Review: patients in nursing-led units are better prepared for discharge than those receiving usual care
Correspondence to: Dr P Griffiths, King’s College London, London, UK;
Are nursing-led inpatient units (NLUs) more effective than usual inpatient care in preparing patients for discharge?
Medline, CINAHL, EMBASE/Excerpta Medica, Cochrane Library, Healthcare Management Information Consortium database, and British Nursing Index (to November 2006); Cochrane Effective Practice and Organisation of Care Group’s specialised register (to October 2006); ISI Web of Knowledge (to January 2007); and experts.
Study selection and assessment:
controlled trials that compared nurse-managed care in an NLU with usual inpatient care on a general acute hospital ward (managed by physicians) in adult patients after acute admission for any physical health condition. NLU care must have been a substitute for some or all of the acute hospital stay, rather than an addition to it. 8 randomised controlled trials (n = 1147), 2 quasi-randomised trials (n = 749), and 1 controlled before–after study met the selection criteria (range of mean ages 64–81 y, 40–86% women). Quality of individual studies was assessed using the criteria of the Cochrane Effective Practice and Organisation of Care Group.
included mortality, discharge to institutional care, functional status at discharge, length of hospital stay, readmission within 30 days, and costs.
Groups did not differ for mortality in hospital or at longest follow-up (⩽6 mo) (table). Patients who received care in an NLU had lower risks of discharge to an institution and hospital readmission within 30 days (table). Mean length of hospital stay was 7.4 (95% CI 2.9 to 12) days longer in the NLU group (8 studies). At discharge, patients who received care in an NLU had better functional status (6 studies). Daily costs were lower for NLU care than for usual care in 6 of 7 studies reporting costs. Total costs of NLU care were higher than for usual care in UK studies but lower in US studies.
After acute admission, patients in nursing-led inpatient units have longer hospital stays but are better prepared for discharge than those receiving usual inpatient care.
Griffiths PD, Edwards MH, Forbes A, et al. Effectiveness of intermediate care in nursing-led in-patient units. Cochrane Database Syst Rev 2007;(2):CD002214.
Clinical impact ratings: Case management 6/7; Elderly care 6/7; General surgery 6/7
Transferring patients to the appropriate level of care is an ongoing issue for acute care hospitals. The updated Cochrane review by Griffiths et al compared the effectiveness of post-acute intermediate care in NLUs with usual inpatient care managed by physicians (or shared management by physicians and nurse practitioners) in preparing patients for discharge from hospital.
NLUs, as described in the review, provide nursing care (rather than active rehabilitation or case management) for patients who no longer require acute care but are not yet ready to be discharged home. In the past, hospital-based case management has failed to reduce length of hospital stay or readmissions in adults.1 Nurses are responsible for all admissions and discharges in NLUs. These units were created to save acute bed days in the UK and US because it was thought that pure nursing units would be less expensive.
For hospitals considering the feasibility of implementing an NLU as a way to reduce costs, it is important to note that in the studies included in this review, the skill mix of the nursing workforce has generally been enriched, although overall numbers may be reduced. Costs of care on the NLU were higher than costs of usual care in the UK but lower in the US; this could be related to differences in nursing skill mix. Service developers would be well advised to consider detailed admission criteria, including medical stability and patient preference, to determine which patients are suitable and likely to benefit from the extended recovery time afforded in an NLU.
Reductions in discharges to institutional care and early readmissions and improvements in functional status are associated with the increased length of stay on an NLU, and these advantages could save money in the long term. Analysis of higher quality studies showed that inpatient mortality may be increased on NLUs; thus, more evidence is needed from well-conducted trials to fully determine the safety of NLUs compared with usual care. The review by Griffiths et al acknowledged the role of nursing in leading intermediate care units, although the role of the interdisciplinary team is essential in all settings (even post-acute care) to prepare patients for safe discharge.