  discharging patient from intensive care unit ( icu ) is a difficult and complex process 
 because icu nurses need to provide a lot of critical information to patients and delegate 
 many heavy responsibilities to medical - surgical nurses .
moreover , more than one third of patients who are discharged form icu , 
 develop serious complications and are readmitted to icu .
studies have shown that approximately 10% of patients who are discharged 
 from icu are readmitted to this unit before discharging from the hospital .   moreover ,
despite great technological advances in healthcare provision , icu readmission 
 rate has increased during the past two decades .
the netherlands intensive care 
 evaluation committee 2011 reported that a total of 75000 patients have been admitted to icus 
 so far . considering a mean hospital stay of patients in one day , about
1.6 million euros can 
 be saved yearly by decreasing the icu readmission rate by only one percent .  
moreover ; icu readmissions are associated with increased length of hospital stay ( 3547 
 vs. 1621 days ) , elevated mortality rate , and increased risk for developing nosocomial 
 infections . on the other hand , given the growing demand for advanced medical 
 technologies , the increasing number of elderly people with complicated health problems , and 
 the limited number of icu beds , prioritizing icu hospitalizations and using icu equipments 
 in an optimal way are crucial .   accordingly , special attention has been paid in the last decade to developing strategies 
 for improving patient outcomes once getting discharged from icu .
an innovative strategy for these purposes was the introduction 
 of a new nursing role entitled  liaison nurse  .  
liaison nurse strategy was originally designed in 2001 in several hospitals located in 
 australia .
the primary goal of this 
 strategy is the facilitating of post - icu care provision , minimizing post - icu complications , 
 identifying severely - ill patients who need intensive care , and reducing icu readmission and 
 hospital mortality rates .
liaison nurses are 
 expected to manage post - icu care , provide scientific and educational support to other 
 nurses , establish relationship between icu and ward nurses , and provide intensive nursing 
 care to patients who are in medical - surgical wards .
accordingly , they can 
 maintain the continuity and the quality of care which finally improve patient 
 outcomes .
given the novelty of the 
 nurse liaison strategy , few studies have investigated its effects on patient 
 outcomes .
moreover , there are still 
 controversies about the effectiveness of this strategy for improving patient outcomes .
the 
 aim of the study was to investigate the effect of liaison nurse on patient outcomes after 
 icu discharge .
  this was a single blinded randomized controlled trial that the patients did nt know to 
 selecting for which groups of control and intervention .
the study population consisted of all patients who had been recently 
 transferred from icus to medical - surgical wards of two teaching hospitals located in tehran , 
 iran .
sample size was calculated using the altman s nomogram and the results of a study 
 conducted by chaboyer et al .  
accordingly , with considering  of 0.05 ,  of 0.1 , and a power of 0.9 , the sample size was 
 determined to be 40 patients in each group .  
participants were recruited by the convenience sampling and were randomly allocated to 
 either the control or the experimental groups regardless of the hospitals ( figure 1 ) .
flow diagram of subject progress through the phases of randomized trial   the inclusion criteria were having an age of 1885 years , having no cardiac dysrhythmia , 
 and having no immune disorders , leucopenia , or cancer .
if patients developed conditions that 
 the liaison nurse could not or was not privileged to manage , they were excluded from the 
 study .
accordingly , the exclusion criteria were experiencing cardiac arrest and need for 
 resuscitation , developing hemodynamic instability , being transferred to other clinical 
 settings , and discharging from hospital with personal consent .  
patients in the experimental group received the study intervention by researcher for three 
 consecutive days : when patient was transferred from icu to medical - surgical wards , the 
 liaison nurse of the study introduced herself to patient and his or her family members . 

then , she started collecting data about patients condition through reading their medical 
 records .  
moreover , the liaison nurse as researcher monitored patients baseline vital signs and 
 informed them about the characteristics of medical - surgical wards and nurses , how to access 
 nurses in these wards , differences between these wards and icus , and the reason for 
 transferring patients from icu to these wards .
in addition , the liaison nurse taught them 
 about the dietary regimen , the importance of daily self - care activities , and how to cope 
 with new conditions .
the liaison nurse also answered patients questions and helped them to 
 perform their self - care activities .
patients vital signs and clinical conditions were 
 monitored and documented twice a day for three days by a checklist .
medical - surgical nurses 
 were also informed about patients conditions , their care plan , and their educational needs . 

after the intervention , patients vital signs , level of consciousness , length of hospital 
 stay , need for re - hospitalization in icu , and satisfaction with care were measured and 
 documented by the checklist .
the liaison nurse was collected study data by using three tools ; a ) a checklist , b ) the 
 early warning score , and c ) the patient satisfaction instrument .
the patient assessment tool consisted of 
 items on the functions of : the cardiovascular system : heart rate , blood pressure , edema , and capillary filling 
 time ; the nervous system : the history of cerebrovascular accident and the level of 
 consciousness was determined by glasgow coma scale ;   the respiratory system : percutaneous oxygen saturation , body temperature , cough , the 
 color and the volume of sputum ;   the digestive system : route of nutrition , appetite , pattern of elimination , and weight ; 
  the urinary system : the color and the volume of urine and the serum levels of 
 electrolytes , urea , creatinine , albumin , and also fasting and postprandial glucose ;   the musculoskeletal system : mobility , joint mobility and range of motion , independence 
 in doing daily activities , and muscular strength .   
, for the early 
 diagnosis of life - threatening conditions and significant alterations in patients state of 
 health .
ews assesses patient s 
 clinical condition based on items such as respiratory rate , heart rate , level of 
 consciousness , body temperature , and systolic blood pressure .
each item is scored on a 
 four - point scale from zero to three ( figure 2 ) .
the 
 total score of the instrument is interpreted as follows : scores 02 : the nurse continues providing routine care and monitors vital signs every 
 twelve hours ;   score 3 : the nurse immediately modifies the vital sign monitoring schedule from every 
 twelve hours to every two hours .
if the problem persists after three rounds of vital 
 signs monitoring , the nurse needs to monitor patient and provide intensive care ;    score 4 : the nurse reports patient s condition to physician performs the continues 
 monitoring of vital signs , and measures intake and output ( i / o ) every two hours ;    score 5 : the nurse monitors patient s vital signs and blood oxygen saturation hourly 
 and reports patient s condition to the resuscitation team .
if the patient acquires a 
 score of 5 at three subsequent rounds of monitoring , the nurse reports the condition to 
 physician to decide on transferring patient to icu ;    score 6 : the nurse reports patient s condition to both physician and resuscitation 
 team when the patient is transferred to icu .  
this figure shows early warning score   the researcher used the 25-item patient satisfaction instrument ( psi ) for measuring 
 patient satisfaction with care .
, this 
 instrument consists of three domains including nurses professional practice ( seven items ) , 
 patients confidence in nurses ( eleven items ) , and nurses patient education services ( seven 
 items ) .
items are scored on a five - point likert scale ranging from 1 ( completely disagree ) 
 to 5 ( completely agree ) .
we invited ten icu nurses who had the work experience of more than fifteen years to 
 evaluate the content validity of the checklist .
the reliability of the ews had been 
 previously determined using the guttman split - half method which yielded a correlation 
 coefficient of 0.868 .
hajinezhad et al . , evaluated the reliability of the psi and reported a 
 coronbach s alpha of 0.90 for the instrument .  
the normality of the variables were assessed by using the 
 kolmogrov - smirnov test .
the chi - square , the independent - samples t - test , and the repeated 
 measures analysis of variance ( anova ) tests were used for comparing the study groups in 
 terms of the demographic characteristics , the length of hospital stay , ews , and patient 
 satisfaction .
this study was approved by the ethics committee of baqiyatallah university of medical 
 sciences , tehran , iran .
  the age of participants ranged from 22 to 82 years with a mean of 59.5 ( 14.24 ) years .
the results of the chi - square test 
 revealed that the intervention and control groups did not differ significantly in terms of 
 demographic characteristics such as gender , education , employment , reason for 
 hospitalization , and history of previous hospitalization in icu ( p > 0.05 ) ( table 1 ) .   the results of the independent - samples t - test showed that there were no significant 
 differences between the two groups regarding heart rate , respiratory rate , systolic blood 
 pressure , post - icu level of consciousness , satisfaction with care , and the length of 
 hospitalization in medical - surgical wards ( p>0.05 ) . results of variables associated with 
 hospitalization of patients are shows in table2 .  
moreover , the results of the independent - samples t and the repeated measures anova tests 
 indicated that the study groups did not differ significantly regarding the post - icu ews 
 scores ( p>0.05)(table 3 ) .
however , the results of 
 the independent - samples t - test showed that the difference between control and intervention 
 groups in terms of body temperature was statistically significant ( p<0.05 ) .
  this study was conducted to investigate the effect of liaison nurse on post - icu patient 
 outcomes .
the findings revealed that liaison nurse had no significant effect on icu 
 re - hospitalization rate and the length of post - icu hospital stay . in line with this study , 
 doric et al .
, reported that liaison nurse s services did not significantly affect the rate 
 of icu re - hospitalization and the length of hospitalization stay
mean ( sd ) , f = repeated measures anova   however , green and edmonds found that a five - year care plan provided by liaison nurses 
 significantly reduced the rate of icu re - hospitalization  from 2.3% to 0.5% .
, also reported that liaison 
 nurse strategy reduced the rate of pediatric icu re - hospitalization from 5.4% to 
 4.8% . according to chaboyer et al .
, 
 contradictions in terms of the effect of liaison nurse strategy on patient outcomes can be 
 attributed to factors such as differences in patients clinical conditions , complexity and 
 diversity of post - icu care , differences in the length and the types of liaison nurses 
 interventions , and differences in the types , scale , and the management systems of the 
 settings of the studies
, noted that liaison nurses can produce more significant effects on patient outcomes 
 in large - scale hospitals that have several icus and higher icu admission and discharge 
 rates .  
the findings of our study revealed that liaison nurse strategy had no significant effect 
 on patient satisfaction .
chaboyer et al . , also reported the similar findings . however , coffin et al .
, found that 99% of their 
 participants were satisfied with liaison nurses care services .
this contradiction is probably related to the differences in 
 liaison nurses clinical competence and communication skills .
we also found that the care 
 services provided by liaison nurse only decreased patients body temperature and had no 
 significant effects on heart rate , respiratory rate , blood pressure , and level of 
 consciousness .
doric et al . , noted that liaison nurses can positively affect patients 
 survival and empowerment .
to the best of 
 our knowledge , none of the previous studies investigated the effects of liaison nurse 
 strategy on patients vital signs and level of consciousness .  
this 
 study had also limited budget and also was required to be completed in a short period of 
 time .
accordingly , designing and conducting long - term and large - scale studies may produce 
 different results and more persuasive evidence .
  study findings suggest that care services provided by an icu liaison nurse has limited 
 effects on patient outcomes .  
however , according the contradiction among the studies , further studies are needed for 
 exploring factors that improve care quality and patient outcomes as well as for providing 
 clear evidence about the effectiveness of liaison nurses .
 
 introduction : recent studies suggest that liaison nurse 
 intervention might be effective to solve the gap between intensive care unit and wards , 
 but little studies are known about the effect of this intervention . 
 the aim of this study 
 was to investigate the effect of liaison nurse service on patient outcomes after 
 discharging from intensive care unit . 
 methods : in this single blinded randomized controlled trial , a 
 total of 80 patients were selected by convenience sampling method from two teaching 
 hospitals located in tehran , iran . 
 patients were randomly allocated to either the 
 experimental or the control groups . 
 patients in the experimental group received post - icu 
 care from a liaison nurse and patients in the control group received the routine care . 
 
 after the intervention , patients vital signs , level of consciousness , length of hospital 
 stay , need for re - hospitalization in icu , and satisfaction with care were measure . 
 data 
 were analyzed by spss ver.13 software . 
 
 results : none of the participants experienced icu 
 re - hospitalization . according to the result and 
 there were no significant differences 
 between the study groups regarding heart rate , respiratory rate , systolic blood pressure , 
 post - icu level of consciousness , satisfaction with care , and length of hospitalization in 
 medical - surgical wards . 
 however , the study groups differed significantly in terms of body 
 temperature . 
 
 conclusion : care services provided by an icu liaison nurse has 
 limited effects on patient outcomes . 
 however , considering the contradictions among the 
 studies , further studies are needed for providing clear evidence about the effectiveness 
 of the liaison nurse strategy . 
Introduction
Materials and methods
Results
Discussion
Conclusion
Acknowledgments
Ethical issues
Conflict of interest