Researchers can use a range of strategies to improve responses from electronic surveys, including sending up to three reminders, personalising each email, adding the updated response rate to reminder emails, and stating the average time it would take to complete the survey in the title of the email.

Summary Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta‐analysis to assess hospital re‐admission rates following critical care admission and to explore potential re‐admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re‐admission and critical illness, limited to the English language. Two reviewers independently applied eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. The primary outcome was acute hospital re‐admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta‐analysis. The analysis incorporated data from 3,897,597 patients and 741,664 re‐admission episodes. Pooled estimates for hospital re‐admission after critical illness were 16.9% (95%CI: 13.3–21.2%) at 30 days; 31.0% (95%CI: 24.3–38.6%) at 90 days; 29.6% (95%CI: 24.5–35.2%) at six months; and 53.3% (95%CI: 44.4–62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factors were associated with excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection after hospital discharge. Hospital re‐admission is common in survivors of critical illness. Careful attention to the management of pre‐existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at‐risk critical care survivors can reduce the risk of subsequent rehospitalisation.

Under recognition and poor assessment of alcohol use can have major implications for critically ill patients.

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BackgroundNational Institute for Health and Care Excellence (NICE) guidelines on intravenous fluid prescribing for adults in hospital, issued in 2013, advised less use of 0.9% sodium chloride than current practice, provided a logical system for prescribing and suggested further study of electrolyte abnormalities.AimsTo describe the steps taken to establish and monitor guideline introduction and to assess effects on clinical biochemistry results, in a general hospital setting.MethodsWe used established principles of change to modify education, teaching, record keeping and audit throughout the hospital, changed the availability of intravenous fluid preparations in the wards and monitored the use of intravenous fluids. We anonymously linked local clinical chemistry records to nationally available patient records (NHS Scotland SMR01). We chose specified medical emergencies, and major emergency and elective general and orthopaedic surgery, where management would require intravenous fluids, for a two-phase cross-sectional study between 2007 and 2017, spanning the change in prescribing. Primary outcomes were abnormal bicarbonate, sodium, potassium and incidence of acute kidney injury (AKI), and secondary outcomes were mortality and length of stay.ResultsOver the study period, sodium chloride 0.9% use decreased by 75%, and overall intravenous fluid use decreased from 0.65 to 0.40 L/occupied bed day. The incidence of acidosis decreased from 7.4% to 4.8% of all admissions (difference −2.7%, 95% CI −2.1 to −3.0). No important changes in other electrolytes were noted; in particular, plasma sodium values showed no adverse effects. Stage 1 AKI increased from 6.7% to 9.0% (difference 2.3%, 95% CI 1.6 to 3.0), but other causes for this cannot be excluded. Mortality and length of stay showed no adverse effects.Conclusions and implicationsEffective implementation of the guidelines required substantial time, effort and resource. NICE suggestions of fluid types for maintenance appear appropriate, but prescribed volumes continue to require careful clinical judgement.