POSU: A pilot study looking into the feasibility,safety and efficacy of a post-operative surgical unit for high-risk patients

Introduction

In this ambitious quality improvement project, we investigated the possibility of using operating theatre post-operative recovery ward to care for high-risk patients overnight.

Background

There is increasing recognition of the need for hospitals to provide a care environment that fills the gap between ward level care and critical care for post-operative patients. The Critical Futures Report published in 2017 by the Faculty of Intensive Care Medicine has recognised the need for enhanced, level 1.5 care. ¹ Within our trust we have identified cohorts of patients that often require unplanned overnight recovery stays following surgery, or are admitted to critical care but have few interventions. These patients may be better cared for in an intermediate care setting.

Method

We conducted a pilot study investigating the feasibility and safety of running a post-operative surgical unit (POSU) in the main operating theatre recovery ward overnight. We selected 56 patients undergoing elective hip or knee primary or revision arthroplasty that the anaesthetist felt would benefit from overnight, enhanced care. For the majority of patients this level of post-operative care was an upgrade from the intended ward level care.

The POSU was largely nurse lead and strongly protocolised. Patients received advanced haemodynamic monitoring with an arterial line and fluid balance was closely monitored. Protocol initiated fluid therapy and vasopressor infusions could be started by nursing staff. Through close proximity to the emergency operating theatre overnight review from the on-call surgical, anaesthetic or intensive care teams was facilitated.

Results

This pilot focused on assessment of patient safety in the POSU, efficacy of such a unit and the feasibility of running a POSU in the operating theatre recovery ward.

Safety was assessed through prospectively collecting data on patient outcome. We demonstrated that the POSU was a safe enhanced care recovery environment for the provision of level 1.5 care. Of the 56 patients admitted, 88% had an arterial line and 83% had arterial blood gas analysis to guide care; 71% of patients were reviewed by an anaesthetist or intensivist overnight. During the pilot study there were no inpatient deaths or recorded adverse events.

To assess efficacy, we monitored the post-operative recovery of the cohort of patients who stayed in the POSU and compared that to the general orthopaedic population. We demonstrated a comparable incidence of AKI in this select high-risk surgical group as that of the general orthopaedic population (12.5% vs. 10.8%). ² The mean Length of hospital inpatient stay for patients admitted to POSU was marginally lower than for patients who received ward-based care (8.0 days compared to 8.2) (see Figure 1).

Figure 1.

Graph showing length of hospital inpatient stay of all primary hip and knee arthroplasty patients during the period over which the POSU pilot was running.

Feasibility of a POSU was assessed using patient feedback. Feedback was mostly positive; however, it did demonstrate that the main operating theatre recovery ward was not an appropriate setting. In particular the lack of hot food, relative’s visiting space and privacy were highlighted.

Conclusion

In this small pilot study, we have demonstrated that running a POSU for high-risk post-operative orthopaedic patients is safe, well received by patients and staff and does not appear to increase length of hospital inpatient stay. We have shown that the main operating theatre recovery ward is an unsuitable site for a POSU and a dedicated overnight recovery area is required.