Chapter 5: Guidelines for the Provision of Emergency Anaesthesia Services 2022

Published: 07/02/2022


The objective of this chapter is to describe current best practice for emergency anaesthesia services. ‘Emergency’ within this chapter applies to anaesthesia that is given in immediate (within minutes of a decision to operate) or urgent (within hours of a decision to operate) procedures as classified by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).

The provision of emergency anaesthesia differs from elective anaesthesia in that it is required 24/7. The demands on the service vary in an unpredictable manner because of the severity of illness, urgency of treatment and number of cases. The unpredictable nature of emergency anaesthesia creates greater challenges to providing a service that meets recommended standards of care. This unpredictable nature means that hospitals need to have sufficient capacity and flexible systems in place that can respond to variations in demand and severity of patients’ illnesses.

Patients undergoing emergency anaesthesia are a heterogeneous group. They range from relatively well patients to the complex and very ill. Most patients, however, requiring emergency anaesthesia survive without serious complications and continue to have a similar quality of life to the one they had before their acute illness.

There is a significant variation in outcomes of emergency patients, in both place and time.1,2 The resources, pathways and compliance with accepted treatment also vary significantly between hospitals,3,4 and compliance with accepted standards of care varies from day to day and at different times during the day.

There are large and increasing numbers of patients who are admitted acutely to hospital with surgical conditions, many requiring surgical intervention.5 This is projected to increase because of the demographic changes of an increasingly elderly population, which pose unprecedented challenges in the provision of emergency services.6

The recommendations in this chapter include the basic requirements to provide an emergency anaesthesia service, but the provision of a good quality service is much more than this. It is about creating a culture of improvement and providing the facilities to enable this culture to flourish. This may not happen by accident. This type of improvement is much more about sociological, cultural and behavioural change rather than just ‘medical technology’ or ‘yet another protocol’.7,8,9,10,11 Integral to this change is for staff to feel involved and valued.7,12,13 ‘Top down’ management approaches are severely limited in creating lasting improvements.6,14,15

An individual simply ‘doing their best’ is no longer enough. Evidence-based pathways and quality improvement programmes need to be implemented. Within these programmes, individuals can still strive for excellence, but as part of a whole team.4,16,17,18 To enable patients to receive high-quality emergency anaesthesia, local and national supporting services and facilities are required. Of particular importance is timely access to operating theatres, radiology, critical care and other multidisciplinary teams.2,5,10,19

The National Emergency Laparotomy Audit (NELA) has shown how improvements of care and outcomes can be achieved through improved care pathways, increased compliance with these pathways, and greater attention to detail. The audit has also highlighted the importance of risk assessment and appropriate care and treatment throughout the hospital journey of the patient. The Royal College of Anaesthetists has been developing the concept of the anaesthetist as the perioperative physician. Improved care pathways and role of anaesthetist as a periperative physician will have a significant impact on provision of emergency anaesthesia services.20

Reduction of unnecessary deaths is one of the top NHS priorities; services for emergency patients is one of the areas highlighted for improvement.6 As well as reducing mortality and complications, the provision of a high-quality emergency anaesthesia service should be responsive to patients’ needs and should be aimed at improving patient experience. Adequate resources and funding will be crucial to the delivery of a high-quality emergency anaesthesia service.21,22,23

Despite the challenges, the quality of the anaesthesia services provided for emergency patients should match that provided for elective patients, including the seniority of the anaesthetist treating the patient.2 The recommendations within this document describe the features of a high-quality emergency anaesthesia service. The implementation of these recommendations will enable consistency in the standards of care provided at all times and in all places. It is recognised that the implementation of the recommendations will depend on the type, volume and complexity of the emergency workload, and will likely to vary from organisation to organisation.2

1. Organisation and administration

Quality should be at the heart of every aspect of the delivery of emergency anaesthetic and surgical care.5,9,14,24


The provision of a high quality emergency service should be an explicit aim of the hospital executive and senior staff team. This should be reflected in hospital published plans and by the provision of a management structure to support this aim.19  The required standards set out in this document apply to all organisations, but the methods used to achieve them may vary.2,23

GPP Strong

Organisations should explicitly recognise the 24/7 nature of emergency work, and this requires a specific organisational approach for standards to be achieved throughout the whole of the week.

GPP Strong

The hospital business plan should address the predicted growth in surgical emergencies, ageing population and any changes as a result of regional specialisation.16 Future planning should be based on accurate and timely data. Mathematical modelling for matching theatre demand and capacity could be beneficial.25

GPP Strong

Each department of anaesthesia should have a plan in place for the emergency anaesthetic workload to be delivered effectively and safely.26

GPP Strong

Organisations should have a service improvement team that coordinates national and local projects and encourages a multidisciplinary approach to emergency surgical care, using data to provide high quality information to drive change and support service development.2,27 Quality improvement tools, together with good data entry and organisational support, should be considered, as they can create feedback strategies which drive improvement.28

GPP Strong

Emergency and elective work should be separated (whenever practically feasible) to improve clinical care for patients.4,29

GPP Strong

Rapid and effective communication is crucial in emergency situations. Communication strategies should consider the use of technologies such as smart phones, and standardised methodology such as situation, background, assessment, recommendation.30

GPP Strong

There should be adequate provision of postoperative beds for emergency surgical patients, including high-level care to allow timely discharge of patients from theatre recovery areas.

GPP Strong

Medical leadership structure


Every department of anaesthesia undertaking emergency surgery should appoint a senior clinical lead (see Glossary) with adequate provision within their job plan and support to develop and lead emergency anaesthesia within the organisation.19 This role could include liaison with other departments.

GPP Strong

The anaesthetic clinical lead for emergency anaesthesia should be part of a multidisciplinary team with access within the governance structure to trust board level, with explicit pathways of communication.

GPP Strong

Day-to-day management of emergency workload

Access to theatres should be based on the principle that no patient should deteriorate while waiting for surgery. Unnecessary delays to accessing theatre should be actively avoided.2


There should be clarity of leadership and roles to supervise the day-to-day running of emergency theatres and the emergency anaesthesia service. Those undertaking these roles should be clearly identifiable to all working that day and easily accessible at all times.

GPP Strong

The emergency operating list should be easily accessible to all medical and operating department staff so that there is shared awareness of the emergency load and resource requirements, within the principles of patient confidentiality.31,32 The operating list displayed in theatre should be the most current version.

GPP Strong

The language in all communications relating to the scheduling and listing of procedures must be unambiguous and avoid the use of abbreviations. Laterality must always be written in full (i.e. left or right).13

M Mandatory

Adequate emergency theatre time should be provided throughout the day to minimise delays and avoid emergency surgery being unnecessarily undertaken out of hours when the hospital may have reduced staffing to care for complex postoperative patients. Consideration should be given to staffing of additional evening (twilight) emergency sessions with autonomously practising anaesthetists.

GPP Strong

Dedicated emergency lists for some individual surgical services (e.g. paediatrics) should be considered as they may be an effective use of resources and improve patient flow and care.29

GPP Moderate

Efficient management of emergency list is essential to ensure timely access to emergency theatre. Golden patient concept to identifying and getting the first patient on the list ready has been effective in prompt starting of emergency lists. Dedicated holding bays have shown to reduce turnaround times. Such and other innovative systems should be considered to improve efficiency of emergency lists.33,34

GPP Strong

Emergency/NCEPOD booking system


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.35

GPP Moderate

Departments should consider a web-based live system that can be remotely accessed by all relevant personnel including senior staff who are on-call off site. A dynamic system can be set to order the list according to clinical priority, NCEPOD classification and time of booking. Real time updates should avoid delays and improve workflow.

GPP Moderate

Prioritisation of non-elective/emergency surgery

Emergency surgical patients are at risk of deterioration if treatment is delayed. Determining patient priority and enabling timely access is crucial to reducing harm. Local arrangements to prioritise patients based on clinical urgency should be established.36


Local systems should be in place to triage patients with surgical emergencies. NELA reports a proportion of patients for laparotomy arriving in theatre within three separate time frames (< 2 hours; 2–6 hours; 6–18 hours).2 The World Society of Emergency Surgery study group proposed a classification to triage patients for surgical emergencies. These timeframes could be used as a guide and adapted to design local triage systems.36

GPP Strong

Prioritisation of cases based on their clinical urgency is not the sole domain of any single specialty. It requires a team approach involving discussion between different surgical groups, anaesthetists and, in some cases, critical care.4

GPP Moderate

There should be a locally agreed policy that explains prioritisation of non-elective cases according to clinical urgency.

GPP Strong

Priority of access should be given to emergency patients over elective patients.5,19,37,38 There should be a clear policy for cancelling elective surgery to enable additional emergency theatre provision.13

GPP Strong

The theatre booking system should enable the identification and prioritisation of high-risk cases.

GPP Strong

The urgency of emergency cases should be clearly and unambiguously coded.4

C Strong

There should be regular review of delays to facilitate improved theatre access and to promote accurate urgency coding at booking.

GPP Strong

Certain urgent procedures cannot be performed out of hours owing to patient, specialist staff or equipment factors. Hospitals should consider collecting data on these procedures and creating alternative pathways.

GPP Strong

There should be local arrangements in place to facilitate scheduling of procedures that not meet the description of either emergency or elective surgery.

C Strong

Preanaesthetic assessment

Guidelines for preoperative assessment and preparation are comprehensively described in GPAS Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients.


Some aspects of preanaesthetic assessment and preparation of the emergency patient differ from those of the elective patient. These include severity of illness, fluctuating condition of the patient and the 24/7 nature of emergency work. Staffing levels and seniority of anaesthetists should be adequate to enable preanaesthetic planning and assessment that is appropriate to the patient’s risks associated with surgery. This should be informed by a formal assessment of risk of mortality and morbidity.2,4,39

C Strong



There should be a formalised integrated pathway for non-elective adult general surgical care, which should be patient centred and include:2,5,19,29,40


  • a clear diagnostic and management plan made on admission41
  • early identification of comorbidities (including diabetes, dementia, cardiac pacemakers and internal defibrillators) and their management according to hospital guidelines
  • medicine reconciliation to assess the risk of existing medications (including anticoagulation) and the risk associated with stopping long term medication38
  • preoperative investigations and testing as appropriate42,43
  • adequate testing capacity appropriate for the patient group and nature of local procedures to avoid delayed admission to the theatre/procedure room
  • an investigation, such as ECG, should be considered a core skill for an emergency anaesthetist
  • building capacity for provision of special investigations, such as focused cardiac ultrasound among emergency anaesthetists trained to carry out the procedure
  • communication of mortality risk to members of the multidisciplinary team; this allows early senior input, including senior members of the anaesthetic team, and allocation of resources commensurate to the patient’s risk of death following surgery2,4
  • informed consent for surgery including identification of decision making proxies i.e. a lasting power of attorney2,5
  • a plan for postoperative care.2,5
GPP Strong

All hospitals should have guidelines in place for the recognition and management of patients with sepsis; compliance with these guidelines should be regularly audited.10,44,45

C Strong

An anaesthetist, anaesthesia associate or advanced nurse practitioner should preoperatively assess all patients undergoing emergency surgery who require anaesthesia. Adequate time should be available for this assessment to occur as clinical urgency allows.43,46

C Strong

A full anaesthetic management plan should be recorded in the patient's records or anaesthetic chart and should be initiated preoperatively.47

C Strong

The experience and expertise of the anaesthetist assessing the patient preoperatively should be appropriate for the complexity and level of risk of the patient.45 The decision to operate on high-risk patients should be made at a senior level, involving surgeons and those who will provide intra and postoperative care.4,5,19

B Strong

Preoperative assessment of patients, especially those at very high risk, can benefit from a multidisciplinary team approach involving cross specialty advice.48 Early consultation with appropriate medical specialties should occur for appropriate conditions, such as delirium, acute kidney injury, diabetes mellitus and ischaemic heart disease.4

C Strong

All decisions concerning the consent process (see Section 9) and treatment plans, including decisions about whether or not to operate, should be documented clearly, noting what risks, benefits and alternatives were explained to the patient within the time constraints of emergency care.46,49

C Strong

There should be a system in place for alerting medical staff to any change in the clinical condition of the emergency surgical patient while awaiting surgery.41,50

C Strong

There should be provision for preoperative admission of the critically ill patient to level 2 and/or level 3 care facilities for stabilisation and optimisation if required.3,10

C Strong

Guidelines for fasting before anaesthesia for emergency surgery should comply with national guidelines.51

C Strong

Guidelines for postoperative planning should include plans for nutrition, including facilitation of enteral access or vascular access for parenteral support.52,53,54

C Moderate

Preoperative risk assessment


There should be a formalised integrated pathway for non-elective adult general surgical care which should be patient centred and should include risk assessment and identification of the high-risk patient.2,4,5,40

C Moderate

There should be locally agreed guidelines for risk assessment and documentation.

C Strong

All patients should undergo venous thromboembolism risk assessment and receive appropriate thromboprophylaxis.5,55 This should include guidance on the novel oral anticoagulants and the management of patients requiring emergency surgery who are receiving them.56

C Strong

Preoperative risk stratification should inform the decision making process for critical care admission.2,24

C Strong



All areas, including emergency departments, admitting acutely ill patients should have early warning pathways to ensure prompt recognition of a deteriorating patient to trigger an appropriate response.57 This should include policies for early medical review and early escalation to the responsible consultant surgeon or equivalent.10,48,58,59,60,61

B Strong

Transportation of the emergency patient


Transport of patients within the hospital and between hospitals should be undertaken in a timely manner, without unnecessary delays and in accordance with established guidelines and standards.10,62,63,64,65

B Strong

Staffing should be provided at a level such that emergency theatre activity and critical patient care are not compromised when intra and inter hospital transfers are undertaken.62

C Strong

All necessary equipment to facilitate safe transport of the patient should be available at all times.10,62,64 Standardisation of transfer bags should be considered.62

B Strong

Departments should have local guidelines for intrahospital transfers.

GPP Moderate

Where transfers between hospitals are foreseeable (e.g. transfers to major trauma, neurosurgical or paediatric centres) local arrangements should be in place to ensure safe and timely transfer, which may involve a retrieval service.62

C Moderate

Arrangements should be in place for appropriately trained and competent staff, insurance (personal and medical indemnity), crash test compliant equipment, ambulance booking procedures, procedures for receiving patients, communication between medical teams and families and documentation and procedures for repatriation of staff and equipment once the transfer and handover are completed.10,62,64

B Strong

Hospitals should collect data on inter and intrahospital transfers, including the effects on the emergency theatre and critical patient care. The transfer arrangements should not result in the interruption of a busy emergency list.

GPP Moderate


The handover of the care of a patient occurs at multiple points. Effective handover is a critical component of a patient safety culture.66 At handover, there is potential to introduce additional risk because of a loss of information and a lack of clarity. This is of particular relevance to emergency patients. There is evidence that implementing a structured handover programme is associated with reducing medical errors and preventable adverse events.57,67


Handovers for patients requiring an emergency procedure should be structured to ensure continuity of care.68

C Moderate

Handover protocols for patients requiring an emergency procedure should include clear documentation of care delivered and the future treatment plan for the patient.13,69

C Strong

Organisations must create standardised documentation for patients undergoing invasive emergency procedures that promotes the sharing of patient information between individuals and teams at points of handover, and forms a documented record for future reference.13

M Mandatory

There should be appropriate overlap between shift changes, to ensure adequate time for handover. Time for handover should be included in job plans and rotas and accounted for in work shift planning.47,70

C Strong


General policies pertaining to the perioperative pathway are comprehensively described in GPAS Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients.


The following policies (see Glossary) should be immediately and reliably available at sites where emergency anaesthesia and sedation are provided:

  • management and running of the emergency theatre, including an escalation plan for emergency theatre capacity and staffing5
  • management of anaesthetic emergencies, including guidelines for children
  • difficult airway management, including the ‘can’t ventilate, can’t oxygenate’ scenario, fasting times, preanaesthetic assessment of the airway, availability and maintenance of the equipment and training of staff71,72,73
  • major haemorrhage protocol, including clinical, laboratory and logistic responses74,75
  • blood transfusion policy, including transfusion for inter- and intrahospital transfers76
  • safe extubation of patients following emergency anaesthesia
  • management of the deteriorating patient77,78
  • whom to call and what facilities can be used if two or more emergencies occur simultaneously
  • a policy for the management of organ donation and retrieval10,79,80
  • a policy for managing delirium in the perioperative period.
B Mandatory

Appropriate clinical policies and standard operating procedures for operating theatres should be in place and available at all times, including a resuscitation policy and major incident plans.81

C Strong

All staff, including anaesthesia assistants, locum, agency and trust grade staff must have undergone an appropriate induction that includes the contents of relevant policies and standard operating procedures.13

M Mandatory

An escalation policy should be in place for all medical, healthcare professional and managerial staff. An emergency protocol should be in place and understood by all relevant staff. This should include the names and method of contact, which should be prominently displayed in appropriate areas. Internal hospital telephone switchboards should have ready access to rotas and methods of contacts.

GPP Strong

A clear method of communication between and within theatre teams, including related areas (e.g. obstetric or paediatric wards) should be in place concerning the urgency category of an emergency, escalation and who to contact.82

C Strong

All patients undergoing emergency procedures must have the World Health Organization checklist completed. A modified checklist with fewer items may be more appropriate in some emergencies.5,19,83,84,85

M Mandatory

There should be a clear process in place for the referral of emergency patients requiring critical care, including paediatric patients, to an appropriate facility.9,48,59

GPP Strong

Use of blood products should be minimised whenever possible by the employment of restrictive transfusion thresholds together with methods to minimise blood loss and allogenic transfusion.74

C Strong

Hospitals must have audited policies and procedures for the administration of blood and blood components that comply with standards set out by the National Blood Transfusion Committee.76 Hospitals should have systems in place to ensure that blood can be crossmatched, issued and supplied in a timely manner.

GPP Mandatory

2. Staffing requirements

Patients receiving emergency anaesthesia are among the sickest in the hospital and are often treated by multiple teams. It is imperative for good patient care that staffing should be sufficient in quantity, quality, seniority and skill mix for the expected work load (patient caseload, case mix and severity of illness, together with the out-of-theatre workload).10,29,86 The systems and environment within which people work and treat patients should be supportive of staff, enabling them to provide the best treatment possible, and are outlined in further detail in GPAS Chapter 1: The Good Department.7,87

Anaesthesia and theatre teams


Hospitals admitting emergency surgical patients should provide, at all times, a dedicated fully staffed operating theatre appropriate to the clinical workload. There should be provision to increase necessary resources to manage fluctuating workload and provide an acceptable standard of care.13,27,38

C Strong

The level of staffing should be sufficient to provide a continuous emergency anaesthesia service in the theatre complex without interruption. Other service requirements (e.g. remote sites, trauma calls and advice) should be anticipated and managed through local arrangements.13 Such service requirements should not result in interruption of busy emergency lists.88

C Strong

Staff working in emergency theatres have to deal with multiple surgical teams, a wide range of procedures, unpredictable situations at short notice and changes to planned activity. Staffing levels in the emergency theatres should reflect appropriate skill mix and seniority to deal with the demands of the service.14

GPP Strong

Staff working in emergency theatres should have a wide range of competencies to manage a range of specialties and complexities.66

GPP Strong

The role of an ‘emergency theatre coordinator’ (see Glossary) should be considered for departments with a large emergency workload so that patient flow and prioritisation of cases can be actively managed.

GPP Moderate

Non-clinical aspects of managing an emergency list should be adequately supported for efficient running of the list.47

GPP Strong

At all times there should be an on-site anaesthetist who has the ability and training to undertake immediate clinical care of all emergency surgical patients. Explicit arrangements should be in place to provide support from additional anaesthetists appropriate to local circumstances.

GPP Strong

The emergency anaesthesia team should be led by an autonomously practising anaesthetist (see Glossary) and include other healthcare professionals involved in the delivery of anaesthesia for emergency surgery, including other departments such as radiology, medicine and emergency departments.3

C Strong

Anaesthetists assigned to provide cover for emergency lists should not also be assigned to undertake other activities such as elective work or supporting professional activities.89


Anaesthesia for emergency surgery should be delivered by a competent individual with appropriate supervision; the level of supervision should reflect the severity of the case and the seniority of the individual in accordance with the RCoA’s Guidance on Supervision arrangements for anaesthetists.90

C Strong

Anaesthetists in training should be given the appropriate level of responsibility, according to their competence and level of training, to gain the experience of emergency anaesthesia to enable them to function as a consultant later in their career. Anaesthetists in training must be appropriately supervised at all times; rotas and staffing arrangements should be in place to facilitate this training.91

M Strong

Anaesthesia associates should work under the supervision of a consultant anaesthetist at all times as outlined by the RCoA.92,93 In some emergency situations, a ratio of one to one and direct supervision may be more appropriate in view of the high incidence of comorbidities, complications and mortality.

GPP Strong

Patients receiving emergency anaesthesia care in a non-theatre location should be cared for by anaesthetists with the same level of competency and assistance as those receiving emergency care in the theatre environment. Certain circumstances may require additional assistance; local arrangements should allow sufficient personnel and resources to support this assistance.82,94

C Strong

There should be dedicated administrative staff to support all aspects of the emergency anaesthesia service and to support and coordinate non-clinical activity.13,89

C Strong

Whenever emergency surgery is undertaken, the recovery unit should be open continuously and adequately staffed.82 Until patients can maintain their own airway, breathing and circulation, they should be cared for on a one-to-one basis, with an additional member of staff available at all times.69

C Strong

Recovery staff should have immediate access to the appropriate clinician in the perioperative period.

GPP Strong

Staff wellbeing

General recommendations for staff wellbeing can be found in GPAS Chapter 1: The Good Department.


Working to deliver emergency surgery is often a stressful, challenging environment. Stress, 'burnout' and mental ill health are major causes of sickness absence. NHS organisations should ensure that those in leadership positions work to promote and protect the health and wellbeing of staff.95

C Strong

There should be adequate staffing levels to ensure that rest breaks can be taken without interrupting the flow of the emergency theatre(s). Appropriate facilities for these rest breaks should be provided.95,96,97

C Strong

When members of the emergency team are involved in a critical incident, it may not be possible to find an immediate replacement. The situation and clinical commitment of individuals involved should be immediately reviewed by an appropriate senior person and if necessary alternative arrangements to cover emergency service should be made.98

C Strong

3. Equipment, services and facilities



In all areas in which emergency anaesthesia is undertaken, the following equipment is required for the safe delivery of anaesthesia. The equipment should be readily available at all sites where patients received anaesthetic intervention:

  • oxygen supply including an emergency back-up supply
  • self-inflating bag
  • facemasks
  • suction equipment
  • airways (naso- 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)
  • equipment for invasive blood pressure and central venous pressure
  • cardiac output monitoring.
GPP Strong

Patients receiving emergency anaesthesia care in a non-theatre location should have access to anaesthetic equipment, monitoring, drugs and personnel as in the theatre environment.

GPP Strong

Specialist equipment that is not commonly used or that is not time critical should be available if required (e.g. Oxford pillow, cell saver, hoists and transoesophageal EEG).

GPP Strong

Emergency theatres should be equipped with an appropriate ventilation system. Details of ventilation and air change times should be known and factored into list management in all areas where an aerosol generating procedure may be performed during emergency anaesthesia.99,100

C Strong

The geographical arrangement of theatres, emergency departments, critical care units, cardiac care, interventional radiology and imaging facilities should allow for the rapid transfer of critically ill patients.

GPP Strong

Appropriate blood storage facilities should be in close proximity to the emergency operating theatre and should be clearly identifiable. Satellite storage facilities or a clear process for preservation of the cold chain should be in place to enable resuscitation to be effectively performed in appropriate non-theatre locations such as interventional radiology suites.

GPP Strong

Hospitals should ensure that staff are trained and competent to use the equipment provided.

GPP Strong

Equipment should be properly maintained and replaced in a timely and planned fashion.101,102

C Strong

Theatre operating tables should be available to permit all types of emergency surgery to be undertaken. Appropriate operating tables with imaging access (carbon fibre), adjuncts for proper positioning and warming devices should be available.

GPP Strong

There must be appropriate equipment available for transfer of the patient within the theatre, together with the appropriate staff trained to use it safely.101,103,104

M Mandatory

There must be full provision of personal protective equipment and shielding from blood spray, radiation and hazardous substances for all staff working in the operating theatre. Guidance should be provided on its use.103,105,106

M Mandatory

Near-patient testing for haemoglobin, blood gases, lactate, blood sugar and ketones should be readily available (see Glossary) for emergency theatres.107

C Strong

Near-patient testing for coagulopathy should be considered, particularly in areas where major blood loss is likely.74 If near-patient testing is not available, laboratory testing should be readily available.


A fully equipped resuscitation trolley should be available in all areas in which emergency anaesthesia is undertaken. These trolleys should be colour coded and should maintain uniformity within the trust, to improve safety.74,108

C Strong

High-flow nasal oxygen should be available in the emergency theatres.73,109,110,111,112

C Strong

A rapid infuser allowing the infusion of warmed intravenous fluids and blood products should be available in the emergency theatre.73,113,114 Staff should undergo regular training in its use and they should be able to troubleshoot common problems.

C Strong

A cell salvage service should be available for cases where massive blood loss is anticipated. Staff who operate this equipment should receive training in how to operate it, and should use it with sufficient frequency to maintain their skills.75,115

C Strong

Equipment necessary to provide a range of patient analgesia should be available. There should be adequate facilities for postoperative monitoring of patient analgesia.8,116

C Strong



The standards of monitoring provided in all locations where emergency procedures are performed, including non-theatre locations, should be the same as those provided in theatres.107 This includes temperature and end tidal CO2 in recovery.

C Strong

Appropriate equipment for invasive blood pressure, central venous pressure and cardiac output monitoring should be readily available.

GPP Strong

Equipment for monitoring the depth of anaesthesia should be available for patients receiving emergency anaesthesia (e.g. processed EEG) particularly if total intravenous anaesthesia is used for emergency surgery.117,118

C Strong



All areas in which emergency anaesthesia is undertaken should be adequately stocked at all times with the range of medications required for immediate use in all types of urgent cases appropriate to the case mix accepted by the hospital. Prefilled syringes supplied by the pharmacy should be considered, especially in busy units.

GPP Strong

Anaesthesia teams should consider carrying prelabelled and/or prefilled drug boxes.119

GPP Moderate

Specialist medications that are not commonly used or that are not time critical should be readily available (see Glossary) if required (e.g. dantrolene, esmolol, N acetylcysteine, octreotide).

GPP Strong




Facilities to enable immediate life, limb or organ saving surgery should be available at hospitals accepting emergency surgical patients. Sites that accept patients for emergency surgery should ensure access to all core specialties,  including postoperative care facilities, a full range of laboratory and radiological services and sufficient critical care capacity appropriate to the case load and case mix.2,57,120,121

C Strong

Explicit arrangements should be made for the provision of care from specialties that are not available on site (e.g. neurosurgery, cardiothoracic, vascular, ear, nose and throat, maxillofacial, hepatobiliary, burns and plastic surgery, geriatric medicine, palliative care medicine).

GPP Strong

Critical care

This guideline relates only to the provision of critical care for patients receiving emergency anaesthesia. General provision of critical care is outside of the scope of this document. Further information can be found in the Faculty of Intensive Care Medicine and Intensive Care Society 2019 Guidelines for the Provision of Intensive Care Services.122

Adequate critical care facilities are integral to the care of ‘high risk’ patients receiving emergency anaesthesia.3,10,123 It is known that patients identified as requiring critical care and admitted directly from theatre have significantly improved outcomes than those admitted following a period of postoperative deterioration (e.g. from a ward).124,125


There should be provision for a high level of care for emergency patients where necessary.4

C Strong

Critical care should be considered for all high-risk patients requiring emergency surgery. As a minimum, patients with an estimated risk of mortality of 5% or higher should be considered for critical care.5 There should be close preoperative liaison and communication between the surgical, anaesthesia and critical care teams, with the common goal of ensuring appropriate safe care in the best interests of the patient.19

C Moderate

There should be locally agreed protocols for postoperative critical care admission, and compliance with these protocols should be audited.

GPP Strong

Hospital level audit data should be examined to determine whether national standards for postoperative critical care admission are being adhered to. Where compliance is poor, a change of local policies and reconfiguration of services should be considered, to enable all high risk emergency patients to be cared for on a critical care unit after surgery.2

C Strong

4. Training and education

Teamwork is fundamental to the safe delivery of patient care in emergency surgery. Staff working in emergency theatres have to deal with multiple surgical teams with repeated changes to the composition of the team.


The core theatre team (see Glossary) should remain consistent where possible.13

C Strong

Anaesthetists should be given support and time to familiarise themselves with non-theatre locations and local working arrangements, (e.g. during induction sessions prior to undertaking on-call responsibilities).13,126

C Strong

Multidisciplinary teams working together in emergency theatres should undergo training together, with a focus on teamwork, communication, human factors and handover.13,68,127,128,129

C Strong

Teams should train for and practise their standard operating procedures for serious, complex and rare emergencies, as well as for major incidents. There should be regular multidisciplinary training for emergency situations, and simulation training should be considered.81,127,130

C Strong

All staff should have access to adequate time, facilities (including simulation) and funding to undertake training.

GPP Strong

Anaesthetists with a job plan that includes emergency anaesthesia should demonstrate continuing education in emergency anaesthesia and continuing professional development as required for this aspect of their work. Departments have a responsibility to enable this development with local teaching where appropriate and by facilitating access to other education and training.19

GPP Strong

Regular daytime emergency lists should be used as a teaching resource and staffed appropriately to facilitate this.131


All efforts should be made to ensure that anaesthetists in training receive adequate experience in emergency anaesthesia, and completion of workplace-based assessments should be supported.1 Departments should monitor the frequency and the nature of non-theatre calls to establish whether the anaesthetists in training receive appropriate support and training and the patients receive adequate care. Departments should use these data to review resource allocation.

C Moderate

When new members join teams, particular care should be taken to introduce them to the members of the team and to ensure that their care is harmonised with that of other team members and teams.13

C Moderate

Departments should consider developing diagnostic ultrasound skills as appropriate to emergency anaesthesia.

GPP Moderate

Clinicians undertaking emergency anaesthesia must be familiar with managing patients with a tracheostomy.72,73

M Mandatory

5. Patient Information

The basic principles of information and consent that apply to elective patients also apply to emergency patients. For emergency patients there are additional considerations that may make this process more complex and difficult to deliver. These include patient factors (fear, pain, analgesic medications, pre-existing comorbidities and frailty), disease (uncertainty of diagnosis and prognosis) and situational factors (speed of decision making, multiple medical inputs and uncertainty of critical care requirements). These additional issues should be understood and taken into account when an emergency patient is given information or consent is sought. This is particularly true in vulnerable patients (i.e. patients with learning disabilities, dementia and communication difficulties).

Evidence of the efficacy and feasibility of delivery of these principles for emergency anaesthesia is limited.

The Royal College of Anaesthetists has 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.


If needed, patients and/or advocates should have access to an interpreter wherever possible to facilitate communication.132

C Strong

Consideration should be given to assessing a patient’s understanding of information given. At the end of an explanation, patients should be asked if they have any questions. Any such questions should be addressed fully and details recorded. If urgency allows, this is better undertaken in the presence of patient’s relative(s) and/or carer(s).46,133 When this is not feasible in an emergency situation communicating the decisions to the next of kin should be considered. If there is no next of kin, independent medical advice or a second opinion should be sought.

C Moderate

Paper and/ or electronic based patient information leaflets in addition to a verbal explanation should be provided to emergency patients to improve retention of information.134

GPP Strong



All practitioners must follow the practices outlined in the GMC decision making and consent guidance.135 Documentation of the risks discussed or the dialogue leading to a decision is required in accordance with paragraphs 50–55.

M Mandatory

Informed consent should take into account the benefits and risks of the procedure, alternative options available and the option of doing nothing. Consent should be given at the earliest possible opportunity in view of limited time available for the patients having emergency surgery to consider the information.4,15,136,137 All discussions should be clearly documented.

C Strong

As part of a quality improvement programme, hospitals should develop a local understanding of the adequacy of their consent process and information supplied to patients undergoing emergency surgery, by proactively seeking patient feedback and allocating appropriate resources to this process.138

C Strong

Assessment of capacity must be time and decision specific; an individual’s capacity to make particular decisions may fluctuate or be temporarily affected by factors such as pain, fear, confusion, the effects of medication or intoxication by alcohol or other drugs.57,139

M Mandatory

Breaking bad news, clinical benefit and end-of-life decisions


Interventions that are unlikely to alter outcomes and may add to patient distress should be recognised and communicated with the patient and their relatives or supporters at the earliest opportunity.140

C Strong

A team approach should be considered for breaking bad news and discussions around clinical benefit and end-of-life decisions with patients and relatives.

GPP Moderate

Discussion and reasons behind decisions taken, as well as the information given to the patient and relatives, should be clearly recorded.141,142

GPP Strong

Mortality discussions (see Glossary) should be documented for patients undergoing an emergency laparotomy.143

GPP Strong

Hospitals should have pathways to alleviate pain and suffering, which should be individualised to the needs of the patient and discussed with their relatives or supporters.144

C Strong

Hospitals should have local policies (see Glossary) for when a patient dies in theatre or soon after in recovery. This should include arrangements to maintain dignity for the patient and to give relatives the best support possible. It should also include arrangements to minimise the impact on other patients being treated in the theatre complex.

GPP Strong

Hospitals should offer the same level of access for discussion and explanation to relatives of patients who die in the theatre complex or not having undergone surgery as they do for those who die in critical care.

GPP Strong

Where end-of-life care is instituted, it should be in accordance with national and local guidance and audited for quality in the same way that surgical care is audited.145

C Strong

Hospitals should have a treatment escalation plan and/or do not attempt cardiopulmonary resuscitation (DNACPR) guidance and documentation that complies with national requirements.110,146

C Strong

Patients who may require surgical procedures with DNACPR decisions in place should have senior members of the anaesthesia and surgical team review the condition of the patient and the DNACPR status. Where feasible, a discussion should take place with the patient and their next of kin. It may be appropriate to suspend components of a DNACPR decision (e.g. tracheal intubation) to allow surgery to proceed safely.77

C Strong

6. Areas of special requirement

Patients who are older

There is an increasingly older population presenting to hospitals for emergency surgery, reflecting the changing population demographics. Patients who are older have a decreased physiological reserve and higher incidence of comorbidities, polypharmacy, frailty and cognitive decline, making decision making more complex in this patient group.147 Poor cognition, hearing and eyesight may make communication difficult. Some 50% of patients undergoing emergency laparotomy are over 70 years of age and 55% of these patients are ASA3 or above.43

When patients who are older are admitted following trauma, assessment by a geriatrician is associated with reduced mortality.148 In patients who are older having a laparotomy, postoperative geriatric medicine review is associated with substantial lower mortality.149

The outcomes following emergency surgery for patients who are older (particularly those who require support for daily living) are worse than for younger patients. For emergency laparotomy, the mortality of a patient aged over 70 years is six times higher than that of a patient younger than 50 years.2 Functional outcomes are unpredictable, but one-third of octogenarian survivors will not recover to their preoperative function.150,151

General recommendations for patients who are older are described in GPAS Chapter 2: Guidelines for the Provision of Anaesthesia Services for the perioperative Care of Elective and Urgent Care Patients.


Older patients who are admitted following trauma should have a geriatric assessment.148

B Strong

All older patients who require emergency surgery should be routinely assessed for multimorbidity, frailty, cognition and polypharmacy.3,7,8,55

C Strong

Planning of care and decisions to operate should reflect the outcomes for older patients who are having emergency surgery, and should include discussion of issues around risks and benefits, clinical benefit and realistic longer-term outcomes (e.g. a requirement for nursing home care). This discussion should involve the multidisciplinary team as well as the patient, families and carers where possible.8

C Strong

Previous DNACPR orders are not necessarily a contraindication to surgery and should be reviewed on a case by case basis by the multidisciplinary team, in discussion with the patient and their next of kin, prior to anaesthesia if at all possible.152,153

C Strong

Postoperative pain protocols should be individualised to suit each patient and should take account of any possible cognitive impairment.154 Specific algorithms for the assessment of pain and postoperative analgesia protocols are recommended in older patients.

C Strong

The risk of postoperative functional decline following emergency surgery should be considered. Policies (see Glossary) 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.8,10,155

C Strong

Patient with a frailty score of 5 and above should receive a comprehensive geriatric assessment. There should be a focus on multidisciplinary working and integrated pathways to reduce complications. This includes shared decision making based on best treatment options and informed patient preferences.

C Strong

There should be planning at local and regional level for the increase in resources that will be required for increasing numbers of older patients needing emergency surgery.8

C Strong

Paediatric emergencies

Most paediatric emergency anaesthesia is for minor surgery in previously fit and healthy children. A large proportion of this work is undertaken in non-specialist hospitals, where arrangements should be in place for treating simple emergencies in children with no complex comorbidities.

Emergency anaesthesia may also be required for non-surgical procedures such as magnetic resonance imaging (MRI) or computed tomography (CT). 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 paediatric patients are comprehensively described in GPAS Chapter 10: Guidelines for the Provision of Paediatric Anaesthesia Services.


Anaesthesia for children should be undertaken or supervised by anaesthetists who have undergone appropriate training and have maintained their competence.131,156

C Strong

Hospitals should define the extent of emergency surgical provision provided for children and the thresholds for transfer.

GPP Strong

Emergency paediatric surgical care should be provided within a network of secondary and tertiary care providers. Networks should agree standards of care and formulate care pathways for emergency surgery.

GPP Strong

Departments should participate in regular network audits of emergency surgical work.157,158,159,160

C Strong

Children with severe comorbidities who require emergency anaesthesia should be treated in a specialist paediatric centre. However, if transfer is not feasible, the most appropriately experienced senior anaesthetist should provide anaesthesia and support resuscitation and stabilisation.161,162

C Strong

Transfer of children to specialist centres is usually undertaken by regional paediatric emergency transfer services. Time critical transfers such as neurosurgical emergencies may need to be transferred by the referring hospital. Local policies (see Glossary) should be in place for the management of such transfers and the most experienced anaesthetist with appropriate skills; an anaesthetic practitioner should accompany the child.164

C Strong

Patients with obesity

Obesity is an increasingly significant health issue in the UK.164 The health survey for England 2019 estimates that 28% of adults in England have obesity and a further 36% are overweight. Patients with obesity are at an increased risk of heart disease, diabetes, cancer and stroke. Obesity can make surgery particularly challenging.165


An operating table in the emergency area, hoists, beds, positioning aids and transfer equipment appropriate for patients with obesity should be available and staff should be trained in its use and their limitations.92,164

C Strong

Specialist positioning equipment for the induction of anaesthesia and intubation in the patient with obesity should be available in the emergency area.164

C Strong

Patients with morbid obesity who require emergency surgery should have experienced anaesthetists and surgeons available (typically, but not exclusively, at consultant level) to minimise operative time.164

C Strong

Patients with morbid obesity should be considered for level 2 or 3 critical care postoperatively, including the provision of continuous positive airway pressure therapy and other respiratory support measures.164

C Strong

As there are additional risks for patients with obesity, consider undertaking these procedures within daylight hours.

GPP Strong

High-risk patients, including emergency laparotomy

High-risk patients are defined as having a predicted risk of death greater than or equal to 5%.2,5 Some lower-risk patients are still at significant risk following emergency surgery (e.g. 2% mortality risk is higher than almost all elective surgery). Those patients undergoing emergency laparotomy constitute a defined group, of whom the majority are in the high-risk category. The NELA has demonstrated an approach to auditing provision of care against national standards to drive improvements in care and, ultimately, patient outcomes. These principles can be applied to high-risk patients undergoing emergency anaesthesia.2,5,19,27,40


Hospitals should have care bundles for the anaesthetic management of common and high-risk surgical emergency patients to improve outcomes.2,43,166

C Strong

Systems should be in place to ensure timely surgical review (typically at a consultant level) of high-risk patients, access to diagnostic imaging and urgent reporting.

GPP Strong

There should be a documented evaluation of mortality and relevant morbidity risk prior to surgery using a standardised perioperative risk tool.143,167,168 This will inform both clinicians and the patient about decision making and consent.2

C Strong

High-risk patients should have timely access to appropriate care including resuscitation, antibiotics, interventional radiology or surgery.167

C Strong

Hospitals should have policies for the assessment and management of suspected sepsis. ‘The Sepsis Six’ is a pragmatic approach to this.167 Early consideration of surgery and antibiotic prophylaxis should be considered in patients who are at high risk of sepsis.

C Strong

High-risk patients (5% or above mortality risk) or lower-risk patients undergoing high-risk surgery should receive direct consultant anaesthetist and consultant surgeon delivered care in the operating theatre.2,169

C Strong

Older high-risk patients undergoing an emergency laparotomy should have a postoperative geriatric medicine review.149

C Strong

High-risk patients (5% or above mortality risk) or lower-risk patients undergoing interventions that require higher postoperative care due to the nature of the procedure, such as liver resection surgery, should receive postoperative care in the critical care unit.2

C Strong

Hospitals should consider postoperative critical care if more than four units of blood have been transfused, as this increases risk of pulmonary and infectious complications and mortality.2,170

C Strong

Postoperative facilities should be provided to support the best choice of analgesia for patients undergoing an emergency laparotomy.171

C Strong

Multidisciplinary clinical involvement including critical care, geriatric, paediatric, diabetic teams and other specialists should be considered throughout the perioperative pathway of the patient as appropriate.

GPP Moderate

Hospitals should have clinical and managerial strategies to reduce complications that have been shown to have a major impact on both short and long term outcomes.6,86

B Strong

Diabetes management

An increasing number of patients presenting for emergency surgery have diabetes. These patients have a higher incidence of comorbidities and polypharmacy, which adds to the complexity of diagnosis, and decision making and their medical management. Clinical outcomes following emergency surgery for patients with diabetes are worse than for patients without diabetes.172,173


Patients who have poorly controlled diabetes who are at risk of serious complications and may require meticulous management of fluid, electrolyte and insulin therapy. All locations including remote sites where emergency surgery is performed should be able to manage patients with poorly controlled diabetes 24/7.172

C Strong

Hospitals should consider appointing a lead anaesthetist for diabetes.

GPP Moderate

Hospitals should have mechanisms to promote early identification of the emergency surgical patient with diabetes.

GPP Strong

Hospitals should involve patients in their own diabetes management.172 Most patients with diabetes are experts in managing their own disease and the management of the emergency surgical patient with diabetes can usually be undertaken with only minor modifications in the patient’s usual regimen.

C Strong

Patients with diabetes needing emergency surgery should be assessed for multimorbidity and polypharmacy and should have an individualised explicit plan for managing their diabetes during the periods of starvation and surgical stress. Hospitals should consider a multidisciplinary review of these patients, including the involvement of senior anaesthetic staff and specialist diabetic medical and nursing staff.

GPP Moderate

Hospitals should have explicit policies (see Glossary) on the safe use of variable rate intravenous insulin infusions. The use of a variable rate intravenous insulin infusion adds extra complexity to the fluid and electrolyte management of the surgical patient and this will require additional medical and nursing resources, which sometimes may be better provided in an critical care environment rather than a surgical ward.

GPP Strong

To reduce the harm associated with variable rate intravenous insulin infusions, periods of starvation should be kept to a minimum. This may involve prioritisation of patients with diabetes for investigations and for theatre.

GPP Strong

The patient with diabetes who needs emergency surgery is at additional risk of pressure ulcers and hospitals should have policies to prevent these.

GPP Strong

Non-obstetric emergency surgery in pregnant patients

Pregnant women may present for non-obstetric surgical emergencies. Although the primary duty of care is to the mother, fetal and maternal wellbeing are inextricably linked.

Elective anaesthetic services for the peripartum period are covered in GPAS Chapter 9: Guidelines for the Provision of Anaesthesia Services for an Obstetric Population.


There should be a multidisciplinary team approach to care for pregnant women requiring non-obstetric emergency surgery involving anaesthetists, obstetricians, surgeons, paediatricians and midwives.174,175,176

C Strong

Surgery should be undertaken where neonatal and paediatric services are readily available whenever possible.174

C Strong

Fetal heart rate monitoring should be available. Local policies should outline its use, taking into account fetal viability, the physical ability to perform it and the availability of a healthcare provider able to intervene for fetal indications.174,175,177

C Strong

Informed consent for the surgical procedure should include consideration of fetal wellbeing, the possibility of caesarean delivery and any risks related to anaesthesia for mother and child.176

C Strong

Equipment for maternal positioning and uterine displacement should be available.175

C Strong

Local guidance, including provision for training and audit, should be available for:

  • aspiration prophylaxis175
  • difficult airways and failed intubation73,176,178,179
  • cardiopulmonary resuscitation in the pregnant woman and perimortem caesarean delivery177,178,180
  • anti-D immunoglobulin administration181
  • major haemorrhage, venous thromboembolism prophylaxis and sepsis118,174,177,182
  • anaesthesia and surgery in breastfeeding mothers183,184
  • safe medication administration, including avoidance of codeine in breastfeeding mothers185
C Strong

A maternal death must be reported to the coroner and should be reported to MBRRACE-UK. Medical devices, such as intravenous lines and tracheal tubes, should not be removed prior to postmortem examination.180

M Mandatory

Vulnerable adults


Hospitals must have local policies in place for the identification, support and safeguarding of vulnerable adults.6,136

M Mandatory

Staff should have regular training in the application of the legislation determining mental capacity in the part of the UK in which they are working and should have defined access to patient advocates.186 This is a rapidly changing area and clinicians should have access to expert advice.

C Strong

Diverse cultures and languages


Hospitals should have policies to support patients and staff of diverse religious beliefs and cultural backgrounds.136

C Strong

Hospitals should have arrangements in place to provide language support, including interpretation and translation services (including sign language and Braille). This information should comply with the NHS England Accessible Information Standard.187

C Strong

7. Financial considerations

Part of the methodology used in the chapter in making recommendations 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 but are a synthesis of already existing recommendations. The current compliance rates with many of the recommendations are unknown and 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 current available information.

At present, there is no tariff for the majority of emergency surgical care; funding for emergencies is less than the cost of providing the service. It is estimated that in 2012 there was a national funding reimbursement shortfall of £300 million for care for patients needing emergency laparotomy.78

It is recognised that the funding streams for emergencies must be reviewed. Financial sustainability is a key component of the NHS’s Five Year Forward View.6 For sustainability to be achieved, a ‘whole-system transformation’ programme is being undertaken. This is the development of business models and economic impact assessments to support development of new care models and major service change proposals. A follow-up document, Next Steps for the NHS Five Year Forward View,188 recognises this need and places urgent and emergency care as one of the NHS priority areas for 2017–2018 and 2018–2019. Without adequate dedicated funding for emergency anaesthesia, driving up the quality of care will be difficult and variable.6,21,136

The principle of having defined care pathways for emergencies with a strong emphasis on quality improvement programmes laid out in this chapter fit well with the NHS financial and commissioning principles.136 However, with an ageing population with more extensive comorbidities, emergency anaesthesia and surgery are likely to increase and associated costs are likely to rise.

8. Audit, quality improvement and research

It is important that audit services closely identify areas of best practice and areas where improvements can be made. Regular systematic audit has been shown to improve outcomes.19,189

Detailed recommendations for clinical governance are comprehensively described in GPAS Chapter 1: The Good Department.


Robust data collection underpins much of the success in documenting and learning from experiences.2,19,27 All institutions providing anaesthesia care to patients needing emergency surgery should collect the required data to be able to produce an annual report. This report should be reviewed regularly and used for organisational learning.85


Local level audit of service provision and adherence to the national clinical standards for delivery of anaesthesia for emergency surgery should be a continuing and important part of departmental audit activity.190


Continuing audits of mortality and morbidity outcomes, patient experience, demand on services, emergency theatre capacity, efficiency and productivity should be performed. Reports of relevant data should be made readily available to staff.14,137


National level audit of emergency surgical activity and outcome is essential; all hospitals delivering emergency surgical care must contribute to the recognised national or other major audits of safe practice and critical incident reporting systems.2,130,190,191,192,193,194


Outcomes for types of emergency surgery not covered by national audits should be audited via hospital episode statistics for benchmarking purposes.


Anaesthetists should be involved in audit cycles, preferably using a rapid-cycle quality improvement approach. These cycles benchmark standards of care and may be effective change drivers. This approach is 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.27,189


Quality improvement teams should be considered to drive change. It is important that audit services closely identify areas of best practice and areas where improvements can be made. Regular, systematic audit has been shown to improve outcomes.27,188


Anaesthesia departments should participate in research activities of national bodies including the National Institute of Academic Anaesthesia, Health Services Research Centre, UK Perioperative Medicine Clinical Trials Network and Research and Audit Federation of Trainees.

9. 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 requires departments of anaesthesia to benchmark themselves against them 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 for departments to refer to while working through their gap analyses.

Departments of anaesthesia are given the opportunity to engage with the ACSA process for an appropriate fee. Once engaged, departments are provided with a College guide, either a member of the ACSA committee or an experienced reviewer, to assist them with identifying actions required to meet the standards outlined in the document. Departments must demonstrate adherence to all ‘priority one’ standards listed in the document to receive accreditation from the RCoA. Accreditation 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 that 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 extension, the GPAS recommendations, to ensure that they are able to 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.

Areas for future development

Recommendations for further research

Following a systematic review of the literature, the following areas for future research are suggested. Although these recommendations apply to all emergency patients, they are particularly pertinent to the older patient:7,198


  • research including longer-term follow-up to assess post-discharge complications and readmission rates; where morbidity and mortality are measured, this should be over at least six months
  • research that includes patient-centred outcomes, particularly addressing longer-term issues such as admission to a residential care facility, residual cardiovascular morbidity, difficulties with stoma and tracheostomy care and the impact of postoperative complications
  • research on the impact of rehabilitation on medium and longer-term mortality, morbidity and patient-centred outcomes
  • calibration and validation of risk assessment tools, including predictive values for case sensitivity and specificity, with the outcomes being patient centred
  • research on the impact of changes in population demographics (e.g. the ageing population) on the future resources required
  • further research on the use of care bundles, particularly looking at outcomes from care bundles compared with single interventions
  • research considering consent in the emergency context
  • training methodology and the place of simulation
  • the costing of emergency surgery, including critical care services, cancellation or delay of elective work and care post-hospital discharge
  • development of mathematical models to determine the optimal size of emergency teams on call196
  • network collaboration to establish standards for the top 20 emergency procedures.

Recommendations for local audit

  • Scheduled reports (e.g. NCEPOD, NELA).
  • Participation in local and national audit of risk-adjusted mortality and morbidity.
  • Variation in work patterns, resource allocation, efficiency, systems of care.


Autonomous practising anaesthetist – a consultant or staff grade, associate specialist and specialty doctor who can function autonomously to a level of defined competencies, as agreed within local clinical governance frameworks.

Clinical lead - staff grade, associate specialist and specialty doctors undertaking lead roles should be autonomously practising 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 continuing professional development activities. Individuals should be fully supported by their clinical director and should be provided with adequate time and resources to allow them to effectively undertake the lead role.

Core theatre team – the emergency theatre team consists of surgical, anaesthesia and nursing staff. It may not be possible for the staff working in emergencies to form a core team that is regularly present in the department every day of the week. At the very least, one member of the surgical, anaesthesia and nursing team should be someone who works in the emergency theatre on a regular basis.

Drugs – the word ‘drug’ is used to include all medicinal products including medications, inhalational agents, fluids, certain dressings and external medicines.

Emergency anaesthesia – emergency anaesthesia within this chapter applies to anaesthesia that is given in immediate (within minutes of a decision to operate) or urgent (within hours of a decision to operate) procedures as classified by the National Confidential Enquiry into Patient Outcome and Death.1

Emergency theatre coordinator – an individual who supports the autonomously practising anaesthetist with non-clinical aspects of the emergency list on the day. The non-clinical aspects include but are not limited to coordinating meetings with multidisciplinary teams, updating the electronic booking system if applicable, patient preparation on the wards, including liaising with bed management to improve postoperative flow, availability of surgeons, any special equipment requirement, night handover and order of cases. The emergency theatre coordinator may also assist with incident reporting and activating escalation pathways. The objective is to facilitate the management of cases in an efficient manner and free the clinician to focus on clinical aspects of the patient care.

Mortality discussions – all high-risk patients should be given a clear idea of risk of death. These discussions should be based on an objective risk assessment and involve appropriate members of the multidisciplinary team. The objective is to make clinician recommendations, a shared decision process. These discussions need documenting in medical records, particularly in high-risk patients.


Policies – the term ‘policies’ is used as an umbrella term to refer to a form of locally agreed process that is maintained, kept up to date (reviewed at least every three years), can be used as a reference and is used during induction. This could be in the form of a policy document, practice document or even a piece of software that fulfils the function of the standard. The important criteria are that everyone knows the reference point exists and where to find it, and that the reference point is kept up to date in accordance with the trust/board policies. Policy documents should be standardised in format, have clear review dates and should have been ratified in accordance with trust/board policies.


Readily available – unrestricted access to a facility or a device in a timely manner so that the necessary care and treatment of the patient is not delayed.


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, regional or local anaesthesia. In this document, the term post-anaesthesia care unit 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.


1. Symons N, Moorthy K, Almoudaris A et al. Mortality in high‐risk emergency general surgical admissions. Br J Surg 2013; 100: 1318–25
12. Hubbard R, Story D. Patient frailty: the elephant in the operating room. Anaesthesia 2014; 69(Suppl 1): 26–34
15. Bion J, Richardson A, Hibbert P et al. ‘Matching Michigan’: a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf 2013; 22: 110–23
16. Huddart S, Peden C, Swart M et al. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. Br J Surg 2015; 102: 57–66
17. Huddart S, Peden C, Quiney N. Emergency major abdominal surgery: 'the times they are a-changing'. Colorectal Dis 2013; 15: 645–9
24. Association of Surgeons of Great Britain and Ireland. Patient Safety: A Consensus Statement. London, 2010
25. Pandit J, Westbury S, Pandit M. The concept of surgical operating list ‘efficiency’: a formula to describe the term. Anaesthesia 2007; 62: 895–903
27. Murray D. Improving outcomes following emergency laparotomy. Anaesthesia 2014; 69: 300–5
28. Walker N, Lehman J, Tanqueray T. Using NELA data to produce sustained improvements in patient outcomes: data analysis and feedback strategies at Homerton University Hospital. Anaesthesia 2017; 72 (Supplement 2): 92
30. Johnston MJ, King D, Arora S et al. Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. Am J Surg 2015; 209: 45–51
32. MacKay D, Sisk J, Daniel M, MacRae. B Keeping the flow, a quality improvement project for emergency theatres. Anaesthesia 2018; 73(Suppl 3): 105
33. Key T, Reid G, Vannet N et al. ‘Golden patient’: a quality improvement project aiming to improve trauma theatre efficiency in the Royal Gwent Hospital. BMJ Open Qual 2019; 8(1): e000515. doi: 10.1136/bmjoq-2018-000515
34. Veeratterapillay R, Vasdev N, Maguire N, et al. Theatre utilisation in urology theatres at a UK tertiary referral centre. Urology News 2014;18(6): 7–8
35. Stabile M, Cooper L. The evolving role of information technology in perioperative patient safety. Can Anaesth 2013; 60: 119–26
36. Kluger Y, Ben-Ishay O, Sartelli M et al. World Society of Emergency Surgery study group initiative on timing of acute care surgery classification (TACS). World J Emerg Surg 2013 1; 8: 17
37. Desai SS, Cosentino J, Nagy K. Intentional clinical process design to improve outcomes for patients who require emergency surgery. J Nurs Adm 2018; 48: 407–12
39. Pearse RM, Van Zaane B, Moreno RP et al. Start times of emergency surgery and in-hospital mortality: a cohort study on the eusos database comparing mortality after day shift, evening shift and night shift procedures. In: ESICM 2013Abstracts of Oral Presentations and Poster Sessions. Intens Care Med 2013; 39: S349
43. Association of Anaesthetists of Great Britain and Ireland. AAGBI: Consent for anaesthesia 2017. Anaesthesia 2017; 72: 93–105
44. Poulton T, Murray D; National Emergency Laparotomy Audit (NELA) project team. Pre-optimisation of patients undergoing emergency laparotomy: a review of best practice. Anaesthesia 2019; 74:100–7
46. Surviving Sepsis Campaign. Recommendations: Hemodynamic Support and Adjunctive Therapy. 2013
47. Association of Anaesthetists of Great Britain and Ireland. Theatre Efficiency: Safety, quality of care and optimal use of resources. London, 2003
48. Van de Putte P, Perlas A, Hardman JG. Ultrasound assessment of gastric content and volume. Br J Anaesth 2014; 113: 12–22
49. Edozien LC. UK law on consent finally embraces the prudent patient standard. BMJ 2015; 350: h2877
51. Royal College of Nursing. Perioperative Fasting in Adults and Children: An RCN guideline for the multidisciplinary team. London, 2005
53. Preiser J-C, van Zanten AR, Berger MM, et al. Metabolic and nutritional support of critically ill patients: consensus and controversies. Crit Care 2015; 19: 35
54. Casaer MP, Van den Berghe G. Nutrition in the acute phase of critical illness. N Engl J Med 2014; 370: 1227–36
56. Levy JH, Faraoni D, Spring JL, et al. Managing new oral anticoagulants in the perioperative and intensive care unit setting. Anesthesiology 2013; 118: 1466–74
60. Frost PJ, Wise MP. Early management of acutely ill ward patients. BMJ 2012; 345: e5677
65. Nathanson, M, Andrzejowski J, Dinsmore C et al. Guidelines for safe transfer of the brain-injured patient: trauma and stroke, 2019: Guidelines from the Association of Anaesthetists and the Neuro Anaesthesia and Critical Care Society. Anaesthesia 2020; 75: 234–46
67. Starmer AJ, Spector ND, Srivastava R et al. Changes in medical errors after Implementation of a handoff program. N Engl J Med 2014; 371: 1803–12
69. Association of Anaesthetists of Great Britain and Ireland. Immediate Post-anaesthesia Recovery 2013. Anaesthesia 2013; 68: 288–97
71. Frerk C, Mitchell VS, McNarry AF et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015; 115: 827–48
72. Henderson J, Popat M, Latto I et al. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2012; 67: 452–52
74. Association of Anaesthetists of Great Britain and Ireland. Checking anaesthetic equipment 2012. Anaesthesia 2012; 67: 660–8
75. Association of Anaesthetists of Great Britain and Ireland. Blood transfusion and the anaesthetist: management of massive haemorrhage. Anaesthesia 2010; 65: 1153–61
77. Sheetz KH, Waits SA, Krell RW et al. Improving mortality following emergency surgery in older patients requires focus on complication rescue. Ann Surg 2013; 258: 614–17
78. Khan M, Azim A, O'Keeffe T et al. Geriatric rescue after surgery (GRAS) score to predict failure-to-rescue in geriatric emergency general surgery patients. Am J Surg 2018; 215: 53–7
81. Bennett, S. Preparation for and organisation during a major incident. Surgery 2018; 36: 389–93
83. de Vries EN, Prins HA, Crolla RM et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010; 363: 1928–37
85. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki declaration on patient safety in anaesthesiology. Eur J Anaesthesiol 2010; 27: 592–7
88. Yap C, Hargreaves T, Kelly C. Developing a 24/7 mechanical thrombectomy service. J Neurosurg Anesthesiol 2020; 32: E2–3
105. Taylor J, Chandramohan M, Simpson KH. Radiation safety for anaesthetists. Cont Educ Anaesth Crit Care Pain 2013; 13: 59–62
107. Klein AA, Meek T, Allcock E et al. Recommendations for standards of monitoring during anaesthesia and recovery 2021. Anaesthesia 2021; 76: 1212–23
108. Nolan JP, Cariou A. Post-resuscitation care: ERC–ESICM guidelines 2015. Intensive Care Med 2015: 41: 2204–6
111. Ahmad I, El-Boghdadly K, Bhagrath R et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2019; 75: 509–28
115. Klein AA, Bailey CR, Charlton AJ et al. Association of Anaesthetists guidelines: cell salvage for peri-operative blood conservation. Anaesthesia 2018; 73: 1141–50
118. Pandit JJ, Andrade J, Bogod DG et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth 2014; 113: 549–59
119. Perumal S. Introduction of an 'anaesthetics emergency drugs' box for use in non-theatre situations at Hammersmith Hospital. Anaesthesia 2019; 74: 63
121. Association of Coloproctology of Great Britain and Ireland, Association of Upper Gastro-intestinal Surgeons and Association of Surgeons of Great Britain and Ireland. Issues in Professional Practice. Emergency General Surgery: A joint document. London, 2012.
123. Moonesinghe SR, Walker EMK, Bell M. Design and methodology of SNAP-1: a Sprint National Anaesthesia Project to measure patient reported outcome after anaesthesia. Perioper Med (Lond) 2015; 4: 4
124. Pearse RM, Moreno RP, Bauer P et al. Mortality after surgery in Europe: a 7 day cohort study. Lancet 2012; 380: 1059–65
125. Hutchings A, Durand MA, Grieve R et al. Evaluation of the modernization of adult critical care services in England: time series and cost effectiveness analysis. BMJ 2009; 339: b4353
127. Villemure C, Georgescu LM, Tanoubi I et al. Examining perceptions from in situ simulation-based training on interprofessional collaboration during crisis event management in post-anesthesia care. J Interprof Care 2019; 33:182–9
128. Weller JM, Torrie J, Boyd M et al. Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized controlled trial. Br J Anaesth 2014; 112: 1042–9
129. Parry A. Teaching anaesthetic nurses optimal force for effective cricoid pressure: a literature review. Nurs Crit Care 2009; 14: 139–44
130. Sevdalis N, Hull L, Birnbach D. Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress. Br J Anaesth 2012; 109(Suppl 1): i3–16
133. Kim S, Jabori S, O’Connell J et al. Research methodologies in informed consent studies involving surgical and invasive procedures: time to re-examine? Patient Educ Couns 2013; 93: 559–66
134. Swindin J, Daunt M, Mole J, Banks V. Patient information for emergency laparotomy: what do patients want to know? Anaesthesia 2016; 71: 82
140. Blackwood D, Santhirapala R, Mythen M, Walker D. End of life decision planning in the perioperative setting: the elephant in the room? Br J Anaesth 2015; 115: 648–50
143. Sivarajah V, Walsh U, Malietzis G et al. The importance of discussing mortality risk prior to emergency laparotomy. Updates Surg 2020; 72: 859–65
147. Bolger JC1, Zaidi A1, Fuentes-Bonachera A et al. Emergency surgery in octogenarians: Outcomes and factors affecting mortality in the general hospital setting. Geriatr Gerontol Int 2018; 18: 1211–14
148. Ibitoye S, Braude P, Carter B et al. Geriatric assessment is associated with reduced mortality at 1-year for older adults admitted to a major trauma centre. Ann Surg 2021; 22 July. doi: 10.1097/SLA.0000000000005092
149. Oliver C, Bassett M, Poulton T et al. Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 National Emergency Laparotomy Audit patients. Br J Anaesth 2018; 121: 1346–556
150. Lees MC, Merani S, Tauh K, Khadaroo RG. Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis. Can J Surg 2015; 58: 312–17
151. Alcock M, Chilvers C. Emergency surgery in the elderly: a retrospective observational study. Anaesth Intensive Care 2012; 40: 90
152. Knipe M, Hardman JG. I. Past, present, and future of ‘Do not attempt resuscitation’ orders in the perioperative period. Br J Anaesth 2013; 111: 861–3
164. Association of Anaesthetists of Great Britain and Ireland. Peri-operative management of the obese surgical patient 2015. Anaesthesia 2015; 70: 859–76
166. O'Carroll J, Engleback M, Campbell L et al. Cumulative marginal gains to improve the quality of care and reduce mortality of patients undergoing emergency laparotomy surgery. Anaesthesia 2017; 72: 91
168. Eugene N, Oliver CM, Bassett MG et al. Development and internal validation of a novel risk adjustment model for adult patients undergoing emergency laparotomy surgery: the National Emergency Laparotomy Audit risk model. Br J Anaesth 2018; 12: 739–48
170. Turan A, Yang D, Bonilla A et al. Morbidity and mortality after massive transfusion in patients undergoing non-cardiac surgery. Can J Anaesth 2013; 60: 761–70
171. Pachter D, Cope S. Laws D. Improving patient outcomes following emergency laparotomy: Assessing the impact of quality improvement measures based on NELA recommendations. Anaesthesia 2017; 72: 91
172. Association of Anaesthetists of Great Britain and Ireland. Peri-operative management of the surgical patient with diabetes 2015. Anaesthesia 2015; 70: 1427–40
174. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery during pregnancy. Obstet Gynecol 2011; 117: 420–1
176. Upadya M, Sanest PJ. Anaesthesia for non-obstetric surgery during pregnancy. Indian J Anaesth 2016; 60: 234–41
177. Bouyou J, Gaujoux S, Marcellin L et al. Abdominal emergencies during pregnancy. J Visc Surg 2015; 152(6 Suppl): S105–15
178. Heesen M, Klimek M. Nonobstetric anaesthesia during pregnancy. Curr Opin Anaesthesiol 2016; 29: 297–303
179. shambi MC, Kinsella SM, Popat M et al. Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015; 70: 1286–306
181. Jain V, Chari R, Maslovitz S et al. Guidelines for the Management of a Pregnant Trauma Patient. J Obstet Gynaecol Can 2015; 37: 553–71
182. Chau A, Tsen LC. Fetal optimisation during maternal sepsis: relevance and response of the obstetric anaesthesiologist. Curr Opin Anesthesiol 2014,27:259–266
183. Chu TC, McCallum J, Yii MF. Breastfeeding after anaesthesia: a review of the pharmacological impact on children. Anaesth Intensive Care 2013; 41: 35–40
184. Dallas PG, Bosak J, Berlin C. Safety of the breast-feeding infant after maternal anaesthesia. Paediatr Anesth 2014; 24: 359–71
189. Farrell C, Hill D. Time for change: traditional audit or continuous improvement? Anaesthesia 2012; 67: 699–702
195. Peden C, Grocott M. National Research Strategies: what outcomes are important in peri‐operative elderly care? Anaesthesia 2014; 69: 61–9
196. van Oostrum J, Van Houdenhoven M, Vrielink M et al. A simulation model for determining the optimal size of emergency teams on call in the operating room at night. Anesth Analg 2008; 107: 1655–62