1 Norwich, UK and 2 Liverpool, UK
EditorHaving read the editorial in the BJA,1 we have a number of concerns regarding the widespread adoption of the postoperative critical care unit (POCCU) as a solution to critical care bed shortages. What the authors have demonstrated is that simply increasing the total number of critical care beds in the Royal Liverpool University Hospitals from 13 to 17 produced entirely predictable reductions in cancelled operations.
The most recent Department of Health review of critical care services (Comprehensive Critical Care2) emphasized the importance of classifying critically ill patients on the basis of their dependency (i.e. care required), rather than the location where they were being nursed (e.g. ICU, HDU, POCCU, etc.). The authors admit that their present ICU is constrained by architectural factors and so they have merely expanded their Level 2 or 3 care into the recovery area.
Unfortunately, the authors have missed this point when they claim that the establishment of a critical care facility in the operating theatre may have advantages over ITU expansion. The POCCU beds are indeed critical care beds and are just one solution to the common problem of ICU bed shortage. A number of equally effective solutions exist and hospitals must choose one that suits their needs the best. Our concern about POCCUs and overnight intensive recovery (OIR) is that, although they may manage Level 2 and 3 patients, they may not comply with the standards pertaining to architecture, equipment, facilities and manpower that are required to care for critically ill patients. The standards required are well established,3 and it is clear from the editorial that the POCCU may not meet some of these important standards.
In summary, the authors have described a possible solution, but part of its success may simply reflect the fact that the number of critical care beds has been increased. POCCUs may be a retrospective step because the standards required to care for Level 3 patients may not be met. This is something that the specialties of anaesthesia and intensive care should avoid simply for the sake of expediency.
S. Ridley
P. Nightingale
Norwich
UK
EditorThank you for the opportunity to reply to Ridley and Nightingale. We are disappointed with their concerns about the postoperative critical care unit (POCCU) or overnight intensive recovery (OIR) approach to managing surgical patients. As they say hospitals must choose the [solution] which suits their needs the best. The editorial tried to demonstrate that intensive therapy unit (ITU) expansion may not be the most appropriate response.
Our APACHE II data show consistently higher scores for the ITU than the POCCU each month (mean data for April 1, 2001 to September 30, 2001: ITU 15.3; POCCU 12.6). This suggests that a different patient population is being cared for on the POCCU. The reduction in cancelled operations may not be due to the increase in critical care beds alone. Some of these patients may have had their operation but gone to a surgical HDU and not the ITU, in the days before we opened the POCCU. The opening of the POCCU has therefore also allowed more appropriate use of surgical HDU beds. We believe that this demonstrates that we are achieving, at least in part, our objective of caring better for postoperative surgical patients. Indeed, provision of ITU beds for these patients might represent over-provision.
We are unsure where we miss the point about ITU expansion. Our point is that POCCU or OIR beds are not ITU beds. This allows some flexibility in providing critical care in novel environments. The POCCU allowed the expansion of critical care beds in this Trust. Even if our reduction in cancelled operations was solely due to this expansion, the fact remains that an enlargement of our ITU by four beds could not have been achieved for the same resource as the establishment of the POCCU.
In an ideal world, critical care shortfall would be dealt with by ITU expansion. In ageing hospitals, with scarce resources, we feel it is expedient to provide the best solution we can for our patients.
A. G. Jones
S. J. Harper
Liverpool
UK
References
1 Jones AG, Harper SJ. Ventilating in recoverythe way forward: intensive therapy or critical care? Br J Anaesth 2002; 88: 4734
2 Department of Health. Comprehensive Critical Care: a review of adult critical care services 2000. http://www.doh.gov.uk/pdfs/criticalcare.pdf
3 The Intensive Care Society. Standards for Intensive Care Units. London: Intensive Care Society, 1997