Perioperative medicine

Pre-operative assessment and optimisation

A prospective observational study conducted prior to the pandemic estimated that 14% of surgeries are cancelled on the day.¹⁰ Although system challenges, such as lack of beds and workforce pressures, lead to short-notice cancellations, many patients change their mind at late notice or have their procedure cancelled due to a medical problem on the day of surgery. A large proportion of these non-service-related cancellations are avoidable and occur due to an oversight in pre-operative care.

Patients require evidence-based pre-operative assessment and optimisation tailored to the individual and the surgical procedure. Assessment should incorporate screening for predictors of adverse outcome (eg ‘lifestyle’ factors, poor physiological status, multimorbidity or frailty) as identification can prompt targeted interventions; for example, prehabilitation is a targeted pre-operative programme to address nutrition, physical activity and psychological issues.¹¹ Such programmes incorporate behaviour change interventions, including smoking cessation, alcohol reduction and weight management, during an important ‘teachable moment’ before surgery.¹² Prehabilitation programmes are being established across the NHS, with signals of positive impact, but have been variably implemented. In contrast, the high-risk population often requires optimisation across additional medical, functional, social and psychological domains. In such groups, there is evidence of clinical and cost effectiveness for innovative models of care, using comprehensive geriatric assessment (CGA) and optimisation methodology.^13–15 Although there has been a substantial increase in CGA-based perioperative services over the past 10 years, again there is variable implementation due to shortage of expertise, education and training programmes, and funding.¹⁶

Many patients do not attend for surgery and one in seven patients express regret having had surgery.¹⁷ This suggests a lack of honest communication between patients and professionals about what matters to patients. As such, it is important to ensure clarity about the intended benefits and risks of surgery, alternative treatment options and to ground this in what the patient wants to achieve through a procedure. Many resources are available to support such shared decision making and certainly all ‘high-risk’ surgical patients (defined as having a predicted 30-day mortality risk >1%) should routinely be offered a shared decision-making consultation.^5,18 In settings where this is offered, one in seven patients choose not to go ahead with high-risk surgery, with huge impact both for patients and for healthcare systems.¹⁹ A national approach to establishing such services is required and underway.

Diabetes

It is estimated that up to 15% of patients who have surgery also have diabetes.²⁰ Unfortunately, they are less likely to have successfully completed day-case procedures and have higher postoperative morbidity rates, longer hospital stays and higher readmission rates in comparison with those without diabetes.²¹ This is related to unwarranted variation in perioperative management of diabetes.²² The number of patients with diabetes having glycated haemoglobin (HbA_1c) measured pre-operatively is increasing, yet no specialty has >90% of diabetic patients with a HbA1c <8.5% pre-operatively.²³

It is clear that the identification, management and monitoring of diabetes perioperatively needs to be improved, and this can be supported with ‘whole pathway’ guidelines, such as those published by the Centre for Perioperative Care (CPOC).²⁰ Case studies illustrate how such guidelines can be implemented to reduce pre-operative admissions, insulin errors and hypoglycaemic events, and improve patient experience.⁵ Another centre has developed a technological solution to enhance perioperative diabetic management, with an electronic system that allows monitoring of patients with diabetes through the perioperative period and facilitates timely specialist review where needed. This has reduced postoperative readmissions and saves 100 bed days per month.²¹

Perioperative blood management

One-third of patients presenting for surgery have anaemia, which is a predictor of perioperative morbidity and mortality.²⁴ Perioperative blood management (PBM) pathways provide a systematic approach to the diagnosis and management of anaemia and are evidenced to reduce perioperative transfusion rates.⁵ However, the recent perioperative quality improvement programme (PQIP) report shows that 68% of anaemic patients are still not receiving treatment for anaemia prior to surgery.²³

The Getting It Right First Time (GIRFT) programme has found unwarranted variation in criteria for anaemia diagnosis, availability of diagnostic tests for anaemia, treatment of anaemia and reporting of local transfusion rates.⁵ Results from a GIRFT survey demonstrated that only 60% of trusts have cell salvage equipment that are key to intraoperative blood conservation strategies and reducing perioperative use of blood products. However, there are sites of exemplary practice, illustrating how implementation of a comprehensive perioperative anaemia pathway for patients undergoing surgery with a haemoglobin level <130 g/L can reduce perioperative transfusion rates and reduce length of hospital stay.⁵ Another site has routinely used cell salvage in obstetric theatres since 2007 and offers a competency-based in-house training programme for all anaesthetic practitioners. Up to 40% of collections are sufficient to be processed and, in 2019, the obstetric department transfused only 300 units of blood.⁵ They have demonstrated that the routine use of cell salvage is cost effective and safe.

Day-case surgery

Converting elective inpatient surgical care to day-case activity offers important opportunities to healthcare services, including increased bed capacity and reduced on-the-day cancellation of surgery. This, in turn, helps to tackle waiting lists, allows continuation of elective surgery during periods of service pressure (for example, in winter) and reduces service costs.⁵ More importantly, day-case pathways are well accepted by patients as they offer shorter waiting times, reduced risk of hospital-acquired infection and improved outcomes. Although nationally the proportion of surgical interventions undertaken on a day-case basis continues to increase, there remains variation in the proportion of total elective surgical admissions delivered as day cases between individual NHS trusts, ranging from 44%–89% and within individual specialties.^5,25 Effective perioperative care is essential in helping to facilitate the expansion in day surgery to ensure that:

• there is robust patient selection and management of comorbidities to deliver same-day discharge and prevent unanticipated inpatient admission

• best practice is incorporated for pre-emptive standardised analgesia, antiemetics and hydration regimens to facilitate early discharge

• comorbidities that may have previously prevented day-case admission (such as obstructive sleep apnoea, obesity and dementia) are no longer maintained as absolute contraindications; indeed, only patients with an American Society of Anesthesiologists' Physical Status Score (ASA) IV or those with severe unstable or unmanaged systemic disease should not be considered for day-case surgery²⁶

• there is a robust management plan in place for pre-operative issues that are recognised to cause difficult postoperative management (for example, patients with pre-operative chronic pain need a proactive management plan formulated in collaboration with the pain team to facilitate effective day-case surgery).²⁷

The benefits of day-case surgery combined with advancements in less invasive forms of surgical intervention and a change in culture towards acceptance of day-case procedures as the default are set to see day-case surgery rates increase. Local data can be used to influence practice, as demonstrated at a unit that successfully reduced their admission rate following planned day-case surgery by 5% through embedding a quality improvement programme. Key changes included improved scheduling, enhanced nurse-led discharge protocols, implementation of a postoperative urinary retention policy, improved pain management and implementation of a ‘sip until we send’ policy to prevent pre-operative dehydration. Sharing learning between units is necessary to support uptake of such processes.

The elective surgical population

Despite the benefits of day-case surgery, patients with multiple comorbidities or undergoing complex major surgery often require elective inpatient admission. Unfortunately, there remains widespread unwarranted variation across all specialties in postoperative length of stay, in turn, affecting flow through the hospital. ‘High-risk’ patients, defined either by the surgical procedure or patient-level factors, are particularly at risk of preventable postoperative complications and prolonged admission.²³ The occurrence, severity and duration of such complications can be prevented through quality pre-operative assessment, optimisation, shared decision making and planning of the perioperative period including attention to treatment escalation and advanced care planning.¹⁴

Enhanced recovery (ER) programmes, designed to expedite surgical recovery, promote optimal outcomes and prevent prolonged postoperative hospital admissions were introduced into the NHS over 15 years ago.²⁸ Although the evidence of benefit is clear, GIRFT has observed reduced emphasis on delivery and development of ER pathways.^29,30 Additionally, there is unwarranted variation across surgical sub-specialties in enrolment to ER programmes, despite a high number of commonalities in pathways between specialties.⁵ A simplified and generic enhanced recovery concept has been developed to improve early postoperative recovery by focusing on early drinking, eating, and mobilising (DREAMing).³¹ Although DREAMing concentrates on three easily measurable outcomes, several factors, such as pain control and hydration, must be appropriately maintained before successful DREAMing is achieved.²³

In recent years, other innovative models of care have been established to support delivery of quality perioperative care for patients with coexisting multimorbidity and frailty. Patients with such pathophysiological profiles are more likely to experience postoperative complications, of which, the majority occur from postoperative day 3 onwards and are ‘medical’ in nature (for example, delirium, respiratory complications or acute kidney injury). These evidenced models of care utilise CGA and optimisation methodology; they are increasingly advocated and adopted in the NHS and internationally.¹⁶ Such programmes have highlighted the need for collaborative working between physicians, surgeons and anaesthetists to ensure perioperative care is patient centred rather than specialty centred.^32,33

The emergency surgical population

Emergency surgical admissions account for less than 20% of all surgical admissions, yet they have a major impact on the efficient running of elective surgical services. Interestingly, of those admitted on an emergency surgical take, only 40% proceed to surgery during that admission, with 15% of operations occurring within 24 hours. Within the whole cohort, emergency surgery is more common in those aged 85 years or above than any other age group.⁵ As the number of pre-existing medical comorbidities and frailty also increases with age, it is not surprising that this cohort has the highest level of postoperative complications, prolonged hospital stays and elevated mortality rates of all surgical patients.^5,34–36

Indeed, in 2020, 30-day mortality following emergency surgery for neck of femur fracture was 8.3% and 1-year mortality was up to 30%.37,38 This is not dissimilar to the 1-year mortality seen post-emergency-laparotomy or in patients who presented to urological services with acute urinary retention requiring intervention.^34,39 However, there is significant variation in short- and long-term outcomes for the emergency surgical population, with units employing orthogeriatric teams or CGA-based frailty teams for emergency laparotomy patients demonstrating better outcomes.^13,33,40 Unfortunately, despite the evidence for orthogeriatric models of care, National Institute for Health and Care Excellence (NICE) guidance and a Best Practice Tariff, there remains huge variation in provision of services.^37,41,42 It is, therefore, not surprising that, although National Emergency Laparotomy Audit (NELA) reports an increase in the number of older people undergoing laparotomy being reviewed by a geriatric medicine team over the past 5 years, this figure remains low in the absence of clear financial incentives.

Critical care and enhanced care

Prior to the pandemic, approximately 170,000 patients per annum were admitted to critical care in England and Wales following surgery.⁵ The benefits of early critical care admission compared with ward-level care include higher staffing ratios, recognition of early deterioration, and availability of advanced treatment modalities. Unfortunately, there remains widespread inequity of access to critical care for post-surgical patients due to a shortage of critical care capacity, increasing demand and differences in admission criteria/cultures between providers.⁴³ Lack of postoperative critical care capacity is a leading cause of late-notice surgical cancellations, and patients often experience delays in treatment of post-surgical complications while they await transfer to a critical care unit.¹⁰

Enhanced care services may provide a solution, having been developed to bridge the gap between traditional ward-level care (level 0) and critical care (levels 2/3). These services (more recently termed ‘level 1’) are staffed by a skilled workforce and provide higher levels of monitoring, and intervention than is routinely available on a surgical ward.⁴⁴ This level of care is distinct from critical care but can support early identification of the deteriorating post-surgical patient and commence treatments, such as haemodynamic support without delay.⁵ To support efficient surgical delivery, pre-operative assessment (for elective patients) or on-admission assessment (for emergency admissions) should include a documented decision on whether the patient will require level 1, 2 or 3 care postoperatively and form part of treatment escalation plans.

Enhanced care services established in this manner have reduced length of hospital stay, critical care utilisation and complication rates.⁴³ Further development of these services is hoped to reduce the number of planned and unplanned critical care admissions, reduce on-the-day cancellation of surgery and provide a better postoperative experience for patients.⁴⁵