Journal of Clinical Anesthesia 25 (2013) 202208

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Journal of Clinical Anesthesia

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Original Contribution

How well are prebooked surgical step-down units utilized?,

Serena Shum MD (Anesthesia Resident) a, Rob Tanzola MD, FRCPC (Staff Anesthesiologist) a,
Michael McMullen MD, FRCPC (Staff Anesthesiologist) a, Wilma M. Hopman MA (Research Facilitator) b,
Dale Engen MD, FRCPC, MPA (Staff Anesthesiologist) a,
a
Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queens University, Kingston, ON K7L 2V7, Canada
b
Clinical Research Center, Kingston General Hospital; and Department of Community Health and Epidemiology, Queens University, Kingston, ON K7L 2V7, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Study Objective: To evaluate the utilization of the surgical step-down unit (SSDU) by a sample of patients who
Received 28 March 2012 were preoperatively booked for admission to the unit, and to identify those patient characteristics and
Received in revised form 4 October 2012 perioperative variables that are associated with an intervention in the unit.
Accepted 6 October 2012 Design: Retrospective chart review.
Setting: Canadian tertiary-care facility.
Keywords:
Measurements: Data from 133 elective surgery patients with prebooked SSDU beds were recorded, including
Intensive care
Perioperative medicine
comorbidities, Surgical Risk Scale (SRS), Surgical Apgar Score (SAS), and number and nature of interventions
Postoperative care and events occurring in the SSDU.
Surgical step-down unit, utilization Main Results: Of the 133 patients scheduled for SSDU admission, 60 (45.1%) were actually admitted and the
other 73 (54.9%) were admitted directly to the surgical ward or else discharged. Of the patients admitted to
the SSDU, 48.3% had an intervention during their stay. In logistic regression, the SRS was a signicant
predictor (P b 0.001) of SSDU use, while the SAS was a signicant predictor (P = 0.034) of the need for an
intervention or the likelihood of an event while in the SSDU.
Conclusions: Less than half of patients identied were actually admitted to the SSDU postoperatively; of those,
less than half required an intervention. The Surgical Apgar Score, a score based on intraoperative factors,
predicted the need for an intervention during SSDU admission. Consideration should be given to the
development of a predictive score that emphasizes intraoperative factors and early postoperative factors to
optimize allocation of this scarce resource.
2013 Elsevier Inc. All rights reserved.

1. Introduction institution, decisions regarding postoperative disposition are made

Surgical step-down units (SSDUs) were developed as a means to
improve access to intensive care in a cost-effective manner [1] and to
enrich patient care by providing graded care options [2,3]. Surgical
step-down units have been associated with reductions in admissions
to the intensive care unit (ICU) [4] and patient mortality [5]. In
contrast to medical inpatients who are often transferred to a step-
down unit when in extremis, selected surgical patients are often
admitted to the SSDU for ongoing monitoring and an elevated level of
nursing care. However, these units themselves are a scarce resource
and surgeries are often cancelled due to their unavailability [6]. At our
Supported by departmental funding only.
The authors have no conicts of interest to declare.
Correspondence: Dale Engen, Department of Anesthesiology and Perioperative
Medicine, Victory 2, Kingston General Hospital, 76 Stuart St., Kingston, Ontario K7L 2V7,
Canada. Tel.: +1 613 548 7827; fax: +1 613 548 1375.
E-mail address: engend@kgh.kari.net (D. Engen).
preoperatively. The challenge lies in accurately predicting in the
preoperative period which surgical patients will experience postop-
erative complications that warrant admission to the SSDU.
Numerous scoring tools have been developed to predict postoper-
ative complications. Two of interest to this study are the Surgical Risk
Scale (SRS) and the Surgical Apgar Score (SAS) (Appendix 1). The SRS
[7] is a validated [8] predictive score of mortality based on preoperative
factors. The SAS [9] is another validated [10,11] score, but unlike the
SRS the SAS is based on intraoperative variables. The SRS score was
created to predict mortality in elective, emergent, pediatric, trauma,
inpatient, and day-case general surgery patients [7]. The SAS was
validated in general and vascular surgery patients using the incidence
of 30-day major complications or death [9,10]. While the strength of
association between the SAS and postoperative mortality may vary, the
utility of the score extends across a variety of surgical subspecialties
[11]. We are unaware of any previous studies examining the ability of
either score to determine the location of postoperative care or
subsequent need for intervention(s) during the perioperative period.

0952-8180/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jclinane.2012.10.010
 S. Shum et al. / Journal of Clinical Anesthesia 25 (2013) 202208 203

Currently, there are no data to evaluate the patterns of elective interventions or have an adverse event in the SSDU, were compared
surgical usage of the SSDU in our tertiary-care center. Specically, there using t-tests for continuous data and chi-square tests for categorical
are limited data on the nature of events occurring in the SSDU for data. Duration of surgery was compared using the Mann-Whitney U
elective noncardiac admissions and the incidence of events requiring test. Logistic regression, controlling for age, was used to assess the
nursing or physician intervention. Furthermore, while the literature has ability of the SRS and SAS to predict utilization of the SSDU and the
examined the process of differentiating ICU patients from those need for an intervention or the occurrence of an event while in the
adequately cared for on general surgical wards [12] and SSDUs [13], it SSDU. Surgical procedures were diverse, so they were initially broadly
provides little guidance on making a decision to admit a patient to SSDU categorized by the clinical team on the basis of specialty (eg, general
versus a general surgical ward. The objectives of this study were to 1) surgery, neurosurgery, thoracic surgery) and complexity. This
evaluate actual usage of the SSDU by a sample of patients who resulted in 19 categories, so low-volume surgeries were further
underwent elective noncardiac surgery and who were preoperatively collapsed into an Other Major category (vascular, otolaryngology,
booked for SSDU admission at a tertiary-care facility in Canada, and 2) peripheral limb) and Other Minor (eg, minor urological, general,
identify patient characteristics and perioperative variables (including gynecological, and plastic surgeries) on the basis of consensus.
SAS and SRS) associated with both SSDU use and the occurrence of an Results were deemed to be signicant if P b 0.05. Findings that fell
event or need for an intervention in the SSDU. An intervention or event short of statistical signicance but appeared clinically relevant were
in the SSDU was regarded as a proxy for appropriate SSDU admission. also noted. Formal sample sized calculations were not carried out for
this observational study, but a sample size of 50 is commonly
2. Materials and methods considered a guideline as the minimum number of patients required
for the use of inferential statistics [14]. More than twice that number
Ethics approval was obtained from the Queens University Health was collected so as to allow sufcient power for evaluation of the
Sciences and Afliated Teaching Hospitals Research Ethics Board. subset of those who were admitted to the SSDU.
Eligible patients were those scheduled for elective surgery with an
SSDU room booked preoperatively. Cardiac patients were not 3. Results
included as their postoperative care takes place in a designated
cardiac care unit. Patients were accrued from September 28, 2009 to 3.1. Patient demographics
February 1, 2010, until there was a sufcient sample to permit
subgroup analyses. Patients with a preoperative decision about the A total of 2999 cases were admitted during the study period,
location of postoperative care were identied by a review of the including 2007 elective cases. A cohort of 133 patients (6.6% of
operating room (OR) slate. Decisions regarding postoperative dispo- elective cases; 4.4% of total) was captured by our study. Fig. 1 depicts
sition were made either by surgeons or anesthesiologists. Patients the derivation and course of the 133 patients included for analysis.
were excluded if the decision to admit to the SSDU was made outside Table 1 compares the characteristics of patients who were admitted to
the preoperative period. Data were extracted from the hospitals SSDU with those who were not and of patients who required
electronic record system and each patients paper hospital chart. interventions or had an event in SSDU with those who did not. Of
The SSDU at Kingston General Hospital is part of a 16-bed combined the 47 patients referred by the Surgical Service and admitted to the
medical-surgical unit. The SSDU is an open unit with patient care provided SSDU, only 19 (40.4%) required an intervention or had an event; of the
by the admitting service and nursing care delivered in a 1:2 nurse to 12 referred by the Anesthesiology Service and admitted to the SSDU, 9
patient ratio. The SSDU provides Level 2 critical care and is capable of (75.0%) required an intervention or had an event (P = 0.032).
providing support for a single failed organ system, short-term noninvasive
ventilation, vasoactive infusions, and basic invasive monitoring. Patients
not cared for in the SSDU include those requiring invasive ventilation,
intra-aortic balloon counterpulsation, continuous renal replacement
therapy, and pulmonary artery and intracranial pressure monitoring.
Extensive data covering the entire perioperative period for all
patients were collected (Appendix 2). Preoperative data included
patient demographics, indication for SSDU prebooking, nature of
comorbidities, and calculation of the SRS score. The SRS was calculated
according to published guidelines [7], with scores ranging from 3 to
14, with 14 = the highest risk (Appendix 1). Intraoperative course
was measured with the SAS, which was also calculated according to
published guidelines [9,10], with scores ranging from 0 to 10, with 0 =
the highest risk (Appendix 1).
Events occurring in the PACU and if applicable, the SSDU, were
recorded. They included those events requiring nursing or physician
intervention and ranged from relatively benign postoperative compli-
cations such as pain to indicators of distress, including inotrope use and
intubation. This reected the range of postoperative outcomes in our
sample. The occurrence of adverse events and interventions were then
combined into a single variable for the purpose of comparing patients
with and without an intervention or an adverse event in the SSDU.

2.1. Statistical analysis

Data were collected in Excel and imported into IBM SPSS

software, Version 19.0 for statistical analysis (SPSS, Chicago, IL,
USA). Following descriptive analyses, those admitted and not Fig. 1. Flow chart of patients included for analysis. Pts = patients, OR = operating
admitted to the SSDU, and those who did and did not receive room, ICU = intensive care unit, SSDU = surgical step-down unit.
204 S. Shum et al. / Journal of Clinical Anesthesia 25 (2013) 202208

Table 1
Patient characteristics

Booked SSDU used Booked SSDU not used P-value SSDU intervention/ No SSDU intervention/ P-value
(N=60) (N=73) event (N=29) event (N=31)

Means SD Means SD

Age (yrs) 54.5 20.9 58.5 5.7 0.21 53.1 21.5 55.8 20.5 0.61
Body mass index (kg/m2) 29.7 7.3 31.8 7.9 0.15 31.7 9.1 27.7 4.3 0.062
Surgical Risk Score 9.0 1.8 7.8 1.4 b 0.001 9.3 1.3 8.7 2.2 0.20
Surgical APGAR Score 6.6 1.6 7.0 1.3 0.12 6.1 1.6 7.1 1.5 0.027
Duration of surgery (hrs) 4.6 2.5 3.2 1.7 b 0.001 5.2 2.6 4.0 2.2 0.078

Median 2.8 Median 3.8 P-value Median 5.5 Median 3.5 P-value

N (%) N (%)

Men 32 (53.3) 36 (49.3) 0.65 14 (48.3) 18 (58.1) 0.45

Requested by Surgical Servicea 47 (79.7) 62 (84.9) 0.43 19 (67.9) 28 (90.3) 0.032
Coronary artery disease 9 (15.0) 14 (19.2) 0.53 5 (17.2) 4 (12.9) 0.73
Valvular heart disease 6 (10.0) 7 (9.6) 0.94 6 (20.7) 0 (0.0) 0.009
Arrhythmia 8 (13.3) 12 (16.4) 0.62 4 (13.8) 4 (12.9) 0.92
Obstructive sleep apnea 8 (13.3) 33 (45.2) b 0.001 7 (24.1) 1 (3.2) 0.017
Neuromuscular disease 7 (11.7) 10 (13.7) 0.73 3 (10.3) 4 (12.9) 0.76
Asthma 5 (8.3) 16 (21.9) 0.033 2 (6.9) 3 (9.7) 0.70
COPD 10 (16.7) 5 (6.8) 0.075 4 (13.8) 6 (19.4) 0.56
Renal disease 5 (8.3) 15 (20.5) 0.050 2 (6.9) 3 (9.7) 0.70
Diabetes 8 (13.3) 18 (24.7) 0.10 5 (17.2) 3 (9.7) 0.39
ASA physical status 2 9 (15.0) 12 (16.4) 0.67 3 (10.3) 6 (19.4) 0.34

Orthopedic, inc spine 2 (3.3) 20 (27.4) 1 (3.4) 1 (3.2)

General surgery 9 (15.0) 14 (19.2) 6 (20.7) 3 (9.7)
General surgery liver 7 (11.7) 1 (1.4) 3 (10.3) 4 (12.9)
Neurosurgery 9 (15.0) 3 (4.1) 2 (6.9) 7 (22.6)
Thoracic 19 (31.7) 2 (2.7) b 0.001 7 (24.1) 12 (38.7) 0.42
Gynecology/urology 1 (1.7) 14 (19.2) 1 (3.4) 0 (0.0)
Scoliosis repair 6 (10.0) 0 (0.0) 4 (13.8) 2 (6.5)
Other major 4 (6.70 2 (2.7) 3 (10.3) 1 (3.2)
Other minor 3 (5.0) 17 (23.3) 2 (6.9) 1 (3.2)

SSDU=surgical step-down unit, COPD=chronic obstructive pulmonary disease.

P-values are based on the independent samples t-test (Mann-Whitney U test for duration of surgery) and the Chi-square test (Pearson or Fishers Exact test as appropriate).
a
as compared with Anesthesiology Service.

Obstructive sleep apnea (OSA; 30.8%), diabetes (19.5%), stable
coronary artery disease (17.3%), asthma (15.8%), and arrhythmia and
renal disease (15.0% each) were the most common comorbidities in the
cohort. Signicant differences were noted between patients admitted
and not admitted to SSDU with respect to frequencies of comorbidities.
The SSDU was commonly booked but underused for OSA (P b 0.001) and
asthma (P = 0.033), with similar trends noted for renal disease (P = 0.05)
and diabetes (P = 0.126). The reverse trend was noted for chronic
obstructive pulmonary disease (P = 0.075); those patients were more
likely to go to the booked SSDU. For the subset of SSDU patients, preexisting
cardiac valvular conditions (P = 0.009) and OSA (P = 0.024) were
signicantly associated with receiving an intervention or having an event.
Thoracic surgery, neurosurgery, and liver resection had the highest rates of
SSDU admissions postoperatively. There was also a trend for patients with
a larger body mass index (BMI) to require an intervention or have an event
at the SSDU (P = 0.062).
subset who went to the SSDU, the mean SRS score between those who
did and did not have SSDU interventions or events was not
statistically signicant (9.3 vs 8.1, P = 0.20).
The difference in mean SAS between SSDU and non-SSDU patients
(6.6 vs 7.0, respectively) did not reach statistical signicance (P = 0.12).
However, a signicant difference (P = 0.027) was noted between SSDU
patients who received an intervention/had an event and those who did
not (6.1 vs 7.1, respectively). In logistic regression, controlling for age,
the SRS was a signicant predictor (P b 0.001) of SSDU use, with a 1.8-
fold increase in odds of use with a one-point increase in SRS (95% CI 1.4,
2.5) but the SAS was not signicant (P = 0.68). However, the SAS was a
signicant predictor (P = 0.034) of need for an intervention while in
SSDU, with a reduction in odds of 0.62 (95% CI 0.40, 0.96) for a one-
point increase in SAS; the SRS was not a signicant predictor (P = 0.23).
3.4. Postanesthesia care unit (PACU) course

3.2. Reason for SSDU booking
Indications for requesting an SSDU admission preoperatively were
identied in 94.7% (n=126) of cases and categorized (Appendix 1,
Reasons for SSDU booking). Thirty-four (25.6%) patients had 2
indications. The nature of the surgery (60.9%, n=81) was the most
frequent reason for requesting an SSDU admission preoperatively,
followed by OSA (18.0%, n=24), cardiac monitoring (14.3%, n=19),
morbid obesity (10.5%, n=14), and respiratory monitoring (8.3%, n=11).
Continuation of invasive intraoperative monitoring techniques
(arterial and central catheters) was signicantly different (P 0.001)
between patients admitted to the SSDU and those who were not. The
need for noninvasive ventilatory support [continuous positive airway
pressure/bi-level positive airway pressure (CPAP/BiPAP) support] in
the PACU was associated (P = 0.049) with need for an intervention(s)
or having an adverse event during SSDU admission.
3.5. Surgical step-down unit

3.3. The SRS and SAS During the study period, a total of 255 surgeries were cancelled, of
which 7 (2.7%) were directly attributed to SSDU bed unavailability. Sixty
The SRS was signicantly higher for the cohort of patients (45.1%) patients in our cohort were admitted to the SSDU, which
admitted to the SSDU postoperatively (9.0 vs 7.8, P b 0.001). For the represented 52.2% of the total SSDU admissions for the study period. Of
 S. Shum et al. / Journal of Clinical Anesthesia 25 (2013) 202208 205

Table 2 trend towards increased length of operating time occurred in SSDU

Frequency of interventions and adverse events in the surgical step-down unit (SSDU) patients who required an intervention or had an event compared with
(n=60)
those who did not (4.0 vs 5.2 hrs; P = 0.078, Mann-Whitney U).
Intervention or event N (%)

Pain 15 (25.0) 4. Discussion

Desaturation 12 (20.0)
Hypotension 10 (16.7) In our retrospective cohort review, we discovered that the nature
Abnormal heart rate/arrhythmia 10 (16.7)
of the surgical procedure was the most common indication for
Decreased level of consciousness 9 (15.0)
Dyspnea 4 (6.7) scheduled admission to the SSDU. However, we found no association
RACE Team (Med emergency team call) 4 (6.7) between the nature of the surgery and the subsequent rates of
New CPAP/BiPAP 3 (5.0) postoperative intervention or events. If event/intervention is consid-
Administration of blood products 3 (5.0) ered a surrogate for appropriate admission to the SSDU, then a request
Chest pain/angina 2 (3.3)
by anesthesiologists is better than traditional identication by the
Metabolic acidosis (pH b 7.25) 1 (1.7)
Code 99 (Nonspecic med emergency) 1 (1.7) Surgical Service. Furthermore, less than half of identied patients
Code white (violent patient) 1 (1.7) were actually admitted to the SSDU, and only one of 5 of these
Intubation 1 (1.7) prebooked patients required a postoperative intervention. Many of
Vasopressor/inotrope use 0 (0.0)
these interventions, including optimization of pain management and
Renal failure (eGFR b 35 mL/min) 0 (0.0)
Congestive heart failure 0 (0.0) transfusion of blood products, could be safely performed on a surgical
Code blue (cardiac arrest) 0 (0.0) ward. It appears that the current model of selecting patients
Transfer to ICU 0 (0.0) preoperatively for admission to SSDU based on the nature of the
Death 0 (0.0) surgical procedure is suboptimal.
Interventions per pt (n)
Valvular heart disease and OSA were associated with the need for
0 31 (51.7)
1 11 (18.3) subsequent postoperative intervention(s) or the occurrence of an
2 10 (16.7) event. Interestingly, patients with OSA and asthma were much more
3 5 (8.3) prevalent in the non-SSDU subset than the SSDU subset. This nding
4 3 (5.0)
may indicate that the presence of these respiratory diseases continues
SSDU=surgical step-down unit, RACE team=Rapid Assessment of Critical Event, CPAP/ to be a signicant consideration in SSDU prebooking, as they have
BiPAP=continuous positive airway pressure/bi-level positive airway pressure support, been traditionally. However, with regional anesthesia and remote
eGFR=estimated glomerular ltration rate, ICU=intensive care unit.
oximetry beds, anesthesiologists appear to have determined that
these patients no longer require care in the SSDU. For those OSA
those 60, 29 (48.3%) received an intervention or had an event during patients who were admitted to the SSDU, their comorbidity was a
their stay. Two (1.5%) patients were initially admitted to the ward before signicant predictor for need for an intervention. As the severity of
being transferred to the SSDU; one became septic and the other suffered OSA was not recorded, we can only speculate that this was the
a myocardial infarction. Five (3.8%) patients completed an overnight or differentiating factor between those patients with OSA who were and
12-hour PACU stay, implying that a SSDU bed was needed but were not admitted to SSDU. None of the patients requiring new CPAP/
unavailable. SSDU requirement was not documented in their charts. For BiPAP in the SSDU was previously diagnosed with OSA.
6 (4.5%) patients, a transfer from the PACU to the SSDU was Results of this study support previous ndings that postoperative
documented; but due to SSDU bed unavailability, these patients complications cannot be accurately predicted based on preoperative
completed their SSDU stay in the PACU. factors alone and intraoperative and immediate postoperative factors
Of the 29 patients who required an intervention or had an event, should be taken into consideration when determining postoperative
11 had one intervention, while the remaining patients had two to disposition [12,13,15-19]. In addressing preoperative factors, the SRS
four. The median number of actual interventions (not including score demonstrated the ability to predict patients in our cohort who
events such as nonspecic medical emergencies, cardiac arrests, would be admitted to SSDU, but not necessarily those who would
violent episode(s), and urgent critical care consultations) was 0 (25th require an intervention or have an event. The mean SRS score for
and 75th percentile of 0 and 2, respectively). The frequencies for all SSDU patients was 9.0 while the mean score for non-SSDU patients
collected interventions and events are described in Table 2, as well as was 7.8. These values were associated with a signicant difference in
the number of interventions per patient. The most frequent events/ predicted inhospital postoperative mortality, 10.0% versus 5.0% [7].
interventions were uncontrolled pain (25.0%), desaturation (20.0%), In contrast, the SAS, which focuses on intraoperative variables, was
hypotension (16.7%), abnormal heart rate/arrhythmia (16.7%), and useful in predicting the need for subsequent SSDU intervention(s) and
decreased level of consciousness (15.0). Of the 12 patients who likelihood of an event. It is interesting to note that the SAS was similar
desaturated, three (25.0%) had a preexisting diagnosis of OSA. General between non-SSDU patients and those SSDU patients who did not
surgery (n = 5; 55.6% of surgical type) and spine/scoliosis repair (n = receive an intervention or have an event. However, the SAS was
3; 50.0% of surgical type) are more likely to result in a desaturation unable to reliably identify which patients would be sent to SSDU for
episode in the SSDU (P = 0.005). No other signicant differences were monitoring. A mean SAS of 6.0, which was found in those who
noted among the surgical subspecialties and frequency of SSDU received SSDU interventions, has a 30-day major complication risk of
events/interventions. Intubation, acidosis, and a Code 99 (nonspecic 16.0%, including a 5.0% mortality rate; whereas a mean SAS of 7.0,
medical emergency) each occurred once. The Rapid Assessment of which was found in those who did not receive SSDU interventions, has
Critical Event (RACE) team, which provides urgent critical care a 30-day major complication risk of 6.0%, including a b 1.0% mortality
consultations, was activated on 4 occasions. No one was treated for rate [9]. The nding that the SRS was predictive of SSDU admission
congestive heart failure, required vasopressors, suffered cardiac was not surprising; since a composite of severity and nature of
arrest, was transferred to ICU, or died. surgery is the most cited reason for SSDU admission, it follows that
patients receiving major surgery tend to be sent to the SSDU.
3.6. Surgical duration Similarly, maintenance of robust intraoperative vital signs and
minimization of blood loss during surgical procedures have been
Mean operating duration between SSDU and nonSSDU patients well established in the literature as imperative to good patient
(4.6 vs 3.2 hrs, respectively) was signicantly different (P b 0.001). A outcomes [20-22], and are emphasized by the SAS.
206 S. Shum et al. / Journal of Clinical Anesthesia 25 (2013) 202208
To account for relevant preoperative and intraoperative factors in a
simple yet comprehensive manner, we propose combining the SRS
and SAS tools in selecting patients for the SSDU. As these scores were
not originally designed to distinguish the level of care required by
patients postoperatively, these tools rst must be validated for this
indication. Following validation of these scores in a large prospective
study involving all elective surgeries regardless of type, a possible
model is to use the SRS score to ag patients preoperatively for
potential SSDU need. Subsequently, the SAS would be calculated
based on intraoperative variables to facilitate the denitive decision of
whether to admit to SSDU.
There are some limitations to the study. First, these ndings are
limited to those patients who were booked for the SSDU preoperatively.
Surgical step-down unit patients who were not electively prebooked
represent an important group when assessing the risk factors associated
with SSDU admission; this group would also have a signicant impact
on the SSDU resources and need for intervention, or occurrence of an
event. A larger study encompassing both groups would provide
additional insight into the factors associated with SSDU use.
Routine SSDU admissions such as those required by most
postoperative patients may not be charted as diligently as for those
patients in extremis. Furthermore, we may have overlooked some
SSDU interventions during data collection that, although considered
minor, would have resulted in poorer outcomes had they not
occurred. For example, a routine SSDU admission for thoracic surgery
may involve diligent nursing care that would detect a complication
before it became an adverse event, or before an intervention was
necessary. Second, our method of identifying patients for review may
have inadvertently excluded a number of eligible patients. As our
patients were identied for review through the indication of a
prebooked SSDU bed on the OR slate, clerical errors may have led to
the exclusion of some eligible patients. Patient data were also missed
if the decision to admit to SSDU was made on the day of the surgery or
during the intraoperative period. If the decision to admit to SSDU is
left until the day of surgery, the anesthesiologist is usually the one
who decides. The exclusion of these patient data may explain the low
rate of referrals to SSDU by anesthesia in this study.
Third, the case mix studied in this sample is not representative of
what is typically seen at our institution. In particular, the urgent
nature of vascular surgeries may explain the low incidence of these
surgeries in our sample; only elective surgeries were included. The
decision to admit a vascular surgery patient to the SSDU is also not
routinely made preoperatively, and thus these patient data were not
captured by our methods. Also highly likely is that these patients
required the level of care provided by, and were admitted to, the ICU.
Finally, because this was an exploratory study containing a small
sample size, the external validity of our results may be limited. We
also acknowledge that the current model adopted by our institution,
of preoperatively allocating SSDU beds, may not reect the practice at
other institutions.
Our study was unique in that all elective noncardiac surgery
patients were included. As the sample size is small in this exploratory
study, a larger prospective study at our institution will improve the
generalizability of results to other tertiary-care centers. The overrid-
ing conclusion from this study, that using preoperative variables alone
is insufcient to identify patients at risk for postoperative complica-
tions, parallels that from previous literature [12,13,15-19].
In conclusion, the results of this study suggest that intraoperative
and early postoperative factors in the PACU are more accurate in
predicting postoperative complications and thus more appropriate for
determining patient disposition postoperatively. With the SSDU
becoming increasingly popular as hospitals struggle to provide high-
level care with limited resources, the decision regarding selection of
optimal location of postoperative care will become one of increasing
importance. These ndings may provide a starting point for future
studies on this important decision-making process.
 S. Shum et al. / Journal of Clinical Anesthesia 25 (2013) 202208 207

Appendix 1. Details of the Surgical Risk Scale (SRS) and Surgical

Apgar Score (SAS)
Respiratory
Surgical Risk Scale [7]

Description Score

CEPOD
elective Routine booked nonurgent case, eg, varicose 1
veins, hernia
scheduled Booked admission, eg, colon cancer or AAA 2
urgent Cases requiring treatment within 24 - 48 hrs 3
of admission, eg, obstructed colon
emergency Cases requiring immediate treatment, 4
eg ruptured AAA
BUPA
minor Removal of sebaceous cyst, skin lesions, 1
esophagogastric duodenoscopy
intermediate Unilateral varicose veins, unilateral hernia 2
repair, colonoscopy
major Appendicectomy, open cholecystectomy 3
major plus Gastrectomy, any colectomy, laparoscopic 4
cholecystectomy
complex major Carotid endarterectomy, AAA repair, limb 5
salvage, anterior resection, esophagectomy
ASA physical status
1 No systemic disease 1
2 Mild systemic disease 2
3 Systemic disease affecting activity 3
4 Serious disease but not moribund 4
5 Moribund, not expected to survive 5

The Surgical Risk Scale score was calculated for each procedure by adding the CEPOD (Condential Enquiry into Perioperative Deaths), BUPA (British United Provident Association),
and ASA (American Society of Anesthesiologists) physical status scores.
AAA=abdominal aortic aneurysm.

Appendix 2. Collected data

Surgical Apgar Score [9]

0 points 1 point 2 points 3 points 4 points

Estimated blood loss (mL) > 1,000 601 - 1,000 101 - 600 100
Lowest mean arterial pressure (mmHg) b 40 40 54 55 - 69 70
Lowest heart rate (bpm) > 85 76 85 66 - 75 56 - 65 55

Surgical Apgar Score = sum of the points for each category in the course of a procedure.
Occurrence of pathologic bradyarrhythmia, including sinus arrest, atrioventricular block or dissociation, junctional or ventricular escape rhythms, and asystole also receive
0 points for lowest heart rate.

Preoperative data severe pulmonary hypertension

controlled/uncontrolled OSA
Patient demographics
obstructive or restrictive lung disease
age
asthma
gender
chronic obstructive pulmonary disease (COPD)
body mass index (BMI)
current smoking
surgical procedure received
ASA physical status neuromuscular disease
Reason for SSDU booking
obesity
nature of surgery renal
cardiac monitoring thyroid
respiratory monitoring diabetes
Surgical Risk Scale
obstructive sleep apnea (OSA)
age Intraoperative data
not available
other (specied) Surgical Apgar Score
Service requesting SSDU (anesthesia or surgery), Postoperative data
Whether the surgery was canceled due to SSDU unavailability
Presence of comorbidities: Aldrete Score upon arrival
Cardiovascular Aldrete scoring system* is used to determine a patients readiness
stable/unstable coronary artery disease for discharge from the Postanesthesia Care Unit (PACU) and is
current/remote congestive heart failure (CHF) based on the patients ability to move voluntarily or on command,
left ventricular dysfunction quality of respiration, blood pressure (BP), level of consciousness,
arrhythmia and oxygen saturation (SpO2)
signicant valvular disease intubated on arrival
208 S. Shum et al. / Journal of Clinical Anesthesia 25 (2013) 202208

temperature upon arrival References

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