Royal College of Surgeons of England: Preoperative assessment and optimisation for adult surgery (June 2021)

Summary

Surgery is lifesaving or life-enhancing for millions of patients every year. However, the operation is not in itself an isolated ‘event’: it is part of a process which includes preparation and recovery. Ensuring the quality of the entire perioperative pathway is important to achieving the best possible outcome for every patient. 

This guidance is intended to be used by primary care, surgeons, anaesthetists, perioperative teams and preoperative assessment (POA) services. It applies to all patients who are being considered for surgery, or are on a waiting list for surgery in the non-emergency setting, irrespective of the magnitude of procedure or the type of anaesthesia contemplated. Its recommendations will support the care of individual patients, the recovery of elective services, and achieving key goals of the NHS Long Term Plan including reducing health inequalities and preventing serious health deterioration.

Content

Key recommendations

For Commissioners

1. Investment should be provided to: (a) establish prehabilitation services; (b) enable integrated Care Systems (England), Health Boards (Wales), Regional Health Boards (Scotland) and Health and Social Care Trusts (NI); and (c) expand perioperative services

For NHS X

2. Ongoing work to bridge the Primary - secondary care interface should be accelerated.

For primary care providers, surgeons, anaesthetists and multidisciplinary teams

3. Shared Decision Making (SDM) should be embedded throughout perioperative pathways. beginning at the earliest point where surgery is contemplated, and involving discussion between patient, surgeon, and the broader multidisciplinary team.

4. At the earliest possible point in the surgical pathway (e.g. at the point of referral from primary care, or at the first review in surgical clinic) patients should complete a screening self-assessment health questionnaire, to help shared decision making, risk prediction and optimisation.

5. Referrals from primary care to surgeons and from surgeons to Preoperative Assessment (POA) Services should detail significant medical comorbidities using a “fitness for surgery” process to enable early optimisation and review.

For preoperative assessment services

6. Every patient requiring surgery and/or anaesthesia/anaesthesia-led sedation should undergo formal preoperative assessment before the day of admission.

7. Patients should be assessed for impact of comorbid conditions on functional capacity, perioperative pathways and surgical outcome.

8. Patients should be screened for cognitive impairment, psychological distress and risk of malnutrition using validated tools.

For surgeons, anaesthetists and perioperative multidisciplinary teams

9. All patients being considered for surgical intervention should have their individualised risk assessed using objective measures, combined with senior, experienced clinical judgement.

10. Where possible, surgery should be avoided for 7 weeks after COVID-19 infection, or until symptoms have resolved, to avoid the higher risk of postoperative complications and death associated with earlier surgery.

11. All patients who are being considered for a surgical intervention should be screened for reduced functional capacity/physical fitness using a validated tool such as the Duke Activity Status Index (DASI).

12. All patients should be advised that improving fitness before surgery reduces risk of complications after surgery, and improves length of hospital stay, speed of recovery and quality of life. All healthcare professionals should be competent to deliver universal exercise advice to all patients following UK CMO (WHO) guidance.

13. All patients considered for a major or inpatient elective surgical intervention should be invited to attend a group ‘surgery school’, which may be in-person, via remote access or hybrid.

14. All surgical / perioperative services should have a system for active clinical surveillance of patients on waiting lists, particularly those who have been waiting for longer than 3 months.

15. Prompt preoperative assessment and optimisation, supported by agreed local pathways based on national recommendations, should be prioritised in emergency surgery. This will ensure efficient and safe care which will benefit best use of hospital resources, creating more capacity for both emergency and elective work.