A New Type of Ward for Perioperative Care in Visceral Surgery

Perioperative care in visceral surgery places considerable demands on intensive care resources (1). Capacity shortages on intensive care units, which are often crucial for postoperative care when there is a significant risk of complications (2), lead to delays in planned surgeries and, particularly for patients with oncological diseases, represent a considerable psychological and prognostic burden (3). Up to now, intermediate care units (IMC) have been established as a transitional level to provide adequate care to patients with limited intensive care requirements. An IMC of this kind has been in place at the surgical center of the Heidelberg University Hospital, Germany, since 2004. There, patients are closely monitored and can receive non-invasive ventilation and catecholamines if necessary. Nevertheless, transfer from intensive care (ICU or IMC) to a general ward remains a critical juncture, since premature transfer may be associated with increased mortality (4). In order to minimize this risk and enable a more targeted use of resources, an advanced care unit (ACU) was created at Heidelberg University Hospital to provide an additional level of care between the IMC and the general ward.

Methods

In October 2023, the ACU was established within the general surgical ward. The aim was to provide structured transitional care for patients whose intensive care scores may have decreased but who, in the opinion of the IMC physician on duty, still require a heightened level of monitoring and support. The ACU has four beds in two double rooms; the neighboring IMC comprises 24 beds, also distributed across double rooms. The equipment available on the ACU enables continuous monitoring (ECG, SpO₂, and noninvasive blood pressure), supplemented by electronic curve recording in the same documentation system as in intensive care, as well as the use of infusion pumps for thrombosis prophylaxis and diuretics. In contrast to the IMC, life-saving systems such as noninvasive ventilation or continuous catecholamine treatment are not available on the ACU. The nurse-to-patient ratio is at least 1: 4 (nurse:patient) and is ensured around the clock. By comparison, the IMC maintains the same standard ratio of intensive care nurses to patients specified for intensive care units. This analysis was conducted retrospectively using electronic patient records and documentation systems. In addition to baseline characteristics, patients’ SOFA (sequential organ failure assessment) and TISS-28 (therapeutic intervention scoring system) scores were recorded at the time of transfer to the ACU. The SOFA score is used to assess organ dysfunction, whereas the TISS-28 score reflects a patient’s nursing and treatment requirements, for example, in the form of continuous monitoring, pharmacological management, and intensive care support.

Results

Between October 2023 and April 2024, 110 patients received care on the ACU. The Table provides an overview of the characteristics of the cohort, while the Figure schematically illustrates the flow of patient transfers. The mean length of stay on the ACU was 3.8 (± 4.0) days. Subsequently, 73.6 of patients were transferred to the general ward, 20 needed to be readmitted to the IMC, and 6.4 were transferred to another center for further treatment. The main reasons for readmission to the IMC included respiratory exacerbation, infections, neurological events, and increased requirements for nursing care. No readmissions to the intensive care unit occurred during the study period. No deaths or serious unexpected complications were recorded during stays on the ACU. The median SOFA score was 1, while the median TISS-28 score was 21.

Table. Characteristics of the patient cohort on the advanced care unit (ACU) from October 2023 to April 2024.

		Total n = 110
Age (years)	Mean ± SD	63.8 ± 13 Years
Sex	Male	53 (48.2)
	Female	57 (51.8)
Body mass index (BMI) (kg/m²)	Mean ± SD	26.8 ± 6.5
American Society of Anesthesiologists (ASA) risk classification	I–II	26 (23.6)
	III–IV	84 (76.4)
Mean length of AUC stay		3.8 ± 4.0 Days
Length of post-ACU hospital stay		12.5 ± 7.8 Days
Types of procedure	Pancreatectomy	42 (38.2)
	Hepatectomy	11 (10.0)
	Esophagectomy	8 (7.3)
	Other	49 (44.5)
Cancer	Yes	83 (75.5)
	No	27 (24.5)

SD, standard deviation

Figure.

Schematic illustration of the patient flow, care level, and equipment between an IMC, an ACU, and a general ward. The general surgical ward where the ACU is located is on the same level as the IMC, to which it is directly adjacent. Care teams on the ACU overlap:

Patients receive medical care from IMC physicians and nursing care from staff on the general ward. Patients can be transferred between units according to their health status; however, patients transferred from the general ward always go to the IMC.

ACU, advanced care unit; IMC, intermediate care unit

Discussion

The ACU represents a valuable addition to existing care structures, enabling staff to adapt flexibly to postoperative care needs. In particular, patients who are formally deemed fit for care on a general ward according to intensive care scoring systems such as the SOFA score, but who are regarded as potentially critical by the IMC physician on duty, can be monitored here in a targeted manner and assessed for their stability before transfer to the general ward. Retrospectively, the cohort included in the study was found to have a high risk profile, based on ASA classification, body mass index, and tumor prevalence. Monitoring and treatment requirements were higher than those on the general ward but lower than those on the IMC, which is reflected in the median TISS-28 score of 21. The ACU has the advantage of requiring less equipment and staff compared to the IMC. Thus, resources can be used in a targeted manner to support the multi-stage healing process without putting patient safety at risk. This may help to prevent the morbidity associated with intensive care (5). An analysis of the readmission rate showed that 80 of patients admitted to the ACU no longer required an intensive care bed and could be transferred to the general ward after a mean observation time of 4 days. Compared to the readmission rate from the general ward described in the literature (4–10) (4), the readmission rate from the ACU to the IMC was significantly higher at 20. However, this higher proportion of patients requiring readmission to intensive care benefits from the fact that the ACU is directly connected to the IMC in terms of technical and staffing resources.

Conclusion

Limitations of this study include its exploratory nature and the lack of a control group. Nevertheless, the preliminary results indicate that the integration of an ACU into postoperative care is effective and safe. A prospective evaluation is required to confirm these results.