Anesthesia and Perioperative Medicine

Abstract

Introduction: Anesthesiologists are well suited to care for complex medical patients in the postoperative setting. In our institution, we have developed the Surgical Special Care Unit (SSCU), which opened in June 2008. This intermediate care area provides care to medically complex surgical patients managed by an anesthesiologist. Since the unit has opened, there have been on average, 525 patients admitted per year, with an average length of stay of 4.3 days. In this study, we looked at the rate of transfer for escalation of care before and after the introduction of the SSCU. Our hypothesis was that the involvement of an anesthesiologist in the postoperative care of a surgical patient would reduce the need for escalation of care. Methods: Local research ethics board approval for this study was obtained. We performed a retrospective chart review of all patients who had open repair of abdominal aortic aneurysm (AAA) in our institution for the calendar years of 2007 and 2009. The only difference between these two years was the introduction of the anesthesia directed care in the SSCU. All AAA patients in 2007 went to an intermediate care unit with the same monitoring and nurse to patient ratio as the SSCU. There were no changes in surgical technique or surgeons between 2007 and 2009. We collected information about the movements of patients through the hospital from the operating room to discharge. Movements along the expected care pathway were considered forward moves. Any deviation from the expected care pathway for an increase in acuity of care was considered a backwards move. Results: There were 82 patients in the 2007 cohort of AAA patients (56 elective, 25 emergent and 5 endovascular) and 112 in the 2009 cohort (88 elective, 20 emergency and 14 endovascular). There were 10 deaths in the 2007 group compared to 7 deaths in the 2009 group. This was not statistically significant with a p-value of 0.1206. Twenty-three patients in the 2007 cohort had multiple complications and only 17 in the 2009 group. This was statistically significant with a p-value of 0.0324. We saw a total of 221 transfers in the 2007 group 9.5% of these being backward transfers. In the 2009 group we saw a total number of 344 transfers, 4.9% of these being backward transfers. This difference was statistically significant with a p-value of 0.0378 and an odds ratio of 2.020 with 95% confidence intervals of 1.041-3.920. Discussion: In conclusion, since the establishment of our anesthesia run SSCU, we have reduced the number of backward transfers in a high-risk patient population. We believe this can be attributed to recognition and treatment of complications earlier in their course, thus reducing admissions to higher acuity care.