Structural and organisational impacts of peri‐operative enhanced care services in the UK : a Retrospective Evaluation of Postoperative Alternatives to Critical Care ( REPACC )

INTRODUCTION: The enhanced care model of peri-operative care has evolved to meet increasing surgical demand, aiming to relieve pressure on critical care and prevent unnecessary cancellation of surgery. Despite widespread adoption of these facilities in the UK, no resources currently describe the national landscape of enhanced care or the organisational impacts of their introduction. METHODS: We conducted a UK-wide, retrospective, observational study. At each site, the local structure of enhanced (level 1) and critical care (levels 2-3) services was recorded alongside time-series data describing patient flow and individual details for all referrals to levels 1-3. Multilevel regression was used to explore the relationships between referral to an enhanced care facility and various organisational outcomes. A cluster analysis was performed to group enhanced care units with similar characteristics. RESULTS: Data were collected between September and November 2023. Of 110 participating centres, 70 (63.6%) had a surgical level 1 unit. In total, 5990 patient referrals to levels 1-3 were followed up, of which 3146 (52.5%) were referred to level 1 and 2844 (47.5%) to levels 2-3. Enhanced care patients were younger, with fewer comorbidities, and were undergoing less complex surgery than those referred to critical care. Referral to level 1 rather than levels 2-3 was associated with a reduced likelihood of cancellation (OR 0.50, 95%CI 0.40-0.64, p < 0.001); cancellation due to a lack of bed (OR 0.27, 95%CI 0.19-0.40, p < 0.001); and a shorter duration of hospital stay (incidence risk ratio 0.58, 95%CI 0.55-0.61, p < 0.001). DISCUSSION: Enhanced care services provide a suitable alternative to critical care for high-risk surgical patients in the UK whilst building surgical capacity and system resilience. These facilities are associated with improved organisational outcomes, associations which may reflect both operational efficiency and the lower clinical acuity of the population they serve.