Advanced Recovery Room Care - an Iterative Model to Improve Outcomes and Reduce Cost in Perioperative Care

The problem: Surgery is essential for approximately 1/3 of healthcare needs, and its volume needs to double out to 2040. However, it has risks, with serious postoperative complications occurring frequently (5%-30% of patients) and postoperative death being the third most prevalent cause of death globally.

Complications result in increased patient suffering and mortality, late adverse events such as re-admission, and two to three-fold increases in resource use (cost). They can be considered 'the hidden pandemic' of modern healthcare and, because of an ageing comorbid population, are estimated to increase by 300% in Australia by 2027.

An Australian National Summit on Postoperative Complications (March 2020), chaired by G Ludbrook, acknowledged the importance of this problem. Its report identified the need for a Systems approach, with an evidence base, clear pathways of care matched to individual patients' risks and needs, techniques to minimize unnecessary practice variation, and relevant performance measures: outcomes (institution- and consumer-centred) and cost.

One solution: In 2017, an Advanced Recovery Room Care model (ARRC) was trialled at RAH. This utilized all the Summit Systems elements and Principles - early validated risk assessment (NSQIP), triage of moderate-risk patients (predicted 30-day mortality: 1-4%) to mid-level high-acuity postoperative care overnight (ARRC), appropriate staff and capacity, precise regular checklist-based assessment, specific physiological goals, repeated re-assessment and re-triage, formal handovers, and evaluation with relevant metrics. This trial revealed that: early serious adverse events were unexpectedly common (50% of patients); these mainly occurred for 12-18 hours postoperatively; and re-admissions were very common (34%).

Reduced complications and sequelae: ARRC resulted in fewer ward-based complications; and an 80% reduction in hospital re-admission days, p=0.1. A 10-bed unit should free up 4000 RAH bed days annually.