University College London Medical School, London, UK.
Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.
Anaesthesia. 2021 Mar;76(3):336-345. doi: 10.1111/anae.15302. Epub 2020 Dec 18.
Postoperative critical care is a finite resource that is recommended for high-risk patients. Despite national recommendations specifying that such patients should receive postoperative critical care, there is evidence that these recommendations are not universally followed. We performed a national survey aiming to better understand how patients are risk-stratified in practice; elucidate clinicians' opinions about how patients should be selected for critical care; and determine factors which affect the actual provision of postoperative critical care. As part of the second Sprint National Anaesthesia Project, epidemiology of critical care after surgery study, we distributed a paper survey to anaesthetists, surgeons and intensivists providing peri-operative care during a single week in March 2017. We collected data on respondent characteristics, and their opinions of postoperative critical care provision, potential benefits and real-world challenges. We undertook both quantitative and qualitative analyses to interpret the responses. We received 10,383 survey responses from 237 hospitals across the UK. Consultants used a lower threshold for critical care admission than other career grades, indicating potentially more risk-averse behaviour. The majority of respondents reported that critical care provision was inadequate, and cited the value of critical care as being predominantly due to higher nurse: patient ratios. Use of objective risk assessment tools was poor, and patients were commonly selected for critical care based on procedure-specific pathways rather than individualised risk assessment. Challenges were highlighted in the delivery of peri-operative critical care services, such as an overall lack of capacity, competition for beds with non-surgical cases and poor flow through the hospital leading to bed 'blockages'. Critical care is perceived to provide benefit to high-risk surgical patients, but there is variation in practice about the definition and determination of risk, how patients are referred and how to deal with the lack of critical care resources. Future work should focus on evaluating 'enhanced care' units for postoperative patients, how to better implement individualised risk assessment in practice, and how to improve patient flow through hospitals.
术后重症监护是一种有限的资源，建议高危患者使用。尽管有国家建议规定此类患者应接受术后重症监护，但有证据表明这些建议并未得到普遍遵循。我们进行了一项全国性调查，旨在更好地了解患者在实践中的风险分层情况；阐明临床医生对患者应如何选择重症监护的意见；并确定影响术后重症监护实际提供的因素。作为第二次冲刺国家麻醉项目的一部分，术后重症监护的流行病学研究，我们在 2017 年 3 月的一周内向提供围手术期护理的麻醉师、外科医生和重症监护医生分发了纸质调查。我们收集了受访者特征、他们对术后重症监护提供、潜在益处和现实世界挑战的意见的数据。我们进行了定量和定性分析来解释这些回答。我们从英国 237 家医院收到了 10383 份调查回复。顾问使用的重症监护入院门槛低于其他职称，表明潜在的风险规避行为更多。大多数受访者报告说重症监护的提供不足，并指出重症监护的价值主要是由于护士与患者的比例更高。客观风险评估工具的使用较差，患者通常根据特定程序的途径而不是个体化的风险评估选择接受重症监护。围手术期重症监护服务的提供方面存在挑战，例如整体容量不足、与非手术病例争夺床位以及医院内流程不畅导致床位“堵塞”。重症监护被认为为高风险手术患者提供了益处，但在风险的定义和确定、患者如何转诊以及如何应对重症监护资源不足方面存在差异。未来的工作应集中在评估术后患者的“强化护理”病房、如何在实践中更好地实施个体化风险评估以及如何改善医院内的患者流程。
