Anaesthesia 2020, 75 (Suppl. 1), e5–e9 doi:10.1111/anae.

14887

Editorial

Postoperative care: who should look after patients

following surgery?
N. Fletcher1,2 and D. T. Engelman3

1 Consultant, St. George’s Hospital, London, UK

2 Chair of the Institute of Critical Care and Anaesthesia, Cleveland Clinic London, London, UK
3 Associate Professor, Department of Surgery, University of Massachusetts-Baystate, Baystate Medical Center,
Springfield, MA, USA
.................................................................................................................................................................
Correspondence to: N. Fletcher
Email: [email protected]
Accepted: 6 September 2019
Keywords: critical care; enhanced recovery; postoperative management; surgery
Twitter: @Echotrainer; @danengelmanmd

We present a broad international perspective of the past, uninterrupted weekly care; however, it is always important
present and future of the organisational factors and staffing to understand our history when attempting to understand
models for the management of patients following both the present and improve the future. When we ask, ‘who
cardiac and non-cardiac surgery. Using recently published should manage the patient after surgery?’, are we, in fact,
large data, we explore differences in human factors and asking who should have ownership of the patient?
outcomes. We examine and describe the difference in Ownership is a much-used term in medicine; however, there
clinical care pathways in the setting of cardiac and non- are two distinct but overlapping meanings to this term.
cardiac surgery between the UK and other high-income There is decision ownership, whereby physicians not only
countries. We report key areas of focus whereby have a personal investment in treatment decisions but also
improvements may be achieved in future training and ownership in the more possessive or transactional sense in
systems management. These include: (1) increasing the relation to a patient – ‘this is my patient’ [2]. We would
availability of intensive care, high-dependency care and suggest that the two meanings may be the flipsides of the
critical care outreach; (2) increasing the availability of same medical coin. The concept of ‘care’ overarches the
trained specialist nurses; (3) expanding the critical care concept of ownership, reflects the compassionate nature of
training of surgeons; and (4) multidisciplinary enhanced the job and suggests an aspiration for an enlightened
recovery programmes. We conclude that a multidisciplinary multidisciplinary team approach. The answer to the
collaborative approach to implementing these key question posed will vary according to national, cultural and
principles along with an evidence-based focus on outcomes institutional norms. The important question is: do we have
and reducing variation is vital to improving clinical any evidence to support a best practice?
outcomes in surgical patients. In looking at this question, we must first distinguish
It was easier in the past. Surgeons looked after surgical between different patients and surgical procedures.
patients on the ward, anaesthetists stayed in the operating Cardiac surgery is very much at the sharp end of the surgical
theatre and intensivists were yet to be conceived. Surgical spectrum, with almost all postoperative patients going to an
ward care was commonly provided by a trainee surgeon intensive care unit (ICU) and cared for by an expanded
with the occasional help of a friendly anaesthetist if a patient multidisciplinary team. On the other hand, postoperative
unexpectedly deteriorated [1]. It may not have been easier if provision of care for patients undergoing other types of
you were the trainee surgeon who provided 168 h of surgery is variable. Those patients who are having

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ambulatory surgery will have limited contact with physicians has been challenged in other studies [14]. The current
as nurse-led care is the current established model. Similarly, cardiac surgical ICU staffing models in the USA were
those patients with limited comorbidities having recently reported [12]. Forty-seven percent of the units that
intermediate or uncomplicated major surgery will be largely were included identified themselves as being managed by
managed by protocol-driven nurse-led care. The zone cardiac surgeons whose primary focus was not the ICU. For
where outcomes are not so assured, and where resources those centres that reported the involvement of a dedicated
are most in-demand and therefore the focus of this article, is ICU consultant, the primary specialties were varied, where
primarily those patients with significant comorbidities pulmonary critical care was the most common specialty
undergoing higher risk major surgery. (67%) followed by anaesthesia/critical care medicine (26%)
[12]. Less than one-third of responding centres met the
Cardiac surgery 2003 SCCM ideal model of around-the-clock in-house
Cardiac surgery in the UK and the USA is probably the most intensive care medical coverage. In the USA, the majority of
scrutinised surgical area in contemporary practice, with centres utilise advanced practice providers (similar to the
considerable discrepancy in the composition of the teams. UK advanced nurse practitioners) for after-hours coverage.
Variabilities in postoperative care can contribute to patient The remaining centres are managed with no dedicated
outcomes following cardiac surgery [3]. Two thirds of after-hours in-house physician or surgeon coverage.
complications following cardiac surgery occur during the Although full-time intensivist coverage may appear to be
postoperative cardiothoracic ICU stay and this is associated desirable, having an ICU closed to cardiac surgeon
with increased risk of early mortality, longer hospital length decision-making may hinder necessary collaborative
of stay and higher rate of discharge to skilled nursing teamwork [15]. The preferred model probably is a mixed
facilities [4, 5]. model, with a full-time intensivist working in close
In the UK, there has been a transition from cardiac collaboration with the cardiac surgeon. Trainee numbers
surgeons looking after all aspects of peri-operative and availability has diminished in the USA with working hour
management, as fewer trainees have been available and as limitations providing less experience managing
postoperative ICU has become more specialised. complicated postoperative critically ill patients during
Anaesthetists and intensivists are now looking after training [16]. Finally, the untoward consequences of global
immediate postoperative management and beyond. billing restrictions in the USA [17], which limit critical care
According to a 2018 Faculty of Intensive Care Medicine billing for postoperative cardiac surgical patients in the first
workforce census, 70% of cardiac critical care specialists 90 days, are unknown.
also deliver cardiac anaesthesia services, although staffing
is under significant stress and the utilisation of advanced Non-cardiac surgery
critical care practitioners is increasing to support or even The EuSOS study published in 2012, attempted to look at
replace trainee doctors [6]. A large-scale UK study mortality and admission to ICU after major non-cardiac
demonstrated that the operative surgeon rather than surgery in Europe [18]. There was wide national variation
procedural anaesthetist was associated with variations in and a surprising 4% in-hospital mortality, compared with
mortality [7]. However, despite a wealth of UK outcome around 2% for elective cardiac surgery. Even more notable
data, it has not proven possible to establish any relevant was the fact that 73% of patients who died were not
causal outcomes associated with critical care either by admitted to ICU at any stage of their admission. It is
speciality or staffing patterns [8, 9]. There is some single- uncertain which medical teams were managing these
centre evidence from Canada to Israel which links the patients, but it is not unreasonable to assume that it was the
introduction of intensivist-directed ICU care of cardiac parent surgical team. A more recent broad-ranging study
surgical patients to improvements in length of stay [10] and across the UK, Australia and New Zealand investigated the
mortality [11], although other changes in the organisation of provision of postoperative care [19]. Although the study did
care accompanied this intervention. not attempt a link to outcomes, the investigators uncovered
In the USA, postoperative cardiac surgical ICU models some interesting findings with relevance to this discussion.
vary widely [12]. In 2003, the Society of Critical Care Thirty-one percent of hospitals had high-acuity
Medicine (SCCM) and the American College of Critical Care postoperative care areas outside of ICU and operating
Medicine stated that the ideal ICU model should have 24-h theatres, with a median nurse to patient ratio of 2:1. Fifty
in-house staffing by dedicated intensive care physicians percent of the patients in these areas were managed
[13]. However, the data surrounding this intensivist model exclusively by the surgical team. Another finding in this

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study, of concern for the National Health Service in the UK, of data researchers, we cannot precisely identify what
was the much lower nursing ratios on standard surgical makes the difference in postoperative care, whether it is
wards in the UK compared with Australia and New Zealand who looks after the patient or where they are located. So
(6.0 vs. 3.75 vs. 4.45, respectively). What is clear from these how do we prioritise, organise and improve services for our
studies is that the UK has a lower provision of ICU beds for patients? The outcomes that are important to patients and
surgical patients than comparable countries. The those that are important to physicians after surgery
consequences of this state of affairs in the UK, whether it be frequently differ [20]. In the real-world of medicine, the most
predominantly economic or cultural, is that surgical teams effective way of achieving genuine change is how we train,
look after a high proportion of high-acuity patients who organise and engage the next generation of doctors, nurses
would otherwise be managed in an ICU (level 3 care) or and other professionals. We suggest four themes that must
designated high-dependency unit (HDU, level 2 care) by be considered to improve postoperative care and patient
trained critical care physicians. There are more surgically outcomes (Fig. 1).
managed high-acuity ward areas in Australia, in addition to
more intensive care beds. Increased availability of ICU, HDU and critical care
outreach
Improving postoperative care Critical care beds (level 2 or 3) for non-cardiac surgery are a
The EuSOS study also demonstrated that mortality varies restricted resource in the UK. To reduce mortality and other
significantly across European countries, but it is clearly not significant adverse outcomes following major surgery,
possible to simplify this outcome to differing rates of particularly for the higher risk population, ICU bed
postoperative ICU admissions. Even assuming we are able availability must be expanded. This requires appropriate
to successfully collect and standardise big healthcare data investment, expansion of intensive care physicians,
across countries, multiple factors influence mortality after intensive care medicine training programmes and
surgery, many of which are beyond the sphere of influence expansion of other members of the multidisciplinary team. It
of healthcare provider institutions. Despite the best efforts requires a redesign of surgical training and rotations of staff

Figure 1 Key themes of postoperative outcome improvement. ICU, intensive care unit; HDU, high-dependency unit; ERAS,
enhanced recovery after surgery.

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who manage high-level care areas in collaboration with value. These are the keys to successful postoperative
physician assistants and specialist nurses. Critical care management, rather than focusing on patient ownership.
outreach is undergoing expansion but is essential to The recently published ERAS guidelines for the peri-
support surgical postoperative management of the higher operative care of cardiac surgical patients, itself an
risk patients [21]. international collaboration between surgeons, anaesthetists
and intensivists, emphasise the need for standardising best
Increasing the availability of trained specialist nurses practice [22, 23].
Medical working hours have been reduced as the focus has In conclusion, there are many different staffing models to
increased on safe working practices, and out-of-hours provide care for surgical patients, but success requires
working has become steadily more intense. There are other planning, adequate resource allocation, training and
factors at play, but the overall result is that anaesthesia, multidisciplinary collaboration, rather than ownership
surgery and intensive care rotas are increasingly conflicts. Regardless of the staffing model, adherence to
threadbare. Although nursing rotas are similarly under evidence-based best practice and continual re-assessment of
stress, the increasing use of healthcare assistants for high- progress and areas of deficiency will be the keys to success.
acuity surgical areas is not an adequate substitution,
particularly out-of-hours. Recruitment and resources need Acknowledgements
to be directed at training and retaining high-quality DE is a consultant for Edwards Lifesciences and Biomerieu.
specialised nurses for surgical wards and improving nursing NF has no competing interests.
ratios in the UK towards those of surgical units in Australia
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