Current Anaesthesia & Critical Care 21 (2010) 142147

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Current Anaesthesia & Critical Care

journal homepage: www.elsevier.com/locate/cacc

FOCUS ON: ENHANCED RECOVERY

Pre-operative preparation: Essential elements for delivering enhanced recovery pathways

Michael Swart*, Kerri Houghton
Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, Devon TQ2 7AA, United Kingdom

s u m m a r y
Keywords: Pre-operative preparation Pre-operative assessment Pre-operative testing

Pre-operative preparation is the rst stage in the enhanced recovery process. If it goes wrong it will adversely impact on the peri and post-operative stages of enhanced recovery. If done well it enables the success of enhanced recovery. At this stage the expectations of the patient and their family are set to prepare them for the planned surgery and its effects on the patient. It involves both primary and secondary care. Information is transferred both from the patient and to the patient. This is done by verbal, written and increasingly electronic communication. The patient is evaluated to ensure that there is no medical or social cause to prevent the enhanced recovery process. This has been referred to in the past as pre-assessment but is probably more accurately called pre-operative preparation. 2010 Published by Elsevier Ltd.

1. Overview: the objectives of a pre-operative preparation service The development of a coherent pre-operative service is fundamental to delivering the smart pathways of an enhanced recovery service. Assessment and preparation of the patient referred for potential elective surgery needs to start in primary care and continue seamlessly into secondary and tertiary services. All patients should receive the same standard of pre-operative service whether or not it is intended that they will follow an enhanced recovery pathway. This includes patients who have their surgery in the out patient clinic or the day surgery unit (often described as ofce based surgery and ambulatory surgery in North America). The service should be designed in such a way that it achieves the following  agreement with primary care that they will only refer patients for non-urgent surgery if they are in the best possible condition and are willing to consider having surgery as a treatment option.  clarity around what the patient expects to achieve by undergoing a surgical procedure.  a process that is completely patient focussed.  no unnecessary delays for patients, clinicians and hospitals.

* Corresponding author. Tel.: 44 01803 655196. E-mail addresses: michael.swart@nhs.net (M. Swart), kerri.houghton@nhs.net (K. Houghton). 0953-7112/$ see front matter 2010 Published by Elsevier Ltd. doi:10.1016/j.cacc.2010.02.003

 waiting times compatible with achieving an 18-week Referral to Treatment Time (18-week RTT) in England or other agreed treatment target times.  a full medical and social assessment.  immediate access to the appropriate tests and investigations.  a comprehensive information package specic to each surgical procedure that takes into account the patients social, cultural, and ethnic background.  an individualised assessment of risk to help the patient in using informed decision making to achieve consent.  access to a range of health professionals to plan care appropriate to the operation and the patients individual needs.  a nurse based service supported by doctors from all of the required medical specialties.  optimisation of patients condition prior to surgery including access to weight and smoking management and exercise programmes.  a plan for managing therapies prior to admission such as anticoagulation and diabetic treatment.  identication of the necessary level or type of post-operative care.  a discharge process that is planned right from the start, including home visits and support in the community where appropriate.  excellent communications with patients, carers and all agencies involved in their care.  efciency for the health community through minimising do not attends (DNAs), cancellations on the day of surgery and inability to access critical care beds through inadequate planning.  the ability to admit on the day of surgery.

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 a clear point of contact for the patient throughout the preoperative period.  a denite date for surgery, booked at a time convenient for the patient.  the ability to combine the pre-operative service with other clinics or investigations to provide a one-stop visit.  the above will clarify the patients expectations for perioperative and post-operative care.  a strategy for ongoing management of patients who either decline surgery or have their surgery deferred for medical reasons must be in place.

The stages that need addressing are 1. information gathering 2. information giving 3. the ordering of appropriate investigations, tests and the scrutiny of any abnormal ndings 4. organisation of actions consequent on them, including further investigation or tests 5. review and as necessary, further communication with the patient 6. as appropriate, further communication with any clinicians caring for the patient 7. discussion between patient and clinical staff leading to informed decision making and consent 8. optimisation of the patients condition Ideally a pre-operative service should be combined with booking for ease of communications. Stages 13 can easily be achieved through a number of models      primary care practitioners telephone interviews internet questionnaire or other IT-supported methods an intermediate assessment service a secondary care based service

2. History In 1949 J. Alfred Lee described his Anaesthetic Out Patient Clinic that was intended to make patient as safe for surgery as possible.1 He states that patients should be seen and as soon as possible after his name is added to the waiting list. This and many other comments he makes hold just as true sixty years later. Thirty years ago most UK surgical practice involved pre-operative admission to hospital for investigations instigated by trainee medical staff the day or days before surgery. This was followed by a long post-operative stay in hospital. Changes in surgical practice, an increased volume of surgery, the advent of both ofce based and same day surgery, reduction in trainee doctors hours and a desire to drive down health care costs have led to the development of pre-operative assessment clinics. These have been predominantly nurse-led2,3 usually with some medical support particularly for high-risk patients.4 There are a number of different styles of clinic in use and while there is no uniformity between different countries or even within the same country they do share many common themes.5,6 In addition to the publications describing the out patient pre-operative process there is evidence that changing the pre-operative process to an out patient clinic reduces cancellations on the day of surgery, reduces investigations and reduces patients anxiety.710 3. The optimum process and setting for pre-operative preparation All patients undergoing elective surgery should undergo preoperative assessment that is centred on preparing the patient and their family for the proposed surgery. Information gathering and test ordering is the easy part of the process; decision making consequent on these ndings and addressing the detail of organisation of the admission is much more difcult. Pre-operative preparation should start in Primary Care from the time that a referral to a specialist service is made for possible surgery. The general practitioner can play a major part by performing a t for list health screening, identifying causes of increased morbidity such as anaemia, sub-optimal diabetic control, obesity, smoking and general low levels of physical tness and instigating management plans to optimise the patients condition. As soon as surgery becomes a denite option, further elements of the preparation can take place and a face-to-face pre-operative assessment should be performed as soon as possible in the specialist setting by clinicians who fully understand the enhanced recovery pathway and its requirements. Pre-operative assessment and preparation can take place wherever there is access to the skills that can deliver the components described in the Overview section. This could be achieved in a variety of ways and places depending on local facilities, policies and protocols. Delays that affect compliance with 18 week RTT (referral to treatment) or more challenging local targets must be avoided.

Stages 47 involve more complex patients and processes and will normally require some specialist input. Stage 8 can and should take place at every possible opportunity as the patient moves through the surgical pathway from primary care to secondary care and back. Everyone who interacts with the patient should be involved in this process irrespective of the professional background or relationship with the patient. There should be a clear model which risk straties patients and then denes how the pre-operative preparation process should be conducted and by whom. Lower risk patients can be seen by nurses trained in pre-operative assessment, while higher risk patients will need to see an anaesthetist and may in addition need to undergo advanced testing. Peri-operative risk of death and morbidity can be inferred from the age and sex of the patient. In the UK the Ofce for National Statistics through the government actuarial department (www.gad.gov.uk) publishes life expectancy data for age, sex and region.11 Adding in a history of medical co-morbidities can further rene this risk. Heart failure is probably the biggest risk factors but other risk factors have been demonstrated by Lee in a Revised Cardiac Risk Score.12,13 Finally individual hospital data and national data on survival after different types of major surgery can rene the risk assessment even further. To optimise the use of medical and nursing staff it may be helpful to triage patients into three groups based on risk of peri-operative death. Patients can then be assigned to a low risk (risk of death better than 1 in 200) nurse-run clinic, to a medium risk (risk of death between 1 in 100 and 1 in 200) clinic with nurse and anaesthetist, or a high-risk (risk of death more than 1 in 100), medically led clinic with facilities for advance testing. A model that has been successfully trialled in knee and hip joint in knee and hip joint replacement surgery is described in Appendix A. Achieving true informed decision making is difcult without a face-to-face interview although tools are being developed to help support this process. Patients may prefer personal contact with a team who will deliver their care in hospital. Some patients may wish to have initial engagement with their pre-operative preparation by using the Internet in the comfort of their own home or near to their home at their primary care health centre. Others may want to attend a clinic on the site where they are going to have the future

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surgery. Undergoing surgery for the rst time or in an unfamiliar setting provokes a similar emotional response as having an important job interview, taking a medical school or medical specialty examination. Before turning up for the surgery, job interview or exam you would want to know exactly where to go on the day, which entrance, car park or transport system to use and what time this will take. You may even want to do a dry run. There is the potential benet of reassurance by seeing a familiar face. In addition many questions that are important to patients concern issues that have a low importance to doctors and nurses. For example up to date information on car parking, amenities and public transport may be best obtained from staff with local knowledge. Routine pre-operative investigations and tests should be in accordance with the National Institute for Clinical Excellence (NICE) guidelines for pre-operative investigations for patients having elective available on the NICE website.14 The trend seems to be to reduce the number of investigations made pre-operatively. This started with cataract surgery and is moving into other ambulatory surgery. If patients are t and well at home and undergoing surgery, there should be minimal need for as a day case and then you returning to your own home medical investigations?1517 The chosen pre-operative process should be acceptable and convenient for patients and allow them to access all relevant information. If there is no direct contact, other methods of obtaining factual data such as blood pressure, height and weight will be necessary. The structure for the pre-operative preparation service should be designed to provide both a generic and procedure specic service. 4. Moving beyond consent to informed decision making Patients should be fully informed about the planned procedure by implementing the Good Practice in Consent Implementation Guide: Consent to Examination or Treatment (available from www. dh.gov.uk/consent).18 Informed decision making and is everything that takes place before a patient nally agrees or consents to a treatment, procedure or investigation. Consent can be viewed as the nal stage of the informed decision making process and It is based on the legal concept that without informed consent the doctor or nurse could be held liable for assaulting the patient. Informed decision making is everything that goes on before you agree or consent. There are some subtle differences between informed consent and informed decision making. Informed decision making involves assessing all the risks and benets of all types of treatment or non treatment. It also focuses on how patients make decisions, how we can help patients with assessing risk and benet of treatment and no treatment options and how we communicate these risks and benets. Put simply consent is looking at things from the doctors and nurses perspective, informed decision making is looking at things from the patients perspective. 5. Organisation Within an acute Trust, pre-operative preparation services should be combined under clear leadership from both a lead nurse and a lead anaesthetic consultant who are empowered to develop the service, design protocols and deliver education. A manager who is involved in the delivery of the surgical services should support them. There is no merit in separating out patients who are on an enhanced recovery pathway from other elective inpatients all patients should receive the same standard of care (enhanced recovery). Close links with Surgical Admissions areas/wards should be developed to ensure that pre-operative assessment is facilitating day of surgery admission for most patients, preferably to

a dedicated area separated from post-operative patients. Dialogue with Primary Care is an essential component and should be part of the remit of the leads. Administrative assistance is essential to support communications at all levels. Patient opinion and feedback should be designed into the service. Some optimising treatments can be started in Primary care for example  the optimal management of hypertension  early ferrous sulphate treatment to avoid unnecessary transfusion in patients with iron decient anaemia (males with Hb < 13, females with Hb < 12 g/dL)  pre-emptive improved diabetes management to reduce high HbA1C levels  smoking cessation  dietary advice to both improve nutritional status and gain or lose weight as appropriate  improving physical tness through formal or informal exercise programmes Pre-operative assessment should be performed by trained and competent pre-operative assessors who should be able to order and perform basic investigations and make referrals according to guidelines agreed locally by anaesthetists. This can be done safely by nursing staff.2 The anaesthetist giving the anaesthetic is ultimately responsible for the decision to proceed, but if all anaesthetists work within the agreed guidelines, the number of cancellations on the day will be negligible. Clinics with an anaesthetist present should be established to address the following functions  review of the clinical notes of patients who the pre-operative assessment nurses have identied as having a potential problem  review of any abnormal test and instigation results and the instigation of the of appropriate actions  appointments with patients undergoing major surgery for example in category 2 of Appendix A  appointments for patients requiring advanced testing such as cardiopulmonary exercise testing or dobutamine stress echocardiography if available to help assess the risk of the proposed surgery  plus extended consultation with patients who have a perioperative risk of dying that is more than 1 in 100 such as category 3 in Appendix A  optimum placement of the patient for post-operative level of care(day surgery unit, surgical ward, high dependency unit, critical care unit) 6. Stafng levels An approximation for a standard district general hospital (DGH) case-mix for 20,000 elective surgical patients per annum of whom currently 5000 are likely to be inpatients and 15,000 would be day cases would be as follows: 6.1. Nursing staff for inpatient pre-operative preparation Number of Registered Nurses (RGN) and Health Care Assistants (HCA) needed to assess 5000 inpatients per year.  In a given year a whole time equivalent (1 wte) RGN will work 42 weeks. This is determined by 52 weeks minus 8 weeks annual and bank holiday leave minus 2 weeks for mandatory training, study leave and sick leave

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 Each week the RGN working full time in POA requires 5 h management time for letters, referrals to other health care professionals, chasing up and managing the outcomes of pathology, radiology and microbiology tests  Teaching and assessment of trainee medical staff, nursing staff and ancillary staff is about 2 h per week  Therefore each whole time equivalent RGN is available for preoperative preparation for 30 h per week, 42 weeks of the year 1260 h per annum  Average time to assess and prepare a surgical inpatient is 45 min (1.33 patients per hour)  One RGN can therefore conduct 1260 1.33 consultations per year 1676 patients  Total RGN required for 5000 inpatients per year 5000/ 1676 3 RGN  Health Care Assistants (HCA) support is required at a ratio of 1 HCA : 2 RGN 1.5 HCA (Personal communication from Jackie Bell Pre-Operative Assessment Manager South Devon Health Care NHS Foundation Trust and Jane Jackson Nurse Consultant Pre-Operative Assessment West Hertfordshire Hospitals NHS Trust.) 6.2. Anaesthetic The surgical and patient case-mix will determine the number of hours of anaesthetist time that are required (see Appendix A). Patients in the amber category have a 1 in 200 risk of dying and should be seen by an anaesthetist. Patients in the red category have a 1 in 100 risk of dying and should see an anaesthetist and potentially undergo more sophisticated assessment such as a cardiopulmonary exercise test, dobutamine stress echo or equivalent followed by a consultation that supports informed decision making. Most of the literature on preoperative assessment of high-risk patients is centred on identifying the risk of a post-operative cardiac event in patients in patients undergoing non-cardiac surgery. There are some excellent guidelines on when to perform a cardiac test to identify cardiac disease before elective surgery.1921 These are often misused as guidance to assess peri-operative risk of death. The literature on long-term survival after high risk non-cardiac surgery is limited.2224 The approximate medical staff requirement per 5000 inpatients is  5 sessions per week for review of notes and results and to see booked patients (excluding high risk patients who are dened as having a peri-operative risk of dying to be 1 in 100 or worse)  5 sessions per week for cardiopulmonary exercise testing (or other equivalent investigation) and an extended consultation session for high-risk patients  1 clinical leadership session per week for audit, research, teaching, protocol development, IT development, primary care liaison  A session is 5 h 1.25 PAs  TOTAL [ 11 session (13.75 PA) per week Note that this does not cover back lling for annual or study leave 6.3. Laboratory technician support This may be needed for the maintenance of the cardiopulmonary exercise testing equipment and performance of the test or an equivalent test such as dobutamine stress echocardiography. 6.4. Pharmacist The presence in the pre-operative evaluation clinic has many benets particularly for patient safety and their input includes

 medicines reconciliation for individual patients  prescribing of current medication on drug charts ready for admission  implementation of protocols for thrombo-prophylaxis  implementation of anticoagulation protocols  diabetic management in liaison with diabetic nursing service 6.5. Therapists and specialist nurses  physiotherapy and occupational therapy have a important role to play, particularly in recovery from orthopaedic surgery and rehabilitation both in primary and secondary care  interactions with social services  specialist nurses, e.g. diabetes, stoma care, surgical specialty specic

7. Monitoring the service The pre-operative assessment service should be continuously audited and evaluated. This should look at both the process and outcomes from the different perspectives. The perspectives should include the patients, medical and nursing staff, managers and commissioners.2528 Audit information should include  number of patients who attended pre-operative assessment  number of patients who did not attend pre-operative assessment  number of patients who did not attend surgery following preoperative assessment  for day surgery number of overnight stays, with reasons  number of operations cancelled on the day of surgery or the day before surgery because the patient said the appointment was inconvenient no longer wanted the operation did not follow pre-operative instructions had a pre-existing medical condition undetected or not optimised - suffered any other failure of the process  number of operations cancelled on the day of surgery or the day before surgery because the surgeon advised that the operation was no longer necessary  number of operations cancelled by the hospital because essential resources (beds, surgeons, anaesthetists, equipment, etc) were not available  number of patients who did not proceed to surgery  number of patients not achieving day of surgery admission and reasons  feedback from patients on the quality of the service Customer Care training can greatly enhance awareness of patient perspectives. Work in evaluating pre-operative assessment and preparation clinics has to be focused on the patient, looking at their views on the service.

8. Training Pre-operative clinics are a rich source of clinical experience for all clinicians. In particular, >50% of the competencies for a Year 1 Foundation Programme doctor could be meet through such a clinic. The training needs of nurses and administrative staff must also be met. Conict of interest None.

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Appendix A

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3. Kinley H, Czoski-Murray C, George S, McCabe C, Primrose J, Reilly C, et al. Effectiveness of appropriately trained nurses in pre operative assessment: randomised controlled equivalence/non-inferiority trial. British Medical Journal 2002;325:13238. 4. Rushforth H, Burge D, Mullee M. Nurse-led paediatric pre operative assessment: an equivalence study. Paediatric Nursing 2006;18:239.

M. Swart, K. Houghton / Current Anaesthesia & Critical Care 21 (2010) 142147 5. Cantlay KL, Baker S, Parry A, Danjoux G. The impact of a consultant anaesthetist led pre-operative assessment clinic on patients undergoing major vascular surgery. Anaesthesia 2006;61:32349. 6. Bader AM, Sweitzer B, Kumar A. Nuts and bolts of pre operative clinics: the view from three institutions. Clevland Clinic Journal of Medicine 2009;76(Suppl. 4):S104S111. 7. Edward GM, Biervliet JD, Hollmann MW, Schlack WS, Preckel B. Comparing the organisational structure of the preoperative assessment clinic at eight university hospitals. Acta Anaesthesiologica Belgica 2008;59:337. 8. Rai M, Pandit J. Day of surgery cancellations after nurse-led pre assessment in an elective surgical centre: the rst 2 years. Anaesthesia 2003;58:6857. 9. Knox M, Myers E, Hurley M. The impact of pre-operative assessment clinics on elective surgical case cancellation. Surgeon 2009;7:768. 10. Power LM, Thackray NM. Reduction of pre operative investigations with the introduction of an anaesthetic-led preoperative assessment clinic. Anaesthesia and Intensive Care 1999;27:4818. 11. Klopfenstein CE, Forster A, Van Gessel E. Anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety. Canadian Journal of Anaesthesia 2000;47:51155. 12. http://www.statistics.gov.uk/StatBase/Product.asp?vlnk 14459 [accessed January 2010]. 13. Hernandez AF, Whellan DJ, Stroud S, Lena Sun J, OConnor CM, Jollis JG. Outcomes in heart failure after major non-cardiac surgery. Journal of the American College of Cardiology 2004;44:144653. 14. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major non-cardiac surgery. Circulation 1999;100:10439. 15. http://www.nice.org.uk. 16. Hepner DL. The role of testing in the preoperative evaluation. Cleveland Clinic Journal of Medicine 2009;76(Suppl. 4):S22S27. 17. Schien OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, et al. The value of routine preoperative medical testing before cataract surgery. The New England Journal of Medicine 2000;342:16875. 18. Chung F, Yuan H, Yin L, Vairavanathan S, Wong DT. Elimination of preoperative testing in ambulatory surgery. Anesthesia and Analgesia 2009;108:46775. 19. www.dh.gov.uk/consent. 20. Eagle KA, Berger PB, Calkins H, Chatman BR, Ewy GA, Fleischman KE, et al. ACC/ AHA Guideline update for perioperative cardiovascular evaluation for noncardiac surgery executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to update the 1996 guideline on perioperative cardiovascular evaluation for non-cardiac surgery). Journal of the American College of Cardiology 2002;39:54253. 21. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischman KE, et al. ACC/AHA 2007 guidelines on perioperarative cardiovascular evaluation and care for non-cardiac surgery: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. Circulation 2007;116(17):e418e499. 22. Poldermans D, Bax JJ. Dobutamine echocardiography: a diagnostic tool comes of age. European Heart Journal 2003;24:15412. 23. Carlisle J, Swart M. Mid-term survival after aortic aneurysm surgery predicted by cardiopulmonary exercise testing. British Journal of Surgery 2007;94:9669.

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24. Wijeysundera DN, Scott Beattie W, Austin PC, Hux JE, Laupacis A. Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort. BMJ 2010;340:b5526. 25. Dexter F. Design of appointment systems for preanesthesia evaluation clinics to minimize patient waiting times: a review of computer simulation and patient survey studies. Anesthesia and Analgesia 1999;89:92531. 26. Edward GM, Lemaire LC, Preckel B, Oort FJ, Bucx MJ, Hollmann MW, et al. Patient experiences with preoperative assessment clinic (PEPAC): validation of an instrument to measure patient experience. British Journal of Anaesthesia 2007;99:66672. 27. Edward GM, Das SF, Elkhuizen SG, Bakker PJ, Hontelez JA, Hollmann MW, et al. Simulation to analyse planning difculties at the preoperative assessment clinic. British Journal of Anaesthesia 2008;100:195202. 28. Edward GM, de Haes JC, Oort FJ, Lemaire LC, Hollmann MW, Preckel B. Setting priorities for improving the preoperative assessment clinic: the patients perspective and the professional perspective. British Journal of Anaesthesia 2008;100:3226.

Other sources of information

29. Guidelines for the provision of anaesthetic services. Royal College of anaesthetists, www.rcoa.ac.uk; July 1999. 30. AAGBI safety guideline: pre-operative assessment and patient preparation the role of the anaesthetist 2, www.aagbi.org; January 2010. 31. The Preoperative Association, www.pre-op.org. 32. Good practice in consent implementation guide: consent to examination or treatment. Department of Health, www.dh.gov.uk/consent; November 2001. 33. Better by the day? Day surgery in Scotland. Accounts Commission for Scotland, www.audit-scotland.org.uk; 1997. 34. Day surgery: operational guide. Department of Health, www.dh.gov.uk; August 2002. 35. Day surgery follow-up progress against indicators from a short cut to better services. Audit Commission, www.audit-commission.gov.uk; 2001. 36. British Association of Day Surgery, www.bads.co.uk. 37. Step guide to improving operating theatre performance. NHS Modernisation Agency; June 2002. http://www.institute.nhs.uk/option, com_joomcart/ Itemid,26/main_page, document_product_info/products_id,241.html. 38. Jean Sweitzer Bobbie, editor. Handbook of preoperative assessment & management. Philadelphia, PA, USA: Lippincott Williams & Wilkins; 2000. 39. Murthy BVS. Improving the patients journey: the role of Pre-operative Assessment Team. The Royal College of Anaesthetists. Bulletin May 2006;37: 18857. 40. A POA dataset has been developed to give a high level indication of the elds of data to be covered within the POA assessment process, http://www. poaunscheduledcare.org/protocol_pa.asp. It also indicates what data is expected to be automatically populated by the IT system from Connecting for Health. For more information on this dataset visit the DOAS POA project website.