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To make the best of this approach we need to make sure patients and all health care professionals including GPs and multidisciplinary hospital teams work together to: Identify anaemia early in the pathway. Make the patient aware of this and all actions going forward. Find the cause of the anaemia. Use tried and tested treatments for anaemia before surgery. This could include advice on changes in diet, oral treatments such as iron supplements and the use intravenous iron when necessary. Make sure the patient has a personalised treatment programme including providing appropriate information about the pros and cons of the different approaches suggested to the patient and how long these should be continued. Communicate clearly between different members of the team so that operations are not cancelled unnecessarily and improve the interface between primary care and hospitals. Talk openly to the patient about the benefits and risks of managing anaemia and the surgery.

This guideline includes recommendations on: information for patients measuring temperature warming patients before their operation, including transfer to the operating theatre keeping patients warm during their operation, including ambient temperature in the operating theatre and temperature of intravenous fluids keeping patients warm after their operation

The latest expert guidance on routine operations recommends: Within 10 days of your planned surgery date If you have a positive test, or COVID-19 symptoms, elective surgery should not take place because you may be infectious to others (as well as risks to you). Between 10 days and 7 weeks before your planned operation date Reduce your risks of catching COVID-19. If meeting people, consider social distancing, wearing a facemask, opening windows or meeting outdoors. If you test positive or have COVID-19 symptoms: You MUST inform your surgical team. Elective surgery may need to be delayed. Your health professional may undertake a risk assessment with you to decide whether the risks of delaying are worse than the risks of problems with surgery and COVID-19. At any time before surgery Please ensure you stay healthy and prepare for surgery: Ensure you have had a full course of vaccinations including a 3rd dose/booster. Vaccination reduces the chance of getting COVID-19 and of spreading it as well as reducing the severity of the illness if you get it. Regular exercise, nutrition and stopping smoking reduce complications from surgery by 30–80%. There is more information here: www.cpoc.org.uk/patients

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.

The investigation explored: Safety issues associated with the establishment of surgical services in independent hospitals to support the NHS and in particular the specialist services that are in place to deliver patient care. The assessment of patients prior to surgery to identify their risk and suitability for an operation and where it was to be undertaken; this included identification of patients with frail physical states. Key findings included: National and local NHS organisations had limited understanding of independent hospitals’ capabilities. This resulted in variation in how independent hospitals were used during Covid-19. Some independent hospitals saw patients with increasingly complex conditions and undertook more complex operations during Covid-19. The increasing complexity was well managed where capability of the independent hospitals had been evaluated and addressed prior to implementation of new services. Where pathways between NHS and independent hospitals were effective, it was often found that relationships between the hospitals had been longstanding and direct. There was variation in how preoperative assessments were undertaken across NHS and independent hospitals. This included what tests were ordered and risk assessments undertaken. Preoperative nutrition screening was inconsistent across NHS and independent hospitals. Examples were identified where it was not undertaken, or undertaken too late to allow any preoperative optimisation – that is, to make sure the patient was in the best possible nutritional state before their operation. Remote preoperative assessment became the norm during Covid-19, but created risks when staff were not able to see the patient. Lack of video call facilities and staff preference meant assessments were commonly done by telephone. Safety recommendations HSIB recommends that NHS England and NHS Improvement ensures that effective processes have been implemented in integrated care systems to identify local capability and capacity of their independent acute hospitals. HSIB recommends that NHSX expands its work programme addressing the challenges associated with interoperability of information systems used in healthcare to include transfer of information between the NHS and independent sector in support of safe care delivery. HSIB recommends that the Care Quality Commission reviews and appropriately develops its methodology for regulatory assurance of arrangements between NHS and independent providers for the provision of care across care pathways. This is to include any screening and risk management processes used to ensure the safe transfer of care between providers. HSIB recommends that NHS England and NHS Improvement reviews models of perioperative care for their value and impact. This should inform future work to support implementation of a standardised approach, based on evidence, across all healthcare providers that deliver surgical services. HSIB recommends that NHS England and NHS Improvement establishes a process to ensure that findings of the National Institute for Health Research’s policy research programme into frailty in younger patient groups are reviewed and acted upon.

Download frailty pathway infographic Download the guidelines

Anaesthesia is the largest hospital speciality in the UK, involved in a third of all hospital admissions, while perioperative care covers a patient's care from when they first contemplate surgery to their full recovery. The GIRFT national report for anaesthesia and perioperative medicine contains 18 recommendations based on information gathered from the 134 trusts in England with an anaesthesia and perioperative medicine service. It seeks to improve outcomes for patients having surgery in the new COVID-19 environment, including reducing the amount of time they spend in hospital. You will need a FutureNHS account to view this report, or you can watch a short video summary summarising key recommendations.

The Green Paper project is a nine-month programme of consultation and research about how to advance the perioperative care agenda. It aims to draw CPOC’s diverse community of partners together around a shared set of priorities for change and a vision for the future. The project will draw on a wide evidence base, building on work already happening within CPOC, our partner organisations and across the entire health and care sector. We will also reach out to our community of thousands of health professionals and patients to generate new evidence that will enable us to develop future policy and make the best possible case for change. Get involved The Green Paper can't be delivered without the active participation and help of everyone working to deliver better patient-centred care. If you would like to get involved with this project, then please consider joining the informal ‘sounding board’ of healthcare professionals, patients, and policymakers. The kinds of things CPOC will be looking for your help with include: Giving your views as CPOC develop their policy thinking, e.g. by taking surveys, feeding back on draft papers or reports, testing the messaging, and helping plug evidence gaps or prioritise what CPOC explore further. Championing the work on social media and to your personal and professional networks. Blogging for CPOC to share your experiences, reflecting on new findings, and informing the public about this work. Attending workshops or events CPOC may host as part of the consultation work for this project. If interested email cpocgreenpaper@rcoa.ac.uk.

A significant backlog of elective surgical cases has built up during the COVID-19 crisis. The freeze on elective surgery has produced a waiting list that may take years to clear. In the US, the CDC has issued guidelines that "facilities should establish a prioritization policy committee consisting of surgery, anesthesia and nursing leadership to develop a prioritization strategy appropriate to the immediate patient needs". According to the CDC, this committee should work around 'objective priority scoring'. The MeNTS (Medically-Necessary, Time-Sensitive Procedures) instrument is a clever attempt to deliver this scoring, responding to availability of resources and the situation around COVID-19. However, the key challenge is that that the list needs to be prioritised in a way that reflects patient needs and ensures their safety. This is not something that MeNTS can deliver. It also is built around COVID-19 related limitations on resources and this will vary in significance depending on the hospital location and where it is in the journey out of lockdown. The risks of mortality and complications for a patient are a complex combination of the severity of the procedure and the physiological variables of the patient. As an example, a 55-year-old undergoing a radical laproscopic prostatectomy has a risk of mortality of 1.6%. However, if the patient has low blood pressure, that risk triples. If the patient also has low sodium then the risk is 10 times higher [C2-Ai insights]. The spectrum of different operations and key physiological variables creates at least 40 million potential combinations and hence risk. This is hard to manage with one patient but trying to prioritse a group of 5, 10, 100, 1,000 or even 10,000 becomes unmanageable. New patients will be joining the list while others leave following their procedures and so triage of the list will not be a one-off event. The list will need to be populated and triaged intelligently and in a consistent way repeatedly at least until there is a return to ‘normality’. There is evidence that some trusts are attempting to build their own systems for prioritisation. This may be possible around matching operative type and resource availability but the efficiency of these systems overall should be a concern. Best intentions are fine but, when reviewed later, the ability to correctly prioritise patients to minimise harm and mortality is likely to be limited if not flawed. C2-Ai’s COMPASS Surgical List Triage system is an example of a system that can support evidence-based triage and individualised risk assessment of patients, while supporting the objectives of the CDC. It supports clinical decision making across all phases from crisis back to steady state. It has been developed by the creator of the POSSUM system and is built around the world’s largest patient data set (140 million records from 46 countries) through the support of NHS Digital. The underlying algorithms are constantly refined against new and existing data sets to ensure relevance and accuracy. The Surgical List Triage tool combines the mortality and complication risks from the different patients to derive the prioritisation. The system carries out bulk assessments using individualised risk assessments for each patient. These reflect the operative type and their physiology to calculate the risk of mortality and complications, as well as providing a detailed breakdown of potential complications with percentage probability with a simple click. This system also suggests patients that should be reviewed for potential optimisation before any procedure. The physician can click on the link to see the detailed risks for the patient to support their decision making. The system can be used regularly to maintain the logic and integrity of the elective surgical list. This is superior to the potentially fragmented approach where parts of the list are manually considered in isolation as this cannot support effective optimisation of the whole list and the absence of any supporting evidence means the triage will vary enormously. COMPASS SLT is an evidence-based approach that supports optimal ordering of the list and clinical decision making that reduces avoidable harm and mortality. This in turn reduces variation, and cost while freeing bed capacity and also allowing the list to be tackled more quickly. When a patient comes in for the operation, an individual risk-assessment can be done using the COMPASS Pre-Operative Risk Assessment app. This provides a final check on whether the patient’s condition would justify optimising their condition before their procedure. However, it also details the most likely post-procedural complications individualised for the patient and their condition. That allows the treatment pathway to be tailored to that patient as well as recruiting the patient into their own recovery. For example, knowing that chest infection is the highest risk for a patient supports a conversation with them to stress the need for them to get up and about on the day of the operation. As an aside, the risk of mortality and complications can also be used as a strong element in showing informed consent has been obtained from the patient. In combination, these tools can provide a platform to support effective and ongoing triage of the list while reducing harm and unnecessary costs. The systems are currently in use in 12 trusts in the NHS. How are you prioritising waiting lists? We'd be interested to hear and share how you and your trust are dealing with the backlog.

This report teases out the ‘ingredients’ for successful team working at system, organisational, team and individual level. In the COVID-era, multidisciplinary perioperative teams can be at the front and centre of supporting staff to deliver the best possible care. Key messages Our review found that multidisciplinary working is worth prioritising. There is evidence that in some cases multidisciplinary working can: speed access to surgery, if that is an appropriate treatment option improve people’s clinical outcomes, such as reducing complications after surgery reduce the cost of surgical care by helping people leave hospital earlier However, these benefits are not always apparent. More work is needed to explore which types of multidisciplinary working are most effective and what infrastructure and resources are needed to strengthen and sustain multidisciplinary care around the time of surgery.