Portal de Periódicos da CAPES

Editorial III

2002; Elsevier BV; Volume: 88; Issue: 4 Linguagem: Inglês

10.1093/bja/88.4.473

1471-6771

A. Jones, Sheila Harper,

Intensive Care Unit Cognitive Disorders

All anaesthetists in the UK are familiar with the concept of 'ventilating a patient in recovery.' In effect, this is the provision of critical care in the recovery ward, usually because of insufficient critical care resources. It is a largely unsatisfactory situation, but there is a paucity of data on the extent of the practice and the consequences for patients, and for their medical and nursing carers. In this issue, Ziser and co-authors quantify the problem in their hospital in Haifa, Israel, and review some of its challenges.1Ziser A Alkobe Nmarkovits R Rosenberg B. The postanaesthesia care unit as a temporary admission location due to intensive care and ward overflow.Br J Anaesth. 2002; 88: 577-579Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Their solution is to bring the data to the hospital management with a request for more ITU beds. This is a counsel of perfection, which will find more or less sympathy from the management of different UK trusts. Is it possible to make a virtue of necessity, and provide postoperative critical care in a satisfactory operating theatre environment? The Israeli experience is well recognized by British anaesthetists. Four hundred patients were admitted to their Post-Anaesthesia Care Unit (PACU) in 2.5 yr because they required a critical care or ward bed, which was not available elsewhere in the hospital. They are described as 'overflow' patients. Ten per cent of these patients stayed longer than 24 h. The mean stay was over 12 h. Over 70% of the patients were mechanically ventilated and had invasive monitoring. First, it is necessary to demonstrate why ad hoc management of these cases in the recovery ward is a bad thing. After all, intensive therapy is an expensive resource (£1200–1500 per bed per day in the UK); if adequate care can be given elsewhere at times of bed saturation, surely this may be more cost effective? Ziser and co-authors identify the following adverse factors associated with use of the recovery area: • The greatest patient load occurred at night, coinciding with lowest staffing levels. • Problems with relatives visiting patients. • The effect on routine postoperative patients of observing dying patients. • Continuity of surgical cover. Similar problems have been experienced since 1990 at the Royal Liverpool University Hospitals. A long-standing under-provision of intensive care beds led to large numbers of inter-hospital transfers of critically ill patients, and an expanding number of patients cared for in an inadequately staffed and poorly equipped recovery room. As a result of an audit carried out in 1995, a successful approach was made to purchasers for additional funding, both to increase the number of intensive care beds by two, and resource the recovery overflow work. However, this did little to reduce the pressure on the recovery ward. In spite of improved equipment and staffing levels, staff morale fell. There was a feeling that the critically ill patients were receiving a second-class service. Recovery nurses felt they were inexperienced and under-trained to care for ITU patients. It was difficult within the on-call system to provide anaesthetic and intensivist continuity of care. The routine work of the recovery ward was at times severely disrupted by the critical care 'bays'. At the same time, high occupancy of intensive care facilities in the hospital and region made stopping the service impossible. Despite full ITU occupancy and utilization of the recovery ward, postponement of major surgery because of a lack of a postoperative critical care bed was frequent (two to three patients per week), and sufficient to jeopardize the achievement of Trust targets. Patients were receiving suboptimal care (although the best in the circumstances), routine major surgery was being disrupted, and staff morale was low, causing problems with recruitment and retention. Two options were considered. First, the approach, as advocated by Ziser and co-authors,1Ziser A Alkobe Nmarkovits R Rosenberg B. The postanaesthesia care unit as a temporary admission location due to intensive care and ward overflow.Br J Anaesth. 2002; 88: 577-579Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar to greatly increase intensive therapy provisions; or, secondly, to provide a postoperative critical care facility in the operating theatres. The ITU capacity was increased from 12 to 13 beds. Further expansion, however, would have been very difficult. A new building would have been required, new staff would need to be recruited, and medical rotas would need to be redesigned so that patients could be safely cared for. Consequently, this development would have required considerable investment from outside funding bodies. Although a plan is in place to expand the hospital's high dependency capacity, this would not address the patient who required ventilatory support, which accounted for a large proportion of the elective surgery postponements. There is very little published about alternative models of care apart from intensive therapy and high dependency. Prien and von Aken2Prien T Von Aken H. The perioperative phase as a part of anaesthesia. Tasks of the recovery room.Anaesthesist. 1997; 46: S109-S113Crossref PubMed Scopus (10) Google Scholar suggest that the PACU could be used to improve the condition of a postoperative patient, allowing eventual discharge to an area of lower dependency immediately after surgery. This was the model we adopted. Space for a four bedded critical care unit had been identified in a redundant part of the forward waiting area in the operating theatres. This area could be rebuilt for a relatively small capital investment. The main problem was to address medical and nursing staffing cover in order to provide good quality care. However, it was possible to do this within Trust resources. Consequently, the decision was taken to make detailed plans for the development of a Post Operative Critical Care Unit (POCCU) on the grounds that this was readily achievable, whereas further ITU expansion would remain a longer-term aspiration. Consequently, a successful bid was made for central investment from funds for critical care development, and the POCCU opened on December 1, 2000. Does experience so far justify this approach? Table 1 shows that on average approximately 40 patients per month were cared for in the POCCU. Of these, 78% were admitted from the operating theatre after elective or emergency surgery. Although the POCCU did admit patients who were 'ITU spill over', early fears that the unit would be swamped by patients needing ITU, who had no bed available, were not borne out.Table 1Admissions to the Royal Liverpool University Hospitals POCCU for 7 months in 20012001FebruaryMarchAprilMayJuneJulyAugustAdmissions (n)45353245413739Bed occupancy (%)84588063755758Postoperative patients (n)40342730322825 Open table in a new tab Several factors affected these figures. It has been a strict policy not to accept referrals to the POCCU from outside the Trust, as the POCCU is not an intensive therapy unit. However, more importantly, the POCCU has allowed greater flexibility of critical care bed use. For instance, less dependant patients may be transferred from the ITU to the POCCU, to make space for a more seriously ill patient. This has resulted in longer mean stays on the ITU (R. Wenstone, personal communication), but has reduced the number of periods when no critical care bed is available in the Trust. Consequently, cancellation of elective major surgery has been reduced from two to three per week, to an average of three per month. This ranges from a figure of no cancellations in 1 month to six cancellations in another. The POCCU has been staffed by anaesthetists rather than intensivists. Initial fears that clinical skills would be inadequate have been allayed. However, as a result of the constraints of modern anaesthetic training, the extra level of cover has been from an extra consultant tier. During the period from hours 08:00 to 20:00, a consultant anaesthetist whose duty is to the emergency service including the POCCU is on site. After 20:00, the emergency service covers the POCCU as well as other non-elective work. If the number of hands is insufficient, a 'second on call' consultant is available. The initial informal visits and advice by intensivists has been formalized into the developing ITU outreach service. Thus, critically ill postoperative patients can be cared for without an increase in ITU establishment, and without compromising the quality of care. The nursing staff of the POCCU are provided from recovery ward staff. Prior to the opening of the unit, several experienced ITU nurses were recruited. This has allowed recovery nurses with no critical care experience to be supported while training, and allows all nurses to rotate through the less stressful recovery ward environment. This has proved an attractive role with nursing applicants. Ongoing training includes regular attachments in the ITU, which has improved relations between the two groups of staff. Aps3Aps C. Operating theatres. Cutting edge.Health Service J. 2000; 110: 24-25PubMed Google Scholar describes a similar solution in the care of postoperative cardiac surgery patients in the Guy's and Saint Thomas' Hospital. Using 'creative demolition', a five (later nine) bedded Overnight Intensive Recovery (OIR) was established adjacent to the recovery ward. From 1983 to 1999, 55% of cardiac surgery patients received their postoperative care in the OIR rather than the ITU, and the OIR is currently managing 65–75% of cardiac cases. Aps emphasizes the vital importance of any postoperative critical care facility being considered separately from ITU, although acknowledging that ITU support is essential. He estimates that the annual cost of a four bedded OIR is £94 500 per bed (compared with £380 000 for an intensive therapy bed), but points out that less ambitious projects will be cheaper. Ziser and co-authors1Ziser A Alkobe Nmarkovits R Rosenberg B. The postanaesthesia care unit as a temporary admission location due to intensive care and ward overflow.Br J Anaesth. 2002; 88: 577-579Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar have quantified a problem, which all anaesthetists have to deal with regularly, 'ventilating patients in recovery'. The Royal Liverpool and Guy's experience shows that the establishment of a critical care facility in the operating theatre may have advantages over ITU expansion.