Differences in the characteristics, treatment, and outcomes of patient groups reviewed by intensive care liaison nurses in Australia: A multicentre prospective study

Abstract

Background

There is a lack of knowledge about tasks intensive care unit liaison nurses (ICU LNs) perform during patient review, despite this role operating in at least 31 acute care hospitals in Australia.

Objectives

To evaluate the tasks that ICU LNs perform during patient review in the following referral subcategories: review after ICU discharge, rapid response team (RRT) review, and ward referral.

Methods

A 2-month prospective observational study using standardised case report forms to collect data on patients reviewed by ICU LNs in 20 Australian hospitals was conducted.

Results

From 3799 patients screened, 3542 were included, among whom 1933 (54.6%) were men, and the mean (standard deviation) age was 63 (19.4) years. The admitting units were surgical 1765 (49.8%) and medical 1696 (47.9%), and the breakdown of referral types were routine review after ICU discharge (1732; 47.9%), RRT review (1208; 34.1%), and ward referral (602; 17.0%). Patients subject to ward and RRT reviews were older, more likely to be medical admissions with less favourable vital signs on the initial review, and less likely to have repeat reviews. Of note, ward reviews were more likely to receive palliative care. Intensive care liaison nurse–initiated medication prescription and investigation ordering was uncommon. The most common interventions included consultation with medical staff, bedside education, adjusting oxygen flow and patient position, and directing the change in frequency of vital sign measurement. In-hospital mortality was lower in patients reviewed after ICU discharge (2.3%), compared with those after RRT review (2.8%) and ward referral (4.4%).

Conclusions

Most patients were reviewed after ICU discharge or in the context of the RRT. RRT and ward patients were less physiologically stable and more likely to die in hospital. The most common interventions performed by the ICU LN were nontechnical skills including clinical education, consultation with medical staff, and changes to vital sign frequency. Finally, the most common medication therapies administered related to intravenous therapy and electrolyte administration.

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.