Surgical cancellation and changes in postoperative level of care among high and moderate risk surgical patients in the UK.

Background: The clinical and administrative pressures leading to cancellation of surgery are well established. However, it is not known whether the same factors lead to a change in patients' planned postoperative destination and level of care. Methods: We conducted a secondary analysis of the REPACC dataset; a nationwide, retrospective, observational study examining the provision of enhanced and critical care services in the UK. The reasons for cancellation and changes to the level of care received postoperatively were ascertained from free-text data. Results: Our analysis included 5990 patients from 65 sites across the UK, of which 539 (9.6%) had their surgery cancelled. The most common reason for surgical cancellation was a lack of resources (51.0%), primarily bed shortages (37.1%). Among the 5451 patients who proceeded with surgery, 81.3% received the anticipated level of care postoperatively, 3.9% required escalation and 14.8% were de-escalated to a lower level of care. Changes to the anticipated level of care occurred most often among patients initially triaged to enhanced care. Clinical reasons were the major cause of escalation (53.3%) and de-escalation (61.2%) postoperatively with bed shortages accounting for a minority. Patients were commonly de-escalated following a postoperative assessment (21.8%). Conclusion: Cancellation of surgery in the UK is primarily a consequence of resource scarcity, whereas clinical reasons account for the majority of those re-allocated to different levels of care postoperatively. Future work should explore the clinical and health economic impacts of this dynamic bed management with particular focus on the role of enhanced care as an interface between critical care and the ward.