June 2024 (Volume 6) Complex surgical patients not admitted to critical care
A QASM assessor stated: ‘We recognise futility when it comes to operate or not, or ICU or not, but it is important to link the two in the surgeon's plan. Even preoperatively, if ICU is consulted, a joint decision can sometimes be made to counsel the patient and family to embark on nonoperative management, or even palliation.’
PURPOSE:
To determine if Queensland assessors considered that medical care of the surgical patient could have been better had the patient been admitted to a critical care unit - either a high dependency unit (HDU) or intensive care unit (ICU) (jointly termed ICU in this report).
BACKGROUND:
ICUs provide peri-operative specialised observation, medical care and end-organ support when recovery with a reasonable quality of life is considered likely. ICU care is an expensive and finite resource; admissions may be declined if meaningful recovery is considered unlikely or if beds are unavailable. In Queensland in 2021-22, there were 8.1 funded beds per 100,000 population1
Figure 1. Declined admissions to ICU (median and IQR) by region, 2021/2022
Note: Data from 122 contributing ICUs. ACT (3), NT (2) and TAS (3) excluded for individual reporting to avoid identification of individual ICUs.
Source: Figure 18, Intensive Care Resources and Activity Report 2021/20221
METHODS:
QASM reviewed surgical mortality data for patients who died in hospital between January 2018 and December 2023.
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RESULTS:
QASM assessors reviewed the data of 6,367 surgical patients. Approximately half (42.5%, n = 2,706) were not admitted to ICU. Of these, assessors deemed that 151 patients (5.6%) would have benefited from ICU admission. The proportions were similar across all years. The median age of patients who assessors considered could have benefitted from admission to ICU was 81 years (IQR 73–88), with 98% classified as ASA (American Society of Anesthesiologists) Grade 3 or above. These were mainly emergency admissions (91.4%) under General Surgery (n = 77) or Orthopaedics (n = 45).
For patients with declined ICU admission, assessors determined that all aspects of patient care could have been significantly improved if ICU admission had occurred. Clinical management issues (CMIs) occurred in 72 patients who could have benefited from ICU admission. These patients had a total of 101 CMIs, of which 60 were considered preventable. More than 70% of CMIs were directly related to declined ICU admission, compared with 24.9% associated with other areas. CMI areas associated with declined ICU admission included unsatisfactory medical management/non-use of ICU, delay in diagnosis and in recognising complications, and delayed surgery (Table 1).
Table 1. Areas where care could
2023
DISCUSSION:
Assessors were significantly more likely to note preoperative assessment and postoperative management as areas for improved care in patients not admitted to ICU but who should have been, compared to the decision to operate and intraoperative technical issues. The precise reasons for declined ICU admission have not been revealed in this study. This may have been contributed to, at least in part, by ICU resource limitations, in particular noting that this report covers the period when COVID-19 was prevalent in Australia. Patient-focused use of ICU resources can occur if surgeons and intensivists have early pre- and postoperative discussions. The decision to operate was questioned by QASM reviewers in 10 patients.
In the small percentage of surgical patients who died (n = 151, 2.4% of the total cohort, over 4 years) without being admitted to ICU, their outcome may have been different had they been admitted to an ICU. This report is but a snapshot and could underestimate the issue, especially as the Australia and New Zealand Intensive Care Society (ANZICS) has reported this as a persisting issue. This report does cover the period when COVID-19 was prevalent in Australia. The most recent ANZICS data show that Queensland ICUs had the highest number of declined ICU admissions in Australia and Aotearoa New Zealand (5.0%)1
Timely and collegiate communication between surgeons and intensivists may result in efficiencies in ICU admissions or tilt the goal of care away from the surgeon’s curative efforts towards recognition of futile surgery and compassionate care.
RECOMMENDATIONS:
• Surgeons and intensivists are encouraged to improve cooperation to achieve patient-centred outcomes.
• Surgeons are encouraged to escalate to their Director of Surgical Services if patients are unable to be accepted to ICU due to capacity issues.
• All Queensland hospital ICUs are encouraged to participate in ANZICS benchmarking processes.
have been different/improved in patients declined ICU admission, January 2018–December
101)
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The following QASM cases* highlight ICU bed shortages, declined ICU admission and its impact on care for complex surgical patients. Conversely, a case where ICU admission was appropriately declined is also included.
CASE STUDY 1: An 89-year-old female presented with small bowel obstruction (SBO). The same day, she had an oral contrast follow-through. The next day, there was no passage of contrast into the large bowel and the on-call surgeon made the correct decision to proceed to surgery given no clinical or radiological progress.
For postoperative care, the ICU was consulted verbally. However, the situation changed to ICU beds being unavailable. The operation was postponed to the following day in anticipation of ICU bed availability.
Surgery was performed the next day as planned. A necrotic segment of small bowel was resected and anastomosed. The procedure was difficult due to dense adhesions. An enterotomy was recognised and repaired. During surgery, the patient needed inotropic support, which was weaned in recovery.
After reviews in recovery, the ICU team decided the patient did not need postoperative ICU admission. Because of the patient’s postoperative course on the ward, the surgical team felt that an ICU admission was necessary. The ICU team was involved again. Advice was provided without taking the patient to ICU.
On the ward, the patient deteriorated, with increasing oxygen requirements. A repeat CT scan showed extensive free fluid and gas, raising the possibility of anastomotic leak. The ICU was consulted again, but at that point the patient decided to refuse any further surgery or admission to ICU. She died on postoperative day 5.
LESSON: There is a need for postoperative ICU access for an elderly patient undergoing emergency laparotomy for SBO. The lack of ICU beds contributed to a delay in surgery, and refusing postoperative ICU care may have contributed to her death.
CASE STUDY 2: An 88-year-old patient’s presentation suggested ischaemic gut. The patient was seen within 4 hours. Surgery and an ICU bed were organised. On histology, perforated jejunal diverticulitis was diagnosed.
The 4-hour operation (with a consultant present) was difficult. It is unclear why the Fellow’s operation report stated: ‘to the ward’, given the operation length, the patient’s comorbidities and the prior organisation of an ICU bed.
On postoperative day one, anaesthetic review prompted ICU review, with heart failure suspected. After this review, ICU admission was deemed unnecessary.
After midnight, on postoperative day 2, an ICU consultant attended a ward call for slurred speech, stridor and wheeze. Naloxone was given with ‘some effect’ although the upper airway sounds persisted. At 1 am, after a phone conversation with the patient’s daughter, the ICU registrar documented that an acute resuscitation plan was in place. This limited care to ‘ward-based’ only, with non-invasive ventilation, intubation and CPR excluded. Later that day, another ICU review noted that low saturations had been restored. Fluid overload and opiate sedation were again diagnosed.
On postoperative day 3, another ICU registrar noted gurgling upper airway noises and anxiety. The ICU consultant stated that a ‘ceiling of care’ had been reached. Opiates were given sublingually and via the nasogastric tube. The patient died later that day. In this case, the planned ICU admission was cancelled without documented reasons. The impression is that the surgical and ICU teams interpreted the care limitations communicated by the patient and/or family to mean that ICU admission was inappropriate. For the patient to remain on the ward despite early and clear deterioration with several ICU reviews, meant that any chance of salvage from fluid management and narcosis was lost.
LESSON: Surgeons should play a pivotal role in preoperative and postoperative care. If surgery is performed with curative intent, then maximum postoperative care should be given, including ‘short, sharp ICU stay’ to optimise the outcome.
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CASE STUDY 3: An 87-year-old male was admitted following a fall. He was noted to have serum potassium of 7.0 mmol/L. The predominant injuries were left rib fractures and haemopneumothorax.
Overnight, the patient was admitted under the surgical team. The following morning, consults were made to general medicine, physiotherapy and the acute pain service. Telemetry was requested by the medical team in the context of hyperkalaemia. Fentanyl patient-controlled analgesia (PCA) was commenced by the acute pain service, pending insertion of a regional block.
That evening, the patient had a medical emergency team (MET) call for hypotension and non-anion gap acidosis. Chest X-ray showed no significant changes from admission. His deterioration did not appear to be directly trauma-related. Following the MET call a paravertebral block was placed.
The patient deteriorated over the following days despite frequent, thorough and well-documented reviews, and interventions by all teams. He became febrile and delirious and ultimately developed pneumonia. Family discussions occurred at several intervals. It was clear that good palliation was the primary goal.
There was no apparent traumatic basis for the MET call on day one. The patient’s superimposed thoracic injuries led to an unrecoverable situation despite all appropriate ward-based measures being instituted.
LESSON: Treatment goals were appropriately assessed and modified according to circumstances; documentation was thorough. There was no indication for transfer and it was appropriate that the patient was not admitted to ICU. This case was well-managed by all teams.
• Queensland Intensive Care Clinical Network (QICCN)
*Case studies were edited from QASM cases and first- or second-line assessments generated by expert surgeons in the field. Any recommendations relate to the cases as they were presented.
RESOURCES:
• Australian and New Zealand Intensive Care Society (ANZICS) https://www.anzics.com.au/
• Clinical Services Capability Framework: Intensive care services (health.qld.gov.au)
• Clinical Services Capability Framework: Intensive care services – children’s
REFERENCES:
1. Australian and New Zealand Intensive Care Society. Intensive Care Resources and Activity in Australia and New Zealand – Activity Report 2021/22. 2023; Melbourne. Available from: https://www.anzics.com.au/wp-content/uploads/2023/06/2022-ANZICS-CCR-ActivityReport.pdf
