Effectiveness of intermediate care in nursing-led in-patient units

 

Abstract

Background

The Nursing led inpatient Unit (NLU) is one of a range of services that have been considered in order to manage more successfully the transition between hospital and home for patients with extended recovery times. This is an update of an earlier review published in The Cochrane Library in Issue 3, 2004.

Objectives

To determine whether nursing-led inpatient units are effective in preparing patients for discharge from hospital compared to usual inpatient care.

Search methods

We searched The Cochrane Library, the Specialized Register of the Cochrane Effective Practice and Organisation of Care (EPOC) group, MEDLINE, CINAHL, EMBASE, BNI and HMIC databases. Citation searches were undertaken on the science and social science citation indices. Authors were contacted to identify additional data. The initial search was done in January 2001. The register search was updated in October 2006, the other database searches were updated in November 2006 and the citation search was run in January 2007.

Selection criteria

Controlled trials and interrupted time series designs that compared the NLU to usual inpatient care managed by doctors. Patients over 18 years of age following an acute hospital admission for a physical health condition.

Data collection and analysis

Two reviewers independently extracted data and assessed study quality.

Main results

Ten random or quasi-random controlled trials reported on a total of 1896 patients. There was no statistically significant effect on inpatient mortality (OR 1.10, 95% CI 0.56 to 2.16) or mortality to longest follow up (OR 0.92, 95% CI 0.65 to 1.29) but higher quality studies showed a larger non-significant increase in inpatient mortality (OR 1.52, 95% CI 0.86 to 2.68). Discharge to institutional care was reduced for the NLU (OR 0.44 95% CI 0.22 to 0.89) and functional status at discharge increased (SMD 0.37, 95% CI 0.20 to 0.54) but there was a near significant increase in inpatient stay (WMD 5.13 days 95% CI -0.5 days to 10.76 days). Early readmissions were reduced (OR 0.52 95% CI 0.34 to 0.80). One study compared a NLU for the chronically critically ill with ICU care. Mortality (OR 0.62 95% CI 0.35 to 1.10) and length of inpatient stay differ did not differ (WMD 2 days, 95% CI 10.96 to -6.96 days). Early readmissions were reduced (OR 0.33 95% CI 0.12 to 0.94). Costs of care on the NLU were higher for UK studies but lower for US based studies.

Authors' conclusions

There is some evidence that patients discharged from a NLU are better prepared for discharge but it is unclear if this is simply a product of an increased length of inpatient stay. No statistically significant adverse effects were noted but the possibility of increased early mortality cannot be discounted. More research is needed.

 

Plain language summary

Effectiveness of intermediate care in nursing-led in-patient units

Patients who suffer an acute illness and are admitted to hospital are often admitted into an acute care ward with many services provided. But while recovering from the illness they may not need those intense services and will need to prepare to go home. Nursing led inpatient units, which are managed by nurses as opposed to physicians, have been designed to prepare patients for home. Ten studies, including over 1800 patients, were analysed to determine if patients sent to a nursing led inpatient unit benefited or at least fared no worse than patients in a unit providing usual care. Compared to usual care, patients in nursing led inpatients units functioned better and experienced greater well-being; more patients were discharged home and not to an institution after about 3 months (but not after 6 months); fewer were readmitted back into hospital soon after discharge; but they stayed in hospital longer. The number of deaths during stay in hospital and 3 to 6 months after discharge was similar between the units (but there was a trend for more deaths early while in nursing led inpatients units that needs to be researched further). It is still not known whether nursing led inpatient units save money - studies in the United Kingdom found them more expensive than usual care units but studies in the United States found them cheaper.

 

摘要

背景

護理住院中心之中期照護的效果

護理住院中心(Nursing led inpatient Unit (NLU))是一個範圍的服務，它的考量是為了成功管理需要長時間復原的病患從醫院轉介到居家。這是一篇更新早期發表在考科藍圖書館2004年第3期文章的回顧。

目標

確定護理住院中心對於準備出院病患相較於一般住院照護的效果。

搜尋策略

我們檢索The Cochrane Library，the Specialized Register of the Cochrane Effective Practice and Organisation of Care (EPOC) group，MEDLINE，CINAHL，EMBASE，BNI及HMIC資料庫。採用科學與社會科學引文索引來檢索文獻。聯絡作者以確定其他的資料。2001年1月完成初步的檢索。2006年10月更新記錄的檢索，2006年11月更新其他資料庫的檢索，而2007年1月進行參考文獻的檢索。

選擇標準

比較NLU與由醫師管理之一般住院照護的對照試驗與間斷時間序列分析。18歲以上因為身體健康狀態而急性住院的病患。

資料收集與分析

兩名回顧者分別摘錄資料並評估研究品質。

主要結論

10篇隨機或類隨機對照試驗，報告總數1896名病患的結果。對於住院死亡率(OR為1.10，95% CI為0.56 to 2.16)或最後追蹤時間的死亡率(OR為0.92，95% CI為0.65 to 1.29)沒有統計顯著效果，但品質較高的研究顯示住院死亡率有非顯著性的增加(OR為1.52，95% CI為0.86至2.68)。NLU組病患出院後入住機構照護的風險減少(OR為0.44，95% CI為0.22至0.89)且出院時的功能狀態增加(SMD為0.37，95% CI為0.20至0.54)，住院天數有接近顯著性的增加(WMD為5.13天，95% CI為−0.5天至10.76天)。早期再住院的風險減少(OR為0.52，95% CI為0.34至0.80)。一篇研究比較NLU對於慢性嚴重疾病相較於ICU的照護。死亡率(OR為0.62，95% CI為0.35至1.10)及住院天數沒有差異(WMD為2天，95% CI為10.96至−6.96天)。早期再住院的風險減少(OR為0.33，95% CI為0.12至0.94)。英國的研究顯示NLU的照護成本較高，但美國的研究則顯示較低。

作者結論

有一些證據顯示從NLU出院的病患有較佳的出院準備，但不清楚是否這僅是住院天數增加的結果。沒有發現副作用有統計顯著性，但增加早期死亡率的可能性不能被漠視。需要更多的研究。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

急性疾病患者通常入住急性照護病床並有許多的服務提供。但在疾病康復期間他們也許不需要集中式的服務且可能需要準備出院回家。護理住院中心是由護理人員所管理，而非醫生，其被設計用來使病人準備出院回家。分析10篇研究，包括超過1800名病患，確定是否病患被送到護理住院中心比提供一般照護的中心具有效益或至少不會更糟。相較於一般照護，護理住院中心的病患其功能性較佳且感受較多的福利；有較多的病人出院回家且約三個月後(但不是六個月後)不入住機構式照護；較少的病患在剛出院後又再度入院；但他們住院天數較長。各中心的病患其住院期間及出院後三至六個月的死亡人數是相同的(但護理住院中心有較多早期死亡的人數，這需要進一步研究)。目前仍不清楚是否護理住院中心可以節省經費－英國的研究發現護理住院中心比一般照護中心昂貴，但再美國的研究則發現較便宜。