Editorial III

Surgical critical care: the Overnight Intensive Recovery (OIR) concept

C. Aps1

1 Guy’s and St Thomas’ NHS Trust, Department of Anaesthetics, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK E-mail: chris.aps{at}gstt.sthames.nhs.uk

Provision of critical care for surgical patients competes with other pressures on the finite intensive care unit resources available. These pressures are well recognized, and include requirements for medical patients, ward-generated emergencies, admissions from A&E, inter-hospital transfers, and winter bed pressures. Surgical patients also compete with themselves for ICU admission either from other elective patients or theatre-generated emergencies. The net result is familiar to the anaesthetist and either leads to cancelled elective procedures,1 or problems with the postoperative management of sick patients. The latter was again highlighted in the National CEPOD report for 2002, in which postoperative deaths were associated with difficulties with providing critical care support or facilities.2

These pressures can translate to unwanted demands on a general recovery unit to provide postoperative ventilation, perhaps with i.v. cardiovascular support, as a substitute for the lack of an ICU bed. NHS targets for elective surgical activity, waiting times, and cancellation rates exacerbate the situation. It is often difficult for recovery nursing staff to be able to control what they may perceive to be the inappropriate use of recovery.

Despite these concerns, there has been considerable interest amongst not only anaesthetists, but also theatre staff in the potential for providing safe short-term critical care in the recovery setting, to offset the shortage of ICU beds for surgical patients. This real interest has, for example, has been reflected in requests for formal presentations on recovery-based critical care to National Annual Conferences of both the National Association of Theatre Nurses (2002), and the Association of Operating Department Practitioners (2003).

The recovery ward or postoperative care unit has attractive features that lend it to examination as a possible environment for surgical critical care. It is staffed by nurses trained in the care of the postoperative patient, is supervised by anaesthetists, and is near the operating theatre. The infrastructure in an existing recovery room (piped gases, suction, etc.) is probably in place already. It is easy to provide the necessary equipment for artificial ventilation and monitoring. Indeed, in an emergency, one would expect facilities and expertise sufficient to be able to intubate and ventilate in any recovery room.

St Thomas’ Hospital, London has enjoyed a long history of developing the role of general recovery. Initially, in the early 1980s, this took the form of the introduction of postoperative care for the cardiac surgical, fast-tracked and immediately extubated patient in the general recovery ward.3 In subsequent years, further recovery development led to the Overnight Intensive Recovery (OIR) concept, which defines identified recovery beds that are able to offer up to level 3 critical care4 for any surgical patient for a period of 24 h. Although other workers have reported their experiences with similar initiatives, there is a paucity of published work on the use of recovery for this purpose.

Early reports tended to concentrate on the use of recovery facilities to provide an alternative to the ICU for the postoperative management of cardiac surgical patients, who were usually fast-tracked.5 6 In many respects, this probably deterred recovery units from developing their recovery facilities for other patients, as the perception was clearly that this lay solely in the domain of cardiac surgery.7 More recent papers, however, begin to describe the role of recovery in the management of patients following non-cardiac surgical procedures, albeit as a response to the failure of the ICU to accept them.8 9

Ziser and colleagues10 reported their experiences with the Post-Anaesthetic Care Unit forced to accept a variety of surgical patients, the majority artificially ventilated and with invasive monitoring, as an ‘overflow’ from the ICU. Interestingly, around 90% of their patients were discharged within 24 h, an experience common to those who offer such a service.

In a previous Editorial in this journal, Jones and Harper9 offer a more pragmatic approach, similar to that adopted here. Rather than use data, such as described by Ziser, in an attempt to force management to provide more ICU beds,10 they realized the inevitable need for postoperative critical care and reported the development of recovery to address it.

The non-cardiac surgical activity that receives postoperative critical care in the OIRs of Guy’s and St Thomas’ has been outlined elsewhere.11 The differing activity between St Thomas’ (the acute site) and the sister hospital Guy’s (elective site) is demonstrated by the observation that 28% of patients requiring OIR at St Thomas’ were those requiring critical care following emergency surgery. The surgical specialties or elective procedures that received intensive recovery care were: oesophagectomies, general surgical, major vascular, trauma orthopaedics, major plastics, gynaecology, and ophthalmic (St Thomas’); whilst at Guy’s, elective orthopaedics, urology, renal (including transplants), major ENT, maxillofacial, vascular stents, and thoracic were received. In total, 327 patients were admitted to the two OIRs in the year 2002–3, an increase of 80 on the previous year. Most were artificially ventilated. In addition, another 175 patients stayed in the general recovery area overnight, without mechanical ventilation, for observation (level 2 postoperative critical care4). The majority of patients in the OIR were discharged after a one-night stay, with some staying two nights or more. Some were discharged the same day. The number of bed days for this cadre was 365, giving an average bed day requirement of 1.1 bed days.

There is strong agreement that such practice within a recovery unit that is not adequately and properly developed, staffed and supported does not allow for the safe conduct of postoperative critical care. This is also the increasing concern of recovery nurses in some Trusts who find themselves persuaded to look after ventilated patients or to deal with overflows of patients from the ICU into their general recovery wards, without them having the skills to achieve this.

The aim of this Editorial is to share the operational policies that we have consistently adopted since 1988, when the first Overnight Intensive Recovery facility was opened in the general recovery ward at St Thomas’ Hospital, and which have made this practice a safe and successful alternative to the ICU for short-term postoperative critical care.

The OIR concept states that short-term post-operative critical care for surgical patients can be provided by developing beds within theatre recovery facilities to an acceptable standard appropriate for the management of an artificially ventilated patient.

The key to defining the concept lies within the term ‘Overnight Intensive Recovery’, that is the duration of stay should be short (Overnight), management is (Intensive), Levels 2–3, Critical Care, in a Recovery Unit.

The operational policy is relatively simple. It relies on 10 principles, which are:

OIR beds are part of a theatre recovery service and should be within, or in close proximity to, the postoperative recovery area.

OIR beds should be properly equipped to provide critical (intensive) care. This should not be short-changed. Correct beds, locally familiar ventilators, CPAP circuits, invasive monitoring, a generous supply of syringe drivers, and all the paraphernalia to manage the patient safely is mandatory. This will incur a capital cost to acquire the equipment and a revenue consequence for the disposable items and the drugs for each patient’s needs.

The service is available to postoperative surgical patients only. Preoperative resuscitation in the OIR is not allowed except in the event of a major incident, when the OIR can be considered a valuable asset in coping with large numbers of casualties.12 Medical patients are not admitted, as they are inappropriate to the skills of the attending perioperative staff and will block beds. Allowing overflow of patients from the ICU is also discouraged as it will displace and hamper recovery activity.

The OIR nursing staff are part of the recovery nursing establishment, which contains a supervising element of critical care-trained nurses. Around 40% of our nurses are so trained and there will always need to be an F Grade or above in any one shift who possesses a critical care qualification. The nature of OIR care will require a 1:1 patient: nurse ratio, as for any ventilated patient.

The medical staff supporting an OIR are anaesthetists. A rostered anaesthetic trainee should be free to answer calls to the OIR and recovery. How this is achieved will vary locally. The owning consultant surgeon retains overall responsibility for his/her patient, but delegates care to the attending staff. Communication with the surgical team, however, is important in terms of planning clinical management and most especially if there is a deterioration in the state of the patient. Consultant anaesthetists provide senior doctor input in terms of policy, discharge and admission decisions, on-call cover, and supervision of the attending trainees. There should be identified consultant anaesthetist OIR sessions with twice daily ward rounds or patient reviews conducted with the trainee and nursing staff. In addition, a nominated consultant anaesthetist should ideally act as ‘champion’ to the OIR, to lead on OIR issues as they relate to the whole organization.

Patients admitted to the OIR facility should need less than 24 h of critical care. Admissions are from the operating theatres only. Patients who are expected to need complex or prolonged critical care should be admitted directly from the operating theatre to the formal ICU instead. Specialist organ support such as dialysis or haemofiltration is not offered in the OIR. Experience has shown that most clinicians can sensibly predict the duration of critical care needed and therefore most admissions to the OIR are usually appropriate.

Admissions to the OIR are made by agreement with the OIR nurse in charge of that shift, who will be in the best position to assess the skill mix and workload, bearing in mind that the OIR is part of the total recovery facility with its own clinical obligations.

A good working relationship with the ICU is vital. The perception that the OIR is somehow a threat or an inferior service to intensive care must be overcome.13 An OIR is merely a facility offering short-term surgical critical care, to a well-defined patient population in the correct place and with the right personnel. Once it is recognized that OIR alleviates the total demands made upon the ICU by sequestering ‘elective’ postoperative ventilation, this problem disappears. However, the quid pro quo is that the OIR must have the back up of the ICU of advice and for transfer to the ICU for the sicker patient who needs more prolonged, complex support.

The OIR offers 24-h stay only. This is an important principle. The advantages of clearing bed spaces for the next day’s surgical critical care needs are obvious, especially in terms of avoiding operative cancellations for the lack of a critical care bed. Numerous audits have shown that, in practice, it will not quite work out like that, because of blocked beds in the areas patients are discharged to, for example, surgical wards, HDU or the ICU. Expect a 90% successful discharge from the OIR in a well-run unit. There will be considerable pressure for OIR beds to pick up deficits elsewhere in the system, which is to be energetically avoided.

A strict policy of transfer to the ICU must be agreed for patients still needing critical care after 24 h. We have observed a 5–10% transfer rate to the ICU from the OIR consistently over the years. This depends on the type of surgical populations or procedures and is usually caused by respiratory, cardiac, renal, or neurological problems. The underlying argument for this policy is that the duration of critical care needs beyond 24 h redefines the acuity of that patient to require true ICU care. Moreover, the short-stay policy, which works well in the OIR, does not lend itself to good continuity of care over a longer period.

An organizational understanding that the OIR has a finite postoperative function, and can only operate safely and effectively within fairly narrow limits, will help reduce any incorrect demands made upon it. The obvious abuses that can occur are requests to take medical patients or to allow patients to overspill from the ICU. In our experience, the former is dealt with by the acceptance that such admissions are not best managed in a surgical environment, staffed by anaesthetists and recovery nurses. ICU overspill into recovery or OIR as a means to expand ICU capacity threatens the critical care needs generated from theatres. It is fair to point out that the development of an OIR already increases the capacity of the ICU to admit more patients, and to impair the function of recovery by overspilling makes no sense and must not be allowed. Finally, the firm agreement with the ICU to take OIR patients after 24 h has proved easy to sustain, but in practice may not always be possible if there are no ICU beds at the time. The practical resolution of this can be difficult, but is based on a priority transfer to the ICU as soon as possible. The involvement of the consultant intensivists with such a patient whilst in the OIR, is invaluable in terms of maintaining standards of care and effecting transfer to the ICU.

In conclusion, this OIR concept requires discipline to implement and manage within these basic principles in order to provide both a safe environment and high standards of postoperative critical care for surgical patients. That said, the advantages of realizing the potential of the recovery service in sharing critical provision have been shown to be significant in respect of maintaining surgical activity and support, with positive issues relating to staff development, training and recruitment. Most importantly, the OIR alleviates the ICU from a specific short-term workload, which is arguably more suitably managed in these alternative facilities.

References

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2 ‘Functioning as a team?’ The 2002 Report of the National Confidential Enquiry into Perioperative Deaths. 10

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