Outcome Variations
A Before and After Trial of The Effect of a High-Dependency Unit on Post-Operative Morbidity and Mortality
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Summary
Posted By: Gordon S. Doig
E-Mail: gdoig@med.usyd.edu.au
Posted Date: 16 May 2005
Title: A Before and After Trial of The Effect of a High-Dependency Unit on Post-Operative Morbidity and Mortality
Authors: R. BELLOMO, D. GOLDSMITH, S. UCHINO, J. BUCKMASTER, G. HART, H. OPDAM, W. SILVESTER, L. DOOLAN, G. GUTTERIDGE
Reference: Critical Care and Resuscitation 2005; 7: 16-21
Link: Click here for a direct link to the paper. A password may be required for access to fulltext.
Abstract: Objective: It has been suggested that the availability of a high-dependency unit (HDU), to facilitate graded admission to, and discharge from, an intensive care unit (ICU), might decrease post-operative morbidity. We wished to determine whether the addition of a 4-bed HDU to a tertiary 17-bed ICU facility at a University-affiliated hospital would decrease post-operative morbidity and mortality.
Methods: A prospective controlled before-and-after trial was performed with the opening of a 4-bed HDU. Consecutive patients admitted to hospital for major surgery during a 4-month control (pre-HDU) phase and during a 4-month intervention (HDU) phase were studied for the incidence of serious adverse events (SAEs), mortality after major surgery and mean duration of hospital stay.
Results: There were 1319 operations performed in 1125 patients during the pre-HDU period and 1369 operations performed in 1127 patients during the HDU period. During the HDU period there was an excess in unscheduled surgery cases (674 during HDU vs. 531 during the pre-HDU period; p < 0.0001). In the pre-HDU period, there were 414 SAEs in 190 patients compared with 456 SAEs in 209 patients during the HDU period (NS). There were no significant changes in any of the individual SAEs measured except for the incidence of post-operative acute pulmonary edema, which increased from 19 cases to 46 during the HDU period (p = 0.028). This increase was associated with a greater number of patients requiring re-intubation (52 vs. 75 cases; p = 0.044). The introduction of an HDU had no effect on mortality (80 deaths vs. 76; NS) and failed to reduce mean hospital length of stay (21.8 vs. 24 days; NS).
Conclusions: The introduction of a 4-bed HDU in a teaching hospital was associated with a marked increase in unscheduled surgery and failed to reduce the incidence of post-operative SAEs, post-operative mortality, and mean duration of hospital stay.
 
Are the recommendations valid?
1. Are the outcome measures accurate and comprehensive?
The authors reported a comprehensive list of serious adverse events, deaths and hospital length of stay.
The authors did not report HDU or ICU LoS, hospital costs, duration of invasive or non-invasive ventilation,or other less severe adverse events.
2. Were the comparison groups similar with respect to important determinants of outcome, other than the one of interest, and were residual differences adjusted for in the analysis?
2a. Did the investigators measure all known important prognostic factors?
No. The authors could have recorded or calculated some form of measure that captures the degree of risk involved in the surgical procedure (Ex. ASA, POSSUM , duration of surgery, estimated blood loss, presence of co-morbidities, etc).
2b. Were measures of patients' prognostic factors reproducible and accurate?
No. Very few accurate prognostic factors were recorded.
2c. Did the investigators show the extent to which patients differed on these factors?
No. Many true measures of prognosis were not recorded.
2d. Did the researchers use some form of multivariate analysis to adjust for all the important prognostic factors?
No multivariate analysis was conducted. A multivariate analysis may have helped to explain whether the increase in 'unscheduled surgery' explained the increase in respiratory failure.
2e. Did additional analyses (particularly in low-risk subgroups) demonstrate the same results as the primary analysis?
No additional analysis was conducted.
 
What are the recommendations?
1. What are the recommendations?
The introduction of an HDU failed to decrease any of the recorded serious adverse events and was associated with an increase in incidence of acute pulmonary oedema (PO) and respiratory failure (RF) requiring re-intubation.
Will the recommendations help you in caring for your patients?
1. How will the recommendations help you?
Unsure. Due to deficiencies in the study, we do not know if the increase in PO and RF are iatrogenic complications of the HDU or if they are related to changes in the patient population during the introduction of the HDU.

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