Objective

According to the “Thoracic Surgery State of the Nation 2015” survey, the majority of thoracic surgery units routinely provided post-operative high level care admission (HLCA). Five years ago we elected to routinely transfer major thoracic surgery patients directly to the ward after appropriate exclusion criteria for high risk patients. Here we aim to establish the safety of our practice and whether it should be recommended nationally.

Methods

We performed a retrospective analysis of relevant hospital databases for the period 2010-2015 to identify all major thoracic surgery cases (bi/lobectomy, pneumonectomy and thymectomy). We analysed HLCA (planned and unplanned), in-hospital mortality and post-operative length of stay and identified the patient and procedure related risk factors for planned or unplanned HLCA. We also intend to conduct a national survey to gather a more detailed landscape of current UK practice.

Results

See summary in Fig. 1. Risk of mortality was 0.8% despite only 8.9% planned HLCA. All mortalities occurred following escalation of care. Pneumonectomy, thoracotomy / sternotomy and myaesthenia were predictors for planned HLCA. Respiratory dysfunction secondary to atelectasis or pneumonia was the most common cause of unplanned HLCA with recent smoking as the most common risk factor. We estimate potential savings of approximately £200,000 over five years based on one overnight HDU stay.

Conclusion

Providing safe immediate post-operative ward care requires refinements prior to, during and following the procedure. These include: identification of high risk patients i.e. recent smoking history, performing minimal access surgery, offering paravertebral rather than epidural block and easy access to unplanned HLCA. To achieve this requires highly trained and motivated nursing, pain and physiotherapy teams. This system is safe and also offers significant reduction in costs and cancellations.