Critical care provision is fundamental in all developed health systems
in which severe disease and injury is managed. This is especially true
in major trauma centres and high-acuity establishments, where acutely
unstable patients can be admitted at any time, requiring clinical
monitoring and interventions appropriate for their burden of illness.
This single-centre, prospective service evaluation applied validated
scoring systems to a surgical population, sampling and following those
considered “high-risk” through to discharge or death, alongside all
intensive care unit (ICU) admissions during 2019. Primarily we aimed to
quantify the number of patients objectively suitable for Level 2
critical care, conventionally provided in a high-dependency unit (HDU)
setting. Secondary outcome measures included ICU readmission rate,
in-hospital mortality, and delays to ICU admission and discharge. Of the
“high-risk” surgical patients, more than eight per week were found to
have peri-operative Portsmouth Physiological and Operative Severity
Score for the enUmeration of Mortality and morbidity (P-POSSUM) scores
that would advocate critical care admission. Only one individual
received scheduled peri-operative critical care. Post-operative
mortality in this group was 6.1%, though none of these patients was
admitted to ICU prior to death. There were 605 ICU admissions in 2019,
with 32.1% of admitted days spent at the equivalent of Level 2 critical
care, which could have been administered in a HDU if one was available.
The ICU readmission rate was 6.45%. This data demonstrates substantial
unmet critical care needs, with patients not uncommonly managed in
clinically inappropriate areas for extended periods due to delays
accessing ICU. A designated HDU may mitigate clinical risk from this
subgroup, reducing morbidity and in-hospital mortality, and this
methodology for assessing requirements could be used in other similar
institutions.