Eur J Cardiothorac Surg 2004;25:123-126
© 2004 Elsevier Science NL
The effectiveness of high dependency unit in the management of high risk thoracic surgical cases
Shilajit Ghosh*,
Richard S. Steyn,
Joseph F.K. Marzouk,
Frank J. Collins,
Palababu B. Rajesh
Birmingham Heartlands Hospital, Bordsley Green East, Birmingham B9 5SS, UK
Received 8 October 2002;
received in revised form 11 September 2003;
accepted 14 September 2003.
* Corresponding author. Tel.: +44-121-424-2000; fax: +44-121-424-0442
e-mail: shilajitghosh{at}hotmail.com
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Abstract
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Objective: To assess the effectiveness of high dependency unit (HDU) in the management of high-risk thoracic surgical cases at a single dedicated thoracic surgical unit. Introduction: There is a strong drive to improve postoperative management in a cost-effective way. The number of high-risk thoracic surgical procedures undertaken is increasing rapidly. The HDU can be an effective weapon in the armoury of thoracic surgeons to treat these patients effectively without the need for managing in the extreme environment of expensive intensive care beds. Method: Patients who had undergone lobectomy, pneumonectomy and oesophagectomy were included in the study, as they formed the bulk of the high risk thoracic surgical procedures undertaken by our unit. All data were collected retrospectively from case notes and computerised patient tracking system, for the period between April 2000 and March 2001. Result: One hundred and ninety-one lobectomies (174 for malignancy), 86 pneumonectomies and 50 oesophagectomies were performed during the time period of the study. Of these, 189 (99%) lobectomies, 82 (95%) pneumonectomies and 47 (94%) oesophagectomies were electively admitted to HDU. The mean HDU stay was 21.8 h. Operation discharge time was 7.3 days for lung resections and 9.1 days for oesophagectomy. The overall 30-day mortality was 1.9% for lobectomy, 11% for pneumonectomy and 2% for oesophagectomy. Two oesophagectomies, one lobectomy and three pneumonectomies had to be transferred from HDU to ITU for either mechanical ventilation or more invasive monitoring. Four pneumonectomies, two lobectomies and two oesophagectomies had to be readmitted to HDU with respiratory failure or cardiac instability. Of all the readmitted patients, one pneumonectomy and one lobectomy died. The causes of death were myocardial infarction, pulmonary embolism, adult respiratory distress syndrome and septicaemia. Discussion: The above results clearly demonstrate that a well-equipped and properly manned HDU can greatly facilitate management of high-risk cases with favourable outcome. It provides excellent pain control facilities, detects complications early and avoids unnecessary ITU admissions. It also provides an excellent training opportunity for both medical and nursing staff.
Key Words: High dependency units • Intensive care units • Cost effectiveness • Training
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1. Introduction
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Postoperative management of thoracic surgical patients has been the subject of many debates [1–4]. It is well recognised that for successful running of a surgical unit, it is imperative that postoperative care be maximised [5]. This very concept had led to the formation of ‘nightingale’ wards in the past where ill patients were nursed closer to the nurses station [6]. With advances in technology, intensive care units were developed. The high dependency unit has been variously defined in the literature. The association of Anaesthetists of Great Britain and Ireland define HDU as ‘an area for patients who require more intensive observation, treatment and nursing care than can be provided on a general ward. It would not normally accept patients requiring mechanical ventilation, but could manage those receiving invasive monitoring’ [7].
This was an observational study to look at the results of managing postoperative patients in a HDU setting over a period of 1 year. This institution carries out 10% of the UK's thoracic surgical work and has had a purpose built HDU since 1991. It seemed prudent to audit the management of the large number of thoracic surgical procedures performed over a period of 1 year between April 2000 and March 2001, as the national shortage of ICU beds were causing major concern in the UK. We decided therefore to look into major and complex procedures performed. Pulmonary and oesophageal resections constituted the major admissions into HDU.
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2. Materials and methods
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All data were retrospectively collected from HDU charts and the patient data system of the hospital. A total of 277 patients were identified who had undergone elective thoracotomy for lung resection and 50 patients had undergone oesophagectomy. Of the total number of oesophagectomies, 47 patients who had undergone elective and two patients urgent oesophagectomy for malignancy. One patient had oesophagectomy for high-grade dysplasia in Barrett's oesophagus.
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3. Results
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Between April 2000 and March 2001, 86 pneumonectomies, 191 lobectomies (174 for malignancy) and 50 oesophagectomies were performed. The clinical characteristics of these patients are summarised in Table 1 while the indications for surgery are summarised in Table 2. Of these cases, 189 lobectomies (99%), 82 pneumonectomies (95%) and 47 oesophagectomies (94%) were managed in the HDU. The average stay in the HDU was 21.8 h. The average length of stay in the hospital was 7.3 days for lung resection and 9.1 days for oesophagectomies. The 30-day mortality was 1.9% for lobectomy, 11% for pneumonectomy and 2% for oesophagectomy. Of the patients that initially went to HDU, one lobectomy, two oesophagectomies and three pneumonectomies had to be transferred to ITU, as they required mechanical ventilation or needed more invasive monitoring with inotropes. Of the total number of patients discharged from HDU to the ward, four pneumonectomies, two lobectomies and two oesophagectomies had to be readmitted back with respiratory failure or cardiac instability. Of those re-admitted, one oesophagectomy, one lobectomy and three pneumonectomies were successfully managed in the HDU. Direct admissions to ITU from theatre/recovery were two lobectomies, four pneumonectomies and three oesophagectomies. The decision to transfer directly to ITU was taken in three patients during surgery who demonstrated cardiac instability. Two patients initially monitored in the recovery unit were re-explored for bleeding and then were transferred to ITU after re-exploration. Two patients with failed extubation at the end of the procedure were transferred to ITU for weaning by the anaesthetists. Two patients who deteriorated while in recovery necessitating reintubation were transferred to ITU for monitoring and ventilation. Causes of death were myocardial infarction, pulmonary embolism, bronchopleural fistula, adult respiratory distress syndrome and septicaemia. Postoperative complications are summarised in Table 3. Fig. 1 illustrates the pathway of patient care following surgery in our unit.
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Fig. 1. Flow chart of patient management. This flow chart explains the pathway of patient care following major thoracic surgery. The haemodynamically stable patients are extubated and following a short stay in recovery unit are transferred to the HDU. Haemodynamic instability warranting continued or re-mechanical ventilation or invasive haemodynamic monitoring, either per-operatively, in recovery unit or in HDU prompts transfer of patients to ITU.
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4. Discussion
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The HDU at our institution has been functional since 1991. Initially it was a four-bed unit, which later expanded to six beds. The unit is geographically situated distinctly from the ITU but adjacent to the general thoracic ward. All the beds have standard equipment, which includes monitoring equipment with ECG leads; two invasive ports and leads; saturation port and probe; peripheral temperature port and temperature probe (non-disposable) and non-invasive blood pressure port and cuff/tubing; Flo-guard infusion administration pump; syringe pump; double oxygen point; high grade and low grade suction point. The observations of each patient are recorded on a special chart for the entire length of stay in the HDU. The unit is staffed by specially trained nurses 24 h a day, 365 days a year. The thoracic surgical team is primarily responsible for the management of patients in HDU. The SHO's are first on call for the HDU with the registrars acting as second on call. There is active input from the physiotherapists. There is close liaison with the anaesthetic and the intensive care team in decision making of high-risk patients. The nurse patient ratio is in the order of 1:2, but may vary to o1:1, depending on the severity of the patient's condition.
The criteria for admission to our HDU are non-ventilated patients who have thoracotomy, oesophagectomy, bilateral video assisted thoracoscopic surgery (VATS) and sternotomy. Also included are pre and post-operative thoracic surgical patients who have cardiovascular or respiratory instability, including those requiring facial continuous positive airway pressure (CPAP) and/or central venous pressure monitoring but not mechanical ventilation. Patients awaiting urgent surgery who do not require immediate mechanical ventilation or inotropic support (e.g. perforated oesophagus transferred from a peripheral hospital). Patients who have continuous infusion via an epidural catheter, for the first 24-h period following the insertion of the catheter and thoracic trauma patients who require intermediate level of care require close monitoring
The key issues in the management of postoperative major thoracic surgical cases are intensive cardio-respiratory monitoring and effective pain management. Ten to 15% of all post-operative complications occur within the first 24 h and early recognition of the problem is vital in preventing significant morbidity and mortality [8]. There have been concerns raised about the level of postoperative care in the UK. The NCEPOD report of 1991/1992 reported that out of a total postoperative mortality of 1616, 70% of these patients had an American Society of Anaesthetists (ASA) score of 3 and above. Yet, 1001 of this high risk group of patients did not receive any initial HDU or ITU care [8]. Another report by Gamil et al. [9]concluded that 17% of postoperative complications could have been avoided had there been facilities for HDU care. However, lack of resources has meant that HDU care is still grossly inadequate [10]. In a report published by the Royal college of Anaesthetists in1992/1993, only 39 hospitals in the UK and Ireland had provisions for HDU. Another report by the Department of Health stated that only 20% of hospitals with ITU facilities had functional HDU [11]. With increasing numbers of thoracic surgical procedures done, the demand for specialist supervision is increasing. In a number of published reports, the inappropriate utilisation of ITU resources has been highlighted. Figures between 21 and 40% of all ITU admissions as being inappropriate has been quoted [11]. Therefore, it is important to correctly utilise the available resources in the most efficient manner. It is evident from our study that the HDU provides an excellent means of addressing impending problems early without the need for patients to be nursed in an extremely stressful environment of intensive care. To focus on costs, the cost of treatment in ITU on a daily basis is £800 per day. The cost of treating a patient in our HDU is substantially lower at £440 per day (Birmingham Heartlands Hospital). This significant difference in cost is primarily due to the nursing costs/salaries in the ITU compared to HDU due to differences in patient to nurse ratio. Also accounting for the difference in the costs are the overheads of maintaining ventilators and the airflow system in the ITU. The cost substantially escalates when additional measures are required, such as continuous invasive cardiac monitoring and renal support.
It is evident from our findings that our unit is able to perform a large number of cases with an acceptable rate of complications and mortality. It also emphasises the fact that a three tier system comprising the ITU, HDU and the ward avoids unnecessary admissions to the ITU, enabling resources to be used effectively. The HDU also provides an excellent opportunity for surgical trainees as well as nursing staff to gain experience and training in management of ill patients as management is primarily the responsibility of the surgical team.
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Footnotes
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Presented at the 16th Annual Meeting of the European Association for Cardio-thoracic Surgery, Monte Carlo, Monaco, September 22-25, 2002.
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References
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Abstract
1. Introduction
