Efficacy of Information interventions in reducing transfer anxiety from a critical care setting to a general ward: A systematic review and a meta-analysis

1. Title:
Authors:
Joanne Brooke, Nazeeha Hasan, Julia Slark, Pankaj Sharma
Ambika Rai

2. Contents
1. Review objectives and questions
2. Selection criteria
3. Searching evidence
4. Research/evidence appraisal
5. Data extraction
6. Data synthesis
7. Conclusion of recommendation

3. Review Objectives and Questions
• Objective
– To carry out a comprehensive systemic review on the
efficacy of information interventions on reducing
anxiety in patients and family members on transfer
from a critical care setting to a general ward
The population (P)Intervention (I)Outcome (O)

4. Selection Criteria
• Study populations: patients and their family members
(not terminally ill; admitted to ICU or CCU followed by a
transfer to a general ward; length of hospital stay ranged
from 1 to 8 days)
• Allocation of participants to intervention or control is
randomly assigned or block intervention
• Interventions: different
• Setting: hospitals

5. Selection Criteria
• Transfer anxiety is measured by the State Trait Anxiety
Inventory (STAI)
• The data should come from randomized controlled trials
(RCT) studies comparing interventions with standard care
• All these studies were detailed publication

6. Selection Criteria
• Limitations
– the authors did not think about the other factors which
would influence the outcomes of research, such as
age (child or adult), gender, relationship of the family
members to the patient, the times of patients’
admission

7. Searching Evidence
• It is good to use five electronic databases (MEDLINE,
EMBASE, CINAHL, Cochrane Database of Systematic
Reviews, and Google Scholar) to search a range of
sources in order to identify an initial set of relevant
studies (health-related bibliographic databases)
• Focus on the hospital’s setting
• Date: from January 1, 1990 to January 1, 2011

8. Searching Evidence
• The authors used full text journals electrical searched,
hand searched, and web searching, but they did not point
out the unpublished papers, citation list and conference
abstracts
• Just search in English  other languages should be
included for convenience in order to examine for internal
validity

9. Searching Evidence
Search words
transfer or anxiety or transfer anxiety or stress
- in conjunction with intensive care unit (ICU) or coronary
care unit (CCU) along with and/or as Boolean operators
•Boolean result can improve the overall search performance
by providing early indication of the quality of the results,
thereby speeding up the iterative query-refinement process

11. Research/ Evidence Appraisal
• Type of research design: high-quality randomized
controlled trials comparing an intervention
• The meta-analysis includes a clearly expressed research
problem and purpose
• A comprehensive search of the literature for eligible
studies conducted (266 studies were searched initially.
Finally, only 5 RCT studies met their inclusion criteria)
• It would be better to understand with flowchart

12. Data Search and Selection

14. Research/ Evidence Appraisal
• The total sample size achieved with the pooling of data
from 5 studies and the sample size is at N=629
• The findings from the statistical results interpreted
including examination of: (1) the benefit of the
intervention, (2) the effect size of the intervention
showing odd ratio (OR) respectively and 95% confidence
interval (CI)

15. Research/ Evidence Appraisal
Not mention
•how many participants in control groups and how many in
experimental groups
•Magnitude of relationships among study variables
•Sensitivity and specificity of diagnostic tools
•Relative risk of outcomes in the treatment versus the
control group

16. Research/ Evidence Appraisal
Comments
•The quality assessment form should be used for the
selection of studies in order to prevent selection bias
•At least two independent researchers have to analyze in
order to find out any discrepancies and reduce selection
bias

17. Data Extraction
• Data were extracted by both dichotomous and
continuous outcomes
– To estimate pooled odds ratios (ORs)
– Weighted mean difference (WMD) for continuous data
– WMD measured the difference in means of each study
between the groups by using the same scale,
measured all outcomes

18. Data Extraction
• The degree of agreement between the reviewers was not
stated
• A previously piloted data should be included for data
collection form and for reviewers
• Used standardized data abstraction table to provide a
detailed discussion of issues arising from the conduct of
the review
• Clearly provide the limitations of this SR （ useful for
further researcher to plan carefully ）

19. Data Synthesis
• Data analysis: using Comprehensive Meta Analysis
v2.2.023
• Heterogeneity was tested using chi-square
– homogeneity and heterogeneity were found and meta-analysis was
still used in this article because of random effect
• Data were extracted to estimate standard Mean
differences (SMDs), pooled odds ratios (OR), and 95% CIs
using both and random effect model
• Fixed model and random effect were used

21. Data Synthesis
• Liaison nurse intervention study was excluded because
mean and SD could not be derived due to reporting of
median and interquartile range
• Individualized education intervention was not analyzed as
it already has mean and SD
• The remaining 3 studies were further analyzed for OR,
confidence interval (CI) and P value
• Did not mention about the missing data/risk of bias

22. Conclusion of Recommendations
• Informative interventions (pre-transfer family conference,
transfer letter, and individualized transfer methods) are
helpful in reducing patients and family members’ anxiety
• The results are valid and conclusions are consistent with
the results and directions  for further research
• The results are expressed clearly with implications for
clinical practice like recommending all ICU departments
to provide appropriate written and oral information before
transfer

24. Conclusion of Recommendations
• A lack of referenced definitions for the independent
variables is highlighted in the quality assessment which
may have introduced information bias and furthermore
affected the external validity and reproducibility of the
studies and made cross-comparison of the studies
questionable

25. Conclusion of Recommendations
• They conclude the separating adult and children does not
make any different in the result because of small number
of studies in each group
• Not mentioned about the adequacy of overall sample size
for meta-analysis

26. Any question or comment…