Chapter 2: Guidelines for the Provision of Anaesthesia Services for Preoperative Assessment and Preparation 2019
Preoperative assessment and preparation is a process. It involves primary care, anaesthesia and other specialties. The general practitioner has a major role to play by ensuring that patients are ‘fit for referral’ and by initiating the shared decision-making process. Development of strong links with primary care can facilitate this.
Part of the process is an assessment to check it is safe to proceed with anaesthesia and surgery. It is also about both optimising and preparing the patient for anaesthesia and surgery. The anaesthetist plays a key role in co-ordinating this process with other medical specialties and healthcare professionals.
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, he or she should be as fit as possible for surgery and anaesthesia. Preoperative assessment and preparation allow risks to be clearly identified and mitigated, or managed in a planned and consistent way.
The preoperative clinic and anaesthetist have important roles to play in ensuring that shared decision-making becomes a reality. This is defined as a process in which clinicians and patients work together to select tests, treatments, management or support packages, based on clinical evidence and the patient’s informed preferences. It involves the provision of evidence-based information about options, outcomes and uncertainties, together with decision support counselling and a system for recording and implementing patients’ informed preferences. The individual values of patients and their perspective on how healthcare interacts with their life are key to this.1
1. Staffing requirements
The WHO sign in should take place before induction of anaesthesia.8
Anaesthetists need time to cover the following essential points in the more immediate preoperative phase. The anaesthetic room is not usually an appropriate place for this except in an emergency.
- Interview and medical case notes review to establish current diagnoses, current medicines and past medical and anaesthetic history.7,8
- Examination, including airway assessment.
- Review of results of relevant investigations.
- The presence of any risk factors, including methicillin-resistant Staphylococcus aureus (MRSA) screening and risk of venous thromboembolism.
- The need for further tests to give the patient more information about their individual risk. This information also needs to be disseminated to the anaesthetist involved in the case as well as the extended perioperative team.
- The patient’s understanding of and consent to the procedure and a share in the decision-making process.
- An explanation of the options for anaesthesia, an opportunity to ask questions, and agreement to the anaesthetic technique proposed.
- Preoperative fasting, the proposed pain relief method, expected sequelae, and possible major risks (where appropriate).
- The prescription and ordering of any preoperative medication including carbohydrate drinks.
- A plan for the perioperative management of anticoagulant drugs, diabetic drugs and other current medications.
- A process of medicines reconciliation by a pharmacist or pharmacy technician should be in place preoperatively.
- The documentation of details of any discussion in the anaesthetic record.
- Information that may be reinforced by attendance at communal sessions such as ‘joint school’ for hip and knee surgery at which there may be input from an anaesthetist, orthopaedic surgeon, occupational therapist, physiotherapist, acute pain specialists, pharmacists and ward nurse.
The following time allocation (per week) is a guide to the minimum physician anaesthetist staffing that should be provided per 1,000 inpatients passing through a preoperative preparation clinic:
- reviews and consultations 1 session per 1,000 inpatients per year (1.25 programmed activities) e.g. 3000 patients = 3 sessions
- high risk clinics 1 session per 1000 inpatients (1.25 programmed activities)
- clinical leadership for the service 1 session per 5,000 inpatients (1.25 programmed activities)
Clinical leadership is for audit, research, teaching, protocol development, IT development and primary care liaison. Backfill to cover staff who are on leave and secretarial support should also be provided.10
Local protocols should determine the grade, experience and competency-based training of the nurse undertaking preoperative assessments and accompanying the patient to the operating department.9 For 1,000 patients, the following minimum staffing is required:10
- 0.6 registered nurses
- 0.3 healthcare assistants
This staffing to patient ratio is based on 80% of patients as day cases and 20% as inpatients assuming day case patients have a 30-minute nurse consultation and inpatients have 45 minutes. This is only a guide, as complex patients may be scheduled for minor surgery and fit patients may be scheduled for major surgery.
Perioperative time should be allocated for the work the anaesthetist undertakes on the day of surgery for both preoperative and postoperative care. The times allocated might vary per patient but for most theatre lists, it approximates to one hour per four hours spent in the operating theatre suite or two hours per eight hours in the operating theatre suite.
There must be the ability to provide the patient with the appropriate chaperone, as per GMC guidance on intimate examinations and chaperones.11 When examining a patient, anaesthetists must be sensitive to what the patient may consider as intimate, which could include any examination where it is necessary to touch or even be close to the patient.
2. Equipment, services and facilities
There should be a reception desk and receptionist to meet and greet patients as they arrive in a preoperative preparation clinic. They can ensure the patient’s attendance is registered and that the patient is directed to the appropriate member of staff or to a 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.
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 oximeter and electrocardiography machines.
There should be equipment and facilities for blood tests and urine analysis.
There should be facilities for the storage of patients’ paper notes in a secure environment to enable access to previous anaesthetic records and medical alerts.
Information from the patient’s preoperative assessment should be readily available, ideally as part of an electronic patient record so that information is easy to transfer between locations and to enable data collection for later analysis.12
3. Areas of special requirement
Most paediatric anaesthesia is for minor surgery in previously fit and healthy children. A large proportion of this work is performed in non-specialist hospitals. All anaesthetists with a CCT or equivalent should be competent to provide perioperative care for common surgical conditions in children aged 3 years and above. Anaesthesia may also be required for non-surgical procedures such as magnetic resonance imaging (MRI) or computed tomography (CT) scans. 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.
Recommendations for children’s services, including the preoperative phase of anaesthesia, are comprehensively described in chapter 10.13
The particular needs of children should be considered at all stages of perioperative care. They should ideally attend a preoperative clinic staffed by nurses experienced in preassessing children. Children may benefit from a visit to the locality to which they will be admitted, and familiarisation with the environment and personnel.14 There should be access to play specialists.
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.15,16 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.17
A parent or legal guardian should ideally be with the child up to the point of moving into the operating theatre.
Parents and carers should be enabled to remain as close to their child as possible during the process of anaesthesia and recovery. There should be a space available within close proximity to theatres where they can wait and be contacted.
Where sedative premedication is considered, this should be discussed with parents and carers.
Anaesthesia for children should be undertaken or supervised by senior anaesthetists who have undergone appropriate training. In the UK, all anaesthetists with a CCT or equivalent will have obtained higher paediatric anaesthetic training. 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 direct care, continuing professional development and/or refresher courses, and should be considered within annual appraisal and revalidation.20
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. Complex children, e.g. ASA 3 with significant comorbidity, should be discussed with the carers and referred to a tertiary centre if the local infrastructure cannot meet their needs.21,22
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.19 These areas should be child-friendly.
Children undergoing surgery should be grouped into paediatric lists, or together at the start of mixed lists.22
All clinical staff working with children should have up to date certification in Safeguarding Level 2.
There should be a policy in place for pregnancy testing in the under 16s. This should adhere to Royal College of Paediatrics and Child Health guidance.25
Information on the risks and the common side effects of anaesthesia in children should be discussed and offered in writing to children, parents and guardians.16
Recommendations for obstetric services, including the preoperative phase of anaesthesia, are comprehensively described in chapter 9.13
Preoperative assessment, optimisation and shared decision making in older 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 to support older patients with polypharmacy 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.27,28,29,30
Patients with frailty are at increased risk of adverse postoperative outcome. Older patients undergoing intermediate and high-risk surgery should be assessed for frailty using an established tool or scoring system. Pathways of care providing proactive preoperative interventions for frailty, involving therapy services, social services and geriatricians, should be developed.28,31,32,33 Older patients should have access to a consultant geriatrician. Opportunities for joint geriatric and surgical clinical governance should be considered.32,34
The risk of postoperative functional decline and complex discharge related issues should be considered.
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.
Older patients should be assessed for the risk of developing postoperative delirium. Preoperative interventions should be undertaken to reduce the incidence, severity and duration of postoperative delirium. Hospitals should ensure guidelines are available for the prevention and management of postoperative delirium that are circulated preoperatively to the relevant admitting teams.31
There should be established liaison with social services for patients who need such support to prevent delay in discharge.
Morbidly obese patients
Every hospital should nominate an anaesthetic lead (see glossary) for obesity.35
Experienced anaesthetic and surgical staff should manage obese patients. Ideally, morbidly obese patients should be preassessed by a senior anaesthetist.35
Additional specialised equipment is necessary and should be available for every morbidly obese patient at all stages of the pathway. Advance warning of these elective patients should be given to the appropriate department in the hospital by the preoperative assessment team.35
Patient dignity should be maintained by ensuring appropriate equipment and clothing is available and by staff attitudes to obesity.
Preoperative assessment, optimisation, manipulation of patients’ normal drugs and shared decision-making in patients with diabetes requires a cross specialty approach involving anaesthetists, surgeons, diabetologists and diabetes inpatient specialist nurses. The development of such teams requires time and resources. This should be recognised and provided.38
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.38
Patients with diabetes are at increased risk of concurrent morbidity. These conditions should be identified and optimised where and when possible.38
Patients with diabetes are at increased risk of drug errors and drug interactions. Pathways should ensure drug reconciliation, which is vital to these at risk patients.38
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 unbefriended, then the involvement of an Independent Mental Capacity Advocate (IMCA) should be sought.39
Some patients who are housebound 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.
4. Training and education
The RCoA has established essential knowledge, skills, attitudes and workplace objectives needed in the area of preoperative assessment in training to attain a Certificate of Completion Training (CCT) in anaesthesia. This is outlined in the RCoA CCT Curriculum, which was updated in July 2016.40 Preoperative assessment is a core component of MSc, Postgraduate Certificate and Postgraduate Diploma courses in perioperative medicine. The Preoperative Association has produced competency standards on nursing skills for preoperative assessment.
Training of anaesthetists includes attaining the competency to perform medical assessment of patients before anaesthesia for surgery or other procedures.40
The preoperative assessment service should enable multidisciplinary training for medical students, nurses, specialist doctors in training and allied health professionals. Educational materials are available to facilitate this.41 Training schools should give consideration to establishing specific modules in preoperative assessment for senior trainees.
Preoperative 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, whilst minimising delays in the patient journey.
The anaesthetist should have the skills to hold a competent interview, assess and communicate the chance of benefit and harm, and facilitate shared decision-making.
5. Organisation and administration
Preoperative assessment is an essential component of the surgical pathway and should be afforded suitable time and resource.
Optimum organisation is described in the Preoperative Preparation module of the NHS Institute for Innovation and Improvement’s ‘Productive Operating Theatre’ tool. This toolkit has been designed to help theatre teams to work together more effectively to improve the quality of patient experience, the safety and outcomes of surgical services, the effective use of theatre time and staff experience.42
Organisation of preoperative preparation is essential for enhancing the quality of care in a number of ways:
- if a patient is fully informed, they will be less stressed and may recover more quickly
- a health check is an opportunity to optimise medical health before anaesthesia and surgery
- planning admission and discharge individually ensures that patient and carers know what to expect, facilitating earlier postoperative care at home
- cancellations due to patient ill health or non-attendance are reduced
- admission on the day of surgery and early discharge are more likely
- the waiting list is validated.43
Timing of preoperative assessment
Most patients undergoing elective surgery should attend a preoperative preparation clinic.5,6 Healthy patients having minor day case surgery can in certain circumstances have telephone or electronic based assessments. If this supplies sufficient information it may negate the need to attend a face to face clinic. If this approach is used it is important that staff skilled in preoperative assessment review the preoperative information and determine whether further assessment is required.
In the case of emergency and urgent surgery, assessment should take place as early as possible.41
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.
If the patient has not been seen in a preoperative clinic, for example those admitted for emergency surgery, they should undergo an equivalent assessment and preparation process with the findings documented, before their final anaesthetic assessment. Most expedited emergency surgery patients should be able have the same assessment and preparation as elective surgery patients.
Sufficient anaesthetic sessions should be provided to allow a review of the medical notes or consultations when required between senior anaesthetists and patients at increased risk of mortality and morbidity (>1 in 200 risk of dying within 30 days of surgery). There should also be resources for patients at greatest risk (>1 in 100 risk of dying within 30 days of surgery) to undergo more extensive testing and discussion that will help inform the consent process.
There should be sufficient time before an operation for the anaesthetist to conduct a satisfactory preoperative assessment. If this does not happen, it is possible that surgery may be delayed or postponed. The provision of a good preoperative assessment and preparation process should minimise this.
Following admission and prior to undergoing a procedure that requires general or regional anaesthesia, all patients should have a preoperative visit by an anaesthetist or suitably trained assistant, ideally a person directly involved with the administration of the anaesthetic.5 This should be done to confirm earlier findings or, in the case of the emergency admission, initiate preoperative anaesthetic assessment and care.
Liaison with internal and external colleagues
The secondary care preoperative service should liaise closely with primary care and commissioners to promote a ‘fitness for referral’ process.44
Anaesthetic departments and their preoperative assessment services should engage with local primary care providers to ensure (prior to surgical referral) that the patient has:
- engaged in shared decision-making from the outset
- gone through a ‘fitness for referral’ process, to identify and optimise conditions amenable to treatment, for example:
- diabetes and patients at risk from undiagnosed diabetes
- respiratory disease, e.g. asthma, chronic obstructive pulmonary disease, sleep disordered breathing
- atrial fibrillation
- heart disease
- anaemia (haemoglobin <120g/L), particularly for surgery where significant blood loss is predictable46
- acute or chronic pain
- been given appropriate lifestyle advice and support regarding smoking, alcohol, obesity, malnutrition, recreational drugs or inactivity47,48,49
- been assessed for possible frailty and cognitive impairment with information included at the time of referral – both of these conditions are increasingly recognised as being associated with adverse outcomes following surgery.
General practitioners are well placed to initiate such processes and this has potential benefits in terms of reducing delays and avoidable cancellations as well as longer-term health benefits for patients.
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.
High-risk patients should be discussed in regular specialty multidisciplinary team (MDT) meetings with anaesthetic representation. Such an arrangement facilitates robust team decision-making with regard to patient care while minimising delays in the surgical pathway. Clinical time should be agreed in job plans to reflect this commitment. There should be an anaesthetic MDT led by anaesthetists and including cardiologists, respiratory physicians, surgeons and haematologists to discuss high-risk surgical patients, do quick in house referrals and make plans for presurgery optimisation and postoperative management.50
The output from consultations with patients at increased risk of mortality or morbidity should 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.27
The secondary care clinic should be predominantly led by suitably trained nurses or other extended role practitioners using agreed protocols and with support from an anaesthetist.
There should be a nominated medical and nursing lead for preoperative assessment.
An anaesthetic preoperative assessment service should involve consultant anaesthetists and staff grade, associate specialist and specialty (SAS) doctors.5,6,51 Dedicated anaesthetic presence in the preoperative assessment and preparation clinic is required for:
- the review of results and concerns identified by nursing staff
- consultations with patients identified by a triage process to allow optimal delivery of preoperative assessment resources
- cardiopulmonary exercise testing or other functional assessment of fitness on high-risk patients and a subsequent consultation on the chance of harm or benefit
- the training and support of nursing 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 before surgery
- developing links with clinical commissioning groups
- the establishment of internal protocols for patients such as those with diabetes, obese patients or those on anticoagulant therapy.
Each hospital should have agreed written policies, protocols or guidelines, following national guidelines where these are available, covering:
- the time allocated for the anaesthetist to undertake preoperative care in both outpatient clinic and ward settings. Job plans should recognise an adequate number of programmed activities5,6
- preoperative tests and investigations52,53
- preoperative blood ordering for potential transfusion54
- management of anaemia including parenteral iron therapy to reduce the risk of allogenic blood transfusion55
- management of diabetes and anticoagulant therapy, including newer anticoagulant drugs56,57
- preoperative fasting schedules and the administration of preoperative carbohydrate drinks 5,6,58
- antacid prophylaxis
- latex and chlorhexidine allergies
- escalation of care in the event of perioperative complications to the intensive care unit
- continuation of regular medication
- locally agreed protocol for the administration of thromboprophylactic agents to patients undergoing surgery, including venous thromboembolism risk assessment, for identification of patients at low, moderate and high risk, and a recommended prophylactic method for each group (including timing of administration to patients undergoing regional anaesthesia)56,57
- referral of patients from a nurse-led clinic to medical staff for further review
- pregnancy testing before surgery
- use of the WHO Surgical Safety Checklist10,36
- management of acute pain in complex patients, e.g. opioid-tolerant patients
- perioperative management of pacemakers including implantable cardioverter defibrillators.
Business planning by organisations and anaesthetic departments should ensure that the necessary resources, including enough time, are targeted towards preoperative assessment. This should include administrative support at an appropriate level.
There should be a process in place to identify patients with specific problems such as dementia (with risk of postoperative delirium) and poor nutritional status (with increased risk of morbidity).
Objective assessment of risk should be routine. Identification of higher risk should trigger advanced planning specific to that case. Each hospital should have a system in place to identify high-risk surgical patients who require additional assessment. This should be based on:27
- heart failure
- ischaemic heart disease (myocardial infarction or angina)
- stroke (cerebral vascular event or transient ischaemic attack)
- peripheral arterial disease
- renal impairment
- type of surgery
- aerobic fitness.
High-risk surgical patients should have their predicted 30-day mortality recorded preoperatively. The National Confidential Enquiry into Patient Outcome and Death report on high-risk surgery recommended the assessment and recording of 30-day predicted mortality for high-risk surgery (defined as a greater than 5% risk).63 The national emergency laparotomy audit and the national hip fracture database both recommend the recording of predicted 30-day mortality.64,65 There are validated prediction scores for 30-day mortality after hip fracture, elective abdominal aortic aneurysm surgery and all types of surgery.61, 62, 63 There are also validated prediction scores for longer-term mortality after surgery for hip fracture and elective surgery for abdominal aortic aneurysm.61,62
Predicted 30-day mortality, recorded preoperatively and determined in a high-risk surgery preassessment clinic, could be used to plan postoperative high-dependency care for elective high-risk surgery.70
Co-ordination and communication
Preoperative care requires careful co-ordination and communication with individual surgeons, general practitioners, medical records, outpatient clinics and specialist services such as diabetes. The anaesthetic lead for the preoperative preparation clinic should ensure adequate systems are in place, and be responsible for overseeing the adequacy of these processes.6
Preoperative assessment should take place as early as possible in the patient’s care pathway so that all essential resources and obstacles can be anticipated before the day of the operation, including discharge arrangements.6
As a result of the assessment, the appropriate level of postoperative care can be determined and booked in a day surgery facility, ward, high dependency unit (level 2 care) or critical care unit (level 3 care), enabling both optimum care and efficient planning
Patients should be admitted to a ward or alternative facility with sufficient time before the operating list on which they are scheduled. If an adequate preoperative assessment has been performed, admission can be on the day of surgery but it remains essential that the anaesthetist who will be administering the anaesthetic is able to confirm the findings of the assessment and agree final details with the patient.
Discharge planning should be started 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 social services. This will minimise late cancellation of operations and reduce the length of stay in hospital.71
A preoperative blood ordering schedule should be agreed with the local transfusion service for each procedure and appropriate system in place to facilitate timely provision of blood products.54
Anticipated difficulty with anaesthesia should be brought to the attention of the anaesthetist as early as possible before surgery. This includes planned admission to a critical care unit, the need for special skills, such as those of fibre optic intubation, obesity, complex pain problems or a known history of anaesthetic complications.
Operating lists should be made available to the anaesthetist before the list starts.
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.72
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.72 After a change in the theatre list a further team brief should take place.
Written guidelines should cover 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.
Eighty per cent of patients undergoing elective surgery can expect to follow a day surgery pathway. If inpatient care is necessary, an enhanced recovery pathway is now considered to provide optimum care and the preoperative service should ensure that patients are clear about their own responsibilities and expected length of stay.41
There should be provision for carbohydrate drinks to take preoperatively where appropriate.44
A designated pharmacist should be 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.
6. Financial considerations
Business planning by hospitals and anaesthetic departments should ensure that the necessary time and resources are directly targeted towards preoperative preparation.58
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.73
7. Research, audit and quality improvement
The NHS Modernisation Agency outlined measurable key performance indicators in theatre management and preoperative assessment. These are still applicable.74
Regular audits of the following aspects of preoperative care may include:
- the effectiveness of preoperative information provided to patients
- preoperative documentation of consultation by anaesthetists
- consent to anaesthesia
- the effectiveness of preoperative assessment services
- preoperative visiting (patient waiting time, proportion of one stop visits)
- preoperative airway assessment
- preoperative fasting in adults and children
- appropriate preoperative medication
- choice of technique: general, local or regional anaesthesia
- cancellation on day of surgery due to a failure in the preoperative assessment process.
8. Implementation support
The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, aims to provide support for departments of anaesthesia to implement the recommendations contained in the GPAS chapters. The scheme provides a set of standards, and asks departments of anaesthesia to benchmark themselves against these using a self-assessment form available on the RCoA website. Every standard in ACSA is based on recommendation(s) contained in GPAS. The ACSA standards are reviewed annually and republished approximately four months after GPAS review and republication to ensure that they reflect current GPAS recommendations. ACSA standards include links to the relevant GPAS recommendations so that departments can refer to them while working through their gap analyses.
Departments of anaesthesia can subscribe to the ACSA process on payment of an appropriate fee. Once subscribed, they are provided with a ‘College guide’ (a member of the RCoA working group that oversees the process), or an experienced reviewer to assist them with identifying actions required to meet the standards. Departments must demonstrate adherence to all ‘priority one’ standards listed in the standards document to receive accreditation from the RCoA. This is confirmed during a visit to the department by a group of four ACSA reviewers (two clinical reviewers, a lay reviewer and an administrator), who submit a report back to the ACSA committee.
The ACSA committee has committed to building a ‘good practice library’, which will be used to collect and share documentation such as policies and checklists, as well as case studies of how departments have overcome barriers to implementation of the standards, or have implemented the standards in innovative ways.
One of the outcomes of the ACSA process is to test the standards (and by doing so to test the GPAS recommendations) to ensure that they can be implemented by departments of anaesthesia and to consider any difficulties that may result from implementation. The ACSA committee has committed to measuring and reporting feedback of this type from departments engaging in the scheme back to the CDGs updating the guidance via the GPAS technical team.
9. Patient information
Patients should be fully informed about the planned procedure and participate in a shared decision-making process. Consultation skills for shared-decision making should be used to prepare patients for anaesthesia, surgery and analgesia. The patient should determine the information provided to obtain their consent for treatment. Patients should be informed of the increasing number of decision aids available at NHS Direct to help them with their choices.2,3,76
Information should be provided with enough time for the patient to consider and reflect on before anaesthesia and surgery take place.
Information can be provided in a range of formats, including written leaflets and on the internet. Details of websites that provide reliable, impartial and evidence-based information should be made available to patients when appropriate. Where possible formats should include large print, Braille and audio. Information should conform to the ‘Accessible Information’ standard set by the Department of Health for those with disabilities.77
All patients undergoing elective procedures should be provided with easily understood information materials covering their operation, anaesthesia and postoperative pain relief, before admission to hospital. Provision of this information should be documented in the patient’s notes.78
The anaesthetist should explain what the patient will experience before and after anaesthesia, and include any choices of anaesthetic technique and details of postoperative management.
The anaesthetist should invite and answer questions from the patient or, if appropriate, the patient’s relatives.
The anaesthetist should document in the patient’s case notes that all of the above have been properly performed.
The competent patient has a fundamental right, under common law, to give, or to withhold, consent to examination, investigation and treatment.79
No other person can consent to treatment on behalf of any adult. If a lasting power of attorney 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.79
The scope of the authority that has been given by a patient should not be exceeded except in an emergency. In an emergency clinical situation in which it is not possible to determine a patient’s wishes, a patient must be treated without their consent, provided the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition. The treatment provided should be the least restrictive of the patient’s future choices.79
In the case of children under the age of 16 years, consent should be given by the parent or guardian. In England and Wales, a child who is deemed ‘Gillick competent’ under the age of 16 years may give, but not withhold, consent.79
A recent judgement of the UK Supreme Court in the case of Montgomery v Lanarkshire Health Board clarifies some aspects of consent to medical treatment. Consent is a process and it should be viewed as an opportunity for a dialogue and not a one-way flow of information. The doctor must find out which risks are relevant to each ‘particular patient’ and tailor the consent process accordingly. The doctor must not, by fear of non-disclosure, ‘bombard the patient’ with technical information. This is more likely to promote confusion. The GMC states: ‘The test of materiality is whether a reasonable person in the patient's position would be likely to attach significance to the risk, or the doctor should reasonably be aware that the particular patient would be likely to attach significance to it.2,3,80
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'.80
Where risks of adverse patient outcome with surgery are identified as being high, the preoperative assessment consultation facilitates 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 - ideally a preoperative MDT meeting.
Patients consenting to be subjects of research
A patient’s consent to participate in research projects should be obtained by those conducting the study and not by the anaesthetist providing care for the operation. Consent should be obtained on a separate signed document and approval should be sought from the anaesthetist who will be delivering the anaesthetic to the patient.79,81
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
- cardiopulmonary exercise testing – its use and evidence.
Clinical lead - SAS doctors undertaking lead roles should be autonomously practicing doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues. 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.
Elective surgery – intervention planned or booked in advance of routine admission to hospital. Timing to suit patient, hospital and staff.
Expedited emergency 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.
Immediate emergency surgery – immediate life, limb or organ-saving intervention; resuscitation simultaneous with intervention. Normally within minutes of decision to operate; (A) Life saving (B) Other, e.g. limb or organ saving.
Urgent emergency 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.