CPOC Guidance: Enhanced Perioperative Care

Dr Mo Khaku (Consultant in Anaesthesia at UCLH) & Dr Sam Moore (CPOC Fellow) introduce the concept of Enhanced Perioperative Care and summarise the recent CPOC guidance on this area.

In 2020, CPOC and FICM released [“Guidance on Establishing and delivering Enhanced Perioperative Care Services (EPC)”]. This document provides structured guidance on how to design distinct areas to improve care for patients at high risk of surgical complications and assist with system efficiency. We present a summary of the guidance below.

Purpose of an EPC Facility

EPC facilities are designed to bridge the gap between standard ward care and intensive care, offering enhanced monitoring for patients who are identified as high risk due to co-morbidities and/or surgical factors. Historically, many of these patients would have been admitted to intensive care or high-dependency beds post-operatively. Clinical pressures mean these beds could become unavailable at short notice and increasing co-morbidity within the surgical population means more patients than ever require higher levels of care post-op.

The level of organ support required by post-surgical patients is often different to that of other intensive care patients, meaning resources could be used more efficiently by having a dedicated area for post-operative patients. This also allows services to ring-fence beds to facilitate high-risk elective surgery and encourage the development of specific ERAS pathways that can be individualised for patients, reducing complications and length of stay.

Identifying appropriate patients

Admission can be based on:

1. Predicted 30-day mortality of over 1% using a validated risk score.
2. Major surgical procedure.
3. Need for additional monitoring e.g. arterial line, regular blood monitoring, hourly neuro-observation or free flap observations.
4. Need for additional treatments/interventions e.g. vasopressor infusions, concentrated potassium, infusions for pain control, chest drains.

It is important to note that not all patients will be suitable for an EPC facility. Those who have a very high risk of mortality >5% and those expected to go into multi-organ failure are likely best cared for in a traditional intensive care environment.

Service Design & Staffing

It is essential that EPC facilities are closely connected to critical care services in case of patient deterioration and have multi-disciplinary team input to ensure problems can be addressed promptly 24 hours a day, 7 days a week.

There should be clearly defined leadership, governance processes and clear lines of communication between surgical teams and staff running EPC facilities.

Fundamental to providing truly holistic care is the need for multidisciplinary and multi-professional working. The EPC team should be diverse, reflecting the range of interventions required to optimise outcomes for this group of patients. An example of the staff involved and relevant frameworks are summarised in the tables below:

Table 1: Transdisciplinary approaches to delivering aspects of care in EPC units

Table 2: Frameworks to support development of staff working in EPC units Tables courtesy of CPOC

Staff training and education

Continuous professional development and training are emphasised in this guideline as a route to maintaining high standards of care. For nursing, allied health professionals and pharmacists, an enhanced skills passport was developed to help individual staff members identify existing skills and additional learning needs. It also allows employers to map competencies across different staff groups working within EPC.

Monitoring and evaluation

Regular audits, performance metrics, and feedback mechanisms are recommended to ensure the service is meeting its objectives and identifying areas for improvement. The 2020 guidance suggested a number of key metrics, including unplanned admissions and readmissions to EPC units and transfers to critical care. Post-pandemic, the number of EPC units is likely to have increased, and work is ongoing to understand the current provision of EPC within the UK.

Conclusion

As surgical cohorts age, become frailer, and become more co-morbid, demand for higher levels of post-operative care is increasing. Enhanced Perioperative Care units allow for the provision of high-quality post-operative care while reducing strain on overstretched intensive care units. Multidisciplinary working, with ongoing training and development for staff, is central to providing this care. We highly recommend reading the guideline in full, which can be found at the link at the top of the page.

Does your institution already have an ERC? Does it meet the standards suggested in this document or is there room for improvement? Do you feel it has improved patient care?

References

1. “Guidance on Establishing and delivering Enhanced Perioperative Care Services (EPC)”