LAUSR

We present a broad international perspective of the past, present and future of the organisational factors and staffing models for the management of patients following both cardiac and non-cardiac surgery. Using recently published large data, we explore differences in human factors and outcomes. We examine and describe the difference in clinical care pathways in the setting of cardiac and noncardiac surgery between the UK and other high-income countries. We report key areas of focus whereby improvements may be achieved in future training and systems management. These include: (1) increasing the availability of intensive care, high-dependency care and critical care outreach; (2) increasing the availability of trained specialist nurses; (3) expanding the critical care training of surgeons; and (4) multidisciplinary enhanced recovery programmes. We conclude that a multidisciplinary collaborative approach to implementing these key principles alongwith an evidence-based focus on outcomes and reducing variation is vital to improving clinical outcomes in surgical patients. It was easier in the past. Surgeons looked after surgical patients on the ward, anaesthetists stayed in the operating theatre and intensivists were yet to be conceived. Surgical ward care was commonly provided by a trainee surgeon with the occasional help of a friendly anaesthetist if a patient unexpectedly deteriorated [1]. It may not have been easier if you were the trainee surgeon who provided 168 h of uninterrupted weekly care; however, it is always important to understand our history when attempting to understand the present and improve the future. When we ask, ‘who should manage the patient after surgery?’, are we, in fact, asking who should have ownership of the patient? Ownership is amuch-used term inmedicine; however, there are two distinct but overlapping meanings to this term. There is decision ownership, whereby physicians not only have a personal investment in treatment decisions but also ownership in the more possessive or transactional sense in relation to a patient – ‘this is my patient’ [2]. We would suggest that the two meanings may be the flipsides of the same medical coin. The concept of ‘care’ overarches the concept of ownership, reflects the compassionate nature of the job and suggests an aspiration for an enlightened multidisciplinary team approach. The answer to the question posed will vary according to national, cultural and institutional norms. The important question is: do we have any evidence to support a best practice? In looking at this question, we must first distinguish between different patients and surgical procedures. Cardiac surgery is verymuch at the sharp end of the surgical spectrum, with almost all postoperative patients going to an intensive care unit (ICU) and cared for by an expanded multidisciplinary team. On the other hand, postoperative provision of care for patients undergoing other types of surgery is variable. Those patients who are having