The Effect of ICU Out-of-Hours Admission on Mortality: A Systematic Review and Meta-Analysis

This article by Galloway and others was published in the November 2017 issue of “Critical Care Medicine”

Objectives:  Organizational factors are associated with outcome of critically ill patients and may vary by time of day and day of week. We aimed to identify the association between out-of-hours admission to critical care and mortality.
Data Sources:  MEDLINE (via Ovid) and EMBASE (via Ovid).
Study Selection:  We performed a systematic search of the literature for studies on out-of-hours adult general ICU admission on patient mortality.
Data Extraction:  Meta-analyses were performed and Forest plots drawn using RevMan software. Data are presented as odds ratios ([95% CIs], p values).
Data Synthesis:  A total of 16 studies with 902,551 patients were included in the analysis with a crude mortality of 18.2%. Fourteen studies with 717,331 patients reported mortality rates by time of admission and 11 studies with 835,032 patients by day of admission. Admission to ICU at night was not associated with an increased odds of mortality compared with admissions during the day (odds ratio, 1.04 [0.98-1.11]; p = 0.18). However, admissions during the weekend were associated with an increased odds of death compared with ICU admissions during weekdays (1.05 [1.01-1.09]; p = 0.006). Increased mortality associated with weekend ICU admissions compared with weekday ICU admissions was limited to North American countries (1.08 [1.03-1.12]; p = 0.0004). The absence of a routine overnight on-site intensivist was associated with increased mortality among weekend ICU admissions compared with weekday ICU admissions (1.11 [1.00-1.22]; p = 0.04) and night time admissions compared with daytime ICU admissions (1.11 [1.00-1.23]; p = 0.05).
Conclusions: Adjusted risk of death for ICU admission was greater over the weekends compared with weekdays. The absence of a dedicated intensivist on-site overnight may be associated with increased mortality for acute admissions. These results need to be interpreted in context of the organization of local healthcare resources before changes to healthcare policy are implemented.
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Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis

This paper was published in Critical Care Medicine October 2017 by Goldfarb et al.
Objective:  To determine whether patient- and family-centered care interventions in the ICU improve outcomes.
Data Sources:  We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016.
Study Selection:  We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs.
Data Extraction:  We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes.
Data Synthesis:  There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis.
Conclusions:  Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.
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The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systematic review.

This article was published in the September issue of Human Resources for Health and written by Woo and colleagues.

Background:  The prevalence of chronic illness and multimorbidity rises with population aging, thereby increasing the acuity of care. Consequently, the demand for emergency and critical care services has increased. However, the forecasted requirements for physicians have shown a continued shortage. Among efforts underway to search for innovations to strengthen the workforce, there is a heightened interest to have nurses in advanced practice participate in patient care at a great extent. Therefore, it is of interest to evaluate the impact of increasing the autonomy of nurses assuming advanced practice roles in emergency and critical care settings on patient outcomes.

Objectives:  The objectives of this study are to present, critically appraise, and synthesize the best available evidence on the impact of advanced practice nursing on quality of care, clinical outcomes, patient satisfaction, and cost in emergency and critical care settings.

Methods:  A comprehensive and systematic search of nine electronic databases and a hand-search of two key journals from 2006 to 2016 were conducted to identify studies evaluating the impact of advanced practice nursing in the emergency and critical care settings. Two authors were involved selecting the studies based on the inclusion criteria. Out of the original search yield of 12,061 studies, 15 studies were chosen for appraisal of methodological quality by two independent authors and subsequently included for analysis. Data was extracted using standardized tools.

Results:  Narrative synthesis was undertaken to summarize and report the findings. This review demonstrates that the involvement of nurses in advanced practice in emergency and critical care improves the length of stay, time to consultation/treatment, mortality, patient satisfaction, and cost savings.

Conclusions:  Capitalizing on nurses in advanced practice to increase patients’ access to emergency and critical care is appealing. This review suggests that the implementation of advanced practice nursing roles in the emergency and critical care settings improves patient outcomes. The transformation of healthcare delivery through effective utilization of the workforce may alleviate the impending rise in demand for health services. Nevertheless, it is necessary to first prepare a receptive context to effect sustainable change.

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Prevention of central venous line associated bloodstream infections in adult intensive care units

Despite the potential benefits central venous lines can have for patients, there is a high risk of bloodstream infection associated with these catheters | Intensive and Critical Care Nursing

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Aim: Identify and critique the best available evidence regarding interventions to prevent central venous line associated bloodstream infections in adult intensive care unit patients other than anti-microbial catheters.

Methods: A systematic review of studies published from January 2007 to February 2016 was undertaken. A systematic search of seven databases was carried out: MEDLINE; CINAHL Plus; EMBASE; PubMed; Cochrane Library; Scopus and Google Scholar. Studies were critically appraised by three independent reviewers prior to inclusion.

Results: Nineteen studies were included. A range of interventions were found to be used for the prevention or reduction of central venous line associated bloodstream infections. These interventions included dressings, closed infusion systems, aseptic skin preparation, central venous line bundles, quality improvement initiatives, education, an extra staff in the Intensive Care Unit and the participation in the ‘On the CUSP: Stop Blood Stream Infections’ national programme.

Conclusions: Central venous line associated bloodstream infections can be reduced by a range of interventions including closed infusion systems, aseptic technique during insertion and management of the central venous line, early removal of central venous lines and appropriate site selection.

Full reference: Velasquez Reyes, D.C. et al. (2017) Prevention of central venous line associated bloodstream infections in adult intensive care units: A systematic review. Intensive and Critical Care Nursing. Published online: 26 June 2017

An Official American Thoracic Society Systematic Review: The Effect of Night time Intensivist Staffing on Mortality and Length of Stay among Intensive Care Unit Patients

This systematic review by Kerlin et al was published in the American Journal of Respiratory and Critical Care Medicine in 2017.  The fullajrccm-2016-194-issue-6-cover
text of the article is available to subscribers to this journal via this link
.  The Library and Knowledge Service can obtain the full text of the article for registered members by requesting it via the library website document request form.

Background:  Studies of night time intensivist staffing have yielded mixed results.

Goals:  To review the association of night time intensivist staffing with outcomes of intensive care unit (ICU) patients.

Methods:  We searched five databases (2000–2016) for studies comparing in-hospital night time intensivist staffing with other night time staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta-analyses used random effects models.

Results:  Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographically diverse. Meta-analysis (one randomized controlled trial; three nonrandomized studies with exposure limited to night time intensivist staffing with adjusted estimates of effect) demonstrated no association with mortality (odds ratio, 0.99; 95% confidence interval, 0.75–1.29). Secondary analyses including studies without risk adjustment, with a composite exposure of organizational factors, stratified by intensity of daytime staffing and by ICU type, yielded similar results. Minimal or no differences were observed in ICU and hospital length of stay and several other secondary outcomes.

Conclusions:  Notwithstanding limitations of the predominantly observational evidence, our systematic review and meta-analysis suggests night time intensivist staffing is not associated with reduced ICU patient mortality. Other outcomes and alternative staffing models should be evaluated to further guide staffing decisions.

The role of total cell-free DNA in predicting outcomes among trauma patients in the intensive care unit: a systematic review

This systematic review by Gogenur et al was published in the journal Critical Care in early 2017.  The full text of the article is fully available via this link

Background:  Cell-free DNA has been proposed as a means of predicting complications among severely injured patients. The purpose of this systematic review was to assess whether cell-free DNA was useful as a prognostic biomarker for outcomes in trauma patients in the intensive care unit.

Methods:  We searched Pubmed, Embase, Scopus and the Cochrane Central Register for Controlled Trials and reference lists of relevant articles for studies that assessed the prognostic value of cell-free DNA detection in trauma patients in the intensive care unit. Outcomes of interest included survival, posttraumatic complications and severity of trauma. Due to considerable heterogeneity between the included studies, a checklist was formed to assess quality of cell-free DNA measurement.

Results:  A total of 14 observational studies, including 904 patients, were eligible for analysis. Ten studies were designed as prospective cohort studies; three studies included selected patients from a cohort while one study was of a retrospective design. We found a significant correlation between higher values of cell-free DNA and higher mortality. This significant correlation was evident as early as on intensive care unit admission. Likewise, cell-free DNA predicted the severity of trauma and posttraumatic complications in a majority of patients.

Conclusion:  The amount of cell-free DNA can function as a prognostic tool for mortality and to a lesser extent severity of trauma and posttraumatic complications. Standardizing cell-free DNA measurement is paramount to ensure further research in cell-free DNA as a prognostic tool.

Can high-flow nasal cannula reduce the rate of endotracheal intubation in adult patients with acute respiratory failure compared with conventional oxygen therapy and non-invasive positive pressure ventilation?

This systematic review and meta analysis by Ni et al was published in the January 2017 issue of the journal Chest.

Background:  The effects of high flow nasal cannula (HFNC) on adult patients with acute respiratory failure (ARF) are controversial. We aimed to further determine the effectiveness of HFNC in reducing the rate of endotracheal intubation in adult patients with ARF by comparison to noninvasive positive pressure ventilation (NIPPV) and conventional oxygen therapy (COT).

Methods:  The Pubmed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all the controlled studies that compared HFNC with NIPPV and COT in adult patients having ARF. The primary outcome was the rate of endotracheal intubation and the secondary outcomes were intensive care unit (ICU) mortality and length of ICU stay (ICU LOS).

Results:  Eighteen trials with a total of 3881 patients were pooled in our final studies. Except for ICU mortality (I2=67%, χ2=12.21, P=0.02) and rate of endotracheal intubation (I2=63%, χ2=13.51, P=0.02) between HFNC and NIPPV, no significant heterogeneity was found in outcome measures. Compared with COT, HFNC was associated with a lower rate of endotracheal intubation (Z=2.55, P=0.01), while no significant difference was found in the comparison with NIPPV (Z=1.40, P=0.16). As for the ICU mortality and ICU LOS, HFNC did not show any advantage over either COT or NIPPV.

Conclusions:  In patients with ARF, HFNC is a more reliable alternative of NIPPV to reduce rate of endotracheal intubation than COT.

 

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