Outcomes following a Shortage of High Dependency Unit Beds for Surgical Patients

Abstract

In an environment of resource rationing there are numerous patients who are unable to be admitted to a highdependency unit (HDU) postoperatively despite the belief that this is the optimal discharge destination for them from the recovery room. It is unknown if this is associated with an increase in adverse outcomes. We performed an observational study, over a two-month period, comparing outcomes between patients who were admitted to HDU postoperatively and patients who, although an HDU bed was preferred, were discharged from the recovery room to the general ward due to an unavailability of HDU beds. Our primary outcome variable was hospital length-of-stay. We found an almost twofold increase in hospital length-of-stay in the group of patients admitted to the HDU. ASA IV patients were more likely to be admitted to HDU. However, the increased length-of-stay in the HDU group persisted even after stratifying patients according to ASA status. There was no difference between groups in all other baseline demographic variables, including POSSUM score, which is used as a predictor of postoperative morbidity and mortality. We believe that the most likely explanation for our findings is that the baseline risk between groups is, in fact, subtly different. This is not detected by preoperative scoring systems. However, clinical judgement in the recovery room appears to select a group of patients for HDU admission who subsequently have a slower postoperative recovery, despite no measurable increase in complication rate. That there was no increase in adverse events in the group of patients unable to be admitted to HDU due to a lack of bed availability suggests that current clinical judgement in a resource-rationed environment is functioning adequately, but the study was not powered to detect such a difference.

Randomized multicentre feasibility trial of intermediate care versus standard ward care after emergency abdominal surgery (InCare trial)

“…The strengths of this study are that it is a multicentre, randomized clinical trial with a low risk of bias compared with previous studies. The complex intervention was described thoroughly before the start, good clinical practice monitors assessed adherence to the trial protocol, and the actual monitoring and treatment levels in the intervention groups were reported clearly, as recommended for non‐pharmacological trials.…”

Effect of intermediate care on mortality following emergency abdominal surgery. The InCare trial: study protocol, rationale and feasibility of a randomised multicentre trial

“…In a similar design McIlroy et al . [21] concluded that IC may lead to longer hospital stay, but no effect on 30-day mortality or all-cause morbidity could be shown. Jones et al .…”

The Role of Stepdown Beds in Hospital Care

“…Studies on the impact of SDUs are limited to observational, single-center before/after reports with varying conclusions (9,38,(41)(42)(43)(44)(45)(46)(47). The majority of studies to date provide data on SDUs as a safe post-operative care option, with a particular emphasis on cardiothoracic surgery patients and safe reduction in time to extubation, reducing the need for full intensive care (39,43,44,(48)(49)(50)(51).…”

“…Other studies have failed to find a mortality benefit attributable to the establishment of an SDU or SDU-level care itself (9,38,42,45). The ongoing InCare trial in Denmark is explicitly focused on mortality associated with postoperative SDU care versus ward care after major abdominal emergency surgery (54), and will be the first major multicenter trial evaluating outcomes attributable to different levels of postoperative care.…”

“…They proposed a patient-care area with specialized monitoring and nursing care for cardiac patients no longer requiring full intensive care but not ready for discharge to a regular ward (7). Since then, terminology and definitions of SDU beds remain diverse, (Table 1) (5,(8)(9)(10)(11)(12)(13), although implicit is the provision of a level of care that is intermediate between what is available in a ward bed and in an intensive care bed. Two themes emerge from attempts to define an SDU bed: (1) the nurse to patient ratio for these beds, and (2) the ability to provide specific organ support.…”