Routine critical care step‐down programmes: Systematic review and meta‐analysis

Abstract

Background Patients discharged from critical care to general hospital wards are vulnerable to clinical deterioration, critical care readmission, and death. In response, routine critical care stepdown programmes (CCSDPs) have been widely developed, which involve the review of all patients on general wards following discharge from critical care by multidisciplinary Outreach teams with critical care skills. Aims and objectives This review aims to answer the question: do routine CCSDPs reduce readmission and/or mortality among patients discharged from critical care? Design Systematic review of quantitative studies and meta‐analysis. Methods Six databases were comprehensively searched from inception (CENTRAL, Cochrane Reviews, MEDLINE, Embase, CINAHL and web of Science), alongside grey literature and trial registers. Studies investigating the effect of routine CCSDPs delivered by Outreach nurses on readmission and/or mortality following discharge from adult critical care to general hospital wards were included. Study quality was assessed using the Cochrane ROBINS‐I tool. Results Eight studies met the inclusion criteria, with data from 6 studies pooled in 3 meta‐analyses. Among patients exposed to routine CCSDPs, pooled data estimated a statistically nonsignificant reduction in the risk of readmission to critical care (risk ratio [RR] 0.85; 95% confidence interval [CI] 0.66‐1.09; P = .19), a statistically significant increase in the risk of readmission to critical care within 72 hours (RR 1.49; 95% CI 1.05‐2.12; P = .03), a statistically non‐significant reduction in risk of mortality following critical care discharge (RR 0.90; 95% CI 0.75‐1.07; P = .22), and no association with mortality within 14 days of discharge. Conclusion This review is unable to definitively conclude whether routine CCSDPs reduce critical care readmission or mortality following critical care discharge. Relevance to clinical practice While the synthesized evidence does not suggest a change in policy and practice are warranted, neither does it support routine CCSDPs in the absence of high‐quality evidence.

Integrating Step-down Care in Community-based Paediatric Palliative Services: A Realist Evaluation

“…In response to care gaps and client feedback, Star PALS initiated a progressive step-down programme called COMET from November 2020. Modelled after strategies from Intensive Care Units [10,11], the programme targeted those: (i) without pressing specialist PPC requirements; (ii) with longer expected survival; (iii) demonstrating variable care needs; and (iv) lacking appropriate community follow-up options. COMET involved lower-intensity management within specialist PPC services for enrolled patients—reducing consultation (home visits) frequency and access to certain benefits, while preserving crucial crisis assistance, emergency visits, medication access, and remote support.…”

What's in this issue?

“…In the more immediate post‐ICU period, Tanner and Cornish examined the effect of routine step‐down services on post‐ICU in‐hospital outcomes in their international systematic review and meta‐analysis 6 . Routine visits from Critical Care Outreach Practitioners to patients recently discharged from ICU have been adopted by many UK National Health Service trusts, and are supported by current UK Guidelines for the Provision of Intensive Care Services in adults 7 .…”