The Association Between Perioperative Enhanced Care Unit Characteristics and Surgical Cancelation: A Nationwide Observational Study

BACKGROUND: Patients referred for postoperative care within enhanced care units in the United Kingdom are less likely to have their surgery canceled than those referred to critical care. Presently, it is unclear whether this association remains when examined at an individual hospital level, and whether specific structure and process features of enhanced care services influence cancelation rates within a facility. METHODS: We conducted a nationwide, retrospective, observational study documenting clinical and organizational features of enhanced and critical care facilities in the United Kingdom. Features of interest included resource protections, staffing, and clinical scope. Sites with availability of both enhanced and critical care facilities, with >10 referrals to enhanced care during the study period, were selected for analysis. Cancelation rates of elective surgery within these facilities were quantified over a 3-month period between September 1, 2023, and November 30, 2023. Rates were defined as the number of elective cases canceled divided by the number of elective referrals to each facility. Multilevel regression was used to explore relationships between structure and process features of enhanced care units and surgical cancelation, using a two-level model with cases nested within hospitals to account for institutional confounding. RESULTS: Complete data were available for 65 sites, of which 28 had an enhanced care facility with sufficient activity for analysis, representing 4112 patients referred to enhanced or critical care. In most institutions, surgical cancelation rates were lower within their enhanced care facility than in critical care. Enhanced care units with beds reserved exclusively for elective cases (odds ratio [OR], 0.54 [0.39-0.76]; P < .001) and clinical care involving multiple specialities (OR, 0.48 [0.33-0.69]; P < .001) were associated with reduced odds of cancelation. On the other hand, enhanced care units that permitted admission of emergency cases (OR, 1.61 [1.06-2.43]; P = .024) were associated with a greater odds of cancelation. CONCLUSIONS: Structure and process features of enhanced care pathways are associated with cancelation rates among high-risk surgical patients in the United Kingdom. These findings may explain why cancelation rates in enhanced care are typically lower than within critical care and may have important policy implications.