The Effect of Advanced Recovery Room Care on Postoperative Outcomes in Medium Risk Surgical Patients

Abstract

Background: Postoperative complications are common, and may be under-recognised. This problem is predicted to increase substantially due to our ageing, comorbid population, with impacts on patient outcomes and healthcare costs. Objective: This thesis aims to investigate current models of care delivery in the Post Anaesthesia Care Unit (PACU) and their impact on patient outcomes with a systematic review. A model of Advanced Recovery Room Care is proposed, with the primary hypothesis of feasibility, and exploratory secondary outcomes including a positive impact on a broad range of adverse post-operative events and outcomes. Design: The three papers in this thesis are a systematic review, a correspondence letter and a prospective, multi-centre feasibility study. The systematic review utilised NCBI PubMed, EMBASE and Cumulative Index to Nursing and Allied Health Literature as data sources, and selected all studies published since 1990 investigating health system interventions undertaken in PACU. A total of 3288 unique studies were identified, with 14 selected for full-text review, and 8 included in the review. Narrative synthesis of data was the primary outcome measure, due to the heterogeneity of study designs and primary outcome measures. The Advanced Recovery Room trial was a multicentre, prospective, before-and-after feasibility trial of moderate-risk patients undergoing non-cardiac surgery. Moderate-risk patients (predicted 30-day mortality of 1-4%) were managed in an Advanced Recovery Room Care setting immediately post-operatively, utilising PACU capacity, but extending care until the morning of post-operative day 1, and adding defined assessment checklists and goals of care. For this thesis, the large dataset from the Royal Adelaide Hospital (RAH) was analysed for (i) early post-operative adverse events (published separately as a correspondence letter), and (ii) detailed analysis on outcomes. Results: The systematic review identified four studies that investigated the use of the post-anaesthesia care unit as a non-ICU pathway for postoperative patients, two that investigated the implementation of physiotherapy in PACU, one evaluating the use of a new nursing scoring tool for detecting patient deterioration, and one evaluating a two-track clinical pathway in PACU. The Advanced Recovery Room Care trial was feasible, as defined by recruitment and per protocol management of >120 patients. Data on post-operative adverse events from RAH suggest that there is an undetected and unmanaged high incidence of serious adverse events in moderate-risk surgical patients receiving standard post-operative ward care. Frequent observation in the recovery room setting allowed early detection of these events, rapid implementation of care, and suggested improved outcomes. Conclusion: The systematic review concluded that managing selected postoperative patients in PACU, instead of ICU, does not appear to be associated with worse patient outcomes, however, the strength of evidence is moderate at best. Four of eight studies also examined hospital length of stay, with two finding the intervention was associated with decreased length of stay, and two finding no association. A trial of Advanced Recovery Room Care at the RAH was found to be feasible, and given the indicative data on outcomes, we believe a larger scale trial is warranted.