Case studyA Retrospective Evaluation of Post-operative Alternatives to Critical Care (REPACC)

Delivery of post-operative critical care for high-risk surgical patients represents a significant challenge within the NHS, due in part to high bed occupancy rates, with general and acute bed occupancy increasing exponentially. As a result, rates of on-the-day cancellation of elective surgical procedures for non-clinical reasons are at unprecedented levels, leading to delays to definitive care which is associated with potentially life altering consequences for service users. 

The requirement for a post-operative critical care bed is independently predictive of on-the-day cancellation of elective surgery. Thus, to reduce unnecessary cancellations, and their associated morbidity, new models of care such as Post-Anaesthetic Care (PACU) and Overnight Intensive Recovery (OIR) units have evolved. While these models of care are there to improve organisational efficiency, there is speculation that reduced clinical and risk score thresholds for admission to them may end up increasing the likelihood of on-the-day cancellation if these services are over-burdened. Furthermore, there is concern that the resources available, clinical oversight, and staff training within enhanced care units may not be adequate to care for high-risk patients that would traditionally be admitted to intensive care. 

There is a paucity of independent literature addressing the organisational impacts these models of care can have. It is also yet to be established whether these units achieve their objectives of improving patient flow, reducing pressure on intensive care, preventing on-the-day cancellations, reducing costs, and improving clinical outcomes in intermediate-risk surgical patients. Policy makers therefore have little to guide them in the development of these new models of care, thus exposing patients to an uncertain degree of risk.