Outcomes of Postoperative Overnight High-Acuity Care in Medium-Risk Patients Undergoing Elective and Unplanned Noncardiac Surgery

Abstract

ImportancePostoperative complications are increasing, risking patients’ health and health care sustainability. High-acuity postoperative units may benefit outcomes, but existing data are very limited.ObjectiveTo evaluate whether a new high-acuity postoperative unit, advanced recovery room care (ARRC), reduces complications and health care utilization compared with usual ward care (UC).Design, Setting, and ParticipantsIn this observational cohort study, adults who were undergoing noncardiac surgery at a single-center tertiary adult hospital, anticipated to stay in hospital for 2 or more nights, were scheduled for postoperative ward care, and at medium risk (defined as predicted 30-day mortality of 0.7% to 5% by the National Safety Quality Improvement Program risk calculator) were included. Allocation to ARRC was based on bed availability. From 2405 patients assessed for eligibility with National Safety Quality Improvement Program risk scoring, 452 went to ARRC and 419 to UC, with 8 lost to 30-day follow-up. Propensity scoring identified 696 patients with matched pairs. Patients were treated between March and November 2021, and data were analyzed from January to September 2022.InterventionsARRC is an extended postanesthesia care unit (PACU), staffed by anesthesiologists and nurses (1 nurse to 2 patients) collaboratively with surgeons, with capacity for invasive monitoring and vasoactive infusions. ARRC patients were treated until the morning after surgery, then transferred to surgical wards. UC patients were transferred to surgical wards after usual PACU care.Main Outcome and MeasuresThe primary end point was days at home at 30 days. Secondary end points were health facility utilization, medical emergency response (MER)–level complications, and mortality. Analyses compared groups before and after propensity scoring matching.ResultsOf 854 included patients, 457 (53.5%) were male, and the mean (SD) age was 70.0 (14.4) years. Days at home at 30 days was greater with ARRC compared with UC (mean [SD] time, 17 [11] vs 15 [11] days; P = .04). During the first 24 hours, more patients were identified with MER-level complications in ARRC (43 [12.4%] vs 13 [3.7%]; P < .001), but after return to the ward, these were less frequent from days 2 to 9 (9 [2.6%] vs 22 [6.3%]; P = .03). Length of hospital stay, hospital readmissions, emergency department visits, and mortality were similar.Conclusions and RelevanceFor medium-risk patients, brief high-acuity care with ARRC allowed enhanced detection and management of early MER-level complications, which was followed by a decreased incidence of subsequent MER-level complications after discharge to the ward and by increased days at home at 30 days.

Potential for using simulated altitude as a means of prehabilitation: a physiology study

“…Alongside advances in intra-operative and postoperative care [34], there is an urgent need to examine all potential means of modifying risk pre-operatively.…”

Uncertain Definition of Medium Risk for Outcome Evaluation of Postoperative Overnight High-Acuity Care

“…To the Editor We read with great interest the article by Ludbrook et al, which reported on the potential benefits of a new postoperative overnight high-acuity care unit (advanced recovery room care [ARRC]) with a decreased incidence of subsequent medical emergency response–level complications and increased days at home at 30 days. However, we have concerns regarding inconsistent definitions and potential confounding factors in this study.…”

“…Second, we noticed a discrepancy in the range of 30-day mortality according to American College of Surgeons National Surgical and Quality Improvement Program risk score predictions presented in Table 1 . If the authors used a range of 0.7% to 5% as an inclusion criterion for this study, it is puzzling to observe values exceeding this range in the usual care group (0.7%-5.4%) and the ARRC group (0.2%-5.9%) for all patients.…”

“…Furthermore, we note the lack of information provided regarding other potential confounding factors, such as anesthesia methods (spinal, epidural, or general anesthesia) and perioperative pain control methods and medications. In addition, in eAppendix 1 in Supplement 1, the usual care group predominantly followed the enhanced recovery after surgery protocols and guidelines, whereas the ARRC group seemed to follow ARRC-specific guidelines without enhanced recovery after surgery protocols and guidelines. This difference could potentially act as another confounding factor.…”

Uncertain Definition of Medium Risk for Outcome Evaluation of Postoperative Overnight High-Acuity Care—Reply

“…In Reply We thank Hsu and colleagues for their Letter to the Editor and detailed evaluation of our article . They raise 3 interesting points.…”