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Corresponding author. Iberoamerican Cochrane Centre, Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), C/ Sant Antoni Maria Claret, 167, Pabellón 18, planta 0, 08025, Barcelona, Spain. Tel.: +34 657023927.
Affiliations
Universitat Autònoma de Barcelona, SpainIberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Spain
Universitat Autònoma de Barcelona, SpainIberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), SpainInterdisciplinary Centre for Health Studies (CIESAL), Universidad de Valparaíso, Chile
Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), SpainEpidemiology and Public Health Department, Hospital de La Santa Creu I Sant Pau, Institut de Recerca IIB Sant Pau, Barcelona, SpainCIBER of Epidemiology and Public Health (CIBERESP), Spain
Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), SpainDepartment of Social Medicine and Family Health, Universidad Del Cauca, Colombia
Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), SpainNursing School of Barcelona, Campus Docent Sant Joan de Déu-Private Foundation, University of Barcelona, Spain
Universitat Autònoma de Barcelona, SpainIberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), SpainCIBER of Epidemiology and Public Health (CIBERESP), Spain
Different types of interventions have been assessed for the prevention of adverse events. However, determining which patient-safety practice is most effective can be challenging when there is no systematised evidence synthesis. An overview following the best methodological standards can provide the best reliable integrative evidence.
Objectives
The objective of this study was to provide an overview of effectiveness nonpharmacological interventions aimed at preventing adverse events in the intensive care unit.
Methods
A review of systematic reviews (SRs) was conducted according to the Cochrane Handbook and PRISMA recommendations. PubMed, CINAHL, and Cochrane Library were searched for SRs published until March 2022. Two reviewers independently assessed the study’s quality, using AMSTAR-2, and extracted data on intervention characteristics and effect on prevention of adverse events.
Results
Thirty-seven SRs were included, and 27 nonpharmacological interventions were identified to prevent 11 adverse events. Most of the reviews had critically low methodological quality. Among all the identified interventions, subglottic secretion drainage, semirecumbent position, and kinetic bed therapy were effective in preventing ventilator-associated pneumonia; the use of earplugs, early mobilisation, family participation, and music in reducing delirium; physical rehabilitation in improving muscle strength; use of respiratory support in preventing reintubation; the use of a computerised physician order entry system in reducing risk of medication errors; and the use of heated water humidifier was effective in reducing artificial airway occlusion.
Conclusions
Some nonpharmacological interventions reduced adverse events in the intensive care setting. These findings should be interpreted carefully due to the low methodological quality. SRs on preventing adverse events in the intensive care unit should adhere to quality assessment tools so that best evidence can be used in decision-making.
Adverse events (AEs) are undesirable or unintended patient outcomes associated with healthcare management resulting in prolonged hospitalisation, disability at the time of hospital discharge, or death.
The occurrence of AEs due to unsafe care is approximately one in every 10 patients, and half of them are judged to be preventable. Most of these incidents are related to invasive clinical procedures and therapeutic management.
Strengthening the focus of investigations on preventable AEs interventions can lead to greater clinical benefits and improved translation of patient-safety interventions into clinical practice.
Patients in intensive care units (ICUs) are at a greater risk for AEs not only due to their inherent clinical conditions that lead to multiple treatments but also because they are in a highly complex environment.
SRs are considered at the highest level in the hierarchy of evidence, reflecting the current scientific knowledge and therefore guiding evidence-informed decision-making. However, their conclusions are limited due to the methodological quality and the certainty of the evidence based on included primary studies.
Higgins J.P.T. Thomas J. Chandler J. Cumpston M. Li T. Page M.J.W.V. Cochrane Handbook for systematic reviews of interventions | Cochrane training. 2021
Due to the increasing number of SRs and the multiple preventive interventions being published, it is important to evaluate the current status and provide a summary of effective interventions to prevent them.
Higgins J.P.T. Thomas J. Chandler J. Cumpston M. Li T. Page M.J.W.V. Cochrane Handbook for systematic reviews of interventions | Cochrane training. 2021
Hence, the objective of this article is to provide an overview of SRs assessing nonpharmacological interventions (NPIs) to prevent AEs in the ICU.
2. Method
2.1 Design
We conducted a review of SRs following a protocol registered in PROSPERO (CRD42019147956). Amendments to information provided in the protocol are described in Supplementary material 1.
Reviews of SRs use explicit and systematic methods to collate and appraise the methodological quality and to summarise and analyse their results across our research question identifying specific areas of available or limited evidence. A comprehensive overview can provide an accurate description of the current state of research and thus guide future research.
Higgins J.P.T. Thomas J. Chandler J. Cumpston M. Li T. Page M.J.W.V. Cochrane Handbook for systematic reviews of interventions | Cochrane training. 2021
We developed a systematic search strategy for MEDLINE, CINAHL, and the Cochrane Library to identify studies published from inception until March 2022. English and Spanish language studies were included. The reference list of included SRs was screened to identify potentially relevant studies.
The keywords were selected according to the main components of our clinical question, after a discussion between the research team and tested by an experienced systematic search reviewer before publishing the final version of the protocol. The full search strategy is available in Supplementary material 3.
A pair of trained reviewers independently assessed the inclusion eligibility of the SRs. The first screening was based on the SR title and abstract. We identified papers of peer-reviewed SRs. A full-text assessment was conducted to determine the definitive inclusion of the selected SR. Disagreements in the selection of reviews were resolved by a third reviewer.
2.3 Inclusion and exclusion criteria
2.3.1 Type of studies
SRs of primary studies, including randomised controlled trials (RCTs), quasi-RCTs and controlled observational studies, investigating the effect of NPIs on AEs were included. We considered as an SR any evidence synthesis with a clear systematic methodological approach, a detailed search strategy using at least two database sources, eligible criteria relevant to our research objective, and a narrative synthesis and/or meta-analysis.
2.3.2 Type of patients
Adult ICU patients aged 18 years and above in medical and surgical ICUs were included.
2.3.3 Type of interventions
Any NPIs to prevent AEs focused on patient safety was included, described as new strategies, practices, behaviour, actions, procedures, or environment.
We considered control interventions to be usual care or standard ICU care defined as not providing any therapy specifically aimed at preventing AEs.
2.3.4 Types of outcome measures
Primary outcomes were incidence and ICU mortality related to AEs such as infections (mechanical ventilation–associated pneumonia, bloodstream infection (BSI), central catheter infection, peripheral catheter infection), delirium, reintubation, airway occlusion, pressure ulcers, physical function deterioration, and medication errors. Secondary outcomes were hospital mortality, length of mechanical ventilation, and stay in the ICU or in hospital. Outcomes that reported consequences of AEs in terms of extra treatment(s) or readmission were not the focus of this overview.
2.4 Data extraction
Data from studies such as trial design, the number of included studies, type of intervention, type of AEs, comparator, and outcomes were extracted by one reviewer and checked for accuracy by a second reviewer. Disagreement was resolved through discussion, and a third reviewer was consulted if needed.
2.5 Quality appraisal
Methodological quality of the reviews was assessed using AMSTAR-2,
which provides overall ratings (high, moderate, low, critically low) based on weaknesses in critical domains. A pair of reviewers independently assessed the quality of each study. Disagreements were resolved by a third reviewer. Moreover, we described the confidence in the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for the primary outcomes when the SRs reported them.
2.6 Data analysis and synthesis
The study characteristics and patient outcomes for all the SRs that met our inclusion criteria were grouped by types of AEs in a tabular form. To assess the overlap of primary studies among included SRs, we created a matrix of evidence as a grid, placing all the included SRs in the columns and their respective primary studies in the rows. We calculated the corrected covered area (CCA) for the whole matrix and for each pair of SRs,
We considered overlap to be low if the CCA was below 5%, moderate if the CCA was between 5% and 10%, high if the CCA was between 10% and 15%, and very high if the CCA was above 15%. We repeated this process for each outcome, creating custom matrices including only the SRs and primary studies providing data for each specific comparison. We reported overlap for this custom matrix using the same thresholds mentioned above.
We compiled the pooled effect sizes of meta-analyses reported in the SRs and analysed the intervention components. Most of the effect sizes were expressed in odds ratio (OR); however, when risk ratio (RR) was reported, these were converted to OR if the number of events per group was provided.
Statistical analyses were performed using Review Manager V5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, 2014). Analysis of forest plots was descriptive, and metanalysis was not performed due to the clinical diversity of intervention by outcomes and overlap among primary studies included in the SRs.
3. Results
3.1 Search results
The initial search of all databases yielded 3812 articles (Fig. 1). After the removal of duplicates, 3225 articles remained and were screened via review of their titles and abstracts. The screening resulted in 261 articles that underwent full-text review. A total of 224 articles were excluded because they did not meet our selection criteria. Fifty-six articles were excluded because the intervention was pharmacological, bundles, or educational interventions. A list of excluded studies with the reason for exclusion can be found in Supplementary material 4. Finally, 37 systematic reviews were included in this review.
Fig. 1Summary of search and selection – PRISMA 2020. ICU, intensive care unit; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
3.2 Characteristics of the included systematic reviews
The characteristics of the included NPI SRs are summarised in Table 1. More than half (n = 21) of the included SRs were published after 2016. These reviews incorporated a range of study designs; however, most of them (n = 30) included only randomised controlled trials (RCTs). Thirty-two SRs performed a meta-analysis (86.4%).
Table 1Characteristics of the included studies.
Adverse event
Author
Year
N studies included
Intervention(s)
Comparison(s)
Outcome(s)
ROB assessment
Meta-analysis
Ventilator-associated pneumonia (VAP)
Alexiou
2009
7 RCT
Semirecumbent position; prone position
Supine position
Incidence of VAP; hospital mortality; duration of mechanical ventilation; ICU length of stay
Yes
Yes
Caroff
2016
17 RCT
SSD
Usual care (standard endotracheal tubes)
Incidence of VAP; ICU mortality; hospital mortality; duration of mechanical ventilation; ICU length of stay
The total number of eligible primary studies in the SRs ranged from 227−30 to 2431 studies. The number of patients in the eligible studies ranged from 454
Multimodality respiratory physiotherapy reduces mortality but may not prevent ventilator-associated pneumonia or reduce length of stay in the intensive care unit: a systematic review.
S.,et al. Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis.
Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: a systematic review and network meta-analysis.
Effects of nonpharmacological delirium-prevention interventions on critically ill patients' clinical, psychological, and family outcomes: a systematic review and meta-analysis.
Systematic early versus late mobilization or standard early mobilization in mechanically ventilated adult ICU patients: systematic review and meta-analysis.
Effects of rehabilitation interventions on clinical outcomes in critically ill patients: systematic review and meta-analysis of randomized controlled trials.
High-flow nasal cannula compared with conventional oxygen therapy or noninvasive ventilation immediately postextubation: a systematic review and meta-analysis.
Effect of high-flow nasal cannula oxygen therapy versus conventional oxygen therapy and noninvasive ventilation on reintubation rate in adult patients after extubation: a systematic review and meta-analysis of randomized controlled trials.
Preventive use of respiratory support after scheduled extubation in critically ill medical patients-a network meta-analysis of randomized controlled trials.
Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis.
Prevention of ventilator-associated and early postoperative pneumonia through tapered endotracheal tube cuffs: a systematic review and meta-analysis of randomized controlled trials.
Heat and moisture exchangers (HMEs) and heated humidifiers (HHs) in adult critically ill patients: a systematic review, meta-analysis and meta-regression of randomized controlled trials.
Effectiveness of interventions to prevent pressure injury in adults admitted to intensive care settings: a systematic review and meta-analysis of randomised controlled trials.
Effect of high-flow nasal cannula oxygen therapy versus conventional oxygen therapy and noninvasive ventilation on reintubation rate in adult patients after extubation: a systematic review and meta-analysis of randomized controlled trials.
The total number of interventions evaluated was 27, and VAP was the most frequent AE studied with seven NPIs. Usual care, defined as the standard care received by patients and determined by the treating centre during ICU admission, standard medical, and nursing care, was the most common control group.
3.3 Methodological quality of SRs
The AMSTAR-2 quality scores of the included reviews are described in Table 2. Twenty-eight (75.6%) SRs scored critically low on methodological quality, six (16.2%) SRs scored low, three (8.1%) scored moderate, and only one (2.7%) scored high. The main deficiencies noted in critical domains were failure to report a prior registered protocol, adequacy of the literature search, and justification for excluding studies, while in noncritical domains, the main deficiencies were reasons for study design selection and describing the included studies in adequate detail. None of the included SRs fulfilled all the AMSTAR-2 criteria. Regarding the certainty of the evidence, only six (16.2%) SRs reported the certainty of evidence for the primary outcomes.
3.4 Methodological quality of the primary studies included in the SRs
The Cochrane Risk of Bias tool (RoB) was the most-used tool to determine methodological quality of the primary studies (62.2%), while 10 (24.3%) SRs only provided a narrative discussion of quality, and five (13.5%) SRs did not assess RoB. Most review authors noted that results should be interpreted with caution due to methodological study limitations.
3.5 Overlap assessment
The 37 included SRs comprised a total of 246 individual primary studies. The overall CCA, considering all SRs and all primary studies included in the reviews, was 1.0% (slight overlap). Supplementary material 5 provides a detailed assessment of the overall overlap among SRs.
Six of 17 comparisons regarding VAP outcomes included at least two SRs. Considering only SRs and primary studies providing data for each specific comparison, the overall CCA and detailed CCA by pair of reviews were very high for all the comparisons. For example, comparison 1.1.1 includes four SRs, comprising a total of 17 individual primary studies. Of these, seven were included in all SRs. This is reflected in the detailed overlap assessment, which shows that all SRs have a CCA of at least 47.1% (very high overlap).
One comparison regarding the incidence of delirium included four SRs and the overlap assessment was high (10.3%). Two comparisons regarding reintubation outcomes included at least two SRs, and the overlap assessment was high for the comparison of high flow nasal cannula (HFNC) versus conventional oxygen therapy (COT) and very high for the comparison noninvasive ventilation (NIV) versus conventional oxygen therapy (Supplementary material 6).
For other AEs studied, comparisons included only one SR; therefore, no overlap assessment was possible.
3.6 Effects of patient-safety interventions
3.6.1 Ventilator-associated pneumonia
3.6.1.1 Incidence of VAP
VAP definition varied among the studies depending on the diagnosis criteria used. Eight SRs considered VAP according to clinical, laboratory, and imaging findings, and three SRs did not provide this information.
Multimodality respiratory physiotherapy reduces mortality but may not prevent ventilator-associated pneumonia or reduce length of stay in the intensive care unit: a systematic review.
assessed seven different NPIs for preventing VAP. Subglottic secretion drainage (SSD) compared with no drainage was assessed in four SRs, with a total of 44 RCTs and 10,193 patients. Results showed a statistically significant effect ranging from an OR of 0.48 (95% confidence interval [CI]: 0.38, 0.60) to an OR of 0.55 (95% CI: 0.46, 0.66).
Semirecumbent position compared with supine position was evaluated in two SRs
with 11 RCTs and 1096 patients. Results showed a statistically significant effect ranging from an OR of 0.42 (95% CI: 0.29, 0.59) to an OR of 0.47 (95% CI: 0.27, 0.82). Only one of them
and showed a statistically significant reduction in the incidence of VAP: (OR: 0.38; 95% CI: 0.28, 0.52). This effect was based on a total of 10 RCTs and 967 patients. The other comparison showed no differences between the experimental and control group for this outcome (Fig. 2a) .
Fig. 2Forest plot of the influence of non-pharmacological interventions to reduce ventilator-associated pneumonia (VAP). (a) Incidence of VAP. (b) ICU mortality related to VAP. (c) Hospital mortality related to VAP. CI = confidence interval; ICU, intensive care unit; SSD = subglottic secretion drainage.
Multimodality respiratory physiotherapy reduces mortality but may not prevent ventilator-associated pneumonia or reduce length of stay in the intensive care unit: a systematic review.
Multimodality respiratory physiotherapy reduces mortality but may not prevent ventilator-associated pneumonia or reduce length of stay in the intensive care unit: a systematic review.
and showed a statistically significant reduction in the ICU mortality related to VAP (OR: 0.67; 95% CI: 0.47, 0.96). This effect was based on five RCTs and 603 patients. The other comparison showed no differences between the experimental and control group for this outcome (Fig. 2b).
3.6.1.3 Hospital mortality related to VAP
Five experimental interventions for preventing hospital mortality related to VAP were assessed in eight SRs;
was SSD compared with no drainage, with a total of 35 RCTs and 8520 patients. Measures of effect ranged from an OR of 0.91 (95% CI: 0.73, 1.13) to an OR of 1.03 (95% CI: 0.80, 1.32) (Fig. 2c).
S.,et al. Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis.
Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: a systematic review and network meta-analysis.
Effects of nonpharmacological delirium-prevention interventions on critically ill patients' clinical, psychological, and family outcomes: a systematic review and meta-analysis.
assessed interventions to prevent delirium. Some authors compared environmental intervention (changes in light or sound/hearing) vs usual care in 26 RCTs. Results were not significant, ranging from an OR of 0.83 (95% CI: 0.49, 1,41) to an OR of 1.22 (95% CI: 0.92, 1.62). Only one of them
Effects of nonpharmacological delirium-prevention interventions on critically ill patients' clinical, psychological, and family outcomes: a systematic review and meta-analysis.
found that earplug use was associated with a lower incidence of delirium than usual care: an OR of 0.59 (95% CI: 0.44, 0.79). This effect was based on five RCTs and 832 patients.
grouped different NPIs and found these were effective in reducing incidence of delirium with an OR of 0.66 (95% CI: 0.50, 0.87). This effect was based on 14 studies (cohort and RCTs) and 3372 patients.
Effects of nonpharmacological delirium-prevention interventions on critically ill patients' clinical, psychological, and family outcomes: a systematic review and meta-analysis.
found that early mobilisation (moderate-certainty evidence), family participation (moderate-certainty evidence), and music (low-certainty evidence) have a statistically significant effect on decreasing delirium incidence.
S.,et al. Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis.
Systematic early versus late mobilization or standard early mobilization in mechanically ventilated adult ICU patients: systematic review and meta-analysis.
assessed muscle strength at ICU discharge using the Medical Research Council scale and physical function using the Barthel Index or Short Form (SF-36) questionnaire to measure mobility–disability. We could not pool results from those SRs because the interventions assessed were different.
assessed physical functional status and muscle strength using the WHO International Classification of Functioning, Disability and Health. Physical rehabilitation in the ICU was assessed in comparison to usual care, and the experimental group demonstrated an improvement in muscle strength (mean difference (MD): 8.62; 95% CI: 1.39, 15.86).
For early or systematic mobilisation compared with late or standard care, authors
Systematic early versus late mobilization or standard early mobilization in mechanically ventilated adult ICU patients: systematic review and meta-analysis.
Effects of rehabilitation interventions on clinical outcomes in critically ill patients: systematic review and meta-analysis of randomized controlled trials.
High-flow nasal cannula compared with conventional oxygen therapy or noninvasive ventilation immediately postextubation: a systematic review and meta-analysis.
Effect of high-flow nasal cannula oxygen therapy versus conventional oxygen therapy and noninvasive ventilation on reintubation rate in adult patients after extubation: a systematic review and meta-analysis of randomized controlled trials.
Preventive use of respiratory support after scheduled extubation in critically ill medical patients-a network meta-analysis of randomized controlled trials.
assessed two different NPIs for preventing reintubation. HFNC compared with conventional oxygen therapy was assessed in six RCTs and 1558 patients. Results showed a statistically significant effect ranging from an OR of 0.35 (95% CI: 0.19, 0.64) to an OR of 0.78 (95% CI: 0.62, 0.98). The certainty of the evidence was moderate for two reviews
High-flow nasal cannula compared with conventional oxygen therapy or noninvasive ventilation immediately postextubation: a systematic review and meta-analysis.
Preventive use of respiratory support after scheduled extubation in critically ill medical patients-a network meta-analysis of randomized controlled trials.
Effect of high-flow nasal cannula oxygen therapy versus conventional oxygen therapy and noninvasive ventilation on reintubation rate in adult patients after extubation: a systematic review and meta-analysis of randomized controlled trials.
HFNC-compared NIVs included seven RCTs and 1839 patients. Results did not demonstrate statistically significant effects on decreasing intubation rate, ranging from an OR of 0.82 (95% CI: 0.61, 1.10) to an OR of 1.19 (95% CI: 0.87, 1.63). NIV compared with conventional oxygen therapy was assessed in nine trials, and results did not show a statistically significant effect (OR: 0.62; 95% CI: 0.46, 0.84, moderate-certainty evidence) (Fig. 4a).
Fig. 4Forest plot of the influence of non-pharmacological interventions to reduce reintubation. (a) Rate of reintubation. (b) ICU mortality related to reintubation. (c) Hospital mortality related to reintubation. CI = confidence interval; NPI = nonpharmacological interventions; ICU = intensive care unit; SSD = subglottic secretion drainage; HFNC = high flow nasal cannula; COT = conventional oxygen therapy; NIV = noninvasive ventilation.
Effect of high-flow nasal cannula oxygen therapy versus conventional oxygen therapy and noninvasive ventilation on reintubation rate in adult patients after extubation: a systematic review and meta-analysis of randomized controlled trials.
High-flow nasal cannula compared with conventional oxygen therapy or noninvasive ventilation immediately postextubation: a systematic review and meta-analysis.
Effect of high-flow nasal cannula oxygen therapy versus conventional oxygen therapy and noninvasive ventilation on reintubation rate in adult patients after extubation: a systematic review and meta-analysis of randomized controlled trials.
that compared HFNC with conventional oxygen therapy (OR: 0.89; 95% CI: 0.46, 1.72 to OR: 0.93; 95% CI: 0.57, 1.52; 6RCTs, 1321 participants) and HFNC with NIV (OR: 1.09; 95% CI: 0.79, 1.50 to OR: 1.14; 95% CI: 0.82, 1.58; 5 RCTs, 1284 participants). Results had no statistically significant effects. Only one SR, for each comparison, reported certainty evidence, and it was graded as moderate (Fig. 4c).
3.6.5 Medication error
All SRs examining medication error (ME) included RCTs and NRCTs. We found that pharmaceutical intervention vs usual care did not show significant effects.
However, computerised physician order entry system vs paper-based ordering was associated with a significant reduction in MEs, with an RR of 0.71 (95% CI: 0.68–0.75).
Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis.
Heat and moisture exchangers (HMEs) and heated humidifiers (HHs) in adult critically ill patients: a systematic review, meta-analysis and meta-regression of randomized controlled trials.
including 14 RCTs and 2125 patients. Results were statistically significant, favouring headted water humidifier with an OR of 2.51 (95% CI: 1.27, 4.95), but there were no differences in the prevention of hospital-acquired pneumonia.
Endotracheal tapered cuffs vs endotracheal nontapered cuffs were also assessed in one SR,
Prevention of ventilator-associated and early postoperative pneumonia through tapered endotracheal tube cuffs: a systematic review and meta-analysis of randomized controlled trials.
which included six RCTs and 1324 patients, for prevention of ICU mortality related to hospital-acquired pneumonia, but results were not statistically significant.
found that results were not statistically significant when only RCTs were pooled.
3.6.8 Pressure injury
Two SRs were included; one of them compared reactive bed surface with a standard mattress, and the other compared pre-early with post-early mobility programs to reduce pressure injury incidence. No one showed statistically significant results, and findings were inconclusive due to the differences in clinical characteristics and length of stay of patients.
There were other interventions to prevent AEs (tube displacement and tube occlusion), but we found few SRs included for each one. The individual results of them are summarised in Supplementary material 7.
4. Discussion
To the best of our knowledge, this is the first overview to systematically summarise and assess the quality of SRs and overlap of primary studies on NPIs for preventing AEs in ICU patients. We included 37 SRs of NPIs that evaluated 27 patient-safety interventions to reduce 11 different AEs.
We found the overall confidence of results based on the AMSTAR-2 was critically low because 73.7% of the SRs included had important methodological quality limitations. The main failures in critical domain assessment were reporting without a registered protocol, inadequacy of the literature search, and lack of justification for excluding studies, remaining the unawareness of the reason for their exclusion.
Higgins J.P.T. Thomas J. Chandler J. Cumpston M. Li T. Page M.J.W.V. Cochrane Handbook for systematic reviews of interventions | Cochrane training. 2021
Despite a slight overall overlap for the overview as a whole, our overlap assessment at the outcome level showed a high and very high overlap for 12 comparisons. This overlapping raises awareness of redundant SRs publications in this area.
However, from seven types of NPIs, only three showed significant effects in reducing the incidence of VAP: subglottic secretion, elevating the head of the patient, and kinetic bed therapy. A literature review also found other pharmacological interventions but concluded that these implemented practices should be reviewed due to the low level of evidence.
Many included SRs showed a reduction in the incidence of delirium. Early mobilisation showed a significant effect on preventing delirium; this finding is consistent with a previous clinical practice guideline that recommend performing early mobilisation of adult ICU patients whenever feasible to reduce the incidence of delirium.
Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: a systematic review and network meta-analysis.
Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: a systematic review and network meta-analysis.
Effects of nonpharmacological delirium-prevention interventions on critically ill patients' clinical, psychological, and family outcomes: a systematic review and meta-analysis.
In fact, our findings are supportive of international guidelines, suggesting the use of NPIs as part of a multimodal approach, especially in the management of delirium.
Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
We have not included guidelines or health technology assessments in our search; therefore, possible SRs have not been identified. We have found two guidelines, Devlin et al. (update of the Barr et al. guideline) and DAS-TASK 2015
Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-guideline 2015) – short version.
that performed SRs to answer questions and made recommendations. The guideline of Devlin et al. addresses the management of pain, agitation/sedation, delirium, immobility, and sleep disruption, whereas the guideline of DAS-TASK 2015 tackles the management of delirium, analgesia, and sedation. Our overview agrees with these two guidelines in evaluating the nonpharmacological preventive measures to avoid delirium and the effects of immobility. We agree on the inclusion of most primary studies, except for the benefits of rehabilitation and mobilisation, of which Devlin included 16 RCTs, whereas we included 12 RCTs. However, the evidence was very similar.
Patients’ physical rehabilitation and active mobilisation on their own combined with therapy prevents physical deterioration. However, some authors suggest that best outcomes in physical function are associated with good pain management, awakening, and breathing coordination, delirium management, and early exercise/mobility.
Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
Identifying barriers to delivering the awakening and breathing coordination, delirium, and early exercise/mobility bundle to minimize adverse outcomes for mechanically ventilated patients: a systematic review.
HFNC or NIV compared to conventional oxygen therapy reduced the rate of reintubation, but there were no significant effects on ICU or hospital mortality. The certainty evidence varied among reviews from low to high. These findings are consistent with European Respiratory guidelines regarding the NIV in patients at high risk of reintubation as a conditional recommendation, given the low certainty of evidence.
Rochwerg B., Brochard L., Elliott M.W., Hess D., Hill N. S. Nava S., et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure TASK FORCE REPORT ERS/ATS GUIDELINES. Eur Respir J 2017;50:1602426. doi:10.1183/13993003.02426-2016.
Furthermore, the European Society of Intensive Care Medicine made a conditional recommendation for HFNC following extubation (moderate certainty) in reducing rates of reintubation.
We found that in the ICU setting, the use of a computerised physician order entry system reduces the risk of general medication errors compared with paper-based ordering. However, computerised physician order entry systems are implemented in only about one-third of hospitals. Further research is needed to better characterise links to patient harm.
We only found one SR that indicated that headted water humidifier significantly reduced the incidence of artificial airway occlusion. However, due to the small number of studies included and the low quality of this evidence, it is difficult to be confident about this finding.
Similarl to our findings, other authors have affirmed that there is little evidence on the effects of interventions to prevent HAIs such as infection control programs.
Even our findings on using reactive bed surfaces or implementing a pre-early mobility programme did not show benefits in reducing pressure injuries; the European guideline for prevention and treatment of pressure ulcers remarks that those can be a preventive measure. However, the strength of the recommendation is weak. Moreover, early mobilisation in critical patients is based on good practice statements that are not supported by evidence to be significant for clinical practice.
While it is true that preventing AEs should be considered a patient safety goal, comfort is the principal consideration in supportive care, especially in critical patients.
Norton L., Parslow N., Johnston D., Ho, C., Afalavi, A., Mark, M., et al. Best practice recommendations for the prevention and management of pressure injuries. Foundations of best practice for skin and wound management. A supplement of wound care Canada; 2017. Published online.
We did not search for potential SRs included in the guidelines published; thus, information on other nonpharmacological preventive interventions may have been omitted. Furthermore, our overview is limited by the methodological quality of the SRs and its included primary studies. Results are presented descriptively using findings from SRs, but we did not conduct a meta-analysis grouping data. Participants among SRs included were heterogeneous. Even when patients were in the adult ICU, they had a wide variety of diseases, patient characteristics, reasons for ICU admission, and variation in standard intensive care practices. Furthermore, not all comparisons reported certainty of evidence, which limited drawing conclusions about NPIs.
The main strength is that the overview was carried out rigorously following the Cochrane methodology, with an updated comprehensive literature search, prespecified criteria for searching and analysis, and the selection and quality assessment of included studies evaluated independently by two authors.
Studies should be better conducted and reported to provide adequate information on preventive interventions focused on patient safety and outcomes. Future SRs should be properly designed and conducted using the AMSTAR-2 checklist, principally by providing a research protocol, performing study selection and data extraction in duplicate, providing a list of both included and excluded studies, and assessing the risk of bias in the primary studies. Moreover, we need to synthesise other types of interventions to prevent AEs, including pharmacological intervention, educational programs, and multicomponent interventions, as well as focus the intervention on patient outcomes. Some AEs studied in this overview are not yet included in standard documents or considered quality indicators to optimise patient care. Therefore, our findings could be considered in developing or updating clinical practice guidelines to prevent AEs.
One major limitation to this project is that the search strategy did not include professional guidelines that were constructed using the process of systematic review where the term 'systematic review' was not in the title. Readers are cautioned to search for guidelines and review those in addition to this summary prior to making practice changes. Future authors are cautioned to filter the search strategy by 'systematic review' instead of searching for the words 'systematic review' in the title as it is now standard practice for professional guidelines to be written using the process of systematic review.
5. Conclusions
We found some nonpharmacological interventions reduced AEs in an intensive care setting. A significant effect was found for SSD, semirecumbent position, and kinetic bed therapy in reducing the incidence of VAP; for the use of earplugs, early mobilisation, family participation, and music in reducing delirium; for physical rehabilitation in improving muscle strength; for the use of respiratory support in preventing reintubation; for use of a computerised physician order entry system in reducing ICU mortality related to medication errors; and for the use of headted water humidifier in reducing artificial airway occlusion. However, the findings are questionable due to the variety of patient characteristics, lack of certainty of evidence reported, the very high overlap for some comparisons, and the critically low quality of SRs included, making it difficult to be confident about them. In situations where strength of the evidence to support the evidence is low, clinical leaders are advised to deploy an evidence-based practice model when translating these interventions into practice to monitor quality outcomes. SRs about preventing AEs in the ICU should adhere to quality assessment tools so that best evidence can be used with greater confidence in decision-making.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sector.
Credit authorship contribution statement
Stefanie Suclupe: Conceptualisation, Writing - original draft, Formal analysis, Data curation, Writing - review & editing
Maria Jose Martinez–Zapata: Conceptualisation, Supervision, Writing - original draft, Formal analysis, Data curation, Writing - review & editing.
All authors approved the final version of the study.
Conflict of interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Ethical statement
Ethical statement not applicable the authors undertook a systematic review, no ethical statements to declare.
Stefanie Suclupe is a doctoral candidate at the Methodology of Biomedical Research and Public Health Program, Universitat Autònoma de Barcelona, Spain. Maria José Martinez Zapata is funded by a Miguel Servet research contract (CPII20/00023), Percy Efrain Pantoja by a Rio Hortega research contract (CM19/00168), and Angela Merchan-Galvis by a predoctoral research contract (FI17/00190) from the Instituto de Salud Carlos III.
Appendix A. Supplementary data
The following is/are the Supplementary data to this article:
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