.8% (IQR: 59.3-92.1%) to 96.0% (IQR: 89.3-96.3), P= 0.020.
CONCLUSION
Accuracy rates are improving. Current levels of reported accuracy suggest that routinely collected data are sufficiently robust to support their use for research and managerial decision-making.
Topics: Clinical Coding; Databases, Bibliographic; Humans; Patient Discharge; Registries; Reproducibility of Results; State Medicine; United Kingdom
PubMed: 21795302
DOI: 10.1093/pubmed/fdr054