Guidelines & Resources

Guidelines & Resources

In this section you'll find guidance and resources relevant to perioperative care, produced in collaboration with CPOC's partners or relevant third-party organisations.
 

CPOC produces guidance as an aid to support health care professionals in perioperative care. We use robust processes to develop our guidance taking into consideration expert opinion and the latest research.

We regularly review our guidance on this website.

Guidelines

Enhanced Perioperative Care Services

Enhanced Perioperative Care (EPC) is a model of care for surgical patients who cannot be optimally cared for in a general ward environment. This guidance is a joint publication from CPOC and the Faculty of Intensive Care Medicine.

Enhanced Perioperative Care provides the best pathway for patients with monitoring, treatment or care needs which are greater than those provided on normal postoperative wards, but who are not expected to require Level 2 or 3 (critical care) interventions or staffing to meet their care needs. The aim of establishing an EPC service is to improve quality of care and safety for this group of surgical patients.

EPC facilities will also release critical care capacity previously used to support initial postoperative care for such patients; this will lead to a reduction in ‘last minute’ cancellation of inpatient surgery, for which one of the biggest risk factors is requirement for postoperative critical care. 

An EPC service can protect surgical capacity during times of increased critical care activity, such as during emergency surges or winter pressures.

EPC is not for patients at immediate risk of deterioration and is not a substitute for or step down from critical care. Instead, it bridges the gap between existing ward and critical care facilities, allowing patients to be managed safely in an appropriate environment dependent on their needs.

Enhanced Perioperative Care supports the delivery of holistic, high quality care to surgical patients at increased risk of adverse outcomes. Enhanced care services should provide benefit to patients (reduced likelihood of cancellation and postoperative complications) and to systems (more efficient care, reduced length of hospital stay and reduced pressure on critical care services). Today, in the midst of the COVID-19 pandemic, there are obvious benefits of creating Enhanced Perioperative Care services, to deliver the best quality care, even as Critical Care units are at or above their baseline capacity. However, these services will remain a positive legacy once we have passed through this global crisis – a clinical innovation which will provide enduring benefit to patients and the NHS for years to come.

Read the full guidance here.

National Day Surgery Delivery Pack

Developed in partnership with the Getting it Right First Time (GIRFT) Academy, Centre for Perioperative Care (CPOC) and the British Association of Day Surgery (BADS), this pack is designed to enable NHS Trusts to expand and increase day case surgery for the benefit of the patient and the wider healthcare system.

Day surgery needs to be accepted as the major contributor to the future of surgical services. There is still wide variation in day surgery rates throughout the UK. In the lowest quartile of NHS Trusts, twice as many eligible patients are admitted as inpatients as in the highest quartile, which must be addressed. Day surgery should be the default setting for more than just the 200 procedures identified by BADS. This would not only improve patient care and satisfaction, but would also be highly cost-effective, improve efficiency, improve staff retention and morale and reduce the demand for inpatient beds. This expansion can only be achieved safely by following clear guidelines and creating good pathways aimed at improving quality.

  • Section 1: Background to day case surgery in the UK - addressing common misconceptions and making the case for expanding and increasing day case surgery, especially at a time when the NHS needs to re-start and catch up with demand for elective surgery following the Covid-19 pandemic; identifying variation in day case rates and addressing the areas of greatest opportunity identified by GIRFT.
  • Section 2: The generic day case pathway – the key components that can be applied to existing inpatient activity to convert to a day case approach, including essential information about the best practice management required for the delivery of a high-quality day surgery service and action check lists for each stage of the pathway.
  • Section 3: Procedure specific best practice pathways and templates – a list of day case surgery procedures to be used as ‘default’ day surgery pathways together with links to simple trust level process pathways and template documents for everyday use. In addition, procedures that may be undertaken as an outpatient rather than day surgery are listed because there is a national drive to move procedures down the “intensity gradient” from inpatient to day case settings and from day case theatres to outpatient clinics, where appropriate.

Key Principles

  1. Surgical teams should embrace the BADS Directory of Procedures and develop day surgery pathways and protocols for all appropriate procedures
  2. Default patients undergoing procedures within the BADS Directory to a day case pathway
  3. Ensure all potential day surgery patients are listed and coded with a day surgery management intent
  4. Ensure preoperative assessment protocols for patient selection are inclusive rather than exclusive of day surgery
  5. Progress towards the development of dedicated day surgery units
  6. Progress towards the provision of dedicated day surgery teams
  7. Establish a multidisciplinary day surgery management team
  8. Ensure all day surgery patients are admitted to a dedicated admissions area
  9. Embrace use of day case operating trolleys over hospital beds
  10. Establish protocols for anaesthesia, perioperative analgesia and take-home medication
  11. Ensure that day surgery is a consultant or experienced SAS delivered service, with clear training pathways for the future workforce
  12. Equip day surgery facilities with high quality equipment
  13. Ensure day surgery patients are discharged through a dedicated day surgery ward staffed by nurses with expertise in day surgery nurse led discharge
  14. Ensure the day surgery discharge ward has no capacity to accept inpatient activity and support this with a commitment from managerial teams to protect this policy even at times of escalation
  15. Ensure patients are telephoned the day after surgery for clinical support and patient outcome data collection
  16. Audit day surgery outcomes and benchmark performance against the BADS Directory of Procedures, the BADS Directory of Procedures National Dataset and the Model Hospital
  17. Ensure appropriate coding of procedures to capture accurate activity in benchmarking data (such as Model Hospital and the BADS Directory of Procedures National Dataset)

Find out more and download the full report.

Prehabilitation for people with cancer

Principles and guidance for prehabilitation within the management and support of people with cancer

In partnership with Macmillan Cancer Support, The Royal College of Anaesthetists (RCoA) and the National Institute for Health Research (NIHR) Cancer & Nutrition Collaboration

Macmillan Cancer Support, the RCoA and the NIHR Cancer and Nutrition Collaboration in July 2019 launched a report calling for changes to the delivery of cancer care across the UK, with a greater focus on prehabilitation including nutrition, physical activity and psychological support.

Seventy per cent of the 1.8 million people in the UK living with cancer are also living with one or more other long-term health conditions. The guidance report, Prehabilitation for people with cancer, promotes evidence that when services are redesigned so that prehabilitation is integrated into the cancer pathway:

  • patients feel empowered and quality of life is improved
  • physical and psychological resilience to cancer treatments is maximised
  • long-term health is improved.

Teams from Macmillan Cancer Support, RCoA and NIHR have worked together to develop these principles and guidance together with an action plan. This sets out how NHS organisations across the UK can replicate some of the pioneering work already taking place at a limited number of Trusts – all of which have demonstrated how prehabilitation has improved outcomes and reduced the risk of disease progression.

Access the guidance report here

A review of the perioperative care of surgical patients

This report, released by NCEPOD in 2011, recommends that:

  • There is a need to introduce a UK wide system that allows rapid and easy identification of patients who are at high risk of postoperative mortality and morbidity. (Departments of Health in England, Wales & Northern Ireland)
  • All elective high risk patients should be seen and fully investigated in pre-assessment clinics. Arrangements should be in place to ensure more urgent surgical patients have the same robust work up. (Clinical Directors and Consultants)
  • An assessment of mortality risk should be made explicit to the patient and recorded clearly on the consent form and in the medical record. (Consultants)
  • The postoperative care of the high risk surgical patient needs to be improved. Each Trust must make provision for sufficient critical care beds or pathways of care to provide appropriate support in the postoperative period. (Medical Directors).
  • To aid planning for provision of facilities for high risk patients, each Trust should analyse the volume of work considered to be high risk and quantify the critical care requirements of this cohort. This assessment and plan should be reported to the Trust Board on an annual basis. (Medical Directors) Principal Recommendations T

Click here to read the document in full.

Guidelines for the Provision of Anaesthetic Services (GPAS)

The Guidelines for the Provision of Anaesthetic Services (GPAS) support anaesthetists with responsibilities for service delivery and healthcare managers to design and deliver high quality anaesthetic services. It is developed using a rigorous, evidence-based process, which was accredited by the National Institute for Health and Care Excellence (NICE) in 2016.

Each of the GPAS chapters should be seen as independent but interlinked documents. Guidelines on the general provision of anaesthetic services are detailed in the following chapters of GPAS:

  • chapter 2: guidelines for the provision of anaesthesia services for preoperative assessment and preparation
  • chapter 3: guidelines for the provision of anaesthesia services for intraoperative care
  • chapter 4: guidelines for the provision of anaesthesia services for postoperative care

These guidelines apply to all patients who require anaesthesia or sedation, and are under the care of an anaesthetist. For urgent or immediate emergency interventions, this guidance may need to be modified as described in chapter 5: guidelines for the provision of emergency anaesthesia.

Click here to read the full GPAS guidelines.

NICE guidelines on routine preoperative tests for elective surgery

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available.

When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service.

It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

Click here to read the guidelines in full.

Being Active: An everyday guide for people living with an impairment or health condition

This guide, produced by the English Federation of Disability Sport, Disability Rights UK and Sport England, seeks to provide the information needed to support people living with a disability or health condition to become more active.

While the guide does not discuss the issues around every impairment or sport, it provides broadly applicable advice for people who wish to become more active and overcome the barriers that may be preventing them from doing so.

If you would like further information on the issues discussed in the guide, you can find out more by visiting the Activity Alliance website.

Resources

Developed by Perioperative Local Leads in Scotland, you can access and download the Scottish Standard here.

The 2011 NCEPOD study on perioperative care ('Knowing the Risk', see above) looked at risk and outcome in patients undergoing inpatient surgery. One of the principal recommendations in the report from this study included a need for a way to rapidly and easily identify high risk patients, and in response NCEPOD and SOuRCe created the Surgical Outcome Risk Tool (SORT), a rapid percentage mortality risk estimate for patients who are undergoing non-cardiac, non-neurological inpatient surgery.

Find out more about SORT and access the tool online, or alternatively, you can download the app from the App Store and Google Play.

The Royal College of Anaesthetists commissioned this report in May 2018 at a time when existing sustainability and transformation partnerships (STPs) were beginning to evolve into ICSs. The College was keen to assess the extent to which improvements in perioperative medicine, or opportunities for its role in transforming outcomes, were acknowledged or featured in the emerging thinking.

It identifies best practice and a series of recommendations to embed this within the NHS, as well as highlighting a series of pilot projects that can be scaled up once their impact has been fully assessed.

View and download the report here.

 

This NCEPOD report highlights the quality of diabetes care for patients aged 16 years or older who underwent a surgical procedure. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

View and access the report online

A Healthier Life for All

This essay collection from the Health Foundation looks at improving various aspects of public health – and at the potentially game-changing social and economic benefits to society of doing so. It concludes by proposing the need for a paradigm shift in policy, whereby health is seen as a fundamental component of a prosperous and sustainable society and a priority in all policy areas.

Click here to read the full resource.

POPS Resources for Health Professionals

A collection of resources from the Proactive Care of Older People Service (POPS), an award-winning service and the first of its kind in the UK. It started in 2003 and has rapidly become an essential surgical support service. It is recognised locally and nationally as being of high quality, innovative and clinically effective.

Click here for more information.

Currently, one in six hospital beds are occupied by someone with diabetes and by 2030 it is predicted this will rise to one in four. In hospital, people with diabetes have high infection rates, longer lengths of stay and increased mortality. In 2017, 260,000 people with diabetes experienced a medication error which could have resulted in serious harm or even death, and 58,000 an episode of severe hypoglycaemia.

This report has been created by Diabetes UK in alliance with groups and individuals striving to improve hospital care for people with diabetes. Through engagement with diabetes inpatient teams, ward staff, people with diabetes and hospital management, this report addresses the depth of the challenges facing the NHS in improving diabetes inpatient care. 

Click here to read the full report.

If you have any guidelines or other perioperative resources which you feel should be featured on this website, please view our guideline proposal page.

CPOC Endorsement & Support 

If you are interested in obtaining CPOC endorsement or support for your resource please read our policy and get in touch to discuss things further.