|An integrative review and meta-synthesis of the scope and impact of intensive care liaison and outreach services
|Endacott R, Eliott S, Chaboyer W
The review assessed the scope and impact of intensive care liaison and outreach services. Due to the varied nature of the services, the authors concluded that they should be treated as bundled interventions that delivered a treatment package of care. Variability and low quality of the included studies suggests that the authors' conclusion should be treated with caution.
To determine the activities and outcomes of intensive care unit liaison nurse/outreach services.
CINAHL, MEDLINE, EMBASE, PsycINFO, The Cochrane Library, HTA database, NHS EED, Current Contents and AMI databases and Google Scholar were searched from inception to February 2008 for relevant studies published in English; search terms were reported. Reference lists of retrieved articles and 2007 meetings of three relevant societies were searched.
Randomised controlled trials (RCTs), non RCTs, longitudinal studies, cohort studies, case-control studies and qualitative studies published between 2000 and 2008 that compared the effectiveness of intensive care unit liaison nurse/outreach services in adults aged 18 years or more in any setting were eligible for inclusion. Studies were excluded if they were in a paediatric hospital only, investigated the impact of medical emergency teams only or reported development/validity/reliability of critical care scoring systems only. Also excluded were reviews with no new data and studies with poor methodological quality or no evidence of peer review.
Some included studies identified the structures and activities of intensive care unit liaison nurse/outreach services by interview or survey; others investigated perceptions and attitudes towards these services by interview, survey or focus group; the rest assessed clinical outcomes related to the services. Outcomes studied included patient outcomes (adverse events, discharge delay, hospital mortality, service use and case management) and nursing outcomes (critical care skills, knowledge, discharge planning, access to clinical resource, multidisciplinary collaboration and confidence). Studies were undertaken in UK and Australia.
The authors did not state how studies were selected for inclusion in the review.
Assessment of study quality
Risk of bias in the included studies (selection, performance, attrition and detection) was assessed according to guidance from the Cochrane Reviewer’s Handbook 2005.
Two reviewers independently undertook validity assessment. Disagreements were resolved by consultation with a third independent reviewer.
Data were extracted on intensive care unit liaison nurse/outreach services activities, perception of role and attitude towards services and clinical outcomes, such as admission and readmission rates, discharge planning and delay, length of stay, mortality and adverse events.
Authors of papers were contacted where data were missing. Two reviewers independently extracted data on a data collection form derived from the primary questions; disagreements were resolved by consultation with a third reviewer.
Methods of synthesis
Studies were described in narrative and tabular format in distinct sequential phases according to separate questions on description of structure and activities of services, identification of outcomes and benefits of the outcomes. The last phase was a meta-synthesis of previous syntheses with the Nursing Role Effectiveness Model as an a priori model.
Results of the review
Twenty studies (n=12,583, sample size range six to 2,903) were included. One study was an RCT and the others were either qualitative uncontrolled observational studies (surveys/interviews or focus groups), observational studies with pre/post design or controlled observational studies with block intervention or case-control design. Selection bias, performance bias or lack of control over confounding variables was identified in most of the included studies. Several studies used historical controls or secondary data.
Intensive care liaison nurse/outreach services had a beneficial effect on intensive care unit mortality, hospital mortality, unplanned intensive care admissions/readmissions, discharge delay and rates of adverse events (qualitative analysis; figures not reported). It appeared that a benefit of intensive care liaison nurse/outreach services was improved communication pathways between critical care and ward staff, but this benefit was not specifically measured. There was no evidence that intensive care unit liaison nurse/outreach services had effects on hospital length of stay.
Intensive care unit liaison nurse/outreach services should be viewed as bundled interventions that delivered a treatment package of care; further research was required to identify the extent to which the service contributed to improved patient care.
The review broadly specified a number of research questions on intensive care unit liaison nurse/outreach services. Inclusion criteria appeared appropriate. A wide variety of databases was searched for relevant studies and attempts were made to find unpublished studies. Eligible studies were restricted to those in English, so language bias could not be excluded. Appropriate methods were used for quality assessment and data extraction; methods for study selection were not described, so reviewer error and bias could not be excluded for this part of the review process. The tool used for quality assessment was appropriate and indicated that most studies were biased. The method of synthesis was appropriate as the intervention varied between studies and was not standardised. Qualitative analysis defined some themes that formed the basis of the results, but the authors acknowledged that it was not possible to conclude unequivocally that the services had resulted in improved outcomes. The variability and low quality of the evidence base suggested that specific aspects of the services (roles of nurses, resources and structures), how they were implemented and the types of patients who might benefit needed to be further assessed. The authors' conclusions should thus be treated with caution.
Implications of the review for practice and research
Practice: The authors stated that intensive care unit liaison nurse/outreach services can have significant benefits in terms of patient outcomes and service use. They suggested that the Nursing Role Effectiveness Model provides a useful framework for evaluating the impact of these services.
Research: The authors stated that further research was required to assess the impact of critical care support on the confidence, knowledge and skills of ward nurses and the extent to which the service contributes to improved patient care.
Statewide Emergency Program, Department of Human Services, Melbourne, Australia.
Endacott R, Eliott S, Chaboyer W. An integrative review and meta-synthesis of the scope and impact of intensive care liaison and outreach services. Journal of Clinical Nursing 2009; 18(23): 3225-3236
Subject indexing assigned by NLM
Community Health Services /organization & administration; Intensive Care Units; Nursing; Patient Discharge
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.