Research paperDifferences in the characteristics, treatment, and outcomes of patient groups reviewed by intensive care liaison nurses in Australia: A multicentre prospective study
Introduction
In response to observations that serious adverse events occur commonly in hospitalised patients and many such events are preceded by signs of instability, healthcare policy makers have introduced national standards related to the recognition of, and response to deteriorating patients in Australian hospitals.[1], [2] One of the nine essential elements of this approach involves the implementation of rapid response teams (RRTs), also known as medical emergency teams (MET), which involves activation of a specialised team when a patient has deteriorated. A limitation of this approach is that it remains reactive, and the in-hospital mortality of patients reviewed by the RRT can be as high as 30%.[3], [4] A less reactive and more proactive approach to at-risk and deteriorating patients is the use of intensive care unit liaison nurses (ICU LNs), also known as ICU nurse consultants, which are present in at least 31 Australian hospitals.5 The main benefits of critical care outreach nursing services include reduction in ICU readmission, improved discharge planning, and improved patient flow.[6], [7] Previous studies, which have evaluated ICU LN services, have mostly come from Australia and the United Kingdom.[6], [7] Yet, a recent study from Argentina demonstrates that ICU LN services are beginning to emerge in other countries and describes comparable details in the follow-up of ICU discharge and ward patients with complex care needs.8
There is a growing body of literature describing the role of ICU LNs and the nature of the patients reviewed.[9], [10], [11], [12] These roles include the routine and pre-emptive review of patients discharged from the ICU, patients referred from the ward (typically from nurses), and participation in the RRT.[13], [14], [15], [16] The Australian ICU LN forum previously described the uptake and pattern of case referrals for 17 Australian ICU LN services between 1999 and 2011. This study revealed that ICU discharges, during or after RRT review, and de novo ward referrals comprised 59.3%, 21.7%, and 19.0% of patient reviews, respectively.17
The same group also published the findings of a multicentre prospective observational study of 3799 patients reviewed by ICU LN services.10 This study confirmed that the three most common types of patients reviewed were those after ICU discharge, patients involved in RRT review, and patients referred as part of a ward nurse worried criteria. It also revealed that the in-hospital mortality of ICU LN–reviewed patients was 10.2% overall.10
The purpose of this study is to describe in greater detail the differences in the baseline characteristics, treatment, and outcomes of various patient groups reviewed by ICU LN services in Australia, specifically, the tasks that ICU LNs perform among patients discharged from ICU, in the context of ward referral (for worried or physiological criteria), or after RRT review.
Section snippets
Study design
Expressions of interest to participate in the study were sought via an email sent to all members of the Australian College of Critical Care Nurses ICU LN special interest group. After 28 initial expressions of interest, 20 sites were enrolled in the study. The group did not collect information on LN credentials, scope of practice, or role and responsibilities for the study. We conducted a 2-month prospective observational study in 20 participating hospitals; 17 commenced data collection on 23rd
Details of the overall cohort
During the study, 3799 patients were initially screened by the 20 ICU LN services with adequate data to permit analysis. For the purposes of this study, patients who were subject to total parenteral nutrition or tracheostomy rounds were excluded (257 or 6.8% of cohort), leaving 3542 patients. Among these, 1933 (54.6%) were men, and the mean (standard deviation) age was 63 (19.4) years. The breakdown of the admitting unit included surgical 1765 (49.8%), medical 1696 (47.9%), paediatric 34 (1%),
Summary of major findings
We conducted a 2-month multicentre prospective observational study of the characteristics, treatment, and outcomes of patients reviewed by ICU LN services in Australia. The three groups reviewed in the decreasing order were the following: post-ICU discharge, RRT patients, and those referred from ward staff. Patients discharged from the ICU were younger, had fewer comorbidities, less deranged physiology, appeared to have fewer end-of-life care issues, were less likely to die, and more likely to
Conclusions
In Australia, most ICU LN reviews occur after ICU discharge or in the context of RRT reviews. Patients reviewed after ward referral, or in association with the RRT, appear to be at increased risk with high mortality. Most common tasks performed by the ICU LN related to nontechnical skills, with medication prescription and ordering of diagnostic tests, appear to be less common. Communication and education are important characteristics within the ICU LN role.
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A practical approach to establishing a critical care outreach service: An expert panel research design
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