ANZCA Bulletin - June 2009 - Australian and New Zealand College ...

An anaesthetist-ledPerioperativeCare Unit (PCU)Prof Paul Myleselection of College Councillors is in noway in keeping with the manner in whichcompany boards are formed. Granted theCollege is not the same as a commercialoperation, however there are manyimportant similarities. It is my belief thatthe College must move ahead in developinga process for identifying individuals whowill bring to the College Council the verywide range of skills that are now requiredon the board of any company. This has nowbeen achieved by the College of Physicianswith surprisingly little in the way of majorproblems. I strongly recommend thatANZCA examine the process that wasutilised in moving towards what is now“the Board of RACP”. Of course this mustbe done with very close consultation withall Fellows as was the case in RACP.I should end by saying that all of theabove represents my personal perspectiveand is intended to create discussion anddebate in the interests of ANZCA. I amconfident that the College has the peopleand resources needed to move forwardwith the same success in the next 20 yearsthat has been achieved over the pasttwo decades.Prof Michael Cousins AMDirector, Department of Pain Managementand Research, Royal North Shore HospitalIntensive care units (ICU) developed fromthe speciality of anaesthesia, as a logicalextension of the operating theatre recoveryroom. Intensive (or critical) care medicineis now an independent and vibrant specialty.Modifications to ICU include thestep-down or high dependency unit(HDU), largely to improve cost-efficienciesbecause of flexible staffing and lower-levelmonitoring and therapy. In most countriesICU and HDU bed access have becomeincreasingly limited because of reductions(in real terms) in funding and insufficientICU-trained nursing staff.This has been compounded by anageing population and their concomitantcomorbidity, often undergoing high-risksurgery. At the same time there are growingnumbers of patients with morbid obesityand sleep apnoea. ICUs are unlikelyto cope.Some hospitals have created additionalcritical care beds within an extendedrecovery room environment; this issometimes labelled a post-anaesthesiacare unit (PACU). But in the majority ofcentres a PACU is no more than a standardrecovery room by another name. Thisconcept could be expanded further, asa true perioperative care unit (PCU), inorder to improve the quality of ongoingpostoperative care of high risk patientin a dedicated environment close to theoperating theatre for say, 24 to 48 hoursand perhaps incorporating preoperativeoptimisation.An anaesthetist-led PCU could improvethe safety of patients recovering frommajor surgery. Unlike a typical surgicalward, they can receive a higher level ofmonitoring and vasoactive therapy, usingexperienced nursing staff in a HDUstyleenvironment, and easier accessto senior anaesthetic and surgical staffin close proximity to theatres. This willprovide a more reliable postoperative careenvironment and so can increase surgicalthroughput because of an improvedability to accept complex patients from thehospital waiting list. This should reducehospital stay because of the opportunityto use sophisticated analgesic regimensand so facilitate earlier mobilisationand probably reduce postoperativecomplications. The latter would includea reduction in unplanned admission toICU. A PCU should reduce staff stress andworkforce requirements - why shouldinterns be primarily responsible for suchpatients over the first night after majorsurgery? This is likely to reduce adverseevents and need for medical emergencyteam (MET) calls. A PCU provides a readyenvironment to administer continuouspositive airway pressure therapy in sleepapnoea and morbidly obese patients.Most high-risk patients declarethemselves on the first night after majorsurgery. Respiratory, fluid, and analgesicdemands are typically at their highest andyet medical staffing levels overnight areat their lowest and most inexperienced.If a PCU patient deteriorates they will bedetected earlier, managed better and canthen be either stabilised or transferredto ICU. For the majority of patients whohave an otherwise uneventful recoveryfrom major surgery, they can be reviewedon the day after surgery and usually bedischarged to a general surgical wardfor ongoing care and recovery untilhospital discharge.Prof Paul MylesDirector, Department of Anaesthesia andPerioperative Medicine Alfred Hospitaland Monash UniversityIn part two of the Bulletin’s specialfeature on the future of anaesthesia,ANZCA will look at how technology andpharmacology will provide advancesin anaesthesia and what someinternational commentators aresaying about the future of the specialty.We would like to hear your views.Email: bulletin@anzca.edu.auThe ANZCA Bulletin June 2009 27