Whitehorn, AshleyStern, CindyLudbrook, GuyTran, Liem2025-05-282025-05-282024https://hdl.handle.net/2440/144760BACKGROUND: Postoperative critical care is recommended for patients at high risk of deterioration following surgery, yet many are managed in general surgical wards where they are at risk of physiological decline and delayed management due to limited monitoring. There is a growing interest in high-acuity postoperative facilities, which provide many key elements of critical care outside the intensive care unit, including increased nurse-to-patient ratios, specialised medical personnel, non-invasive ventilation and vasopressor support. These units function as an intermediate level of care between the standard surgical ward and intensive care unit. For simplicity, these environments will be referred to as ‘enhanced postoperative care units’, however the current terminology and organisation of such models vary widely. Despite their potential advantages, evidence on the use of enhanced postoperative care units in clinical practice is lacking. This thesis aims to evaluate the evidence on the effectiveness and safety of enhanced postoperative care units on patient and health service outcomes in adults following non-cardiac, non-neurological surgery. METHODS: A systematic search was conducted in the Cochrane Library, MEDLINE, Embase, Scopus and grey literature sources from 2010 to December 2023. Inclusion criteria included adults undergoing non-cardiac, non-neurological surgery admitted to an enhanced postoperative care unit. Primary outcomes were 30- and 90-day mortality, days at home, hospital length of stay and hospital readmissions. Secondary outcomes included postoperative complications, return to theatre, unplanned intensive care unit admission, number of medical emergency team events, quality of life, quality of recovery, short-term recovery and economic evaluation. Two independent reviewers assessed titles, abstracts and full-text papers against the inclusion criteria and evaluated the risk of bias using JBI standardised instruments. The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the certainty of evidence. Due to clinical and methodological heterogeneity, meta-analysis was not possible, hence only a narrative synthesis was conducted. RESULTS: From 9774 records, 13 reports derived from 12 studies met the inclusion criteria. The narrative synthesis showed that two studies reported a statistically significant decrease in 30-day mortality in favour of enhanced postoperative care units compared to usual care. One study reported a statistically significant increase in days at home at 30 days for patients admitted to an enhanced postoperative care unit. Three studies focusing on hospital length of stay demonstrated that enhanced postoperative care units had a statistically significant reduction compared to usual care. The included studies had low to moderate risk of bias, with small sample sizes. The overall certainty of evidence was rated as very low. CONCLUSION: Evidence is currently insufficient to definitively establish the effectiveness and safety of enhanced postoperative care units in non-cardiac, nonneurological surgery. While most studies were assessed to be of satisfactory quality, considerable clinical and methodological heterogeneity was present. Although the current research is not yet comprehensive, it does suggest that enhanced postoperative care units in this patient population may have potential benefits that warrant further consideration and exploration. Additional high-quality studies are needed and further expansion of enhanced postoperative care units should proceed cautiously with thorough evaluation.enEnhanced recoverypostoperative caresystematic reviewThesis