Postoperative care: who should look after patients following surgery?

We present a broad international perspective of the past, present and future of the organisational factors and staffing models for the management of patients following both cardiac and non-cardiac surgery. Using recently published large data, we explore differences in human factors and outcomes. We examine and describe the difference in clinical care pathways in the setting of cardiac and non-cardiac surgery between the UK and other high-income countries. We report key areas of focus whereby improvements may be achieved in future training and systems management. These include: (1) increasing the availability of intensive care, high-dependency care and critical care outreach; (2) increasing the availability of trained specialist nurses; (3) expanding the critical care training of surgeons; and (4) multidisciplinary enhanced recovery programmes. We conclude that a multidisciplinary collaborative approach to implementing these key principles along with an evidence-based focus on outcomes and reducing variation is vital to improving clinical outcomes in surgical patients. It was easier in the past. Surgeons looked after surgical patients on the ward, anaesthetists stayed in the operating theatre and intensivists were yet to be conceived. Surgical ward care was commonly provided by a trainee surgeon with the occasional help of a friendly anaesthetist if a patient unexpectedly deteriorated 1. It may not have been easier if you were the trainee surgeon who provided 168 h of uninterrupted weekly care; however, it is always important to understand our history when attempting to understand the present and improve the future. When we ask, ‘who should manage the patient after surgery?’, are we, in fact, asking who should have ownership of the patient? Ownership is a much-used term in medicine; however, there are two distinct but overlapping meanings to this term. There is decision ownership, whereby physicians not only have a personal investment in treatment decisions but also ownership in the more possessive or transactional sense in relation to a patient – ‘this is my patient’ 2. We would suggest that the two meanings may be the flipsides of the same medical coin. The concept of ‘care’ overarches the concept of ownership, reflects the compassionate nature of the job and suggests an aspiration for an enlightened multidisciplinary team approach. The answer to the question posed will vary according to national, cultural and institutional norms. The important question is: do we have any evidence to support a best practice? In looking at this question, we must first distinguish between different patients and surgical procedures. Cardiac surgery is very much at the sharp end of the surgical spectrum, with almost all postoperative patients going to an intensive care unit (ICU) and cared for by an expanded multidisciplinary team. On the other hand, postoperative provision of care for patients undergoing other types of surgery is variable. Those patients who are having ambulatory surgery will have limited contact with physicians as nurse-led care is the current established model. Similarly, those patients with limited comorbidities having intermediate or uncomplicated major surgery will be largely managed by protocol-driven nurse-led care. The zone where outcomes are not so assured, and where resources are most in-demand and therefore the focus of this article, is primarily those patients with significant comorbidities undergoing higher risk major surgery. Cardiac surgery in the UK and the USA is probably the most scrutinised surgical area in contemporary practice, with considerable discrepancy in the composition of the teams. Variabilities in postoperative care can contribute to patient outcomes following cardiac surgery 3. Two thirds of complications following cardiac surgery occur during the postoperative cardiothoracic ICU stay and this is associated with increased risk of early mortality, longer hospital length of stay and higher rate of discharge to skilled nursing facilities 4, 5. In the UK, there has been a transition from cardiac surgeons looking after all aspects of peri-operative management, as fewer trainees have been available and as postoperative ICU has become more specialised. Anaesthetists and intensivists are now looking after immediate postoperative management and beyond. According to a 2018 Faculty of Intensive Care Medicine workforce census, 70% of cardiac critical care specialists also deliver cardiac anaesthesia services, although staffing is under significant stress and the utilisation of advanced critical care practitioners is increasing to support or even replace trainee doctors 6. A large-scale UK study demonstrated that the operative surgeon rather than procedural anaesthetist was associated with variations in mortality 7. However, despite a wealth of UK outcome data, it has not proven possible to establish any relevant causal outcomes associated with critical care either by speciality or staffing patterns 8, 9. There is some single-centre evidence from Canada to Israel which links the introduction of intensivist-directed ICU care of cardiac surgical patients to improvements in length of stay 10 and mortality 11, although other changes in the organisation of care accompanied this intervention. In the USA, postoperative cardiac surgical ICU models vary widely 12. In 2003, the Society of Critical Care Medicine (SCCM) and the American College of Critical Care Medicine stated that the ideal ICU model should have 24-h in-house staffing by dedicated intensive care physicians 13. However, the data surrounding this intensivist model has been challenged in other studies 14. The current cardiac surgical ICU staffing models in the USA were recently reported 12. Forty-seven percent of the units that were included identified themselves as being managed by cardiac surgeons whose primary focus was not the ICU. For those centres that reported the involvement of a dedicated ICU consultant, the primary specialties were varied, where pulmonary critical care was the most common specialty (67%) followed by anaesthesia/critical care medicine (26%) 12. Less than one-third of responding centres met the 2003 SCCM ideal model of around-the-clock in-house intensive care medical coverage. In the USA, the majority of centres utilise advanced practice providers (similar to the UK advanced nurse practitioners) for after-hours coverage. The remaining centres are managed with no dedicated after-hours in-house physician or surgeon coverage. Although full-time intensivist coverage may appear to be desirable, having an ICU closed to cardiac surgeon decision-making may hinder necessary collaborative teamwork 15. The preferred model probably is a mixed model, with a full-time intensivist working in close collaboration with the cardiac surgeon. Trainee numbers and availability has diminished in the USA with working hour limitations providing less experience managing complicated postoperative critically ill patients during training 16. Finally, the untoward consequences of global billing restrictions in the USA 17, which limit critical care billing for postoperative cardiac surgical patients in the first 90 days, are unknown. The EuSOS study published in 2012, attempted to look at mortality and admission to ICU after major non-cardiac surgery in Europe 18. There was wide national variation and a surprising 4% in-hospital mortality, compared with around 2% for elective cardiac surgery. Even more notable was the fact that 73% of patients who died were not admitted to ICU at any stage of their admission. It is uncertain which medical teams were managing these patients, but it is not unreasonable to assume that it was the parent surgical team. A more recent broad-ranging study across the UK, Australia and New Zealand investigated the provision of postoperative care 19. Although the study did not attempt a link to outcomes, the investigators uncovered some interesting findings with relevance to this discussion. Thirty-one percent of hospitals had high-acuity postoperative care areas outside of ICU and operating theatres, with a median nurse to patient ratio of 2:1. Fifty percent of the patients in these areas were managed exclusively by the surgical team. Another finding in this study, of concern for the National Health Service in the UK, was the much lower nursing ratios on standard surgical wards in the UK compared with Australia and New Zealand (6.0 vs. 3.75 vs. 4.45, respectively). What is clear from these studies is that the UK has a lower provision of ICU beds for surgical patients than comparable countries. The consequences of this state of affairs in the UK, whether it be predominantly economic or cultural, is that surgical teams look after a high proportion of high-acuity patients who would otherwise be managed in an ICU (level 3 care) or designated high-dependency unit (HDU, level 2 care) by trained critical care physicians. There are more surgically managed high-acuity ward areas in Australia, in addition to more intensive care beds. The EuSOS study also demonstrated that mortality varies significantly across European countries, but it is clearly not possible to simplify this outcome to differing rates of postoperative ICU admissions. Even assuming we are able to successfully collect and standardise big healthcare data across countries, multiple factors influence mortality after surgery, many of which are beyond the sphere of influence of healthcare provider institutions. Despite the best efforts of data researchers, we cannot precisely identify what makes the difference in postoperative care, whether it is who looks after the patient or where they are located. So how do we prioritise, organise and improve services for our patients? The outcomes that are important to patients and those that are important to physicians after surgery frequently differ 20. In the real-world of medicine, the most effective way of achieving genuine change is how we train, organise and engage the next generation of doctors, nurses and other professionals. We suggest four themes that must be considered to improve postoperative care and patient outcomes (Fig. 1). Critical care beds (level 2 or 3) for non-cardiac surgery are a restricted resource in the UK. To reduce mortality and other significant adverse outcomes following major surgery, particularly for the higher risk population, ICU bed availability must be expanded. This requires appropriate investment, expansion of intensive care physicians, intensive care medicine training programmes and expansion of other members of the multidisciplinary team. It requires a redesign of surgical training and rotations of staff who manage high-level care areas in collaboration with physician assistants and specialist nurses. Critical care outreach is undergoing expansion but is essential to support surgical postoperative management of the higher risk patients 21. Medical working hours have been reduced as the focus has increased on safe working practices, and out-of-hours working has become steadily more intense. There are other factors at play, but the overall result is that anaesthesia, surgery and intensive care rotas are increasingly threadbare. Although nursing rotas are similarly under stress, the increasing use of healthcare assistants for high-acuity surgical areas is not an adequate substitution, particularly out-of-hours. Recruitment and resources need to be directed at training and retaining high-quality specialised nurses for surgical wards and improving nursing ratios in the UK towards those of surgical units in Australia and the USA. As emergency admissions to ICU beds have increased and discharge of elderly patients has become more difficult, ring-fencing of beds has become more challenging despite initiatives such as ‘Getting it Right First Time’. This is particularly true for surgical specialties such as bariatrics, where ICU beds for surgical patients with malignancy is appropriately prioritised. High-level care areas on surgical wards have increasingly been established to maintain surgical programmes, but such patients often have multiple comorbidities. Surgical training is increasingly directed to operating time and service commitments, with limited time for surgical trainees to spend meaningful training time in critical care settings. This applies equally to cardiac surgery and to non-cardiac surgery alike. Where possible, critical care medicine should be built into surgical training time to allow more experienced leadership of high-risk patients in collaboration with critical care outreach teams. The enhanced recovery after surgery (ERAS) movement is a valuable addition to peri-operative care, bringing together many of the elements in this article and placing the patient at the very centre of the entire peri-operative pathway. The emphasis is on teamwork, multidisciplinary collaboration, avoidance of conflict, benchmarking, relentless focus on outcomes and reduction in unnecessary variation. Patient-reported outcomes are emphasised in the assessment of value. These are the keys to successful postoperative management, rather than focusing on patient ownership. The recently published ERAS guidelines for the peri-operative care of cardiac surgical patients, itself an international collaboration between surgeons, anaesthetists and intensivists, emphasise the need for standardising best practice 22, 23. In conclusion, there are many different staffing models to provide care for surgical patients, but success requires planning, adequate resource allocation, training and multidisciplinary collaboration, rather than ownership conflicts. Regardless of the staffing model, adherence to evidence-based best practice and continual re-assessment of progress and areas of deficiency will be the keys to success. DE is a consultant for Edwards Lifesciences and Biomerieu. NF has no competing interests.

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