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The effects of intensive care unit-initiated transitional care interventions on elements of post-intensive care syndrome: A systematic review and meta-analysis

Open AccessPublished:June 10, 2021DOI:https://doi.org/10.1016/j.aucc.2021.04.010

      Abstract

      Objective

      The aim of the study was to assess the effectiveness of intensive care unit (ICU)–initiated transitional care interventions for patients and families on elements of post-intensive care syndrome (PICS) and/or PICS-family (PICS–-F).

      Review method used

      This is a systematic review and meta-analysis

      Sources

      The authors searched in biomedical bibliographic databases including PubMed, Embase (OVID), CINAHL Plus (EBSCO), Web of Science, and the Cochrane Library and included studies written in English conducted up to October 8, 2020.

      Review methods

      We included (non)randomised controlled trials focussing on ICU-initiated transitional care interventions for patients and families. Two authors conducted selection, quality assessment, and data extraction and synthesis independently. Outcomes were described using the three elements of PICS, which were categorised into (i) physical impairments (pulmonary, neuromuscular, and physical function), (ii) cognitive impairments (executive function, memory, attention, visuo-spatial and mental processing speed), and (iii) psychological health (anxiety, depression, acute stress disorder, post-traumatic stress disorder, and depression).

      Results

      From the initially identified 5052 articles, five studies were included (i.e., two randomised controlled trials and three nonrandomised controlled trials) with varied transitional care interventions. Quality among the studies differs from moderate to high risk of bias. Evidence from the studies shows no significant differences in favour of transitional care interventions on physical or psychological aspects of PICS-(F). One study with a nurse-led structured follow-up program showed a significant difference in physical function at 3 months.

      Conclusions

      Our review revealed that there is a paucity of research about the effectiveness of transitional care interventions for ICU patients with PICS. All, except one of the identified studies, failed to show a significant effect on the elements of PICS. However, these results should be interpreted with caution owing to variety and scarcity of data.

      Prospero registration

      Keywords

      1. Background

      There is growth in the number of patients surviving intensive care unit (ICU) admission, but they frequently face prolonged physical, cognitive, and psychosocial impairments, summarised as post-intensive care syndrome (PICS).
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      Critical care and the global burden of critical illness in adults.
      Notably, data before the coronavirus disease 2019 (COVID-19) pandemic already showed that 50% of ICU survivors experience new physical, mental, and/or cognitive problems. New research during the COVID-19 pandemic shows even more severe outcomes after ICU admission and endorses the need for patient- and family-centred strategies to help ICU survivors recover.
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      Severe outcomes among patients with coronavirus disease 2019 (COVID-19)—United States, February 12–March 16, 2020. Morbidity and mortality weekly report.
      Not only ICU survivors suffer from PICS, but also up to 75% of the family members report psychological burden (so-called PICS-family [PICS-F]), such as anxiety, depression, or post-traumatic stress disorder (PTSD). PICS and PICS-F are a public health burden with socio-economic consequences.
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      Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.
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      Postintensive care syndrome: right care, right now… and later.
      PICS-(F) can manifest even years after an ICU event.
      Delirium, duration of ventilation, gender, previous physical and mental health state, and negative ICU experiences are significant risk factors for PICS.
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      Prediction models for physical, cognitive, and mental health impairments after critical illness: a systematic review and critical appraisal.
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      • et al.
      New physical, mental, and cognitive problems 1-year post-ICU: a prospective multicenter study.
      Most of these risk factors appeared also as important risk factors in a recently published large cohort study with 4700 patients. This study showed that pre-ICU physical, psychological, and/or cognitive health status are strongly associated with long-term problems of PICS. In more detail, male patients reported less frailty and fatigue than female patients, and patients with pre-existent anxiety had a higher chance of suffering from symptoms of depression and PTSD after ICU admission after 1 year.
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      • et al.
      New physical, mental, and cognitive problems 1-year post-ICU: a prospective multicenter study.
      Because of the wide range of variety in PICS problems, a strategy with an individually approach is preferred. To ensure continuity of care, guidelines advice coordination of patients' recovery pathway by healthcare professionals with appropriate competencies and frequently screening on elements of PICS during transitions of care settings across the continuum of critical illness and recovery.
      • Haines K.J.
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      • Anderson B.J.
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      • Andrews A.
      • et al.
      Prediction models for physical, cognitive, and mental health impairments after critical illness: a systematic review and critical appraisal.
      ,
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      • et al.
      Exploring the scope of post–intensive care syndrome therapy and care: engagement of non–critical care providers and survivors in a second stakeholders meeting.
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      Society of Critical Care Medicine's international consensus conference on prediction and identification of long-term impairments after critical illness.
      • Tan T.
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      Rehabilitation after critical illness: summary of NICE guidance.
      Transitions of care can be defined as ‘a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location”.
      • World Health O.
      Transitions of care.
      • Elliot D.
      • Aitken L.
      • Chaboyer W.
      Critical care nursing.
      • Vincent J.-L.
      The continuum of critical care.
      Patients and their families experience complex transitions as complex, and need proper information and continuity of care during transitions in their recovery journey.
      • Wetzig K.
      • Mitchell M.
      The needs of families of ICU trauma patients: an integrative review.
      • Mitchell M.
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      • Birgan S.
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      • et al.
      The needs of families of trauma intensive care patients: a mixed methods study.
      • Josepha op’t S.A.J.
      • Dautzenberg M.
      • Eskes A.M.
      • Vermeulen H.
      • Vloet L.C.M.
      The experiences and needs of relatives of intensive care unit patients during the transition from the intensive care unit to a general ward: a qualitative study.
      The first major transition during their journey is transfer from the ICU to the general ward and is accompanied by risks of physical deterioration and psychological complaints such as transfer anxiety.
      • Elliot D.
      • Aitken L.
      • Chaboyer W.
      Critical care nursing.
      There is some knowledge about how to smoothen the journey to recovery. For example, preparation by informing patients and families, improving handovers, and investing in personalised care contributes to a safer and effective transfer.
      • Salmond S.W.
      • Evans B.M.
      A systematic review of relocation stress following in-house transfer out of critical/intensive care units.
      Improving structured handovers and implementing ICU liaison nurses or transition programs seem promising interventions to improve continuity of care, reduce ICU readmission, and reduce the risks on the development of PICS and PICS-F.
      • Niven D.J.
      • Bastos J.F.
      • Stelfox H.T.
      Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis.
      ,
      • van Sluisveld N.
      • Hesselink G.
      • van der Hoeven J.G.
      • Westert G.
      • Wollersheim H.
      • Zegers M.
      Improving clinical handover between intensive care unit and general ward professionals at intensive care unit discharge.
      A systematic review is not available for ICU-initiated interventions started within 1 month after ICU discharge and that liaise the transition between intramural and extramural healthcare organisations, defined as transmural care. Both ICU aftercare and follow-up services are varied worldwide and developed in order to help patients come to terms and understanding with their illness and if needed address goals.
      • Prinjha S.
      • Field K.
      • Rowan K.
      What patients think about ICU follow-up services: a qualitative study.
      • Storli S.L.
      • Lind R.
      The meaning of follow-up in intensive care: patients' perspective.
      • Jensen J.F.
      • Thomsen T.
      • Overgaard D.
      • Bestle M.H.
      • Christensen D.
      • Egerod I.
      Impact of follow-up consultations for ICU survivors on post-ICU syndrome: a systematic review and meta-analysis.
      Although these interventions can be beneficial to recovery, transition care interventions emphasise identification of patients' health goals and design and implementation of a streamlined individualised plan of care to strike for continuity of care across settings and between providers throughout episodes of acute illness.
      • Naylor M.D.
      • Hirschman K.B.
      • Hanlon A.L.
      • Bowles K.H.
      • Bradway C.
      • McCauley K.M.
      • et al.
      Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults.
      ,
      • Hirschman K.B.
      • Shaid E.
      • McCauley K.
      • Pauly M.V.
      • Naylor M.D.
      Continuity of care: the transitional care model.
      Thus, to further build this knowledge on transitional care interventions for ICU patients and their families, systematically gained overall insight is needed into which ICU-initiated interventions are effective. Therefore, we performed a systematic review to answer the following research question: “Which ICU-initiated interventions designed to improve the transition of care from to wards and home are effective to prevent elements of PICS and/or PICS-Ffor ICU survivors and their families?

      2. Method

      We conducted a systematic review based on the Cochrane Handbook for Systematic Reviews of Interventions.
      • Higgins J.P.T.
      • Green S.
      Cochrane handbook for systematic reviews of interventions.
      This systematic review is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses statement and registered with PROSPERO (CRD42020136589; available via https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020136589).
      • Liberati A.
      • Altman D.G.
      • Tetzlaff J.
      • Mulrow C.
      • Gøtzsche P.C.
      • Ioannidis J.P.A.
      • et al.
      The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.

      2.1 Database and literature search strategy

      We searched for studies in biomedical bibliographic databases including PubMed, Embase (OVID), CINAHL Plus (EBSCO), Web of Science, and the Cochrane Library with the help of a clinical librarian. We used the following search terms: Critical illness, Intensive Care Units, Critical Care Nursing, Trauma Care, Hospital Emergency Service, transitional care, transition care, continuity of patient care, rehabilitation, continuum of care, patient discharge, discharge planning, patient handoff, health care transition, patient dumping, patient-centered care, patient focus, person centered, family leave, family nursing, caregivers, adult.
      We included studies written in English conducted up to October 8, 2020. In addition, reference lists from the included studies were screened to identify any other relevant articles. We searched the www.clinicaltrials.gov/ website for ongoing or unpublished trials (see Appendix 1 for the search strategy)
      Studies were eligible if they (i) had an experimental design (i.e., [non]randomised controlled trials [RCTs], stepped-wedge studies, interrupted time series analysis, and before–after studies), (ii) were published in English, (iii) included ICU patients and/or family members, and (iv) described at least one component of the transitional care model (TCM), initiated from the ICU for patients and/or family members.
      • Hirschman K.B.
      • Shaid E.
      • McCauley K.
      • Pauly M.V.
      • Naylor M.D.
      Continuity of care: the transitional care model.
      In addition to this, eligible studies should report on at least one of the PICS-related physical, cognitive, or psychological outcomes.
      Studies that described an intervention as ICU follow-up or aftercare, or an intervention for paediatric populations or patients who received end-of-life care who were admitted at the ICU were excluded. We used the definition of the United Kingdom (UK) National Institute for Health and Care Excellence (NICE) to define aftercare
      • Tan T.
      • Brett S.J.
      • Stokes T.
      Rehabilitation after critical illness: summary of NICE guidance.
      , as a golden standard on ICU aftercare and ICU follow-up care is lacking.
      • Jensen J.F.
      • Thomsen T.
      • Overgaard D.
      • Bestle M.H.
      • Christensen D.
      • Egerod I.
      Impact of follow-up consultations for ICU survivors on post-ICU syndrome: a systematic review and meta-analysis.
      Aftercare according to the UK NICE criteria is scheduled 2 to 3 months after ICU discharge, whereas transitional care interventions should be initiated within 1 month after hospital discharge,and include PICS screening as per the recommendations of the Society of Critical Care Medicine (SCCM).
      • Mikkelsen M.E.
      • Still M.
      • Anderson B.J.
      • Bienvenu O.J.
      • Brodsky M.B.
      • Brummel N.
      • et al.
      Society of Critical Care Medicine's international consensus conference on prediction and identification of long-term impairments after critical illness.

      2.2 Screening and selection process

      Two reviews authors (L.C.M.V. and S.A.J.J.H.) independently selected potentially relevant articles based on titles and abstracts of the articles identified by the search using a free web and mobile app (http://rayyan.qcri.org). Full-text versions were obtained when the eligibility criteria matched or if further scrutiny was needed with regard to eligibility. Disagreement about study eligibility was resolved through consensus discussion or resolved by an arbiter (H.V.). All potentially relevant articles were retrieved in full-text and again independently screened by two team members (M.P.J.v.M. and S.A.J.J.H.) to check if the articles fulfilled the inclusion criteria. Disagreements were resolved through consensus, with a third person from the research team acting as an arbiter when agreement could not be reached (L.C.M.V.).

      2.3 Quality appraisal

      Three review authors (A.M.E., M.P.J.v.M., and S.A.J.J.H.) independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.
      • Liberati A.
      • Altman D.G.
      • Tetzlaff J.
      • Mulrow C.
      • Gøtzsche P.C.
      • Ioannidis J.P.A.
      • et al.
      The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
      Again, we resolved any disagreements by discussion, or by involving another author (L.C.M.V.).
      The revised Cochrane risk-of-bias tool for randomised clinical trials, version 2, was used to assess the risk of bias of randomised clinical trials and included the following domains: random sequence generation, allocation concealment, baseline imbalances, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting, and other sources of bias.
      • Sterne J.A.C.
      • Savovic J.
      • Page M.J.
      • Elbers R.G.
      • Blencowe N.S.
      • Boutron I.
      • et al.
      RoB 2: a revised tool for assessing risk of bias in randomised trials.
      For nonrandomised trials, Risk Of Bias In Non-randomized Studies of Interventions assessment tool 1 was used to assess the risk of bias.
      • Jüni P.
      • Loke Y.K.
      • Pigott T.D.
      • Ramsay C.R.
      • Regidor D.
      • Rothstein H.R.
      • et al.
      Risk of bias in non-randomized studies of interventions (ROBINS-I): detailed guidance.
      Again, we resolved any disagreements by discussion or by involving another author (L.C.M.V.). We graded each potential risk of bias as high, low, or unclear. We summarised the risk of bias judgements across different studies for each of the domains listed.

      2.4 Data extraction

      Three review authors (A.M.E., M.P.J.v.M., and S.A.J.J.H.) independently undertook manual data extraction of the included studies. Therefore, we used a structured Microsoft Excel spreadsheet data extraction form to collect the following characteristics of the included studies: design; research methodology; setting; intervention type, categorised into the nine components of the TCM; and professionals who fulfilled a role in the interventions (e.g., ICU nurses or rehabilitations practitioners).
      • Hirschman K.B.
      • Shaid E.
      • McCauley K.
      • Pauly M.V.
      • Naylor M.D.
      Continuity of care: the transitional care model.
      The nine components of the TCM are (i) screening, (ii) staffing, (iii) maintaining relationships, (iv) engaging patients and caregivers, (v) assessing/managing risks and symptoms, (vi) educating/promoting self-management, (vii) collaborating, (viii) promoting continuity, and (ix) fostering coordination.
      • Hirschman K.B.
      • Shaid E.
      • McCauley K.
      • Pauly M.V.
      • Naylor M.D.
      Continuity of care: the transitional care model.
      In addition to this, we collected primary outcome data of elements of PICS, measured in quantified scales: (i) physical impairments on pulmonary, neuromuscular, and physical function; (ii) cognitive impairments on executive function, memory, attention, and visuospatial and mental processing speed; and (iii) psychological outcomes on anxiety, acute stress disorder, PTSD, and depression.
      • Needham D.M.
      • Davidson J.
      • Cohen H.
      • Hopkins R.O.
      • Weinert C.
      • Wunsch H.
      • et al.
      Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.
      There are more than 250 unique instruments to evaluate ICU outcomes.
      • Turnbull A.E.
      • Rabiee A.
      • Davis W.E.
      • Nasser M.F.
      • Venna V.R.
      • Lolitha R.
      • et al.
      Outcome measurement in ICU survivorship research from 1970-2013: a scoping review of 425 publications.
      We defined for each outcome relevant outcome measures, with a selection of the most used validated measurement instruments as summarised by the .
      • Mikkelsen M.E.
      • Still M.
      • Anderson B.J.
      • Bienvenu O.J.
      • Brodsky M.B.
      • Brummel N.
      • et al.
      Society of Critical Care Medicine's international consensus conference on prediction and identification of long-term impairments after critical illness.
      We considered the following secondary outcomes as relevant: ICU or hospital readmission rates (in days), number of readmissions (within 30 days), length of stay (LOS; in days), healthcare consumption such as direct and indirect costs, and patient and family satisfaction (by self-reported numerical rating scales). Any differences were discussed and resolved by a fourth reviewer if required (H.V.).
      In case of multiple time points at which the outcome was measured within a time frame (short-, middle-, long-term), the data of the last measurement were collected. Short-term follow-up was defined as 0 to 3 months, middle-term follow-up was defined as 3 to 6 months, and long-term follow-up was defined as 6 to 12 months.

      2.5 Data analysis and synthesis

      We used the program Review Manager (version 5.4; The Cochrane Collaboration, 2020) to analyse the data. For each primary outcome measurement, mean differences with 95% confidence intervals were estimated using random-effects models. Owing to inaccuracy, reported medians and interquartile ranges were not converted into means and standard deviations. If more than one outcome measurement was assessed for a given intervention, we conducted a meta-analysis. When there was any unacceptable clinical or statistical heterogeneity (i.e., I2 higher than 75%), we presented the results descriptively.
      • Higgins J.P.T.
      • Green S.
      Cochrane handbook for systematic reviews of interventions.

      3. Results

      3.1 Search results

      The search strategy elicited 5052 articles after duplicates were removed. Thirty-nine full-text articles were reviewed by two review authors (M.P.J.v.M. and S.A.J.J.H.) to assess eligibility. For one article, no full text was available, and therefore, it was excluded. In total, five full-text articles fulfilled the inclusion criteria (see Fig. 1).
      Fig. 1
      Fig. 1Flow diagram of the search, screening and selection processes. PRISMA 2009 Flow Diagram
      • Storli S.L.
      • Lind R.
      The meaning of follow-up in intensive care: patients' perspective.
      . TCM = transitional care model; PRISMA = Preferred Reporting Items for Systematic Review and Meta-Analyses.

      3.2 Characteristics of the included studies

      The included studies had different study designs: two studies were RCTs,
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      ,
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      one was a block intervention study,
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      one had a pretest–post-test control group design,
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      and one was a non-RCT.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      and Bench et al.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      published their study protocol separately.
      • Walsh T.S.
      • Salisbury L.G.
      • Boyd J.
      • Ramsay P.
      • Merriweather J.
      • Huby G.
      • et al.
      A randomised controlled trial evaluating a rehabilitation complex intervention for patients following intensive care discharge: the RECOVER study.
      ,
      • Bench S.D.
      • Day T.L.
      • Griffiths P.
      Developing user centred critical care discharge information to support early critical illness rehabilitation using the Medical Research Council's complex interventions framework.
      The studies were conducted in Australia
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      ,
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      and Western Europe
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      ,
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      ,
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (see Table 1). All studies included adult ICU patients. The minimal LOS in the ICU ranged from 10 h up to 72 h. Only one study described duration of mechanical ventilation as an inclusion criterion.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      Four studies investigated transitional care interventions in which families participated.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      The other study was patient focused.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      Table 1Characteristics of the included studies.
      First author (year)CountryStudy designSettingClusters/participantsParticipants at baseline (n)Participants at follow-up, n (%)
      Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      ScotlandTwo-centre RCTAcute care hospitals with a combined medical and surgical department (excluding cardiac surgery and paediatric critical)Clusters: A single general critical care unit in each hospital

      Patients: Adult patients (aged >18 years) who received a least 48 h of continuous ventilation (via an endotracheal and/or tracheostomy tube) in the ICU and if they were considered to be fit for discharge.
      Intervention: 120 (56%)

      Control: 120 (58%)
      Intervention

      At 3 months: 118/120 (98%)

      At 6 months: 99/120 (83%)

      At 12 months: 94/120 (78%)

      Control

      At 3 months: 110/120 (92%)

      At 6 months: 90/120 (75%)

      At 12 months: 91/120 (76%)
      Bench et al.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      (2015)
      EnglandSingle-centre pilot cluster RCTTeaching hospital with a combined medical and surgical ICU departmentClusters: Two ICUs within one hospital providing care for mixed medical, surgical, and trauma patients requiring level 2 (high dependency) or level 3 (intensive) care. Both units functioned as one department, staff rotated between units and patients were allocated based on the availability of a bed.

      Patients: Adult patients (aged >18 years) who spent at least 72 h in the ICU and who were declared medically fit for discharge to a general ward and a normative relative.
      Intervention UCCDIP: 51 (in 36 clusters) (52% M)

      Intervention ICUsteps:

      48 (in 31 clusters) (51% M)

      Control Ad-hoc verbal info:

      59 (in 33 clusters) (53% M)
      Intervention UCCDIP at hospital discharge or 28 days: 45 (88%)

      Intervention ICUsteps at hospital discharge or 28 days: 36 (75%)

      Control Ad-hoc verbal info at hospital discharge or 28 days: 48 (81%)
      Chaboyer et al.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      (2007)
      AustraliaSingle-centre repeated before-and-after design studyTertiary hospital with a combined medical and surgical ICU departmentBlock design: Four blocks were conducted on the one ICU, with each block lasting for 4-month duration. The first two blocks consisted of a control and intervention period, which were followed by a 1-month washout period.

      Patients: Adult patients (aged >18 years) who spent at least 72 h in the ICU and if they were able to provide consent and their family member
      Intervention

      Patients: 53 (59% M)

      Family members: 48

      Control

      Patients: 62 (58% M)

      Family members: 52
      Intervention at the point of physical preparation for the transfer from the ICU to ward:

      48 (91%)

      Control at the point of physical preparation for the transfer from the ICU to ward: 52 (84%)
      Mitchell et al.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      (2004)
      AustraliaBefore-and-after design studyTertiary referral hospital with a combined medical and surgical ICU departmentCluster: One ICU

      Patients: Adult patients (aged >18 years) who spent at least 10 h in the ICU and if they were able to provide consent
      In total, 177 of which 162 completed the questionnaires

      Intervention: 82 (68% M)

      Control: 80 (74%)
      In total: 162/177 (92%)—no details per group given.
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      United KingdomSingle-centre quasi-experimental

      Study
      Tertiary hospital with a combined medical and surgical ICU departmentClusters: Two ICUs located in two separate buildings (buildings I and II)

      Patients: Adult patients (aged >18 years) who spent at least 72 h in the ICU and if they were able to provide consent
      Intervention

      83 (data reported at baseline: 73) (60% M)

      Control:

      85 (data reported at baseline: 75) (64% M)
      Intervention

      At discharge: 73/83 (88%)

      At 3 months: 68/83 (82%)

      At 6 months: 62/83 (75%)

      At 12 months: 56/83 = 67%

      Control

      At discharge: 75/85 (88%)

      At 3 months: 75/85 (88%)

      At 6 months: 69/85 (81%)

      At 12 months: 63/85 = 74%
      ICU = intensive care unit; M = male; N = number; RCT = randomised controlled trial; UCCDIP = User-Centred Critical Care Discharge Information Pack.

      3.3 Characteristics of the interventions under study

      The transitional care interventions, ordered by the TCM, varied across the five studies.
      • Hirschman K.B.
      • Shaid E.
      • McCauley K.
      • Pauly M.V.
      • Naylor M.D.
      Continuity of care: the transitional care model.
      An overview of the interventions can be found in Table 2. Two studies implemented an (personalised) information pack to prepare the transition from the ICU to a general ward provided by ICU nurses.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      ,
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      One study implemented ICU liaison nurses who communicated with ward staff, assessing ward staff skill mix and resources, preparing both the ICU and ward staff for patient transfer, and assessing bed status.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      In one study, a rehabilitation assistant coordinated a highly individualised rehabilitation therapy plan in combination with a self-help ICU rehabilitation manual.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      Another study provided a structured nurse-led follow-up until 3 months after ICU discharge, with (
      • Adhikari N.K.J.
      • Fowler R.A.
      • Bhagwanjee S.
      • Rubenfeld G.D.
      Critical care and the global burden of critical illness in adults.
      ) a booklet delivered at ICU discharge, (ii) ward visits from a ICU clinical nurse specialist, (iii) contact during the first week after discharge from the ward to home, and (iv) an appointment 3 months after discharge from the ICU.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      All studies compared the interventions with care as usual.
      Table 2Description of interventions, comparisons, and outcomes.
      First author (year)InterventionComponents of the transitional care modelComparisonPrimary outcomesSecondary outcomes
      Patients' physical outcomesPatients' cognitive outcomesPatients' psychological outcomesPatients' quality of lifePatient satisfactionReadmissionLength of stayHealthcare consumptionCosts
      Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      Hospital-based physical rehabilitation and information provision delivered during the post-intensive care unit hospital stay by rehabilitation assistants plus a self-help

      ICU rehabilitation manual.

      Key differences with usual care were greater coordination, intensity, and frequency of individual rehabilitation therapies.
      Staffing, maintaining relationships, engaging patients and caregivers, educating and promoting self-managementUsual care, rehabilitation by ward-based multidisciplinary teams plus a self-help ICU rehabilitation manual as recommended in UK guidelines.
      Bench et al.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      (2015)
      (
      • Adhikari N.K.J.
      • Fowler R.A.
      • Bhagwanjee S.
      • Rubenfeld G.D.
      Critical care and the global burden of critical illness in adults.
      ) UCCDIP: Consisting of two booklets (one for the patient and one for the family) without opportunities to reflect/report on experiences or feelings.

      (
      • Team C.C.-R.
      • Team C.C.-R.
      • Team C.C.-R.
      • Bialek S.
      • Boundy E.
      • Bowen V.
      • et al.
      Severe outcomes among patients with coronavirus disease 2019 (COVID-19)—United States, February 12–March 16, 2020. Morbidity and mortality weekly report.
      ) ICUsteps: Information booklet that covered the whole trajectory of critical illness from ICU admission to after hospital discharge, without opportunities to reflect/report on experiences or feelings
      Educating, promoting self-managingUsual care, containing of ‘ad hoc’ verbal ICU discharge information provided by a variety of healthcare professionals.
      Chaboyer et al.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      (2007)
      ICU liaison nurse intervention: Primarily focuses on the coordination of ICU patient transfer and liaison with ward staff. Tasks included communicating with ward staff, assessing ward staff skill mix and resources, preparing both the ICU and ward staff for patient transfer, and assessing bed status.Staffing, maintaining relationships, engaging patients and caregivers, educating and promoting self-management, coordinatingUsual care
      Mitchell et al.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      (2004)
      Written brochure individualised by the bedside nurse to prepare families for patient transfer from the ICUEngaging patients and caregivers; promoting continuity; educating/promoting self-management.Usual care
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      Structured nurse-led follow-up, consisting of four components for patients from ICU discharge to 3 months thereafter: (i) a booklet delivered at ICU discharge, (ii) ward visits, (iii) contact during the first week after discharge from the ward to home, and (iv) an appointment 3 months after discharge from the ICU.Promoting continuity, educating/promoting self-management. Collaborating, assessing, and managing risks and symptomsUsual care, patients and/or relatives received a booklet with printed, standardised information about the discharge from the ICU and the ward stay. If they needed continuing surveillance, they got ward visits from (ICU) clinical nurse specialists. After discharge from the general ward, they received no further ICU follow-up.
      ICU = intensive care unit; UCCDIP = User-Centred Critical Care Discharge Information Pack.

      3.4 Quality assessment

      The overall risk of bias of both the RCTs was high,
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      ,
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      and the overall risk of bias of the nonrandomised studies varied between moderate and serious (see Table 3 and more detailed judgement in Appendies 2 and 3).
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      In both RCTs, the randomisation process and report of the outcomes were adequate (see Appendix 2, Tables 1a–1f).
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      ,
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      In addition to this, both RCTs did not describe possible deviations from the intended interventions explicitly. Two of three nonrandomised experimental studies scored an overall moderate risk of bias but scored a low risk of bias on most of the domains.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      ,
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      Only one nonrandomised study scored an overall serious risk of bias.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      All three non-RCTs may have potential confounding of the effect of the intervention because of the nature of the interventions and the lack of baseline measurements (Appendix 3, Tables 1a–1i).
      • Jüni P.
      • Loke Y.K.
      • Pigott T.D.
      • Ramsay C.R.
      • Regidor D.
      • Rothstein H.R.
      • et al.
      Risk of bias in non-randomized studies of interventions (ROBINS-I): detailed guidance.
      ,
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      Table 3Quality assessment per domain.
      First author (year)Quality assessment
      Quality assessment: summary of risk of bias (revised Cochrane risk-of-bias tool for randomised trials [RoB 2])
      • Sterne J.A.C.
      • Savovic J.
      • Page M.J.
      • Elbers R.G.
      • Blencowe N.S.
      • Boutron I.
      • et al.
      RoB 2: a revised tool for assessing risk of bias in randomised trials.
      Risk of bias arising from the randomisation processRisk of bias due to deviations from the intended interventions (effect of assignment to the intervention)Risk of bias due to deviations from the intended interventions (effect of adhering to the intervention)Risk of bias in measurement of the outcomeRisk of bias in selection of the reported resultOverall risk of bias
      Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      LowSome concernsSome concernsHighLowHigh
      Bench et al.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      (2015)
      LowSome concernsHighHighLowHigh
      Quality assessment: summary of risk of bias (the Risk Of Bias In Non-randomized Studies of Interventions [ROBINS-I] assessment tool
      • Jüni P.
      • Loke Y.K.
      • Pigott T.D.
      • Ramsay C.R.
      • Regidor D.
      • Rothstein H.R.
      • et al.
      Risk of bias in non-randomized studies of interventions (ROBINS-I): detailed guidance.
      Bias due to confoundingBias in selection of participants into the studyBias in classification of interventionsBias due to deviations from intended interventionsBias due to missing dataBias in measurement of outcomesBias in selection of the reported resultOverall bias
      Chaboyer et al.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      (2007)
      ModerateLowLowLowLowModerateLowModerate
      Mitchell et al.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      (2004)
      SeriousLowLowLowLowModerateModerateSerious
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      No InformationLowLowLowLowModerateModerateModerate

      3.5 Heterogeneity

      Owing to heterogeneity of the studies with regard to outcome assessment, pooling was not possible on the primary outcomes (i.e., I2 higher than 75%).
      • Higgins J.P.T.
      • Green S.
      Cochrane handbook for systematic reviews of interventions.
      We were only able to pool data on readmissions, which was one of the secondary outcomes. All other results are reported from single studies.

      3.6 Results of the study: primary outcomes

      The primary outcome data are presented in Table 4.
      Table 4Primary outcomes.
      Physical function
      Follow-upMeasurementStudyTime pointInterventionComparisonResults
      MeanSDMedian (IQR)NMeanSDMedian (IQR)NMDSignificance
      Short-term, 0–3 monthsSF-36-V2

      Physical function
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      At ICU ward discharge27.226.2Not reported7126.220Not reported74[−6.61 to 8.61]Not Significance
      SF-36-V2

      Physical function
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      3 months after ICU discharge54.431.5Not reported6844.526Not reported7510.00 [0.48, 19.52]Significance
      SF-36-V2

      General Health
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      At ICU ward discharge65.820.9Not reported7067.518.1Not reported74−1.70 [−8.10, 4.70]Not Significance
      SF-36-V2

      General Health
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      3 months after ICU discharge60.521.4Not reported6858.919.8Not reported751.60 [−5.18, 8.38]Not Significance
      SF-12 PCSWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      3 months after ICU dischargeNot reportedNot reported34 (26–44)101Not reportedNot reported35 (26–44)96−0.1 [−3.3 to 3.1]Not Significance
      Middle-term, 3–6 monthsSF-36-V2

      Physical function
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      6 months after ICU discharge55.730.9Not reported6256.325Not reported68−0.60 [−10.32, 9.12]Not Significance
      SF-36-V2

      General Health
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      6 months after ICU discharge55.721.7Not reported6256.519.2Not reported69−0.80 [−7.85, 6.25]Not Significance
      SF-12 PCSWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      6 months after ICU dischargeNot reportedNot reported38 (26–47)84Not reportedNot reported33 (25–45)80−2.4 [−6.0 to 1.2]Not Significance
      Long-term, 6–12 monthsSF-36-V2

      Physical function
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      12 months after ICU discharge58.528.6Not reported5656.127.5Not reported632.40 [−7.7]1, 12.51]Not Significance
      SF-36-V2

      General Health
      Jónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      12 months after ICU discharge54.825.5Not reported5655.322.5Not reported63−0.50 [−9.19, 8.19]Not Significance
      SF-12 PCSWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      12 months after ICU dischargeNot reportedNot reported36 (28–51)79Not reportedNot reported37 (27–46)76−2.0 [−5.9 to 1.9]Not Significance
      Psychological outcome
      Follow-upMeasurementStudyTime pointIntervention 1
      Intervention 1: UCCDIP; intervention 2: ICUsteps.
      Intervention 2
      Intervention 1: UCCDIP; intervention 2: ICUsteps.
      ComparisonResults
      MeanSDMedian (IQR)NMeanSDMedian (IQR)NMeanSDMedian (IQR)NMDSignificance
      Short-term, 0–3 monthsAnxiety
      HADS, anxietyBench et al.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      (2015)
      In the ward, 5 days after ICU dischargeNot reportedNot reported7 (17)31Not reportedNotreported7.5 (19)28Not reportedNot reported6 (19)42Not Significance
      HADS, anxietyBench et al.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      (2015)
      At hospital discharge or 28 daysNot reportedNot reported7 (18)17Not reportedNot reported6 (13)8Not reportedNot reported5 (16)13Not Significance
      HADS, anxietyWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)

      3 months after ICU dischargeNot reportedNot reported7 (3–11)98....Not reportedNot reported6 (3–10)870.2 [1.6–1.4]Not Significance
      STAI, anxietyChaboyer et al.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      (2007)
      Before transfer from the ICU to wardNot reportedNot reported37 (18.5)53....Not reportedNot reported40 (21.6)62Not Significance
      STAI, anxiety

      Family
      Chaboyer et al.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      (2007)
      Before transfer from the ICU to ward
      STAI measured on family members.
      Not reportedNot reported39 (16.7)48....Not reportedNot reported40.7 (26.8)52Not Significance
      STAI, anxiety

      Family
      Mitchell et al.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      (2004)
      Before transfer from the ICU to ward
      STAI measured on family members.
      37.1113.45Not reported82....41.2413.21Not reported80−4.13 [−8.24, −0.02]Significance
      STAI, anxiety

      Family
      Mitchell et al.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      (2004)
      24 h after transfer from the ICU to ward
      STAI measured on family members.
      37.7213.92Not reported82....41.4213.42Not reported80−3.70 [−7.91, 0.51]Significance
      Depression
      HADS, depressionBench et al.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      (2015)
      In the ward, 5 days after ICU dischargeNot reportedNot reported6 (16)30Not reportedNot reported6.5 (18)28Not reportedNot reported7 (21)40Not Significance
      HADS, depressionBench et al.
      • Bench S.D.
      • Day T.L.
      • Griffiths P.
      Developing user centred critical care discharge information to support early critical illness rehabilitation using the Medical Research Council's complex interventions framework.
      (2015)
      At hospital discharge or 28 daysNot reportedNot reported6 (12)17Not reportedNot reported4.5 (16)8Not reportedNot reported7 (15)13Not Significance
      HADS, depressionWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      3 months after ICU dischargeNot reportedNot reported7 (4–9)98....Not reportedNot reported7 (3–10)870.5 [−0.7 to 1.6]Not Significance
      HADS, totalBench et al.
      • Bench S.D.
      • Day T.L.
      • Griffiths P.
      Developing user centred critical care discharge information to support early critical illness rehabilitation using the Medical Research Council's complex interventions framework.
      (2015)
      In the ward, 5 days after ICU dischargeNot reported12.5 (32)30Not reportedNot reported16 (35)28Not reportedNot reported14 (39)40Not Significance
      HADS, totalBench et al.
      • Bench S.D.
      • Day T.L.
      • Griffiths P.
      Developing user centred critical care discharge information to support early critical illness rehabilitation using the Medical Research Council's complex interventions framework.
      (2015)
      At hospital discharge or 28 daysNot reportedNot reported11 (27)17Not reportedNot reported10 (23)8Not reportedNot reported12 (23)13Not Significance
      DTSWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      3 months after ICU dischargeNot reportedNot reported11 (0–31)82....Not reportedNot reported10 (2–22)780.5 [−0.7 to 1.6]Not Significance
      Psychological outcome
      Follow-upMeasurementStudyTime pointIntervention 1Intervention 2ComparisonResults
      MeanSDMedian (IQR)NMeanSDMedian (IQR)NMeanSDMedian (IQR)NMDSignificance
      Middle-term, 3–6 monthsHADS, anxietyWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      6 months after ICU dischargeNot reportedNot reported8 (3–11)84....Not reportedNot reported6 (3–11)800.18 [0.7–0.4]Not Significance
      HADS, depressionWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      6 months after ICU dischargeNot reportedNot reported7 (3–10)84....Not reportedNot reported6 (2–10)80−0.12 [−0.6 to 0.4]Not Significance
      DTS (PTSD)Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      6 months after ICU dischargeNot reportedNot reported28 (6–57)84....Not reportedNot reported29 (14–67)805.0 [−13to 15.0]Not Significance
      Long-term, 6–12 monthsHADS, anxietyWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      12 months after ICU dischargeNot reportedNot reported7 (3–12)81....Not reportedNot reported7 (4–10)770.1 [−1.7 to 1.4]Not Significance
      HADS, depressionWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      12 months after ICU dischargeNot reportedNot reported7 (2–10)81....Not reportedNot reported6 (3–9)77−0.13 [−1.6 to 1.3]Not Significance
      DTS (PTSD)Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      12 months after ICU dischargeNot reportedNot reported26 (7–59)81Not reportedNot reported31 (6–58)770.0 [−8.0 to 10.0]Not Significance
      ICU = intensive care unit; UCCDIP = User-Centred Critical Care Discharge Information Pack; HADS = Hospital Anxiety and Depression Scale; PTSD = post-traumatic stress disorder; DTS = Davidson Trauma Scale; STAI = State-Trait Anxiety Inventory; PCS = Physical Component Summary; SD = standard deviation; IQR = interquartile range.
      a Intervention 1: UCCDIP; intervention 2: ICUsteps.
      b STAI measured on family members.

      3.6.1 Physical function and general health

      Two studies
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      ,
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      measured only physical function of the elements of PICS using the SF-36-V2
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      and 12-item Short-Form Health Survey (SF-12) Physical Component Summary (PCS) instruments on different time points (short-, middle-, and long-term).
      • Ware Jr., J.E.
      SF-36 health survey update.
      ,
      • Jenkinson C.
      • Layte R.
      • Jenkinson D.
      • Lawrence K.
      • Petersen S.
      • Paice C.
      • et al.
      A shorter form health survey: can the SF-12 replicate results from the SF-36 in longitudinal studies?.
      Jonasdotitir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      only found a significant difference in physical function at 3 months after ICU discharge in favour of the structured nurse-led follow-up (MD = 10.00; 95% confidence interval [CI] = 0.48 to 19.52), but there were baseline imbalances between the study groups, and no differences were found at all other time points.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      The overall SF-36 health score (General Health) did not show significant differences at 3 months (Mean Difference = −1.70; 95% CI = −8.10 to 4.70), 6 months (MD = −0.80; 95% CI = −7.85 to 6.25), and 12 months (MD = −0.50; 95% CI = −9.19 to 8.19).
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      In addition, Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      reported no significant difference in the SF-12 PCS score, with an individualised rehabilitation therapy plan in combination with a self-help ICU rehabilitation manual compared with usual care at all time points.

      3.6.2 Psychological outcomes

      Psychological outcomes (i.e., anxiety and/or depression) of patients were reported in all five studies.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      Only two studies reported also anxiety rates of family members.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      ,
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.

      3.6.3 Anxiety

      Four studies measured patients' anxiety; two studies
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      ,
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      used the Hospital Anxiety and Depression Scale
      • Snaith R.
      • Zigmond A.
      Hospital anxiety and depression scale (HADS)
      Handbook of psychiatric measures.
      and two studies
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      ,
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      used the State-Trait Anxiety Inventory.
      • Spielberger C.D.
      • Reheiser E.C.
      Measuring anxiety, anger, depression, and curiosity as emotional states and personality traits with the STAI.
      None of the studies reported significant differences in favour of the transitional care intervention compared with the control on short-term follow-up.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      Only Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      reported anxiety rates after 6 (mid-term) and 12 months (long-term) after ICU discharge, but again, no significant differences were found between the individualised rehabilitation therapy plan in combination with a self-help ICU rehabilitation manual compared with usual care. The study of Bench et al.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      found no significant difference in anxiety scores using a User-Centred Critical Care Discharge Information Pack compared with a booklet published by ICUsteps and verbal ad hoc information. Chaboyer et al.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      did not demonstrate a statistically significant beneficial effect from the liaison nurses in terms of anxiety scores between groups for either patients or family members. Mitchell and Courtney
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      showed no significant difference in favour of the intervention (MD = −3.70; 95% CI = −7.91 to 0.51), which consisted of an individualised brochure by the bedside nurse to prepare families for imminent patient transfer from the ICU.

      3.6.4 Depression

      Two studies measured depressive symptoms using the Hospital Anxiety and Depression Scale
      • Snaith R.
      • Zigmond A.
      Hospital anxiety and depression scale (HADS)
      Handbook of psychiatric measures.
      and reported no significant differences on short-term outcomes (MD = 0.5; 95% CI = −0.7 to 1.6).
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      ,
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      also reported no differences on mid-term (MD = −0.12; 95% CI = −0.6 to 0.4) and long-term outcomes (MD = −0.13; 95% CI = −1.6 to 1.3).

      3.6.5 Symptoms of PTSD

      Only Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      reported symptoms of PTSD using a 17-item self-report measure, the Davidson Trauma Scale.
      • Davidson J.R.T.
      • Book S.W.
      • Colket J.T.
      • Tupler L.A.
      • Roth S.
      • David D.
      • et al.
      Assessment of a new self-rating scale for post-traumatic stress disorder.
      An individualised rehabilitation process coordinated by a dedicated rehabilitation practitioner did not show a significant effect on short-term (MD = 0.5; 95% CI = −0.7 to 1.6), mid-term (MD = 5.0; 95% CI = −3 to 15.0), or long-term outcomes (MD = 0.0; 95% CI = 8.0 to 10.0).
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.

      3.7 Results of the study: secondary outcomes

      Data of secondary outcomes are presented in Table 5. All studies reported several secondary outcome measurements of this review, i.e., health-related quality of life (HRQOL)
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      , patient satisfaction,
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      ICU readmission rates,
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      ,
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      ,
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      ICU LOS
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      hospital LOS
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      ,
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      and heathcare costs.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      Table 5Secondary outcomes.
      MeasurementStudyTime pointIntervention 1Intervention 2ComparisonResults
      MeanSDMedian (IQR)NMeanSDMedian (IQR)NMeanSDMedian (IQR)NMean DifferenceSignificance P value
      ICU LOS
      ICU LOSBench et al.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      (2015)
      In days7 (104)516 (62)486 (371)590.24
      ICU LOSChaboyer et al.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      (2007)
      In days6536620.09
      ICU LOSJónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      In days1512.73....2825.75-3.00 [−6.09, 0.09]0.39
      ICU LOSMitchell et al.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      (2004)
      In days0.960.82....0.970.80
      ICU LOSWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      In days11 (6-18)12011 (6-18)120
      Hospital LOS
      Hospital LOSBench et al.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      (2015)
      In days21.5 (132)5116 (132)4822 (166)590.25
      Hospital LOSChaboyer et al.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      (2007)
      In days..18 (17)5315.5 (16)620.57
      Hospital LOSJónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      In days3540.73....4144.75−6.00 [−19.54 to 7.54]0.06
      Post-ICU and hospital LOSWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      In days116–22119106–231190 [−2 to 2]0.90
      MeasurementStudyTime pointIntervention 1Intervention 2ControlRR (95% CI)
      N (%)N (%)N (%)
      Readmission rates
      Readmission rates are given in days.
      ICU readmissionChaboyer et al.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      (2007)
      ICU readmission during the hospital stay0 (0)4 (6.5)0.13 [0.01, 2.35]
      ICU readmissionJónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      ICU readmission within 48 h0 (0)0 (0)
      ICU readmissionJónasdóttir et al.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      (2017)
      ICU readmission within 48–120 h2 (2.8)5 (6.6)0.41 [0.08, 2.05]
      ICU readmissionWalsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      (2015)
      ICU readmission during the hospital stay1 (0.8)7 (5.8)0.14 [0.02, 1.14]
      ICU = intensive care unit; SD = standard deviation; CI = confidence interval; RR = risk ratio; IQR = interquartile range; LOS = length of stay.
      a Readmission rates are given in days.

      3.7.1 Health-related quality of life

      Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      measured HRQOL by using the Mental Component Summary scores of the .
      • Ware Jr., J.E.
      SF-36 health survey update.
      HRQOL scores were unchanged in both groups over time by the intervention (PCS: MD = 0.1; 95% CI = −3.3 to 3.1; Mental Component Summary: MD = 0.2; 95% CI = −3.4 to 3.8).
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.

      3.7.2 Patient satisfaction

      Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      used a nonvalidated satisfaction questionnaire (including nine different domains) that was developed for patients who are discharged from the ICU. Patients who received the transitional care interventions scored significantly higher on six of the nine domains of the satisfaction questionnaire.

      3.7.3 ICU readmissions

      Three studies reported the number of ICU readmission rates during the same hospital stay.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      ,
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      ,
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      A significant reduction in the number of readmission rates was found in favour of a transitional care intervention (pooled risk ratio = 0.22, 95% CI = 0.07 to 0.70, I2 = 0%; see Fig. 2).
      Fig. 2
      Fig. 2Forest plot of pooled readmission rates. CI = confidence interval.

      3.7.4 ICU- and hospital length of stay

      All studies described the ICU LOS in days, and four studies described total hospital LOS.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      • Bench S.
      • Day T.
      • Heelas K.
      • Hopkins P.
      • White C.
      • Griffiths P.
      Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      ,
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      For both outcomes, no significant differences in favour of the transitional care intervention were found.

      3.7.5 Healthcare costs

      Walsh et al.
      • Walsh T.S.
      • Salisbury L.G.
      • Merriweather J.L.
      • Boyd J.A.
      • Griffith D.M.
      • Huby G.
      • et al.
      Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.
      reported the mean cumulative costs for the intervention group and control group. The intervention group showed a cost of £ 48.953, and the control group showed a cost of £ 49,057. They found no difference in mean quality-adjusted life years
      • Weinstein M.C.
      • Torrance G.
      • McGuire A.
      QALYs: the basics.
      between the intervention (mean = 0.54; standard deviation = 0.20) and usual care (mean = 0.54; standard deviation = 0.18) groups (mean difference: 0.00; 95% CI = −0.04 to 0.04).

      4. Discussion

      Evidence from currently available RCTs and nonrandomised experimental studies of varied methodological quality shows no significant differences in elements of PICS and PICS-F in favour of ICU-initiated transitional care interventions. In this review, we found a variety of transitional care interventions, but even studies that implemented multiple interventions did not show a positive effect on elements of PICS and PICS-F. Notably, none of the studies described cognitive impairment outcomes. Larger RCTs are therefore needed to demonstrate if and how transitional care interventions are able to decrease the components of PICS-(F). In this review, we only found significant reduction in readmission rates in favour of the transitional care interventions (i.e., intervention including at least one component of the TCM).
      • Hirschman K.B.
      • Shaid E.
      • McCauley K.
      • Pauly M.V.
      • Naylor M.D.
      Continuity of care: the transitional care model.
      Evidence for the most commonly described psychological impairments of PICS-(F) by patients and family, which are anxiety, depression, and PTSD, is lacking.
      • Fuke R.
      • Hifumi T.
      • Kondo Y.
      • Hatakeyama J.
      • Takei T.
      • Yamakawa K.
      • et al.
      Early rehabilitation to prevent postintensive care syndrome in patients with critical illness: a systematic review and meta-analysis.
      Nevertheless, physical rehabilitation, the use of diaries by ICU patients, and a patient- and family-centred care environment are promising interventions.
      • Inoue S.
      • Hatakeyama J.
      • Kondo Y.
      • Hifumi T.
      • Sakuramoto H.
      • Kawasaki T.
      • et al.
      Post-intensive care syndrome: its pathophysiology, prevention, and future directions.
      • Nikayin S.
      • Rabiee A.
      • Hashem M.D.
      • Huang M.
      • Bienvenu O.J.
      • Turnbull A.E.
      • et al.
      Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis.
      • Rabiee A.
      • Nikayin S.
      • Hashem M.D.
      • Huang M.
      • Dinglas V.D.
      • Bienvenu O.J.
      • et al.
      Depressive symptoms after critical illness: a systematic review and meta-analysis.
      Furthermore, the provision of information by healthcare professionals and adequate communication seems pivotal for treatment of PICS-F.
      • Zante B.
      • Camenisch S.A.
      • Schefold J.C.
      Interventions in post-intensive care syndrome-family: a systematic literature review.
      Transmural transitional care interventions remain underexposed in this review because collaboration between intramural and extramural health care organisations was seldom described. Currently provided ICU aftercare is not the same as transitional care, evidence of effectiveness of ICU aftercare is scarce, and guidelines are not available.
      • Hendriks M.
      • Janssen F.
      • te Pas M.
      • Kox I.
      • van de Berg P.
      • Buise M.
      • et al.
      Post-ICU care after a long intensive care admission: a Dutch inventory study.
      However, ICU aftercare and follow-up services can be beneficial to predict and recognise patients (at risk for) with PICS.
      • Haines K.J.
      • Hibbert E.
      • McPeake J.
      • Anderson B.J.
      • Bienvenu O.J.
      • Andrews A.
      • et al.
      Prediction models for physical, cognitive, and mental health impairments after critical illness: a systematic review and critical appraisal.
      ,
      • Hendriks M.
      • Janssen F.
      • te Pas M.
      • Kox I.
      • van de Berg P.
      • Buise M.
      • et al.
      Post-ICU care after a long intensive care admission: a Dutch inventory study.
      For trauma and cardiac populations, transmural interventions are effective in the form of care pathways, home visit programs, and structured telephone support (STS)in reducing hospital readmissions, reducing pain, improving functional status, and improving disease-specific HRQOL.
      • Bryant-Lukosius D.
      • Carter N.
      • Reid K.
      • Donald F.
      • Martin-Misener R.
      • Kilpatrick K.
      • et al.
      The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review.
      ,
      • Wiertsema S.H.
      • Van Dongen J.M.
      • Geleijn E.
      • Beckerman H.
      • Bloemers F.W.
      • Ostelo R.W.J.G.
      • et al.
      The Transmural Trauma Care Model (TTCM) for the rehabilitation of trauma patients is effective in improving patient related outcome measures: a non-randomized controlled trial.
      More evidence for transmural interventions for ICU patients and their families are needed as these are needed to prepare patients and especially family members returning to daily life at home in their possible role as a caregiver.
      Although the currently described transitional care interventions in our review show no effect on PICS and PICS-F, we recommend that after the current COVID-19 crisis, further research on the multiple transitions for ICU patients should continue. Many patients have gone through multiple transitions during this COVID-19 crisis, sometimes even between institutions in different countries, with limited visitation of family. This raises the question which role these multiple transitions play in the development of elements of PICS. Earlier studies from the post-Severe Acute Respiratory Sundrome (SARS) era show that patients develop long-term impairments such as fatigue, weakness, and depression.
      • Moldofsky H.
      • Patcai J.
      Chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep in chronic post-SARS syndrome; a case-controlled study.
      Experts expect that higher rates of depression and PTSD are likely for patients and their families. Family members' needs in this population in a still-limited-care landscape confirm the need for good transition care. Family members should receive better information and guidance in preparing for a caregiver role that can last for years.
      • Jaffri A.
      • Jaffri U.A.
      Post-Intensive care syndrome and COVID-19: crisis after a crisis? Heart & lung.

      4.1 Strengths and limitations

      This review has some strength and limitations. A strength of this review is that we used a comprehensive sensitive literature search and that each stage of the review was conducted by at least two or three independent reviewers and the use of established tools for quality assessments. None of the studies was designed to examine elements of PICS as an outcome measure. Another strength is that we used the most used and validated instruments summarised by the SCCM.
      • Mikkelsen M.E.
      • Still M.
      • Anderson B.J.
      • Bienvenu O.J.
      • Brodsky M.B.
      • Brummel N.
      • et al.
      Society of Critical Care Medicine's international consensus conference on prediction and identification of long-term impairments after critical illness.
      However, we realise that there are many more instruments to evaluate ICU outcomes (more than 250).
      • Turnbull A.E.
      • Rabiee A.
      • Davis W.E.
      • Nasser M.F.
      • Venna V.R.
      • Lolitha R.
      • et al.
      Outcome measurement in ICU survivorship research from 1970-2013: a scoping review of 425 publications.
      Therefore, we may have missed some outcome data of PICS that were measured using other instruments.
      Since the SCCM introduced the term PICS(-F) in 2012, there is growing awareness in the wide range of symptoms of ICU patients and their family.
      • Needham D.M.
      • Davidson J.
      • Cohen H.
      • Hopkins R.O.
      • Weinert C.
      • Wunsch H.
      • et al.
      Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.
      We used PICS-(F) as an underpinning framework to which outcomes were mapped. The variety in elements of PICS suggests preferring an individual-based plan of care and giving guidance to patients and their families during their recovery pathway. Yet, transitional care interventions as defined by the TCM emphasise streamlined plans of care and continuity of care across settings and between professionals and are not primary focused on patient outcomes.
      • Hirschman K.B.
      • Shaid E.
      • McCauley K.
      • Pauly M.V.
      • Naylor M.D.
      Continuity of care: the transitional care model.
      None of the studies had previously selected a risk group for the development of elements of PICS which are important in the development of post-ICU problems,
      • Haines K.J.
      • Hibbert E.
      • McPeake J.
      • Anderson B.J.
      • Bienvenu O.J.
      • Andrews A.
      • et al.
      Prediction models for physical, cognitive, and mental health impairments after critical illness: a systematic review and critical appraisal.
      ,
      • Geense W.W.
      • Zegers M.
      • Peters M.A.A.
      • Ewalds E.
      • Simons K.S.
      • Vermeulen H.
      • et al.
      New physical, mental, and cognitive problems 1-year post-ICU: a prospective multicenter study.
      which may influence the results. In addition, some studies had a very short ICU admission, and all studies had a relatively short follow-up, which means that possible complaints may not be measurable until later. Another factor that might influence the results of this review is that we included randomised and nonrandomised clinical studies, with some studies showing substantial differences in baseline characteristics.
      • Chaboyer W.
      • Thalib L.
      • Alcorn K.
      • Foster M.
      The effect of an ICU liaison nurse on patients and family's anxiety prior to transfer to the ward: an intervention study.
      • Mitchell M.L.
      • Courtney M.
      Reducing family members' anxiety and uncertainty in illness around transfer from intensive care: an intervention study.
      • Jonasdottir R.J.
      • Jones C.
      • Sigurdsson G.H.
      • Jonsdottir H.
      Structured nurse-led follow-up for patients after discharge from the intensive care unit: prospective quasi-experimental study.
      The difficulty in an appropriate evaluation of complex interventions in RCTs such as a transitional care intervention includes implementation strategies and process evaluations.
      • Gerstein H.C.
      • McMurray J.
      • Holman R.R.
      The importance of randomised vs non-randomised trials–Authors' reply.
      ,
      • Sørensen H.T.
      • Lash T.L.
      • Rothman K.J.
      Beyond randomized controlled trials: a critical comparison of trials with nonrandomized studies.
      We found substantial clinical heterogeneity that made pooling for primary outcomes unfeasible. At last, in this review, we used the definition of the TCM to define the interventions; however, it is possible we could have missed relevant studies that used other definitions.

      5. Conclusions and recommendations

      There is a general paucity of data on the effects of ICU-initiated transitional care interventions on the elements of PICS. Although none of the studies reported a positive effect on elements of PICS and PICS-F, there is still insufficient evidence to draw firm conclusions owing to the small number of studies available and the heterogeneity between the studies. Larger studies are needed as these studies confirm the burden of patients' and family's experiences on multiple aspects of PICS. A clear adapted framework or model may be helpful to share more evidence-based intervention strategies to offer continuity of care to ICU patients and families.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Conflict of Interest

      The authors declare that they have no conflict of interest.

      CRediT authorship contribution statement

      Sabine Adriana Johanna Josepha op ‘t Hoog: Conceptualisation, Methodology, Software, Validation, Formal analysis, Investigation, Data curation, Writing – Original Draft, Visualisation, Project administration, Funding acquisition; Anne Maria Eskes: Conceptualisation, Methodology, Software, Validation, Formal analysis, Investigation, Data curation, Writing – Original Draft, Writing – review & editing, Visualisation; Mariëlle Pieternella Johanna van Mersbergen-de Bruin: Investigation, Data curation; Thomas Pelgrim: Software, Resources; Hans van der Hoeven: Writing – review & editing, Visualisation; Hester Vermeulen: Conceptualisation, Methodology, Writing – review & editing, Visualisation, Supervision; Lilian Christina Maria Vloet: Conceptualisation, Methodology, Software, Validation, Formal analysis, Investigation, Data curation, Writing – Original Draft, Writing, Writing – review & editing, Visualisation, Supervision.

      Appendix A. Supplementary data

      The following is the supplementary data to this article:

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