Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients
Perioperative care refers to the practice of patient-centred, multidisciplinary and integrated clinical care for patients from contemplation of surgery until full recovery. Good perioperative care should improve the patient experience, quality and satisfaction with care. It should improve the health of populations, including returning to home/work and quality of life, and should reduce the per capita cost of healthcare through improving value.
Organisation of perioperative care is essential in the delivery of high quality care to elective and urgent care patients. Preoperative assessment as part of this process enables patients to be fully informed, reducing stress and anxiety, leading to early recovery. It also creates an opportunity for preoperative optimisation of medical conditions prior to surgery whereby patients and carers are aware of planning admission and discharge, facilitating day surgery, early discharge and postoperative care at home. This minimises cancellations on the day due to clinical reasons. It is essential that there is sufficient time between the decision to perform surgery and the procedure itself and that this time is used to ensure the delivery of a good quality service.
Shared decision making should run throughout the patient journey; it is now viewed as an ethical imperative by the professional regulatory bodies, which expect clinicians to work in partnership with patients. Patients want to be more involved than they are currently in making decisions about their own health and healthcare, and there is compelling evidence that patients who are active participants in managing their health and healthcare have better outcomes than patients who are passive recipients of care. If the patient decides to proceed, they should be as fit as possible for surgery and anaesthesia.
Patient outcomes are improved by the optimisation of patients preoperatively and are largely dependent on the complexity of the procedure and the associated comorbidities of the patient. Nevertheless, the staffing, equipment, services and facilities available to patients before the day of procedure, on the day of procedure and early after surgery are fundamental to patient outcomes.
Ultimately, the goal of these guidelines is to ensure a comprehensive, quality service dedicated to the care and wellbeing of patients at all times, and to the education and professional development of staff.
These recommendations do not provide detailed information on how the perioperative pathway for elective and urgent surgery may need to be adjusted during the Coronavirus (COVID-19) pandemic as this is a fast-evolving situation and clinical and public advice may change. Detailed guidance on this has been provided by the National Institute for Health and Care Excellence and the Scottish Intercollegiate Guidelines Network.1,2 Anaesthetists should use the joint guidance hub of the Royal College of Anaesthetists, Association of Anaesthetists, Faculty of Intensive Care Medicine and Intensive Care Society to find the latest information, guidance and resources supporting the understanding and management of COVID-19.3 Where changes in practice persist beyond the pandemic, these changes will be incorporated into the recommendations as the evidence base emerges.
1. Service organisation and administration
Business planning by organisations and anaesthetic departments should ensure that the necessary resources, including adequate time, are targeted towards perioperative care. This should include administrative support.
If appropriate resources are not available, the level of clinical activity pertaining to those resources should be limited, to ensure safe provision of perioperative care.4 The hospital policy for determining, communicating and documenting this process should have input from the anaesthetic department.
Organisation strategy and organisation culture
Hospitals should have a clear and explicit strategy for developing a strong safety culture, which includes the following characteristics: recognition of the inevitability of errors, commitment to discuss and learn from errors, proactive identification of latent threats, and the incorporation of non-punitive, fair and transparent systems for reporting and analysing adverse events.7,8,9
There should be clarity of leadership and roles in the supervision of the day to day running of the anaesthetic department.
Day to day management of workload
Elective theatres should offer spare capacity (such as that resulting from cancellations) to the emergency theatres.20Elective cases may be cancelled, in accordance with agreed local procedures, to facilitate emergency work if required.
When members of the healthcare team are involved in a critical incident, the personal impact on individual team members can be significant.7,21 Following a significant critical incident, the clinical director (see Glossary) or appropriate individual (head of service) should promptly review the immediate clinical commitments of the staff concerned. Relevant support for staff following a critical incident is outlined in GPAS chapter 1: Guidelines for the Provision of a Good Department.
Policies and pathways
Appropriate patient centred pathways should be in place linking through to primary care, clinical policies, checklists and standard operating procedures for operating theatres.
Generic policies covering the entire perioperative period should be held and easily accessible. These include but are not limited to:
The following policies covering the entire perioperative period should be held and easily accessible for the management of patients with additional clinical requirements including, but not limited to:
- patients with obesity27,28
- obstructive sleep apnoea
- allergies, including perioperative management of latex and chlorhexidine allergies
- management of complex cardiovascular disease including patients with cardiac pacemakers and implantable cardioversion defibrillators
- management of significant respiratory impairment including severe chronic obstructive pulmonary disease
- blood/component management for patients who refuse transfusion of blood or blood components29,30
- thromboprophylaxis including the management of patients receiving any anticoagulant therapy31,32,33
- diabetes management34,35
The following policies covering the entire perioperative period should be held and easily accessible for the management of vulnerable patient groups, including but not limited to:
Policies for the management of children in accordance with GPAS chapter 10: Guidelines for the Provision of Paediatric Anaesthesia Services should be held wherever children are anaesthetised or sedated.38
Access to paperless guidelines through a readily available hospital intranet repository is encouraged.
Anaesthetic departments should have a coherent and well managed governance structure with a clinical lead with time identified for the role within their job plan.
All critical incidents should be reported according to local governance procedures.39
Hospitals must have systems in place to facilitate multidisciplinary morbidity and mortality meetings.6
Clinical governance is detailed in GPAS chapter 1: Guidelines for the Provision of a Good department.
2. Staffing requirements before the day of procedure
Before the day of procedure a high quality service will deliver patients whose care has been optimised, who are informed and well prepared for their planned procedure. Organisation of services before the day of procedure should involve multidisciplinary staff, supported by pathways and processes designed to minimise workload and maximise outcome, and ensure appropriate inter-departmental communication.
All patients should be assessed prior to anaesthesia or anaesthesia-led sedation. This could be conducted face to face in a clinic or virtually (any interaction that does not take place face to face).40,41 The majority of preoperative assessment will be nurse led and delivered (in association with allied health professionals and pharmacy staff) using locally agreed and developed protocols.
An anaesthetic preoperative assessment service should involve consultant anaesthetists and staff grade, specialty and associate specialist (SAS) doctors.40,41,42 Dedicated anaesthetic presence in the preoperative assessment and preparation clinic is required for:
- the review of results and concerns identified by preoperative staff
- consultations with patients identified using a triage process to allow optimal delivery of preoperative assessment resources.
- consultation, including shared decision making, on the risks and benefits of anaesthesia and surgery in high risk patients, including arranging and interpretation of functional assessments of fitness. This should also include identifying modifiable risk factors and motivational interviewing (see Glossary), empowering patients to improve outcomes from proposed surgery.43
An appropriate level of staffing and suitable facilities should be available to deliver a good quality preoperative service. Non-anaesthetist health professionals, such as, specialist nurses, pharmacy staff, allied health professionals and Anaesthesia Associates (AAs) add considerable value to the service.41,44,45
There should be a designated lead anaesthetist for this service with specific programmed activities for this role within their job plan. The lead anaesthetist is responsible for:
- the training and support of nursing, ODPs and other staff
- the maintenance of close two-way links with primary care clinicians facilitating agreed evidence based ‘fitness for surgery’ protocols between primary and secondary care. This arrangement also encourages general practitioners to develop a broader knowledge of remediable perioperative risk factors which can be optimised prior to surgery
- developing links with clinical commissioning groups
- the establishment of internal protocols for patients such as those with diabetes, obesity or those receiving anticoagulant therapy
- audit, research, teaching, protocol development and relevant information technology development.
Secretarial and administrative support should also be provided to the preassessment service.
The preassessment clinic should be predominantly led by suitably trained nurses or other extended role practitioners using agreed protocols and with support from an anaesthetist.
Local protocols should determine the grade, experience and competency based training of non-anaesthetist healthcare professionals undertaking preoperative assessments.47 In addition , all members of the team including administrative, managerial and clinical staff who interact with the patient preoperatively should have skills in motivational interviewing and preoperative optimisation.48,49
There must be the ability to provide the patient with an appropriate chaperone, as per General Medical Council (GMC) guidance on intimate examinations and chaperones.49 When examining a patient, anaesthetists must be sensitive to what the patient may consider as intimate. This could include any examination where it is necessary to touch or even be close to the patient.
Paediatric services will have different staffing requirements, see GPAS chapter 10: Guidelines for the Provision of Paediatric Services for detailed recommendations.
Patients who are older and/or frail patients will have different staffing requirements; see section 12 for detailed recommendations.
3. Equipment, services, and facilities before the day of procedure
Facilities for computer based video platforms or telephone consultations should be available.
When patients arrive in a preoperative preparation clinic, there should be a staffed reception desk or automated registration system to ensure the patient’s attendance is registered and that the patient is directed to the appropriate member of staff or waiting area.
The patients’ waiting area should provide adequate seating for the number of patients attending a preoperative preparation clinic. This may be an appropriate place to display patient information leaflets and to play health promotional videos and other materials.
Consulting rooms need adequate furniture, such as a desk, chairs, examination couch and equipment such as computers, scales for measuring height and weight, blood pressure, pulse oximetry, peak flow meter and electrocardiography machines.
There should be equipment and facilities for near patient testing and laboratory blood tests and urine analysis.
There must be a secure environment to enable access to patients’ notes including previous anaesthetic records and medical alerts.6
4. Service organisation and administration before the day of procedure
Objective assessment of risk should be routine and the identification of increased risk should trigger advanced planning specific to that patient. Each hospital should have a consistent and where possible evidence based system in place to identify high risk surgical patients who require additional assessment.50 This assessment should be based on:52
- medication history and allergy status53
- type of surgery including risk of severe postsurgical pain54,55
- dementia and cognitive dysfunction56
- nutritional status
- lifestyle factors (i.e. smoking behaviour, excess alcohol consumption, drug use, obesity)
- psychological factors and anxiety
- functional status
- chronic pain.
As a minimum, all ASA 3–5 patients and those undergoing high risk surgery should have their expected risk of morbidity and mortality estimated and documented prior to an intervention, with adjustments made in accordance with national guidelines in planning the urgency of care, seniority of staff involved and postoperative care.16,52,58,59
There are validated general risk prediction tools available that assess the risk of 30-day mortality (and morbidity) following surgery, as well as procedure specific risk prediction tools for elective aortic aneurysm surgery.59 There is also a wide variety of other screening and risk assessment tools that are useful in estimating the specific or additional risks accrued through the factors listed in recommendation 4.1. The focus is upon improving quality of outcomes through improved perioperative planning based on individual hospital case mix.61,62 Where possible, risk quantification tools should be used to facilitate shared decision making conversations and to enable informed anaesthetic consent consistent with GMC requirements.63,64 Quality improvement outcomes should be assessed through national and local audit. Appropriate tools for risk prediction in perioperative care can be found at www.CPOC.org.uk.
Timing of preoperative assessment
Preoperative assessment should occur as early as possible in the patient’s care pathway. Greater than two weeks preoperatively is recommended as good practice and preferably as close to the point of contemplation of surgery as possible to allow for the optimisation of chronic health conditions and health behaviours, so that all essential resources and obstacles can be anticipated prior to the day of procedure, including discharge arrangements.40 If there are delays to surgery and a significant period of time has elapsed between preassessment and the date of surgery, a repeat preoperative assessment should be undertaken to ensure there are no changes to the patient’s co-morbidities.
Where possible, it is preferable for one stop arrangements to be implemented so that patients can attend preoperative assessment during the same hospital visit as their surgical outpatient assessment. Ideally, the frequency of high risk clinics should allow for one stop patient visits when appropriate. The volume of information may mean that the wrong details are prioritised or recollected. Patients should be given information to reflect on with their family at home, ideally beforehand and always afterwards. The patient should be encouraged to identify questions and be given a route for these to be discussed.65
Each hospital should have agreed written preoperative policies or guidelines, following national guidelines where available, including but not limited to:
- preoperative tests and investigations66,67
- preoperative ordering for potential blood transfusion
- preoperative fasting schedules and the administration of preoperative carbohydrate drinks40,41,68
- default to day surgery for suitable procedures
- escalation to higher levels of postoperative care (e.g. to a critical care unit) should the patient develop perioperative complications
- optimisation and continuation/ cessation of regular medication, including on the day or surgery, and including adjustments to monitored dosage systems69,70
- referral of patients from a nurse led clinic to anaesthetic staff for further review
- pregnancy testing prior to surgery
- breastfeeding guidelines
- implementation of enhanced perioperative care.71
Liaison with internal and external colleagues
The secondary care preoperative service should liaise closely with primary care, other secondary care professionals and commissioners to promote a ‘fitness for referral’ process in line with best practice.
Agreed internal referral pathways to other specialties should be in place for the minority of cases in which this may be required to expedite further investigation and patient optimisation. This should be done in close collaboration between the preoperative assessment lead and nominated representatives from appropriate specialties (e.g. cardiology, diabetes, renal, respiratory and geriatric medicine).
Where the risk of an adverse patient outcome associated with surgery are identified as being high, the preoperative assessment consultation should facilitate a shared patient discussion, which may result in a well-informed individual opting for non-surgical management. Under such circumstances the decision making process should be endorsed through close collaborative discussion with surgical colleagues – this is ideally conducted and documented within a preoperative multidisciplinary team (MDT) meeting.74
The output from consultations with patients at increased risk of mortality or morbidity must be documented in the patient’s medical notes. In addition, mechanisms for clear communication of these consultations to patients, anaesthetists, surgeons, general practitioners and other healthcare workers should be in place.6,52
Co-ordination and communication
Documentation and communication of information on preoperative preparation are essential. Electronic systems should be considered to enable the capture and sharing of information, support risk identification and allow data to be collected and available for audit and research purposes.46,74,78
Discharge planning should ideally start as soon as the patient opts for surgery so that all essential resources and obstacles to discharge can be identified and dealt with, including liaison with primary care and social care services as required. This will minimise late cancellation of procedures.79
A preoperative blood ordering schedule should be agreed with the local blood transfusion service for each procedure and appropriate system should be in place to facilitate timely provision of blood products.
Anticipated difficulty with anaesthesia should be brought to the attention of the anaesthetist as early as possible before surgery.80 This includes planned admission to a critical care unit, the potential need for special skills such as fibre optic intubation, obesity, complex pain problems, a known history of anaesthetic complications or patients with learning disabilities who may require additional resources or theatre time. Local groups such as critical care MDTs or high risk MDTs could facilitate perioperative planning of patients where high risk is identified.81
Where inpatient care is necessary, an enhanced recovery pathway should be followed as this is now considered to provide optimum perioperative care.80,82,83,84,85The preoperative service should ensure that patients are clear about their own responsibilities and expected length of stay to support enhanced recovery pathways.86,87
Consideration should be given to a designated pharmacist being available to provide advice and input into anaesthetic and preoperative assessment. This level of input may range from ad hoc advice through to designated preoperative assessment pharmacists, preferably with prescribing rights, who can undertake medicines reconciliation, produce perioperative medication plans and provide specialist advice.
5. Patient information
All patients (and relatives where relevant) should be fully informed regarding the planned procedure and should be encouraged to be active participants in decisions concerning their care (shared decision making).88,89
The Royal College of Anaesthetists have developed a range of Trusted Information Creator Kitemark accredited patient information resources that can be accessed from our website. Our main leaflets are now translated into more than 20 languages, including Welsh.
All patients undergoing elective procedures should be provided, prior to admission with information on their intended treatment pathway (day surgery or enhanced recovery) that is easy to understand.90 This should include information on the operation, anaesthesia, recovery and postoperative pain relief. Provision of this information should be documented in the patient’s notes.91 The written and verbal information given to patients before their admission to hospital should explain the purpose and nature of their recovery and the recovery department. The Fitter Better Sooner resources published by the Royal College of Anaesthetists and the You and your anaesthetic leaflet, published by the Royal College of Anaesthetists and the Association of Anaesthetists are examples.91,92
The information provided for patients should include information on what will happen to them in the anaesthetic room in the operating theatre and after discharge.93
Information should be provided in a range of formats, including written leaflets or electronic material.94 Details of websites that provide reliable, impartial and evidence based information should be made available to patients when appropriate. Where possible this should include large print, Braille and audio formats. Information should conform to the ‘accessible information’ standard set by the Department of Health for those with disabilities.95
Consultation skills for shared decision making should be used to prepare patients for anaesthesia, surgery and analgesia. Patients should also be informed of the increasing number of decision aids available from NHS Direct to help them with their choices.63,96,97 The use of shared decision making tools such as ‘Benefits, Risks, Alternatives, Nothing’ and ‘Ask 3 questions’ should be considered.98,99
Information should be provided sufficiently far in advance to allow the patient to consider and reflect on this information prior to anaesthesia and surgery.
Patients from non-English speaking groups may require interpreters. Wherever possible, this need should be identified in advance.100 Hospitals should have arrangements in place to provide language support, including interpretation and translation services (including sign language and Braille).95,101,102,103,104 Patients with learning and other difficulties may require special assistance and consideration.
The Mental Capacity Act, Adults with Incapacity (Scotland) Act or the Mental Capacity Act (Northern Ireland) must be complied with.105,106,107 Staff should have regular training in the application of the Mental Capacity Act and have defined access to patient advocates. This is a rapidly changing area, and clinicians should have access to expert advice if required. All NHS trusts are now nationally mandated to have a named safe guarding lead for adults and this individual should be used as appropriate.108
Some patients, both adults and children, may need parents or other members of their family to be with them. This need is best determined at the preassessment clinic visit, so that sensitivities can be taken into account in the operative process.38
All practitioners must follow the practices outlined in the GMC Decision making and consent guidance. Documentation of the risks discussed or the dialogue leading to a decision is required in accordance with paragraphs 50–55.64 Equally, completion of a consent form is not a substitute for a meaningful dialogue tailored to the individual patient’s needs.
Ideally, as part of shared decision making, consent for surgical and anaesthetic procedures should be obtained prior to the day of surgery (see recommendation 4.3), allowing sufficient time for the patient to reflect on their consent discussion.64 The competent patient has a fundamental right, under common law, to give, or to withhold, consent to examination, investigation and treatment.63,64,93
The patient must be made aware of alternative treatment options, or the option for no treatment at all. It is acceptable to recommend one of the alternatives but as the GMC states ‘The doctor may recommend a particular option which they believe to be best for the patient, but may not put any pressure onto the patient to accept their advice’.64,109
No other person can consent to treatment on behalf of any adult. If a health and welfare lasting power of attorney directive is in place, the attorney may be able to assent to treatment on behalf of the patient. There should be a local process and policy in place for patients who lack capacity that conforms to national guidance and the Mental Capacity Act, the Adults with Incapacity (Scotland) Act or the Mental Capacity Act (Northern Ireland).93,105,106,107
6. Staffing requirements for the day of procedure
The outcomes for patients undergoing elective surgery are largely dependent on the complexity of the procedure and the associated optimisation of the patient’s comorbidities of the patient. Nevertheless, appropriate staffing to match the skill mix to the case mix is crucial.
Perioperative time should be allocated for the work the anaesthetist undertakes on the day of procedure for both pre and postoperative care. The time required for pre and postoperative care will vary and should be accounted for in individual job plans.
Anaesthesia departments should have a nominated anaesthetist immediately available (see Glossary) and free from direct clinical responsibilities to provide cover in clinical emergencies, as well as providing advice and support to other anaesthetists.40
The RCoA and Association of Anaesthetists currently do not support enhanced roles for AAs until the statutory regulation for AAs is in place. Where such role enhancement exists or is proposed, responsibility should be defined by local governance arrangements.112
AAs should always work within an anaesthesia team led by a consultant anaesthetist who has overall responsibility for the anaesthesia care provided for the patient and whose name should be recorded in the individual patient’s medical notes.112
The supervising consultant anaesthetist should be easily contactable and should be available to attend within minutes of being requested by the AAs.112
The supervising consultant anaesthetist should not be responsible for more than two anaesthetised patients simultaneously, where one involves supervision of an AA.112
Clinical governance of AAs should follow the same principles as that applied to medically qualified staff. This should include training that is appropriately focused and resourced, supervision and support in keeping with practitioners’ needs and practice responsibilities, and practice centred audit and review processes. AAs should always work within the remit and the educational curriculum of their training programme.
There should be a dedicated trained assistant (i.e. an ODP, anaesthetic nurse or equivalent) who holds a valid registration with the appropriate regulatory body, immediately available in every location in which anaesthesia care is being delivered, whether this is by an anaesthetist or an AA.40,112
Staff assigned to the role of anaesthetic assistant should not have any other duties that would prevent them from providing dedicated assistance to the anaesthetist during anaesthesia.40
7. Equipment, services and facilities on the day of procedure
Equipment and monitoring
The following anaesthetic equipment is required for the safe delivery of anaesthesia, and should be immediately available at all sites where patients receive anaesthetic intervention:
- oxygen supply including an emergency back up supply
- self-inflating bag
- suction equipment
- airways (nasopharyngeal and oropharyngeal)
- laryngoscopes, including at least one type of video laryngoscope
- intubation aids (bougies, forceps, etc.)
- supraglottic airways
- appropriate range of tracheal tubes and connectors
- heat and moisture exchange filters
- trolley/bed/operating table that can be rapidly tilted head down
- method of delivering anaesthesia using volatile anaesthetic agents or infusions (including target controlled infusion algorithms).
Anaesthetic machines should never be able to supply a hypoxic gas mixture.115
The recommended standards of monitoring, by instrument or otherwise, should be met for every patient.114 All monitors should be fitted with audible alarms, with preset but adjustable limits.114,116 The following equipment should be available at all sites where anaesthesia is administered:114
- oxygen analyser
- device to display airway pressure whenever positive pressure ventilation is used, with alarms that warn if the airway pressure is too high or too low
- vapour analyser whenever a volatile anaesthetic agent is in use
- pulse oximeter
- non-invasive blood pressure monitor
- a means of measuring the patient’s body temperature
- a nerve stimulator when neuromuscular blocking drugs are used.
All anaesthetic equipment should be checked prior to use in accordance with the Association of Anaesthetists’ published guidelines.117 Anaesthetic machine checks should be recorded in a log and on each patient’s anaesthetic chart.
The following equipment is required for the safe delivery of anaesthesia and should be available at all sites where patients are anaesthetised in sufficient quantities for the case mix and workload:
- defibrillators and equipment for external cardiac pacing118
- positioning equipment (stirrups for lithotomy, arm boards, head rest for prone positions, bariatric supports etc.)119
- ultrasound imaging equipment for vascular access and regional anaesthesia
- equipment required for the administration of a volatile-free anaesthetic, including infusion pumps, volatile-free anaesthetic machine and/or activated charcoal filters
- adequate numbers and types of infusion pumps and syringe drivers available for high risk medicines120
- at least one readily available portable storage unit with specialised equipment for the management of patients with a difficult airway in every theatre suite including video laryngoscopes and fibre-optic scopes121,122,123
- active patient warming devices124,125
- fluid warming devices, allowing the transfusion of body temperature blood products and intravenous fluids of body temperature126,127
- rapid infusion device for the management of major haemorrhage
- regional anaesthesia equipment, including ultrasound and regional anaesthesia nerve stimulators.
A named anaesthetist with time assigned in their job plan should oversee the provision and management of anaesthetic equipment.129
All anaesthetists, AAs and anaesthetic assistants should receive systematic training in the use of new equipment. This should be clearly documented.129 Anaesthetists should not use equipment unless they have been trained to use it and are competent to do so. The NHS Clinical Negligence Scheme for trusts and Healthcare Improvement Scotland require that hospitals ensure all personnel are trained to use and to check relevant equipment. This may take place at induction for new staff or at the introduction of new equipment. A record of training should be kept. The use of routine checks and associated checklists is an important part of training in anaesthesia and is part of the RCoA’s competency-based training.
User manuals should be available as required for anaesthetic equipment.129
As a minimum, services should be available for:
- blood transfusion
- radiological investigations
- clinical pathology
Near patient testing for blood sugar measurements should be readily available for theatres.
Near patient testing for haemoglobin, blood gases, lactate, ketones and coagulation measurements should be considered, particularly in areas where major blood loss is likely.131 If near patient testing is not available, laboratory testing should be readily and promptly available.
Real time alerts and recommendations (e.g. patient allergy or drug interactions) could be made available using electronic information systems.135
The separation of clinical and non clinical recyclable waste should be considered.138
Up to 80% of patients having elective surgery (see Glossary) will be admitted through a day surgery unit. Provision of day surgery is detailed in GPAS chapter 6: Guidelines for the Provision of Day Surgery. All other patients should be admitted to a ward, admissions unit or similar facility with sufficient time before the operating list on which they are scheduled.
If used, the day of surgery admissions (DOSA) unit should ideally be located close to theatres to allow for efficient list management.
There should be a staffed reception desk or automated registration system to ensure the patient’s attendance is registered as they arrive in the DOSA unit, as well as sufficient seating for the patients throughout their stay.
There should be sufficient consulting rooms or privacy on the DOSA unit for preoperative checks or assessment by nursing, anaesthetic and surgical staff, including a secure environment to enable access to patients’ physical or electronic notes.
There should be equipment and facilities for basic day of surgery physiological monitoring checks, and near patient testing / laboratory blood tests as required for the patient case mix and surgery.
There should be sufficient space and changing rooms including toilets to allow for maintenance of patient dignity in the immediate period pre procedure. Suitable storage of personal effects including the patient’s own medication (e.g. secure storage lockers) should be available during transition through the perioperative pathway. Consideration should be given to providing an opportunity for basic entertainment while waiting for example wi-fi and / or televisions. Furniture should be appropriate to the patient population (e.g. for patients with obesity and those who are frail or older) to allow for their comfort and dignity.
The operating theatre, and anaesthetic room where used, should conform to Department of Health building standards and be appropriately maintained.111
There should be provision of an emergency call system, including an audible alarm.111 A visible indication of the location of the emergency should also be considered.
The geographical arrangement of theatres, emergency departments, critical care units, coronary care, interventional radiology and imaging facilities should allow for the rapid transfer of critically ill patients.111
Anaesthetic sites must have scavenging systems that meet the Health and Safety Executive’s occupational exposure standards for anaesthetic agents.139
Appropriate blood storage facilities should be in close proximity to the operating theatre and should be clearly identifiable.111
Transport and distribution of blood and blood components at all stages of the transfusion chain must be kept under conditions that maintain the integrity of the product.140
Facilities to allow access to online information, such as electronic patient records, local guidelines and clinical decision aids in the theatre suite should be considered.141
Access to theatres and associated clinical areas should be appropriately restricted.111
All drugs required for safe delivery of anaesthesia including emergency drugs, should be available. Some drugs such as dantrolene or intralipid may be held centrally rather than immediately to hand.
Robust systems should be in place to ensure reliable medicines management, including accurate medication history taking and documentation on admission, medication storage facilities, stock review and management, supply, expiry checks, and access to appropriately trained pharmacy staff to manage any medicine shortages.148
All medication containing infusions and syringes should be clearly labelled and ideally colour coded in accordance with the anaesthesia recommended scheme.154
8. Organisation on the day of procedure
Following admission and prior to undergoing a procedure that requires general or regional anaesthesia, all patients should have a preoperative visit by an anaesthetist, ideally a person directly involved with the administration of the anaesthetic.41 This should be done to confirm earlier findings or, in the case of emergency admission, initiate preoperative anaesthetic assessment and care.
If the patient has not been seen in a preoperative clinic, (e.g. those admitted for urgent surgery), they should undergo an equivalent assessment and preparation process with the findings documented before their final anaesthetic assessment. Most patients for expedited urgent surgery should have the same assessment and preparation as for elective surgery.
Up to date, clear and complete information about operating lists should be available to the admissions area, theatre and recovery area. Operating lists should be made available to the anaesthetist before the list starts.
The language in all communications relating to the scheduling and listing of procedures should be unambiguous. Operating lists should include details of the patient’s operation, date of birth, hospital identification number, any alerts and the ward in which they are located. Laterality should always be written in full (i.e. ‘left’ or ‘right’).155
The whole operating team should agree to any change to a published operating list. This list should be rewritten or reprinted, including a date and time of the update and should be clearly identifiable as a changed list.155 Following a change in the theatre list, a further team brief should take place and the admissions area and recovery units should be informed.
Written guidelines should outline the policy for the collection of patients from the ward or admissions unit, as well as the handover by ward staff to a designated member of the operating department staff.156
The theatre team should all engage in the use of the WHO surgical safety process, including the ‘Five Steps to Safe Surgery’ commencing with a team brief, and concluding the list with a team debrief.4,155 Debrief should highlight things done well and also identify areas requiring improvement.157 Teams should consider including the declaration of emergency call procedures specific to the location as part of the team brief.4,111,158
In exceptional circumstances, an anaesthetist working singlehandedly may be called to briefly assist with or perform a lifesaving procedure nearby. This is a matter for individual judgement and a dedicated ODP or anaesthetic nurse should be present to monitor the patient in these exceptional circumstances.114 This should be for as short a period as possible and the person left to monitor the patient should be aware of how to call for further help.
The following policies should be immediately and reliably available at sites where anaesthesia and sedation are provided:
- guidelines for the checking of anaesthetic machines117
- guidelines for the management of anaesthetic emergencies, including anaphylaxis,53,159,160malignant hyperpyrexia and major haemorrhage
- periarrest and cardiac arrest algorithms161
- difficult airway management, including the ‘can’t ventilate, can’t oxygenate’ scenario.123
The following policies should be held and easily accessible for:
- WHO checklist, including time out4
- ‘Stop Before You Block’162
- ‘Do not attempt cardiopulmonary resuscitation’
- death in the operating theatre21
- major incident
- infection control (including antibiotic prophylaxis, staff protection and post exposure prophylaxis)136
- prevention of hypothermia124
- major haemorrhage163
- blood and blood products administration164,165,166
- handover and continuity of clinical care8
- medicines management
- local anaesthetic toxicity
- perioperative care for breastfeeding mothers.
9. Staffing requirements for the period early after the procedure
Emergence from general anaesthesia is potentially hazardous, with patients requiring close observation until recovery is complete.40 The responsibility of anaesthetists for the care of their patients extends into the postoperative period until their discharge from recovery or handover of care to another clinician. Appropriately staffed and equipped recovery facilities should be available during whatever hours of the day elective and emergency procedures are undertaken.40
On occasions, patients may be handed over to the recovery practitioner with a supraglottic airway device in place. The person taking over direct clinical care of such a patient should be specifically trained in the management and safe removal of the airway device.121
If a patient is transferred to the recovery unit with a tracheal tube in situ, the anaesthetist remains responsible for the removal of the tube but may delegate its removal. Delegation should be to an appropriately trained member of staff who is prepared to accept this delegated responsibility.167
An anaesthetist should have overall responsibility for the transport of patients from theatre to the recovery unit.169
The patients anaesthetist should retain overall responsibility for the patient during the recovery period and should be readily available for consultation until the patient is able to maintain their own airway, has regained respiratory and cardiovascular stability and is able to communicate, unless this care has been handed over to another named anaesthetist. Where the patient’s anaesthetist is not the named consultant for that patient (e.g. out of hours, when the consultant is non-resident or distantly supervising a trainee), the consultant should be immediately contactable for advice and guidance at all times, but the resident anaesthetist maintains immediate responsibility for postoperative care of the patient.
The care of an individual patient should be delivered on a one to one basis until the patient is able to maintain their own airway, has respiratory and cardiovascular stability and is able to communicate appropriately. All recovery units should be staffed to a level that allows this to be routine practice and the recovery staff should not have any other duties during this time.169,172,173
A minimum of two members of staff should be present (of whom at least one should be a registered practitioner) when there is a patient in the recovery unit who does not fulfil the criteria for discharge to the ward. If this level of staffing cannot be assured, an anaesthetist should stay with the patient until satisfied that the patient fulfils discharge criteria.172
Adequate provision within job plans should be made for a member of the anaesthetic team to visit the following groups of patients within 24 hours following their operation:
- those graded as American Society of Anesthesiologists (ASA) physical status 3, 4 or 5
- those receiving epidural analgesia on a general ward
- those discharged from the recovery unit with cardiovascular invasive monitoring in situ
- those for whom a request is made by other medical, nursing or other clinical colleagues
- those for whom there is any other appropriate need.
10. Equipment, services and facilities for the period early after the procedure
All patients who have received an anaesthetic affecting central nervous system function and/or a loss of protective reflexes should remain where anesthetised until recovered or be transported safely (with care and monitoring as indicated below) to a specifically designated recovery location for post-anaesthesia recovery.169
The size, design and facilities of the recovery unit must meet the Department of Health and Social Care guidelines.177
The bed spaces should allow unobstructed access for trolleys, x-ray equipment, resuscitation trolleys and clinical staff. The facility should be open plan, allowing each recovery bay to be observed but with the provision of curtains for patient privacy.172
Oxygen and suction should be present in every recovery bay and ideally delivered by pipeline.172
An emergency audible and visible call system should be in place, checked regularly to maintain functionality and understood by all staff.178
An individualised post-anaesthesia care plan should be documented for each patient.179
Careful records, including instructions, patient observations and drug administration, should be maintained (increasingly in an electronic form) and staff should be able to interpret the information and initiate appropriate action where necessary.
Patient information should be continuously recorded and updated (in electronic or written format). Anaesthetic Information Management Systems, a specialised form of electronic health record, should be considered as electronic patient charts in the perioperative and recovery period as they provide a more accurate and complete reflection of the patient’s perioperative physiological parameters.180
A brief interruption of monitoring during transfer of the patient from theatre is only acceptable if the recovery area is immediately adjacent to the operating theatre. Otherwise, monitoring should be continued during transfer to the same degree as any other intra or inter-hospital transfer.114,183
Supplementary oxygen should be available for the transport of patients after general anaesthesia.121
Airway adjuncts should be available in the post-anaesthesia care unit (PACU) to minimise the incidence of upper airway obstruction that may lead to post obstructive pulmonary oedema and severe hypoxaemia.121
If a patient has known visual or hearing impairment or wears dentures, then their corrective lenses/hearing aid/dentures should be readily accessible and available postoperatively.184
11. Service organisation and administration early after the procedure
There should be a named lead consultant for the PACU (see Glossary).172
Processes for the communication and implementation of patient safety alerts should be in place.
All institutions should have protocols and the necessary facilities for managing postoperative care and should review and update these regularly.179
The following protocols should be held and easily accessible for:
- management of postoperative nausea and vomiting
- pain relief for patients with chronic pain185
- blood transfusion
- fluid therapy
- acute coronary syndrome
- respiratory diseases
- monitoring following central and peripheral neuraxial blockade187
- escalation to higher levels of postoperative care (e.g. to a critical care unit) should the patient develop perioperative complications.
Patients should be transferred to the ward, the postoperative care environment or the critical care unit accompanied by two members of staff, at least one of whom should be suitably trained to locally agreed standards.188 The anaesthetic record, recovery and prescription charts together with the postoperative plan, should accompany the patient and be clearly communicated to the receiving ward nurse.
Handover, including on moving to the postoperative care environment or to the ICU, should always be to a member of staff who is competent to care for the patient at that time, and this should be clearly documented.189
If responsibility for care is transferred from one anaesthetist to another, a ‘handover protocol’ should be followed, during which all relevant information concerning the patient’s medical history, medical condition, anaesthetic status, and plan should be communicated.169
There should be an established policy to ensure clear communication of continuing requirements at discharge (e.g. analgesia) to include communication with primary care. This should include written information about common concerns (restarting medication, driving, etc.) and how to contact the hospital when required post discharge. Surgical teams will ordinarily be responsible for most of this process.
12. Areas of special requirement
Most paediatric anaesthesia is for minor surgery in otherwise fit and healthy children. A large proportion of this work is performed in non-specialist hospitals. There are however, a minority of paediatric patients who have significant comorbidities with perioperative care predominantly delivered at tertiary paediatric centres. Anaesthesia may also be required for non-surgical procedures such as radiological investigations. In an emergency situation, anaesthetists will often be part of the multidisciplinary team responsible for the initial resuscitation and stabilisation of the critically ill or injured child prior to transfer to a specialist centre.
Detailed recommendations for children’s services are comprehensively described in GPAS chapter 10: Guidelines for the Provision of Paediatric Services.38
The particular needs of children should be considered at all stages of perioperative care. Children should receive an appropriate preassessment from staff with appropriate paediatric experience.194
The child should be helped to understand events that are happening or will happen, with the use of age-specific and developmentally appropriate explanation and materials.195,196 There are specific issues around consent for children that need to be understood, including the particular requirements for children who are not under the care of their parents.197
A parent or legal guardian should ideally be with the child up to the point of moving into the operating theatre.198
Consideration should be given to appropriate strategies for recognising and managing anxiety of children particularly at induction e.g. play specialists, counselling, psychological support and anaesthetic training around managing preoperative anxiety.
Anaesthesia for children should be undertaken or supervised by anaesthetists who have undergone appropriate training. In the UK, all anaesthetists with a Certificate of Completion of Training (CCT) or equivalent will have completed higher paediatric anaesthetic training or equivalent.199 There will be anaesthetists who have acquired more advanced competencies, thus allowing provision of a more extensive anaesthetic service, and those competencies should be maintained. Unless there is no requirement to anaesthetise children, it is expected that competence and confidence to anaesthetise children will need to be sustained through locally organised clinical experience, continuing professional development and/or refresher courses, and should be considered within annual appraisal and revalidation.
Each hospital should have a written definition of age thresholds and the types of procedure for elective and emergency work, including imaging, which can be provided locally. Children undergoing complex surgical procedures or with significant comorbidity should be discussed with the carers and referred to a tertiary centre if the local infrastructure cannot meet their needs.200,201
Children should be separated from and not managed directly alongside adults throughout the patient pathway, including in waiting rooms, preassessment clinic rooms and theatre areas, including anaesthetic and recovery areas, as far as possible.202 These areas should be child-friendly and should be staffed by suitably trained and qualified practitioners within recovery.188
Preoperative fasting should be minimised as much as possible, especially for infants and younger children.203
There should be a policy in place for pregnancy testing for young female patients under the age of 16 years. This policy should adhere to Royal College of Paediatrics and Child Health guidance.205
Where designated separate areas for children are not available, discrete segregated areas in the pre and postoperative pathways should be available. They should be made as child friendly as possible.111
Children should never be left unattended in the recovery area.207
Children have an increased incidence of postoperative delirium. Recovery staff should have an increased awareness and there should be local protocols for the management of this condition.196
Children with learning disabilities should ideally be recovered in an area with lower levels of noise and lighting and a familiar presence, such as a parent or their carer.196
The presence of learning disability practitioners in recovery when a patient with learning disability is being recovered should be considered.196
All staff working in paediatric recovery should be trained and competent in protocols, and should be familiar with the relevant procedures and personnel if there are safeguarding or child protection concerns that arise while the child is in theatre.204
There should be a minimum of one member of the recovery staff, or an anaesthetist with advanced training in paediatric life support on duty. All members of recovery staff should have up-to-date paediatric competencies including resuscitation.188
Paediatric equipment to cover all ages should be available in recovery, including a full range of sizes of facemasks, breathing systems, airway adjuncts and tracheal tubes. Essential monitoring equipment includes a full range of paediatric non-invasive blood pressure cuffs and small pulse oximeter probes. Capnography should also be available.188
Parents and children should be appropriately educated and equipped with information to address common issues they may face postoperatively, in recovery and on discharge. This information should include leaflets for common procedures highlighting risks and these should be developed locally with support from area networks.208
Guidelines and commonly used algorithms for paediatric emergencies should be readily available and regularly rehearsed.188
Guidelines for fluid management specific to children, and equipment for accurate fluid delivery, should be available.209
Non-peripartum pregnant women and breastfeeding mothers
Anaesthetic services for the peripartum period are covered in GPAS chapter 9: Guidelines for the Provision of Anaesthesia Services for an Obstetric Population.212
A policy should be in place for the management of non-peripartum pregnant women. This should detail the involvement of the multidisciplinary obstetric team, including midwives, neonatologists and obstetricians, depending on gestational stage.213
A policy should be in place for the perioperative care of breastfeeding mothers. This should include guidance to staff on the requirements to facilitate breastfeeding, anaesthesia protocols for breastfeeding mothers, outline supportive measures and provide clear instructions for the patient pre and post anaesthesia or sedation.214
Frail and older patients
With the change in population demographics, a larger number of elderly patients will require operative procedures. Older patients have a decreased physiological reserve, cognitive decline, a higher incidence of multi-morbidity (defined as two or more comorbidities), polypharmacy, and frailty, all of which adds to the complexity of decision making and medical management.215 Poor cognition, hearing and eyesight may make communication difficult. Older patients are at a higher risk of mortality and morbidity after elective and emergency surgery.216,217,218,219 Poor physiological reserve is not limited to the elderly, so frailty pathways and policies should also take into account younger patients with frailty.
Preoperative assessment, optimisation and shared decision making in patients with multiple comorbidities, frailty or cognitive impairment require a cross specialty approach involving anaesthetists, surgeons, geriatricians, pharmacists and allied health professionals. Liaison with a clinical pharmacist in the perioperative period will enable optimisation of medicines and improved management of the patients’ non-surgical comorbidities during this time. The development of such teams requires time and resources. These should be recognised and provided.52,220,223,224,225
Care of the frail and older surgical patient starts at the contemplation of surgery and continues through the hospital stay and beyond. Models of care for frail and older patients should include multidisciplinary management between surgical teams, physicians with expertise in the assessment and management of frailty/delirium and allied health professionals providing consistent hands-on medical care, direction of rehabilitation goal setting and discharge planning until discharge at which point signposting to community services will occur.226
Models of care could include comprehensive geriatric assessment which may have potential to improve outcomes.227
Older patients should have access to a consultant experienced in the management of the older surgical patient to support shared decision making, patient optimisation and perioperative care. Opportunities for joint geriatric and surgical clinical governance should be considered as this model of care is superior to that delivered without this expert support. 218,231,232
The risk of postoperative functional decline and complex discharge related issues should be considered. Procedures should be in place to identify complex patients at pre-assessment and complex discharge planning should begin then. This will require a multi-disciplinary team approach. Guidelines should be developed for the prevention, recognition and management of common postoperative geriatric complications and/or syndromes, including delirium, falls, functional decline and pressure area care.
Mechanisms for the early recognition of patients requiring specialist postoperative input from geriatrician led services and/or critical care should be developed. These should include patients at risk of or presenting with delirium, multiple medical complications, functional decline or those requiring complex discharge planning.
There is a high prevalence of recognised and unrecognised cognitive impairment amongst older surgical patients. This has implications for shared decision making, the consent process and perioperative management. Older patients should have preoperative cognitive assessment using established screening or diagnostic tools.233
Each department of anaesthesia should have a lead anaesthetist for patients with cognitive impairment with sufficient time identified for the role in their job plan.233
There should be established liaison with social services for patients who need such support to prevent delay in discharge.
Obesity is an increasingly significant health issue in the UK. In 2017, 64% of the adult population were overweight or obese, with 29% of the population being classed as obese and 4% morbidly obese (20% of year six children were classed as obese).241
Medical records should include the patient’s weight and body mass index (BMI).242
Ideally, patients with morbid obesity should undergo preassessment by a senior anaesthetist.242
Advanced warning of elective patients with morbid obesity should be given to the appropriate ward/ theatre environment by the preoperative assessment team. Additional specialised equipment is necessary and should be available for every patient with morbid obesity at all stages of the perioperative pathway.242
Patients undergoing bariatric surgery should be considered for level 2 or 3 critical care postoperatively.22
Patient dignity should be maintained preoperatively by ensuring appropriate theatre clothing is available in the day case suite or admissions area.
The safe movement and positioning of patients with obesity may require additional staff and specialised equipment.243,244 An operating table, hoists, beds, positioning aids (including for induction of anaesthesia) and transfer equipment appropriate for the care of patients with obesity should be available in appropriate quantities for the caseload, and staff should be trained in its use.242,245 Additional members of staff should be available where necessary, and manual handling should be minimised where possible.
In view of the increased technical and clinical risks posed by patient with morbid obesity, senior anaesthetic and surgical staff should manage these patients.246
In the postoperative period, the safety of patients with obesity may be improved by the use of supplemental oxygen, non-invasive ventilation (continuous positive airway pressure), monitoring of sedation, and ideally continuous pulse oximetry.247
Patients with obstructive sleep apnoea have a higher incidence of postoperative complications including hypoxia, renal failure, unplanned critical care stay, and delayed discharge. Therefore, consideration should be given to monitoring such patients in a critical care environment postoperatively.248
Critically ill patients
This guideline relates only to critically ill patients undergoing procedures in the operating theatre. General provision of critical care is outside the scope of this document. Further information, including definitions of levels of intensive care can be found in the Faculty of Intensive Care Medicine and Intensive Care Society publication, ‘Guidelines for the Provision of Intensive Care Services.
Some patients may require a higher level of care postoperatively. The Faculty of Intensive Care Medicine and the Intensive Care Society have produced guidelines for the planning and delivery of UK Intensive Care Services. Although critical care is largely outside the scope of GPAS, the following recommendations are highly relevant to immediate postoperative patient management.
Critically ill patients should only be held in the recovery area because of a lack of availability of appropriate facilities elsewhere if recovery staff are appropriately trained, and the recovery unit is appropriately equipped to enable monitoring and treatment to the standard of a level 3 intensive care unit (ICU). In some circumstances, such as a viral pandemic or a major incident involving mass casualties, this may not be possible because of a huge surge in demand. This situation should be seen as exceptional rather than the accepted norm. Non-critical transfer to another hospital should be considered where necessary. It cannot be assumed that it is safe to use the recovery facility as an extension of ICU, and local policies and procedures should govern this issue.250
Where postoperative care is delivered outside of a main ICU (e.g. a level 2 high dependency unit (HDU) or specifically developed PACU), nurse-led, protocol driven care of frequently occurring problems for high risk surgical patients (such as pain, fluid imbalance, nutrition and mild cardiorespiratory compromise) can ensure good patient outcomes.250 Protocols and policies should be agreed between nursing staff, critical care, surgeons and anaesthetists.
Where the postoperative destination is not a main ICU (e.g. a level 2 HDU or specifically developed PACU), the patient should remain in PACU until they are stable and are no longer likely to require immediate support from an anaesthetist. This is of particular importance when transferring patients from recovery to level 2 critical care units that are not staffed by doctors skilled in airway management.
All hospitals should have a clear policy describing the safe triage of surgical patients considered to require postoperative critical care, with guidance on which patients should be admitted immediately to ICU, and which can wait in a standard recovery area for a short period while an ICU bed becomes available. Staff in critical care and recovery units should develop procedures to ensure safe and effective patient care during this transition. While the patient remains in the recovery unit, their care should be the primary responsibility of the staff and doctors working in that location.
Hospitals should have written policies on the management of surgery that is sufficiently urgent that it proceeds when postoperative critical care is desirable but not available; this situation should be considered exceptional.
Diabetes affects 10–15% of the surgical population, and patients with diabetes undergoing surgery have greater complication rates, mortality rates and length of hospital stay. Modern management of the surgical patient with diabetes focuses on:34,252,253,254
- thorough preoperative assessment and optimisation of the patient’s diabetes by a multiprofessional team in line with national guidance253
- deciding whether diabetes can be managed by simple manipulation of pre-existing treatment during a short starvation period (maximum of one missed meal) rather than use of a variable rate intravenous insulin infusion
- optimising the patient to be able to be treated as a day case wherever procedure allows
- safe use of a variable rate insulin infusion when this is the only option.34,250,251,252
Preoperative assessment, optimisation, manipulation of patients’ normal drugs and shared decision making in patients with diabetes requires a cross-specialty approach based on national guidance involving anaesthetists, surgeons, diabetes physicians, diabetes inpatient specialist nurses and pharmacists. The development of such teams requires time and resources. This should be recognised and provided.253,254
Patients with diabetes are at increased risk of adverse postoperative outcomes. Pathways of care providing proactive preoperative interventions to promote day of surgery admission and day surgery should be developed.253
Patients with diabetes are at increased risk of concurrent morbidity. These conditions should be identified and optimised where and when possible.253
Patients with diabetes are at increased risk of drug errors and medication interactions. Pathways should ensure medication reconciliation is performed, as this is vital to these at risk patients. 253 Insulin errors including overdoses occurring due to abbreviations or use of incorrect devices are classed as a never event by NHS Improvements.255,256
Consideration should be given to scheduling patients with diabetes at the start of the operating list, to minimise disruption to the patient’s glycaemic control.
Hospitals should consider appointing a lead anaesthetist for diabetes with appropriate time for the role identified in their job plan.254
Hospitals should have clinical guidelines, including:34
involving patients in the management of their own diabetes
- ensuring that surgical patients with diabetes have an individualised explicit plan for the management their diabetes during periods of starvation and surgical stress; this may require the involvement of senior anaesthetic staff and the availability of equipment to continue or institute variable rate intravenous insulin infusions
- ensuring the prevention, and prompt recognition and treatment of hypo and hyperglycaemia, and hospital-acquired diabetic ketoacidosis
- surgical patient with diabetes have an increased risk of pressure ulcers and policies should be in place to prevent them.
Patients with additional needs
In patients with learning disabilities or special needs, there should be close co-operation with other specialists. A learning disability liaison nurse could be available to support patients and carers while attending the hospital either for outpatients, day surgery or as inpatients. If patients lack capacity and are unaccompanied, then the involvement of an independent mental capacity advocate (IMCA) should be sought.257
Departments should have a policy on how to care for patients with additional needs including those covered under the Equality Act, and consider appointing an assigned lead anaesthetist with time in their job plan for the role.258,259 The policy should incorporate preassessment, deprivation of liberty assessment, consent, pathways to minimise anxiety and considerations for analgesia and discharge planning.
Some patients who are unable to leave their homes and have difficulty in accessing primary or secondary care may benefit from a home visit for their preoperative assessment and preparation. The same may apply to prisoners detained in HM Prison Service.
Translators or interpreters should be available for patients who do not speak or understand English and those who use sign language. Written information also needs to be available in different languages.
13. Training and education
The RCoA has established essential knowledge, skills, attitudes and workplace objectives needed in the training to attain a CCT in anaesthesia. This is outlined in the RCoA CCT Curriculum, which was updated in 2020.260
Training of anaesthetists includes attaining the competency to perform medical assessment of patients prior to anaesthesia and surgery or other procedures.260
The preoperative assessment service should enable multidisciplinary training for medical students, nurses, specialist doctors in training, allied health professionals, pharmacists and pharmacy technicians. Educational materials are available to facilitate this training.86 Schools of anaesthesia should give consideration to establishing specific modules in preoperative assessment and perioperative medicine for senior trainees.
Preoperative and perioperative educational resources should be made available to general practitioners and primary care staff who are instrumental in ‘first contact’ patient consultations prior to secondary care referral. This facilitates robust cross-boundary working relationships and agreed ‘fitness for referral’ protocols, while minimising delays in the patient journey.
Departments should support the anaesthetic workforce with adequate provision made for continuing professional development (CPD).
Trusts should commit themselves to provide the time and resources to educate those who provide intraoperative care for patients.155
Theatre teams should undergo regular, multidisciplinary training that promotes teamwork, with a focus on human factors, effective communication and openness.155
All staff should have access to adequate time, funding and facilities to undertake and update training that is relevant to their clinical practice, including annual mandatory training such as basic life support.155
All members of the anaesthetic team should receive non-clinical training and education, which should be reflected in job plans and job planning. This might include a locally arranged list of topics (e.g. fire safety, consent, infection control, blood product administration, mental capacity, safeguarding children and vulnerable adults, communication skills). Some of this training will be mandatory under the legislation for health and safety at work.68,261
All trainees must be appropriately clinically supervised at all times.6
All patients undergoing anaesthesia should be under the overall care of a consultant anaesthetist whose name is recorded as part of the anaesthetic record. A staff grade, specialty and associate specialist (SAS) anaesthetist could be the named anaesthetist with overall responsibility, if local governance arrangements have agreed in advance that, based on the training and experience of the individual doctor and the range and scope of their clinical practice, the SAS anaesthetist can take responsibility for patients themselves in those circumstances, without consultant supervision.262
Departments of anaesthesia should ensure that a named supervisory consultant is available to all non-consultant anaesthetists (except those SAS anaesthetists that local governance arrangements have agreed in advance are able to work in those circumstances without consultant supervision) based on the training and experience of the individual doctor and the range and scope of their clinical practice.262 Where an anaesthetist is supervised by a consultant, they should be aware of their supervisor’s identity, location and how to contact them.263
There should be induction programmes for all new members of staff, including locums. Induction for a locum doctor should include familiarisation with the layout of the hospital and the location of emergency equipment and drugs, access to guidelines and protocols, information on how to summon support/assistance, and assurance that the locum is capable of using the equipment in that hospital. All inductions should be documented.
CPD and the training of other staff should be facilitated by activities such as the establishment of lead practitioners and accounted for within job plans.
Members of clinical staff working within the recovery area should be certified to a standard equivalent to immediate life support providers, and training should be provided.
At all times, an anaesthetist or at least one other advanced life support provider should be immediately available.
For children, a staff member with an advanced paediatric life support qualification or an anaesthetist with paediatric competencies should be immediately available.167
Core competencies should be updated according to local and national guidelines.
Wherever possible, training should be provided in a multidisciplinary format.179
14. Financial considerations
Part of the methodology used for making recommendations in the chapter is a consideration of the financial impact for each of the recommendations. Very few of the literature sources from which these recommendations have been drawn have included financial analysis.
The vast majority of the recommendations are not new recommendations; rather they are a synthesis of already existing recommendations. The current compliance rates with many of the recommendations are unknown, so it is not possible to calculate the financial impact of the recommendations in this chapter being widely accepted into future practice. It is impossible to make an overall assessment of the financial impact of these recommendations with the currently available information.
The current tariffs for some of the complex major surgical procedures, particularly those done in tertiary referral centres, do not reflect the true cost incurred. Under the circumstances, the use of theatre time and theatre efficiency will come under the spotlight to balance the expenses incurred versus the revenue generated.
The use of electronic health records, with their precise documentation of start times, finish times and the ability to differentiate the time taken to set the patient up for surgery compared with the actual duration of the surgical procedure means that intraoperative anaesthetic practice will come under close scrutiny. As the implementation of electronic health records diffuses across the health service it is vital that anaesthetists engage with the design and standardise documentation to ensure that the data collected are valid and can be meaningfully used to generate information contributing to theatre use and efficiency, and in the future to national data sets.
Business planning by hospitals and anaesthetic departments should ensure that the necessary time and resources are directly targeted towards preoperative preparation.68
A well-designed preoperative service should minimise patient delays through the journey to surgery, while allowing appropriate time for initiation of interventions likely to improve patient outcome. By optimising planning of patient care, with the right staff and resources available, cancellations can be reduced and the efficiency of operating lists improved.
15. Research, audit and quality improvement
Anaesthetists should participate in departmental audit and quality improvement projects, using specific, measurable, attainable, relevant and time-bound (SMART) methodology (see Glossary) and consideration of full audit cycles (e.g. plan, do, study, act). This participation should adhere to the standards and principles outlined in the College’s Raising the Standards: RCoA Quality Improvement Compendum.5
There should be a multidisciplinary and cross specialty programme for auditing intraoperative care.
A system for reporting and regular audit of critical incidents and near misses is an essential part of a well-led safety structure, and there should be multiprofessional involvement in this. The methodology must be explicit and identify underlying relevant factors to inform learning and development of safe systems. All staff must recognise the duty of candour and foster a culture for reporting incidents and concerns.6,155,264
Anaesthetists should be involved in audit and quality improvement cycles, preferably using a ‘rapid cycle’ quality improvement approach. This approach benchmarks standards of care and may be an effective change driver. It is also an excellent way of providing evidence of good practice as defined by the GMC, and mapping the contribution that individuals make to any service within their hospitals.266
Regular revision at locally agreed timeframes and audit of standards of care, guidelines and protocols and critical incident reporting are essential in the continuing development and improvement of post-anaesthetic patient care.172
Nurturing a safety culture, learning from mistakes, preventing harm and working as part of a team are all part of the discipline of safety. To this end, shared learning and quality improvement that contribute towards improvements in safety, such as critical incident reporting with thematic analysis, and communication through morbidity and mortality meetings, could be undertaken.
Areas for future development
Following the systematic review of the literature, the following areas for future research are suggested:
- proactive care of older people and high-risk surgery clinics either separate or combined
- shared decision making clinics
- effective and efficient use of virtual consultations in preoperative assessment post COVID-19.
Clinical director – the overall medical manager of the anaesthetic department.
Elective surgery – intervention planned or booked in advance of routine admission to hospital. Timing to suit patient, hospital and staff.230
Expedited surgery – patient requiring early treatment where the condition is not an immediate threat to life, limb or organ survival. Normally within days of decision to operate.230
Immediate emergency surgery – immediate life, limb or organ-saving intervention; resuscitation simultaneous with intervention. Normally within minutes of decision to operate; (A) Lifesaving (B) Other (e.g. limb or organ saving).
Immediately available – unless otherwise defined, ‘immediately available’ means within five minutes.
Lead anaesthetists – members of the department who have taken on additional responsibilities in a specialist area of practice. They should usually have experience in teaching and education relevant to the role and they should participate in Quality Improvement and CPD activities. Individuals should be fully supported by their Clinical Director and be provided with adequate time and resources to allow them to effectively undertake the lead role. SAS doctors undertaking lead roles should be autonomously practising doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues.
Motivational interviewing - uses a guiding style to engage clients, clarify their strengths and aspirations, evoke their own motivations for change and promote autonomy in decision making.
Recovery unit – may also be referred to as post-anaesthetic recovery unit, theatre recovery, recovery or recovery unit. It is an area, normally attached to theatres, designed to provide care for patients recovering from general anaesthesia, regional anaesthesia, or local anaesthesia. In this document the term post anaesthesia care unit (PACU) is only used to refer to a unit that can offer level 1+ or enhanced care as defined by the Faculty of Intensive Care Medicine.
Responsibility – refers to being accountable and ensuring completion of the specified action rather than physically completing the action yourself.
SMART objectives – SMART is an acronym, giving criteria to guide in the setting of objectives standing for specific, measurable, attainable, relevant and time-bound.
Sterile cockpit – distraction-free period during which only essential and urgent tasks are performed.
Urgent surgery – intervention for acute onset or clinical deterioration of potentially life threatening conditions, for those conditions that may threaten the survival of a limb or organ, for fixation of many fractures and for relief of pain or other distressing symptoms. Normally within hours of decision to operate.230