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There must be a secure environment to enable access to patients’ notes including previous anaesthetic records and medical alerts.⁶

Objective assessment of risk should be routine and the identification of increased risk should trigger advanced planning specific to that patient. Each hospital should have a consistent and where possible evidence based system in place to identify high risk surgical patients who require additional assessment.⁵⁰ This assessment should be based on:⁵⁴

• age
• comorbidity
• medication history and allergy status...

As a minimum, all ASA 3–5 patients and those undergoing high risk surgery should have their expected risk of morbidity and mortality estimated and documented prior to an intervention, with adjustments made in accordance with national guidelines in planning the urgency of care, seniority of staff involved and postoperative care.^{16,54,60,61, 62}

There are validated general risk prediction tools available that assess the risk of 30-day mortality (and morbidity) following surgery, as well as procedure specific risk prediction tools for elective aortic aneurysm surgery.⁵⁹ There is also a wide variety of other screening and risk assessment tools that are useful in estimating the specific or additional risks accrued through the factors...

Preoperative assessment should occur as early as possible in the patient’s care pathway. Greater than two weeks preoperatively is recommended as good practice and preferably as close to the point of contemplation of surgery as possible to allow for the optimisation of chronic health conditions and health behaviours, so that all essential resources and obstacles can be anticipated prior to...

Where possible, it is preferable for one stop arrangements to be implemented so that patients can attend preoperative assessment during the same hospital visit as their surgical outpatient assessment. Ideally, the frequency of high risk clinics should allow for one stop patient visits when appropriate. The volume of information may mean that the wrong details are prioritised or recollected. Patients...

Each hospital should have agreed written preoperative policies or guidelines, following national guidelines where available, including but not limited to:

• preoperative tests and investigations^69,70
• preoperative ordering for potential blood transfusion
• preoperative fasting schedules and the administration of preoperative carbohydrate drinks^{41,42,71, 73}
• default to day surgery for suitable procedures
• escalation to higher...

Each hospital should have agreed protocols, following national guidance where available, including, but not limited to:

• management of anaemia including parenteral iron therapy to reduce the risk of allogenic blood transfusion^{75,76,77,78,79}
• antacid prophylaxis
• preoperative nutritional screening.

The secondary care preoperative service should liaise closely with primary care, other secondary care professionals and commissioners to promote a ‘fitness for referral’ process in line with best practice.

Agreed internal referral pathways to other specialties should be in place for the minority of cases in which this may be required to expedite further investigation and patient optimisation. This should be done in close collaboration between the preoperative assessment lead and nominated representatives from appropriate specialties (e.g. cardiology, diabetes, renal, respiratory and geriatric medicine).