Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis.

OBJECTIVE: To determine whether critical care transition programs reduce the risk of ICU readmission or death, when compared with standard care among adults who survived their incident ICU admission. DATA SOURCES: MEDLINE, EMBASE, CENTRAL, CINAHL, and two clinical trial registries were searched from inception to October 2012. STUDY SELECTION: Studies that examined the effects of critical care transition programs on the risk of ICU readmission or death among patients discharged from ICU were selected for review. A critical care transition program included any rapid response team, medical emergency team, critical care outreach team, or ICU nurse liaison program that provided follow-up for patients discharged from ICU. DATA EXTRACTION: Two reviewers independently extracted data on study characteristics, transition program characteristics, and outcomes (number of ICU readmissions and in-hospital deaths following discharge from ICU). DATA SYNTHESIS: From 3,120 citations, nine before-and-after studies were included. The studies examined medical-surgical populations and described transition programs that were a component of a hospital's outreach team (n = 6) or nurse liaison program (n = 3). Meta-analysis using a fixed-effect model demonstrated a reduced risk of ICU readmission (risk ratio, 0.87 [95% CI, 0.76-0.99]; p = 0.03; I2 = 0%) but no significant reduction in hospital mortality (risk ratio, 0.84 [95% CI, 0.66-1.05]; p = 0.1; I2 = 16%) associated with a critical care transition program. The risk of ICU readmission was similar whether the transition program was included within an outreach team or a nurse liaison program and did not depend on the presence of an intensivist. CONCLUSIONS: Critical care transition programs appear to reduce the risk of ICU readmission in patients discharged from ICU to a general hospital ward. Given methodological limitations of the included before-and-after studies, additional research should confirm these observations and explore the ideal model for these programs before recommending implementation.

Estudo de segurança e eficácia da enoxaparina sódica na profilaxia e terapêutica antitrombótica / Safety and efficacy of sodium enoxaparin in anti-thrombotic prophylaxis and treatment

JUSTIFICATIVA E OBJETIVOS: O uso de heparina de baixo peso molecular (HBPM) na profilaxia ou terapêutica de diversas doenças ou síndromes é de grande importância na prática clínica. O objetivo deste estudo foi avaliar a segurança e a eficácia da enoxaparina sódica, teste (ENOX-T) comparada ao medicamento de referência (ENOX-R). MÉTODO: Foi realizado estudo prospectivo, aleatório, comparativo, unicêntrico e aberto envolvendo pacientes com indicação de profilaxia ou tratamento antitrombótico. Foram incluídos 100 pacientes divididos em 2 braços: profilático (n = 50) e terapêutico (n = 50) divididos em 2 grupos para cada braço (grupo 1: ENOX-R e grupo 2: ENOX-T). Analisou-se em cada segmento os dados clínicos e laboratoriais. A atividade do anti-fator Xa foi aferida em três momentos: basal (1ª avaliação); 1º ou 2º dia (2ª avaliação) e 5º a 7º dia (3ª avaliação). O ultra-som Doppler dos membros inferiores foi realizado na 2ª ou 3ª avaliação do braço profilático. RESULTADOS: Os resultados demonstraram homogeneidade dos grupos nos 2 braços (profilático e terapêutico) quanto a sexo, idade, índice de massa corpórea, creatinina sérica e Apache II. Os valores do anti-fator Xa nos braços profilático e terapêutico demonstraram eficácia adequada dos medicamentos, sem diferença clínica ou estatística entre ambos. A ocorrência de eventos adversos não mostrou diferença clínica ou estatística entre os medicamentos. No braço profilático o ultra-som de membros inferiores acrescentou informações úteis sobre a eficácia dos fármacos estudados. CONCLUSÕES: A enoxaparina sódica teste (ENOX-T) foi segura e eficaz nos pacientes analisados e equivalente ao medicamento de referência (ENOX-R).

BACKGROUND AND OBJECTIVES: Use of low molecular weight heparins (LMWH), either prophylactic or therapeutic, is of most importance in several syndromes and diseases in daily clinical practice. Our objective in this clinical trial was to evaluate safety and efficacy of test sodium enoxaparin (ENOX-T) compared to the reference drug (ENOX-R). METHODS: We conducted a prospective, randomized, comparative, unicentric and open-labeled trial including patients with either prophylactic or therapeutic anti-thrombotic indications. A total of 100 patients were enrolled in two branches: prophylactic (n=50) and therapeutic (n=50) and two groups for each branch (group 1: ENOX-R and group 2: ENOX-T). We analyzed clinical and laboratory data in each segment. Anti-factor Xa was measured in three different moments: baseline (1st evaluation); 1st or 2nd day (2nd evaluation) and 5th to 7th day (3rd evaluation). Doppler-sonography of inferior limbs was performed on all patients in prophylactic group on 2nd or 3rd evaluation. RESULTS: The data showed that both branches (prophylactic and therapeutic) were homogenous in regard of sex, age, body mass index (BMI), serum creatinine and APACHE II severity score at admission. Anti-factor Xa results, in both prophylactic and therapeutic branches, showed expected efficacy to both drugs, without any clinical or statistical difference between them. Adverse events incurred in both groups in a similar way, without any clinical or statistical difference between them. In prophylactic branch, Doppler-sonography of inferior limbs added useful information on drugs efficacy. CONCLUSIONS: We conclude that test sodium enoxaparin (ENOX-T) was effective and safe in our patient's cohort and equivalent to reference drug (ENOX-R).

[Safety and efficacy of sodium enoxaparin in anti-thrombotic prophylaxis and treatment]. / Estudo de segurança e eficácia da enoxaparina sódica na profilaxia e terapêutica antitrombótica.

BACKGROUND AND OBJECTIVES: Use of low molecular weight heparins (LMWH), either prophylactic or therapeutic, is of most importance in several syndromes and diseases in daily clinical practice. Our objective in this clinical trial was to evaluate safety and efficacy of test sodium enoxaparin (ENOX-T) compared to the reference drug (ENOX-R). METHODS: We conducted a prospective, randomized, comparative, unicentric and open-labeled trial including patients with either prophylactic or therapeutic anti-thrombotic indications. A total of 100 patients were enrolled in two branches: prophylactic (n=50) and therapeutic (n=50) and two groups for each branch (group 1: ENOX-R and group 2: ENOX-T). We analyzed clinical and laboratory data in each segment. Anti-factor Xa was measured in three different moments: baseline (1st evaluation); 1st or 2nd day (2nd evaluation) and 5th to 7th day (3rd evaluation). Doppler-sonography of inferior limbs was performed on all patients in prophylactic group on 2nd or 3rd evaluation. RESULTS: The data showed that both branches (prophylactic and therapeutic) were homogenous in regard of sex, age, body mass index (BMI), serum creatinine and APACHE II severity score at admission. Anti-factor Xa results, in both prophylactic and therapeutic branches, showed expected efficacy to both drugs, without any clinical or statistical difference between them. Adverse events incurred in both groups in a similar way, without any clinical or statistical difference between them. In prophylactic branch, Doppler-sonography of inferior limbs added useful information on drugs efficacy. CONCLUSIONS: We conclude that test sodium enoxaparin (ENOX-T) was effective and safe in our patient's cohort and equivalent to reference drug (ENOX-R).