LEARNING & EDUCATIONImplementation Toolkit
Setting up an EPOC unit is a significant undertaking — but you don't have to start from scratch. This toolkit draws on real-world experience from established units to give you practical, honest guidance on what's involved. Work through each section at your own pace, adapt what's here to suit your facility, and reach out for expert advice.
Overview
Ready to set up or improve an EPOC unit? Use this set of resources as a framework for building and maintaining a unit and providing continuous quality improvement in postoperative care.
This toolkit is intended to help anyone interested in starting an EPOC unit, including physicians, nurses, and hospital leadership.
Fundamentals
Essential information to get started, including planning space, staffing, protocols, and data collection.
Models of care
Examine the functions and structures of existing EPOC units and adapt them to suit your facility.
Resources
Guidelines, checklists and instructions to assist centres in initiating and evolving practices.
Fundamentals
This section covers what you need to know before starting an EPOC unit.
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Establishing an EPOC unit requires clinical leadership, organisational commitment, and early engagement across teams. Before you start planning the physical space or staffing model, consider:
Who will champion this at a clinical and administrative level?
Is there leadership support from hospital management?
Have you engaged ICU, surgical, and anaesthetic teams early?
Do you have a plan for building the business case?ion text goes here
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The physical environment shapes how your unit functions. Key decisions include whether to use single rooms or shared bays — each has trade-offs for infection control, staffing visibility, and patient cohort suitability. Your space should be located close to operating theatres and the post-anaesthetic care unit (PACU) where possible.
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Staffing is one of the most complex aspects of setting up an EPOC unit. You'll need to determine your medical and nursing model from the outset.
For nursing, consider whether you'll draw from existing recovery staff, recruit dedicated personnel, or use a combination. Nurse-to-patient ratios should reflect patient acuity — starting at 1:2 and adjusting based on clinical need is a common approach.
For medical cover, anaesthesiologist-led care is central to the EPOC model. Clearly define on-site hours and after-hours availability from the beginning.
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Not all postoperative patients are suitable for an EPOC unit. You'll need agreed admission and exclusion criteria before you open. Tools such as the NSQIP surgical risk calculator can help identify patients most likely to benefit — typically those at moderate risk of complications who are expected to be ward-ready within 24 to 48 hours.
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Don't underestimate how much education referring teams need before your unit opens. Engaging preadmission clinic staff and anaesthetic teams early is key. A clear, simple referral pathway — whether by phone, email, or a shared calendar system — should be in place from day one.
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Staff education is essential. Before opening, ensure your team is trained in arterial line management, vasopressor infusions, regional anaesthesia care, and advanced life support. A skills workbook and orientation programme will help identify gaps and build confidence.
Plan for a minimum of two supernumerary days for experienced staff, and longer for those newer to high-acuity care.
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Continuous monitoring is fundamental to the EPOC model. Confirm that appropriate monitors are available in your space before opening. You'll also need to establish clinical protocols for common scenarios including hypotension management, emergency escalation, pain management, and deteriorating patients.
Define clearly whether your unit will call a code blue or an anaesthetic assist for emergencies — and make sure ICU and all relevant teams know the answer before you open.
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Set up your data collection processes from day one. Recording outcomes, bed flow, and patient data is essential for quality improvement, staffing justification, and building the business case for your unit's future. Connect with the EPOC Network registry to contribute to and benefit from shared benchmarking data.
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No two EPOC units are identical. Our network includes clinicians who have set up units from scratch. If you'd like to speak with someone who has done it, we can connect you.
Key takeaways
Foundation first: Success depends on early leadership buy-in and cross-team engagement — securing clinical and administrative champions, hospital management support, and involvement from ICU, surgical, and anaesthetic teams before any physical or staffing decisions are made.
Space and staffing must match patient needs: Physical layout (single rooms vs. shared bays, proximity to theatres/PACU) and staffing model (anaesthesiologist-led medical cover, nurse ratios reflecting acuity) should be designed around a clearly defined, risk-assessed patient cohort — using tools like the NSQIP calculator to target moderate-risk patients ward-ready within 24–48 hours.
Readiness requires structured preparation: This includes clear referral pathways with early education for referring teams, staff training in high-acuity skills (arterial lines, vasopressors, regional anaesthesia, advanced life support), supernumerary orientation days, and pre-agreed clinical protocols for emergencies and deteriorating patients.
Readiness requires structured preparation: This includes clear referral pathways with early education for referring teams, staff training in high-acuity skills (arterial lines, vasopressors, regional anaesthesia, advanced life support), supernumerary orientation days, and pre-agreed clinical protocols for emergencies and deteriorating patients.
Models of care
This section examines the common characteristics shared by key EPOC units, as outlined in international expert consensus. Search through our templates to see what people are doing in this space and consider the possibilities.
Location
A 10-bed unit (2 four-bed bays, 1 two-bed bay) within the theatre complex, separate from ICU. Sits between the two recovery units, giving proximity to post-operative patients from all specialties. Locally known as Advanced Recovery Room Care (ARRC).
Patients
- 'Medium risk', with NSQIP-predicted 30-day mortality of 0.5–8%
- Non-cardiac surgery, expected to stay in hospital more than one night
- Common specialties: orthopaedic, vascular, gynaecological, general surgery, urology and renal
- Excludes cardiac and neuro/spinal surgery, and cases needing airway monitoring
Duration of care
- From arrival in recovery until post-op day one
- Occasionally longer, depending on clinical need and ward bed availability
Medical staffing
Led by an anaesthetic consultant during the day, with consultant on-call after hours. A dedicated resident medical officer provides 24-hour cover, with at least three months' anaesthesia experience and training in Advanced Life Support and bedside TTE.
Nursing staffing
1:2 on average. Nurses are proficient in recognising and escalating acute deterioration, arterial line management, pain and PONV management, and fluid and hypotension management, including inotropes.
Prevention and early management
Intensive monitoring detects physiological change early, with proactive intervention before deterioration escalates. Protocol-driven medical reviews run hourly for the first 3 hours, then 3-hourly, with overnight reviews at 2200, 0200 and 0600 and a consultant ward round each morning. Goal: ward-ready by post-op day one.
Enhanced recovery
Consistent, evidence-based practice built on ERAS principles. The DrEaMing framework is implemented within 24 hours of surgery ending — drinking free fluids, eating a soft diet, and mobilising with the assistance of at most one person — delivered through protocol-driven care.
Care specifics by system
Cardiovascular
- Advanced haemodynamic monitoring, guided by bedside TTE and haemosphere data
- Continuous blood pressure monitoring for patients on vasopressors or with labile readings
- Limited low-dose peripheral noradrenaline or metaraminol infusions, with a stable or reducing requirement
- Fluid status optimisation
Respiratory
- Continuous pulse oximetry and respiratory monitoring
- High-flow nasal oxygen (maximum 40 L/min or 40% FiO₂)
- Non-invasive ventilation (CPAP/BiPAP) only where pre-existing for OSA
Pain management
- Optimised analgesia to support early mobilisation and oral intake
- Complex multimodal regimens, peripheral and neuraxial nerve blocks, epidural management
- Intrathecal morphine monitored for at least 24 hours post-administration
Central nervous system
- Proactive delirium prevention
- Early recognition and management
- Cognitive monitoring in at-risk patients
- Non-pharmacological orientation strategies
Renal
- Identify at-risk patients
- Optimise fluid and cardiovascular status
- Avoid nephrotoxins
- Consider goal-directed haemodynamic therapy
Source: EPOC Toolkit — Advanced Recovery Room Care (ARRC), Royal Adelaide Hospital
Location
Within the PACU — 8 beds. This lets patients transfer easily from the PACU for overnight care after an unplanned admission. All nurses are trained for both the PACU and the EPOC unit and may work across both during the day.
Patients
- Non-cardiac surgery, planned and unplanned
- Observed 30-day mortality around 3–5% (mostly ASA 3–4)
- Short-term support — expected to be ward-ready by the morning of post-op day one
- Earlier discharge where possible; beds may be used overnight for emergency surgery patients
- Usually single-system support, not multi-organ ICU care
Duration of care
- Usually under 24 hours
- Rarely up to 48 hours
Medical staffing
Anaesthesiologists work with surgical residents, with morning rounds by surgical staff at the unit and rapid access to other specialists, including ICU, cardiology and renal.
Nursing staffing
Specialised, at a 1:2 ratio during the day and 1:2–1:4 overnight, with competency-based training specific to recovery-room nursing.
Prevention and early management
Intensive monitoring — arterial lines, continuous ECG and intermittent echocardiography — guides haemodynamic management. Teams intervene proactively to prevent deterioration, or manage it before it escalates, aiming for ward-ready by post-op day one or earlier.
Enhanced recovery
Evidence-based practice delivered with high compliance to ERAS principles, including early discharge where feasible. The DrEaMing framework — drinking, eating and mobilising, with nursing staff for sitting and physiotherapists for walking — is applied proactively through protocol-driven care.
Care specifics by system
Cardiovascular
- Advanced haemodynamic monitoring (arterial lines, TTE)
- Vasopressor or inotrope infusions with no dose limit
- Fluid optimisation guided by haemodynamic monitoring
- External lumbar drains for thoracic vascular cases
Respiratory
- High-flow nasal oxygen
- Non-invasive ventilation (CPAP/BiPAP)
- Mechanical ventilation, preferably short-duration or as a bridge to ICU
- Continuous pulse oximetry and respiratory monitoring
Pain management
- Optimised multimodal analgesia to support early mobilisation and oral intake
- Optimised peripheral and neuraxial blockade
- Access to specialised acute and chronic pain services
Central nervous system
- Identify at-risk patients
- Proactive delirium prevention
- Early recognition and management
- Pharmacological and non-pharmacological measures
Renal
- Identify at-risk patients
- Optimise fluid and cardiovascular status
- Avoid nephrotoxins
- Goal-directed haemodynamic therapy
Source: Rijnstate Hospital Arnhem
Location
A 6-bed unit (4 open bays, 2 side rooms) adjacent to the PACU, enabling seamless transfer and continuity of care from theatre. Co-located with theatre and the surgical ward, with access to the medical-precinct ICU. Locally known as the Enhanced Care Unit (ECU).
Patients
- Elective surgical oncology (95%)
- Predominantly ASA physical status 3
- Selected via consultant anaesthetist triage
- Short-term, single-organ support ± high-flow nasal oxygen
Duration of care
- 24–72 hours, depending on case complexity and local data
- Majority ward-ready by 24 hours
- Extended admission (48–72 hours) expected for selected procedures, e.g. cytoreductive surgery with HIPEC, total pelvic exenteration
Medical staffing
Anaesthesia-led, with consultant anaesthetists available 7 days a week plus general on-call, supported by perioperative physicians. Unaccredited anaesthesia and perioperative medicine registrars provide 24/7 cover, alongside surgical teams and acute pain specialists, with rapid access to anaesthesia-led rapid response, medical-precinct ICU/CCU and other specialists.
Nursing staffing
Specialised, at a 1:1–1:2 ratio, with competency-based training and a blend of ICU-trained (CCRN) and oncology-trained nurses. A dedicated Professional Development Nurse educator supports the team.
Allied health staffing
Physiotherapists, pharmacists and dietitians support recovery.
Prevention and early management
Open-unit model with shared care through co-rounding with surgeons. Individualised physiological goals support proactive prevention of deterioration, backed by a MINS surveillance program for myocardial injury after non-cardiac surgery. High-frequency rounding — 2 consultant and 5 junior reviews every 24 hours — supports a shared goal of ward-readiness by postoperative day 1–3.
Enhanced recovery
Consistent, evidence-based practice with locally agreed ERAS compliance for all patients. Dedicated pathways cover select colorectal, breast, upper GI and hepato-pancreato-biliary surgery, with more in development. The DrEaMing framework — drinking, eating and mobilising — is delivered proactively through protocol- and data-driven care.
Care specifics by system
Cardiovascular
- Advanced haemodynamic monitoring and support
- Intra-arterial blood pressure monitoring
- Non-invasive cardiac output monitoring
- Point-of-care ultrasound (POCUS)
- Low-dose vasopressor or inotrope infusion
- VTE risk assessment and prophylaxis (STEP bundle)
- Optimised free-flap care
Respiratory
- Continuous advanced respiratory monitoring
- High-flow nasal oxygen (≤50 L / 50%)
- Optimised tracheostomy care
- Physiotherapy-led CPAP
- 'aCOUGH' care bundle
- Early mobilisation
Pain management
- Optimised multimodal analgesia to support early mobilisation and oral intake
- Optimised management of peripheral and neuraxial blockade
- Daily Acute Pain Service (APS) consultant-led rounds
Central nervous system
- Identify at-risk patients
- Proactive delirium prevention, recognition and management (pharmacological and non-pharmacological)
- Delirium order sets
- On-call geriatrician
Renal
- Identify at-risk patients
- Optimise fluid and cardiovascular status
- Avoid nephrotoxins
- Goal-directed haemodynamic therapy
- Optimised glycaemic control
Source: Peter MacCallum Cancer Centre, Melbourne
Download models of care
Resources
Best practice guidelines and instructions to assist centres in initiating and evolving their practices:
Submit your resource
Do you have a resource to share with the Network? Submit your resource here, and we'll review it for inclusion.