Enhanced Care: Admission & Discharge Criteria

• The Freeman PACU is an Adult service only
• All patients booked into PACU must be considered highly likely to be fit for ward discharge by 8am the following morning.
• Invasive monitoring and basic inotrope / vasoactive infusions can be managed but will need to be weanable well before the 8am discharge requirement.
• Significantly unstable patients or those requiring very frequent medical intervention should be referred on for a Critical care bed not admitted to PACU if in doubt discuss with Critical care or On call anaesthetic Consultant.

Elective PACU Admissions

Operative Categories suitable for Consideration for PACU:

Hepatectomy

• Standard Right Hemihepatectomy (not including “extended” resections)
• Standard Left Hemihepatectomy (not including “extended” resections)
• Segmentectomies
• Open RITAs if higher level care required at all.
• (Not Klatskins, or retroperitoneal tumour resections as a general rule)

Pancreatectomies

• Pancreatic surgery is currently not appropriate for PACU as a general rule.

Vascular

• Carotids or AAA/thoracicAA Stents who need more than the basic 4 hour recovery stay ie those who would previously have been cancelled without a back-up HDU bed.

Orthopaedic cases

• The physiologically challenged joint replacement patients who would previously have been booked for HDU
• Some similar spine procedure patients but not the major scoliosis

Major ENT

• Most cases that would previously have required HDU can be considered 
• The presence of a neck stoma does not in itself necessitate admission to PACU as the ENT ward can manage these
• For patients with major neck dissection who have a flap as part of their surgery the frequency of flap-observations necessitate one to one nursing overnight. As a result if they are admitted to PACU they must be the only PACU case that day.

Urology

Again most major urology cases can be managed post-op on the Urology wards and should continue to be so. Where a patient has adverse physiology that would preclude this PACU can be considered.

Non-elective PACU admission

Situations may arise during an operation that necessitate an unexpected need for close monitoring of a patient post-operatively. If the above criteria as for electively booked PACU stay are met and there is a high probability that the patient will be ready for discharge by 8am the following day then admission to PACU may be considered.

No more than 2 patients can be cared for on PACU at any one time. If a non-elective PACU suitable patient needs prolonged post-op close observation during the evening or overnight, they can be cared for in the “Emergency Recovery” bed as the third patient in recovery BUT that precludes recovery staff from taking any further patients.

As such any patients having emergency surgery overnight will have to be recovered by the emergency theatre staff as occurred prior to the 24 hour recovery system being introduced. This third patient should be treated as a Recovery patient and would be eligible for discharge to the ward during the night if they meet discharge criteria. (As opposed to formal PACU patients who must not be discharged between 23.00 hrs and 07.00 hrs as per NICE and NPSA recommendations 2007).

NB Clearly if any patient is likely to need close observation and high levels of intervention for a prolonged period (particularly if likely to extend past 8 am) then every effort must be made to place them into a critical care bed at the earliest opportunity.

Ward J27 is a short stay acute medical assessment ward based on Level 3 Chancellor Wing at SJUH. The old JAMAA area which was designed as a non-bedded area has been redeveloped in order to make it an inpatient area as part of Ward J27.  The project to re-develop and modernise J27 was funded using building and engineering capital and was completed in December 2017.

As part of the Emergency and Specialty Medicine CSU five year Clinical Business Strategy there was a desire to create  one bay of level 1b High Observation Beds (HOBS) for the most unwell patients in Acute Medicine that currently are scattered across the acute assessment wards in Chancellor wing and are increasingly awaiting step down from Critical Care. Cohorting the sickest patients in the CSU will improve patient care, safety, and flow through monitoring, rapid recognition and treatment. Having a dedicated area on the acute floor for these patients will allow:

• Timely transfer from the resuscitation area in the Emergency Department (ED)
• Early senior input from the medicine speciality team
• Support the CSU to better meet the Emergency Care Standard
• This will support right patient, right place, and right specialty

The HOBS area provides three high observation beds for the most acutely unwell adults who require higher level monitoring including fixed cardiac and arterial monitoring, more frequent clinical observations with a higher staff to patient ratio. The area will increase to six beds on the 28 May 2018 and will provide High flow O₂ therapy. The aim of the medical HOBS area is to improve flow from the ED department supporting the ECS standard and department safety. It will improve timely step down from ICU/ HDU and also prevent admissions to critical care for “monitoring” who require more intense nursing but not a critical care bed.

If 1 patient stepped down from a HDU bed 1 day earlier into a HOBS bed the Trust would save £541 per patient or enable surgical procedures requiring ICU/HDU to operate and receive associated income and performance improvement.

Please access the downlodable version of this information below for additional detail.

ELECTIVE HIGH RISK SURGERY Torbay Hospital 

Dr John Carlisle

We categorise the postoperative level of care (0, 1, 1.5, 2, 3) a patient is likely to need before admission for scheduled surgery. We calculate the temporary increase in monthly mortality caused by surgery to determine the level of care after surgery using a calculator developed with national population survival data. Predicted 30-day mortality of >1% is the basis for postoperative HDU care.

This calculation is supplemented by: previous unexpected or prolonged level 1.5 care, specific organ dysfunction, for instance renal impairment with multiple antihypertensive medicines. These patients are likely to benefit from continuous blood pressure monitoring, arterial lactate sampling and vasopressor infusion. For example:

An 80 year-old lady is scheduled for primary hip arthroplasty. She had an acute coronary syndrome seven years ago.  Her fitness is ¾ her expected, with impaired gas exchange from COPD. She has renal impairment (eGFR 28) and takes two antihypertensive medicines. Hip replacement will increase her monthly mortality from 9 in 1000 to 18 in 1000, an absolute increase of 9 in 1000 (0.9%), less than our threshold of >1% for level 1.5 postoperative care. However, we plan for level 1.5 care due to her renal impairment and antihypertensive drugs.

An 83 year-old man is scheduled for a cholecystectomy. He has heart failure after an acute coronary event.  His fitness is 60% his predicted. Surgery will increase his monthly mortality from 24 in 1000 to 28 in 1000 (2.4%): we plan level 1.5 postoperative care.

A 90 year-old man is having a repeat cystoscopy. His monthly mortality without surgery is 33 in 1000 (3.3%), which will increase to 36 in 1000 after a cystoscopy (relative increase 0.3%). We plan for day surgery and same day discharge.

Reference

Swart M, Carlisle JB, Goddard J. Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study. BJA: 104; 100-04

ELECTIVE TKR and THR and 1.5 Care Torbay Hospital

Dr Mike Swart

Driver for change

In 2014 we decided to admit all our elective surgical patients having major surgery with a predicted 30 day mortality of > 1% to a level 2 or 3 critical care bed. The predicted 30 day mortality was determined by a prediction model that used age, type of surgery, comorbidities, and aerobic fitness.

Cancelations on the day of surgery because there was no critical care bed 17 per month.

Intervention

In June 2015 we converted a two-bed bay on an elective orthopaedic ward to provide level 1.5 care. Level 1.5 care was from orthopaedic ward nurses who were given additional training in the use of arterial lines, interpretation of arterial blood gases and the use of metaraminol, amioderone and magnesium sulphate. Medical cover was provided by the ITU medical team.

Outcome

4 years latter 1000 patients treated. No cardiac arrest calls or deaths in the level 1.5 care unit. 40% received a vasopressor (metaraminol). 5% received  amioderone or magnesium sulphate to treat AF. Length of stay 1-2 days.

Cancelations on the day of surgery 1-2 per month.

Please access the downlodable version of this information below for additional detail.