Critical care transition and prevention of ICU readmissions: a bridge over troubled waters.

216 www.ccmjournal. org January 2014 • Volume 42 • Number 1 ICU readmissions are costly, increase length of hospital stay, and are an independent risk factor for hospital mortality (1). In a large national survey from the United States, the rate of readmission within 48 hours of ICU discharge was 2%, with 4% readmitted within 120 hours (2). A similar frequency of 3.3% at 48 hours was reported in a large U.K. study (3). The IMPACT project found no reduction in readmission rates nationally between 2001 and 2007, and there is little evidence to suggest that readmission rates have fallen significantly over the past 20 years (2). Interventions to make ICU discharges safer and to support ward transition have the potential to bring great benefits to patients and significant cost savings In this issue of Critical Care Medicine, Niven et al (4) have performed a systematic review and meta-analysis examining the impact of critical transition programs for patients discharged from the ICU. They identified eight before-and-after intervention studies examining the effect of a transition or support program on ICU readmissions or mortality. A total of 16,433 patients were ultimately included in the analysis. The programs examined by Niven et al (4) were primarily nurse-led support programs and hospital outreach or medical emergency teams (5). In the pooled analysis, these interventions significantly reduced the risk of ICU readmission with an absolute risk reduction from 7.2% to 5.7% (relative risk reduction, 0.87 [0.76–0.99]; p = 0.03). There was a suggestion in the analysis of a reduction in mortality which did not reach statistical significance. The magnitude of effect was similar comparing the nurse-led programs with the hospital outreach teams, suggesting no clear advantage of one approach over the other (4). Limitations of the analysis must be acknowledged. All studies were nonrandomized and all but one of the studies were single center. The study could not address the cost-effectiveness of the examined interventions, and this is an important area for future research. Many of the programs incorporated dedicated members of staff and were resource intensive, requiring at least daily patient reviews until clinical stability (4, 5). Therefore, the small but significant benefits of a proposed program must be weighed against the potential resource cost. All of the included studies were from the United Kingdom, Australasia, or Canada with none from the United States. The United States has seven times as many ICU beds per capita than the United Kingdom, and patients admitted to the ICU in the United Kingdom have very different characteristics, with a higher frequency of mechanical ventilation, a higher illness severity, and a higher ICU mortality (6). The results reported here cannot be easily extrapolated to the United States or other healthcare systems. Allowing for these reservations, this analysis supports the view that ICU transition programs can prevent a proportion of ICU readmissions. Where are we now with step down and outreach services? In their review of critical care services more than a decade ago, the United Kingdom the Department of Health recommended the establishment of outreach services with the aim of preventing deterioration of critically ill patients on the ward, facilitating step down from ICU and educating ward-based staff (7). The guidelines on creation of outreach were not didactic, and so the makeup of services now varies widely. A national postal survey 11. Schmidt M, Azoulay E: Having a loved one in the ICU: The forgotten family. Curr Opin Crit Care 2012; 18:540–547 12. Meert KL, Eggly S, Berg RA, et al; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network: Feasibility and Perceived Benefits of a Framework for Physician-Parent Follow-Up Meetings After a Child’s Death in the PICU. Crit Care Med 2014; 42:148–157 13. Meert KL, Templin TN, Michelson KN, et al: The bereaved parent needs assessment: A new instrument to assess the needs of parents whose children died in the pediatric intensive care unit. Crit Care Med 2012; 40:3050–3057 14. Meert KL, Eggly S, Berger J, et al: Physicians’ experiences and perspectives regarding follow-up meetings with parents after a child’s death in the pediatric intensive care unit. Pediar Crit Care Med 2011; 12:e64–e68 15. Sandler CL, Robinson E, Carter BS: Loss in the NICU: Sibling matters. Am J Hosp Palliat Care 2013; 30:566–568 16. Fanos J, Little G, Edwards W: Candles in the snow: Ritual and memory for siblings of infants who died in the intensive care nursery. J Pediatr 2009; 154:849–853