Surgical Special Care Units: An Unmet Need or a Unique Paradox?

The intraoperative period today is far safer than ever before. This is despite the fact that anesthesiologists and surgeons are working on patients who are sicker than in years past.1,2 In fact, anesthesia-related intraoperative mortality has decreased from roughly 1 in 10,000 patients to <1 in 100,000 patients. Unfortunately, despite continuing advancements toward increasing intraoperative safety, the same cannot be said of the postoperative period. Thirty-day postoperative mortality has shown only marginal improvement in the last decade and remains at 1%–2%, a remarkable 1000 times more than anesthesia-related intraoperative mortality.3–5 An innovative option would be to describe the period within 30 days after surgery as a disease, in which case it would be the third leading cause of death in the United States.6 The conventional postoperative recovery model is a choice between the intensive care unit and the hospital general care floor (ward, nursing floor, general care unit), depending on clinically adjudicated patient stability. While surgical patients who recover on the general care floor are considered stable, they are subject to a disturbingly high number of critical cardiorespiratory complications. Ward hypotension and hypoxemia are common and unpredictable using standard validated tools.7–10 Most heart attacks occur in the first 2 days after surgery and contribute to nearly half of all postoperative deaths.11 In addition, when sudden cardiorespiratory compromise occurs outside the intensive care unit, the associated mortality remains as high as 40%.12 It remains intuitive that a transfer from the closely monitored confines of a care unit such as the intensive care unit or the postanesthesia care unit to the relatively less monitored hospital ward may increase postoperative complications. Indeed, the decision to move a patient from the intensive care unit, postanesthesia care unit, or other monitored environments to the general care floor signals for an improvement in clinical status. Despite this, readmissions to the intensive care unit from the hospital ward remain common and are associated with poor outcomes.13 In this issue of Anesthesia & Analgesia, Mendis et al14 performed a systematic review that examined the use of surgical special care units within a “nontraditional” 3-level model of care, which includes the intensive care unit, the ward, and an intermediate or step-down area that constitutes these surgical special care units. The authors compare critical outcomes for noncardiac surgery patients including postoperative mortality and health care utilization in this nontraditional 3-level model (ie, ward, surgical special care unit, intensive care unit) with a “traditional” 2-level model of care (ie, ward, intensive care unit). In this context, the concept of an intermediate care was borne out of the idea of an area of patient care that would allow for transition from the critical care unit to the hospital floor and possible improved outcomes, which would include decreased intensive care unit readmissions, length of stay, intensive care unit mortality, and in-hospital mortality. Mendis et al14 suggests that a 3-level model of care may actually increase in-intensive care unit mortality with no difference in overall in-hospital mortality.14 Is this a meaningful paradoxical outcome or a function of the heterogeneity of presented data? Furthermore, is there a true unmet need for step-down units and should we continue to romanticize about their presence in most hospital systems? The biggest limitation is the nature of the data of the constituent studies for this review, which are limited, and this is exemplified in the review wherein a number of included studies are before–after design. These are then likely limited by changes over time and regression to the mean. Further, the heterogeneity and near ambiguity of admission criteria into the surgical special care unit make it difficult for true clinical interpretation of this paradoxical outcome. A recent survey of practices across the country highlighted this and concluded that while most of these units admitted “step-down” patients from the intensive care unit, there were still about 39% of units that accepted a mix of step-up patients, step-down patients, postoperative patients, and patients from the emergency department.15 There are important implications for this mix. While sending patients from the intensive care unit constitutes step-down in care, this also translates into a “decanting effect” to which Mendis et al14 have eluted. This effect leads to a higher proportion of patients with intermediate sickness being transferred out of the intensive care unit at an earlier stage. What is left in the intensive care unit is a sicker cohort, hence contributing to the increased intensive care unit mortality that these authors also observed in their systematic review. On the other hand, transfers into the intermediate care units can also be a step-up from the floor, in which case the surgical special care unit is constituting an effective pathway for care of patients of an increased level of acuity, or continuing clinical deterioration on the floor, and where early intervention and escalation of care have likely decreased the likelihood of an increased mortality on the floor. This may also be the case for direct transfers from the operating room or the emergency room. In terms of the clinical spectrum of care, the staffing of these surgical special care units is also ambiguous in available literature. To allow for an effective improvement of care, early transfer back to the intensive care unit, and a continuity of care, most intermediate care units should probably be at least comanaged by intensivists. This is especially so when considering “step-down” units where the bulk of patients have been in critical organ failure in the not-too-distant past. This is not the case in most surgical special care units where only a fifth of all are currently managed by critical care physicians.15 The strength of the work of Mendis et al14 is the novelty of the subject and the perceived need for better answers and clinical direction in this area.14 Hospital systems across the world are leaning toward increasing intensive care unit beds and expanding intensive care unit services beyond the confines of the intensive care unit. While this is a tempting concept, it is certainly not one that is easy from an organizational and a fiscal standpoint. Intensivists are a highly endangered species across the planet, it is expensive to recruit for more providers, and it is even more expensive to build and setup new critical care units. From that perspective, this work asks a really important question—is it better to expand our current critical care services or open up more intermediate care units that may be a less-expensive alternative and may allow us to care for patients who are on the less-severe spectrum of critical illness? This will further free up intensive care unit beds for “real” intensive care unit patients and put this expensive resource to good use. Most of us would start with believing that intermediate care units are an overall beneficial intervention for any hospital system. We now know that this may not always be true; outcomes are truly heterogenous and vary depending on what end of the spectrum of improvement in mortality we would want to examine. Herein, this systematic review also allows the reader to understand (within the limitations of the data that make up the analysis) that there may be a gap between the real and perceived benefits of setting up more intermediate care units. Mendis et al14 was limited to a systematic review and had minimal homogenous data to perform any kind of pooled analyses, although several subset data would have been of significance.14 This and the nature of the included studies, as the authors elute to themselves, were drawbacks of the data and the outcomes stated. However, the message is loud and clear for the clinical researcher who wants to construct an idea examining this area of patient care. The need of the hour is cleaner, well-designed trials, with methodology that would do away with some of the limitations of a before and after trial. An alternating interventions model would be one such variant—wherein patients could be allocated the use of surgical special care units during a given 4-week window and alternating with this not allocated the use of these units on another 4-week window of intervention. These models, used before for other important outcomes, may serve as an easier-to-execute and cheaper alternative to a full randomized control trial for such an experiment.16 The role of improved, continuous, portable, and smarter vital signs monitoring systems to watch patterns of deviation from the norm is also critical as patients transition from the intensive care unit to the step-down unit to the general care floor. Finally, one other proposed model of building surgical special care units is incorporating these as flexible beds within the confines of an intensive care unit. This would allow for effective staffing, appropriate utilization, and resource management to include more step-down or step-up patients within these flexible beds inside an intensive care unit.17 What are some of metrices to be looked at when analyzing the effectiveness of a surgical special care unit or an intermediate care unit? I would recommend (1) hospital and intensive care unit length of stay, (2) intensive care unit 48-hour readmission rate, (3) hospital mortality, (4) 30-day hospital readmission rate, and (5) cost of hospitalization. In the meanwhile, work such as that provided by Mendis et al14 will serve as an important tool to allow anesthesiologists, intensivists, perioperative physicians, and hospital administrators to better understand the real nuances of the complicated structure of an intermediate care unit.14 The real outcome may be paradoxical in some ways for this systematic review, but the bottom line remains that we have to allow for a safer recovery environment for our inpatients. The answer may be a combination of step-down or step-up units, better staffing, resource management, and improved smarter monitoring systems all built in together. DISCLOSURES Name: Ashish K. Khanna, MD, FCCP, FCCM. Contribution: This author helped conceive and write this invited editorial in its entirety. Conflicts of Interest: A. K. Khanna is a part of Medtronic’s executive advisory council. This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.