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Patients must also be made aware at the preoperative assessment visit that conversion to inpatient care is always a possibility and that they should consider how this may impact on their home arrangements, including any dependent relatives.

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...

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.

The WHO’s Surgical Safety Checklist should be used and is fully endorsed by the RCoA as the instrument for promoting team working and patient safety.^10,36

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...

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.