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Article history: Study Objective: To evaluate the utilization of the surgical step-down unit (SSDU) by a sample of patients who
Received 28 March 2012 were preoperatively booked for admission to the unit, and to identify those patient characteristics and
Received in revised form 4 October 2012 perioperative variables that are associated with an intervention in the unit.
Accepted 6 October 2012 Design: Retrospective chart review.
Setting: Canadian tertiary-care facility.
Keywords:
Measurements: Data from 133 elective surgery patients with prebooked SSDU beds were recorded, including
Intensive care
Perioperative medicine
comorbidities, Surgical Risk Scale (SRS), Surgical Apgar Score (SAS), and number and nature of interventions
Postoperative care and events occurring in the SSDU.
Surgical step-down unit, utilization Main Results: Of the 133 patients scheduled for SSDU admission, 60 (45.1%) were actually admitted and the
other 73 (54.9%) were admitted directly to the surgical ward or else discharged. Of the patients admitted to
the SSDU, 48.3% had an intervention during their stay. In logistic regression, the SRS was a signicant
predictor (P b 0.001) of SSDU use, while the SAS was a signicant predictor (P = 0.034) of the need for an
intervention or the likelihood of an event while in the SSDU.
Conclusions: Less than half of patients identied were actually admitted to the SSDU postoperatively; of those,
less than half required an intervention. The Surgical Apgar Score, a score based on intraoperative factors,
predicted the need for an intervention during SSDU admission. Consideration should be given to the
development of a predictive score that emphasizes intraoperative factors and early postoperative factors to
optimize allocation of this scarce resource.
2013 Elsevier Inc. All rights reserved.
0952-8180/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jclinane.2012.10.010
S. Shum et al. / Journal of Clinical Anesthesia 25 (2013) 202208 203
Currently, there are no data to evaluate the patterns of elective interventions or have an adverse event in the SSDU, were compared
surgical usage of the SSDU in our tertiary-care center. Specically, there using t-tests for continuous data and chi-square tests for categorical
are limited data on the nature of events occurring in the SSDU for data. Duration of surgery was compared using the Mann-Whitney U
elective noncardiac admissions and the incidence of events requiring test. Logistic regression, controlling for age, was used to assess the
nursing or physician intervention. Furthermore, while the literature has ability of the SRS and SAS to predict utilization of the SSDU and the
examined the process of differentiating ICU patients from those need for an intervention or the occurrence of an event while in the
adequately cared for on general surgical wards [12] and SSDUs [13], it SSDU. Surgical procedures were diverse, so they were initially broadly
provides little guidance on making a decision to admit a patient to SSDU categorized by the clinical team on the basis of specialty (eg, general
versus a general surgical ward. The objectives of this study were to 1) surgery, neurosurgery, thoracic surgery) and complexity. This
evaluate actual usage of the SSDU by a sample of patients who resulted in 19 categories, so low-volume surgeries were further
underwent elective noncardiac surgery and who were preoperatively collapsed into an Other Major category (vascular, otolaryngology,
booked for SSDU admission at a tertiary-care facility in Canada, and 2) peripheral limb) and Other Minor (eg, minor urological, general,
identify patient characteristics and perioperative variables (including gynecological, and plastic surgeries) on the basis of consensus.
SAS and SRS) associated with both SSDU use and the occurrence of an Results were deemed to be signicant if P b 0.05. Findings that fell
event or need for an intervention in the SSDU. An intervention or event short of statistical signicance but appeared clinically relevant were
in the SSDU was regarded as a proxy for appropriate SSDU admission. also noted. Formal sample sized calculations were not carried out for
this observational study, but a sample size of 50 is commonly
2. Materials and methods considered a guideline as the minimum number of patients required
for the use of inferential statistics [14]. More than twice that number
Ethics approval was obtained from the Queens University Health was collected so as to allow sufcient power for evaluation of the
Sciences and Afliated Teaching Hospitals Research Ethics Board. subset of those who were admitted to the SSDU.
Eligible patients were those scheduled for elective surgery with an
SSDU room booked preoperatively. Cardiac patients were not 3. Results
included as their postoperative care takes place in a designated
cardiac care unit. Patients were accrued from September 28, 2009 to 3.1. Patient demographics
February 1, 2010, until there was a sufcient sample to permit
subgroup analyses. Patients with a preoperative decision about the A total of 2999 cases were admitted during the study period,
location of postoperative care were identied by a review of the including 2007 elective cases. A cohort of 133 patients (6.6% of
operating room (OR) slate. Decisions regarding postoperative dispo- elective cases; 4.4% of total) was captured by our study. Fig. 1 depicts
sition were made either by surgeons or anesthesiologists. Patients the derivation and course of the 133 patients included for analysis.
were excluded if the decision to admit to the SSDU was made outside Table 1 compares the characteristics of patients who were admitted to
the preoperative period. Data were extracted from the hospitals SSDU with those who were not and of patients who required
electronic record system and each patients paper hospital chart. interventions or had an event in SSDU with those who did not. Of
The SSDU at Kingston General Hospital is part of a 16-bed combined the 47 patients referred by the Surgical Service and admitted to the
medical-surgical unit. The SSDU is an open unit with patient care provided SSDU, only 19 (40.4%) required an intervention or had an event; of the
by the admitting service and nursing care delivered in a 1:2 nurse to 12 referred by the Anesthesiology Service and admitted to the SSDU, 9
patient ratio. The SSDU provides Level 2 critical care and is capable of (75.0%) required an intervention or had an event (P = 0.032).
providing support for a single failed organ system, short-term noninvasive
ventilation, vasoactive infusions, and basic invasive monitoring. Patients
not cared for in the SSDU include those requiring invasive ventilation,
intra-aortic balloon counterpulsation, continuous renal replacement
therapy, and pulmonary artery and intracranial pressure monitoring.
Extensive data covering the entire perioperative period for all
patients were collected (Appendix 2). Preoperative data included
patient demographics, indication for SSDU prebooking, nature of
comorbidities, and calculation of the SRS score. The SRS was calculated
according to published guidelines [7], with scores ranging from 3 to
14, with 14 = the highest risk (Appendix 1). Intraoperative course
was measured with the SAS, which was also calculated according to
published guidelines [9,10], with scores ranging from 0 to 10, with 0 =
the highest risk (Appendix 1).
Events occurring in the PACU and if applicable, the SSDU, were
recorded. They included those events requiring nursing or physician
intervention and ranged from relatively benign postoperative compli-
cations such as pain to indicators of distress, including inotrope use and
intubation. This reected the range of postoperative outcomes in our
sample. The occurrence of adverse events and interventions were then
combined into a single variable for the purpose of comparing patients
with and without an intervention or an adverse event in the SSDU.
Table 1
Patient characteristics
Booked SSDU used Booked SSDU not used P-value SSDU intervention/ No SSDU intervention/ P-value
(N=60) (N=73) event (N=29) event (N=31)
Means SD Means SD
Age (yrs) 54.5 20.9 58.5 5.7 0.21 53.1 21.5 55.8 20.5 0.61
Body mass index (kg/m2) 29.7 7.3 31.8 7.9 0.15 31.7 9.1 27.7 4.3 0.062
Surgical Risk Score 9.0 1.8 7.8 1.4 b 0.001 9.3 1.3 8.7 2.2 0.20
Surgical APGAR Score 6.6 1.6 7.0 1.3 0.12 6.1 1.6 7.1 1.5 0.027
Duration of surgery (hrs) 4.6 2.5 3.2 1.7 b 0.001 5.2 2.6 4.0 2.2 0.078
Median 2.8 Median 3.8 P-value Median 5.5 Median 3.5 P-value
N (%) N (%)
Obstructive sleep apnea (OSA; 30.8%), diabetes (19.5%), stable subset who went to the SSDU, the mean SRS score between those who
coronary artery disease (17.3%), asthma (15.8%), and arrhythmia and did and did not have SSDU interventions or events was not
renal disease (15.0% each) were the most common comorbidities in the statistically signicant (9.3 vs 8.1, P = 0.20).
cohort. Signicant differences were noted between patients admitted The difference in mean SAS between SSDU and non-SSDU patients
and not admitted to SSDU with respect to frequencies of comorbidities. (6.6 vs 7.0, respectively) did not reach statistical signicance (P = 0.12).
The SSDU was commonly booked but underused for OSA (P b 0.001) and However, a signicant difference (P = 0.027) was noted between SSDU
asthma (P = 0.033), with similar trends noted for renal disease (P = 0.05) patients who received an intervention/had an event and those who did
and diabetes (P = 0.126). The reverse trend was noted for chronic not (6.1 vs 7.1, respectively). In logistic regression, controlling for age,
obstructive pulmonary disease (P = 0.075); those patients were more the SRS was a signicant predictor (P b 0.001) of SSDU use, with a 1.8-
likely to go to the booked SSDU. For the subset of SSDU patients, preexisting fold increase in odds of use with a one-point increase in SRS (95% CI 1.4,
cardiac valvular conditions (P = 0.009) and OSA (P = 0.024) were 2.5) but the SAS was not signicant (P = 0.68). However, the SAS was a
signicantly associated with receiving an intervention or having an event. signicant predictor (P = 0.034) of need for an intervention while in
Thoracic surgery, neurosurgery, and liver resection had the highest rates of SSDU, with a reduction in odds of 0.62 (95% CI 0.40, 0.96) for a one-
SSDU admissions postoperatively. There was also a trend for patients with point increase in SAS; the SRS was not a signicant predictor (P = 0.23).
a larger body mass index (BMI) to require an intervention or have an event
at the SSDU (P = 0.062). 3.4. Postanesthesia care unit (PACU) course
3.2. Reason for SSDU booking Continuation of invasive intraoperative monitoring techniques
(arterial and central catheters) was signicantly different (P 0.001)
Indications for requesting an SSDU admission preoperatively were between patients admitted to the SSDU and those who were not. The
identied in 94.7% (n=126) of cases and categorized (Appendix 1, need for noninvasive ventilatory support [continuous positive airway
Reasons for SSDU booking). Thirty-four (25.6%) patients had 2 pressure/bi-level positive airway pressure (CPAP/BiPAP) support] in
indications. The nature of the surgery (60.9%, n=81) was the most the PACU was associated (P = 0.049) with need for an intervention(s)
frequent reason for requesting an SSDU admission preoperatively, or having an adverse event during SSDU admission.
followed by OSA (18.0%, n=24), cardiac monitoring (14.3%, n=19),
morbid obesity (10.5%, n=14), and respiratory monitoring (8.3%, n=11). 3.5. Surgical step-down unit
3.3. The SRS and SAS During the study period, a total of 255 surgeries were cancelled, of
which 7 (2.7%) were directly attributed to SSDU bed unavailability. Sixty
The SRS was signicantly higher for the cohort of patients (45.1%) patients in our cohort were admitted to the SSDU, which
admitted to the SSDU postoperatively (9.0 vs 7.8, P b 0.001). For the represented 52.2% of the total SSDU admissions for the study period. Of
S. Shum et al. / Journal of Clinical Anesthesia 25 (2013) 202208 205
To account for relevant preoperative and intraoperative factors in a during the intraoperative period. If the decision to admit to SSDU is
simple yet comprehensive manner, we propose combining the SRS left until the day of surgery, the anesthesiologist is usually the one
and SAS tools in selecting patients for the SSDU. As these scores were who decides. The exclusion of these patient data may explain the low
not originally designed to distinguish the level of care required by rate of referrals to SSDU by anesthesia in this study.
patients postoperatively, these tools rst must be validated for this Third, the case mix studied in this sample is not representative of
indication. Following validation of these scores in a large prospective what is typically seen at our institution. In particular, the urgent
study involving all elective surgeries regardless of type, a possible nature of vascular surgeries may explain the low incidence of these
model is to use the SRS score to ag patients preoperatively for surgeries in our sample; only elective surgeries were included. The
potential SSDU need. Subsequently, the SAS would be calculated decision to admit a vascular surgery patient to the SSDU is also not
based on intraoperative variables to facilitate the denitive decision of routinely made preoperatively, and thus these patient data were not
whether to admit to SSDU. captured by our methods. Also highly likely is that these patients
There are some limitations to the study. First, these ndings are required the level of care provided by, and were admitted to, the ICU.
limited to those patients who were booked for the SSDU preoperatively. Finally, because this was an exploratory study containing a small
Surgical step-down unit patients who were not electively prebooked sample size, the external validity of our results may be limited. We
represent an important group when assessing the risk factors associated also acknowledge that the current model adopted by our institution,
with SSDU admission; this group would also have a signicant impact of preoperatively allocating SSDU beds, may not reect the practice at
on the SSDU resources and need for intervention, or occurrence of an other institutions.
event. A larger study encompassing both groups would provide Our study was unique in that all elective noncardiac surgery
additional insight into the factors associated with SSDU use. patients were included. As the sample size is small in this exploratory
Routine SSDU admissions such as those required by most study, a larger prospective study at our institution will improve the
postoperative patients may not be charted as diligently as for those generalizability of results to other tertiary-care centers. The overrid-
patients in extremis. Furthermore, we may have overlooked some ing conclusion from this study, that using preoperative variables alone
SSDU interventions during data collection that, although considered is insufcient to identify patients at risk for postoperative complica-
minor, would have resulted in poorer outcomes had they not tions, parallels that from previous literature [12,13,15-19].
occurred. For example, a routine SSDU admission for thoracic surgery In conclusion, the results of this study suggest that intraoperative
may involve diligent nursing care that would detect a complication and early postoperative factors in the PACU are more accurate in
before it became an adverse event, or before an intervention was predicting postoperative complications and thus more appropriate for
necessary. Second, our method of identifying patients for review may determining patient disposition postoperatively. With the SSDU
have inadvertently excluded a number of eligible patients. As our becoming increasingly popular as hospitals struggle to provide high-
patients were identied for review through the indication of a level care with limited resources, the decision regarding selection of
prebooked SSDU bed on the OR slate, clerical errors may have led to optimal location of postoperative care will become one of increasing
the exclusion of some eligible patients. Patient data were also missed importance. These ndings may provide a starting point for future
if the decision to admit to SSDU was made on the day of the surgery or studies on this important decision-making process.
S. Shum et al. / Journal of Clinical Anesthesia 25 (2013) 202208 207
Description Score
CEPOD
elective Routine booked nonurgent case, eg, varicose 1
veins, hernia
scheduled Booked admission, eg, colon cancer or AAA 2
urgent Cases requiring treatment within 24 - 48 hrs 3
of admission, eg, obstructed colon
emergency Cases requiring immediate treatment, 4
eg ruptured AAA
BUPA
minor Removal of sebaceous cyst, skin lesions, 1
esophagogastric duodenoscopy
intermediate Unilateral varicose veins, unilateral hernia 2
repair, colonoscopy
major Appendicectomy, open cholecystectomy 3
major plus Gastrectomy, any colectomy, laparoscopic 4
cholecystectomy
complex major Carotid endarterectomy, AAA repair, limb 5
salvage, anterior resection, esophagectomy
ASA physical status
1 No systemic disease 1
2 Mild systemic disease 2
3 Systemic disease affecting activity 3
4 Serious disease but not moribund 4
5 Moribund, not expected to survive 5
The Surgical Risk Scale score was calculated for each procedure by adding the CEPOD (Condential Enquiry into Perioperative Deaths), BUPA (British United Provident Association),
and ASA (American Society of Anesthesiologists) physical status scores.
AAA=abdominal aortic aneurysm.
Estimated blood loss (mL) > 1,000 601 - 1,000 101 - 600 100
Lowest mean arterial pressure (mmHg) b 40 40 54 55 - 69 70
Lowest heart rate (bpm) > 85 76 85 66 - 75 56 - 65 55
Surgical Apgar Score = sum of the points for each category in the course of a procedure.
Occurrence of pathologic bradyarrhythmia, including sinus arrest, atrioventricular block or dissociation, junctional or ventricular escape rhythms, and asystole also receive
0 points for lowest heart rate.