In this section you will find resources relevant to perioperative care, from CPOC's partners and stakeholders.
The NHSX Perioperative Digital Playbook contains case studies and resources to provide support to clinical teams and organisations that are looking for digital tools that support the delivery of patient pathways. Further details of these and other tools can be found in the links below.
CPOC works with its partners and stakeholders to ensure we provide a wealth of up to date resources in perioperative care and sign post where necessary.
If you believe there is a relevant resource that can be added to this page please email CPOC@rcoa.ac.uk
CPOC has not tested these resources and does not partner with the mentioned organisations or promote the effectiveness of any of the products listed. CPOC is simply providing links to these resources.
Please contact us at CPOC@rcoa.ac.uk if you would like us to include another example.
This guidance is intended to be used by primary care, surgeons, anaesthetists, perioperative teams and preoperative assessment (POA) services. It applies to all patients who are being considered for surgery, or are on a waiting list for surgery in the non-emergency setting, irrespective of the magnitude of procedure or the type of anaesthesia contemplated. Its recommendations will support the care of individual patients, the recovery of elective services, and achieving key goals of the NHS Long Term Plan including reducing health inequalities and preventing serious health deterioration.
The guideline contains key recommendations for;
- NHS X
- primary care providers
- surgeons, anaesthetists and multidiscilinary teams
- preoperative assessment services
In this podcast, CPOC’s Director Dr David Selwyn interviews CPOC Deputy Directors Dr Jugdeep Dhesi and Mrs Scarlett McNally along with CPOC’s Patient Representative Lawrence Mudford about how to turn waiting lists for surgery into preparation lists. With over 5 million people now waiting for surgery in England alone, there has never been a more pressing time to consider creative ways that will help us beat the backlog while also delivering better, person-centred care for patients.
Fitter patients who are able to improve their health and activity levels recover from surgery more quickly and with fewer complications. What you do in the time leading up to surgery can have a really big impact on your recovery and long term health.
The Royal College of Anaesthetists' Fitter Better Sooner resources will provide you with the information you need to become fitter and better prepared for your operation.
The guideline covers routine preoperative tests for people aged over 16 who are having elective surgery. It aims to reduce unnecessary testing by advising which tests to offer people before minor, intermediate and major or complex surgery, taking into account specific comorbidities (cardiovascular, renal and respiratory conditions and diabetes and obesity). It does not cover pregnant women or people having cardiothoracic procedures or neurosurgery.
SafeFit has been designed, in response to COVID-19, to support people living with cancer to maintain and improve their physical and emotional wellbeing, whilst following Government guidelines.
It is a free remote trial for anyone in the UK with suspicion of, or confirmed diagnosis of, cancer. We put you in contact with a cancer exercise specialist who will help you during the coronavirus (COVID-19) crisis.
The ASA Guidelines differ from the existing guidelines because it provides new evidence obtained from recent scientific literature as well as findings from new surveys of expert consultants and randomly selected ASA member.
The guideline updates the “Practice Guidelines for the Perioperative Management of Obstructive Sleep Apnea: a Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Obstructive Sleep Apnea,” adopted by the ASA in 2005 and published in 2006.
Moving Medicine offers guidance to help healthcare professionals integrate physical activity conversations into routine clinical care.
Ageing populations have greater incidences of dementia. People with dementia present for emergency and, increasingly, elective surgery, but are poorly served by the lack of available guidance on their peri-operative management, particularly relating to pharmacological, medico-legal, environmental and attitudinal considerations. These guidelines seek to deliver such guidance, by providing information for peri-operative care providers about dementia pathophysiology, specific difficulties anaesthetising patients with dementia, medication interactions, organisational and medico-legal factors, pre-, intra- and postoperative care considerations, training, sources of further information and care quality improvement tools.
By January 2019, all patients who are anaemic who present for elective or urgent surgery (with an anticipated blood loss of > 500 ml or >10% blood volume) in Scotland should have this anaemia investigated and treated prior to surgery. Preoperative anaemia is associated with increased postoperative morbidity and mortality, and with increased transfusion requirements. Treating iron deficiency with iron supplements can reduce the need for blood transfusion. It may also reduce the length of hospital stay and cost.
Information for patients and health professionals with links to their pathways and protocols.
As part of the joint FICM/CPOC Guidance on Establishing and Delivering Enhanced Perioperative Care Services, a means of passporting staff with generic transferrable skills was identified by the working party. A short life-working group led by Dr Michael Bannon, Lead Dean for ICM, developed the initial version.
This suite of multi-professional competencies has been designed to support safe, compassionate and effective care and treatment to Enhanced Care patients. The passport is intended to:
- allow individuals to identify their existing skills and additional learning needs within an evidence based framework.
- allow employers to identify and map the relevant competencies across the different staff groups working within Enhanced Care to ensure patients are able to receive the right care and treatment they require in a timely manner.
Cardiff and Vale University Health Board
The guidance aims to provide a background knowledge of Cystic Fibrosis [CF] for the anaesthetist and give guidance and best practice for the perioperative anaesthetic management of the patient with CF presenting for surgery.
CF affects multiple organ systems. However, the impact of CF on the respiratory and gastrointestinal systems account for the majority of morbidity and mortality. Therefore CF patients are generally considered a high risk group for anaesthesia, particularly given their potential for postoperative respiratory complications.
The Specialised Clinical Frailty Network supports specialised healthcare teams to improve the way specialised care and treatment is tailored to the needs and preferences of individuals living with frailty. The Network commenced in 2018, and has been working with specialised teams to explore how frailty assessment and management can best be integrated into specialised service pathways. The Network is a clinically led quality improvement collaborative.
The Network delivers a programme of support framed around frailty assessment, that will help inform a clinically appropriate and holistic response to meet patient needs. Shared decision making is a key part of this response, ensuring that a patient-centred plan is agreed with patients and their carers, adopting a “what matters to you” philosophy.
The SCFN provides a range of tools and resources to support healthcare staff to improve NHS specialised services for older people living with frailty.
The network is also endorsed by the British Geriatrics Society (BGS.)
Find out more about the network.
This hub brings together articles, national guidelines and best practice relevant to frailty and is frequently reviewed and updated by the BGS Clinical Quality Committee and the BGS Frailty in Urgent Care Settings Special Interest Group (SIG).
Resources for non-geriatricians managing older patients
Multidisciplinary input, in particular input from geriatricians, has been shown to improve outcomes in older and/or frail patients undergoing surgery. However, as yet, many preoperative services do not have access to geriatric expertise.
The following are pragmatic suggestions from non-geriatric, perioperative colleagues working with frail, older patients who have developed ‘trans-disciplinary’ skills to improve the care they offer. They are designed to be complimentary to the CPOC/British Geriatric Society Guidelines for Perioperative Care for People Living with Frailty Undergoing Elective and Emergency Surgery which will be published in Autumn 2021.
There are some suggestions for training and some suggestions of how to use some selected geriatric tools. Non-geriatricians using such tools is not evidence-based but working to assess and optimise areas that have been traditionally in the realm of physicians (such as home situation, medications rationalisation) seems intuitively a beneficial approach, whilst working towards increased expert input.
Whilst some of these resources will be well known/obvious to some, others will not have heard of them and we hope that they prove useful.
1. E-learning for healthcare (www.e-lfh.org.uk). Available for free to all NHS staff. Suggested modules: Frailty Tier 1, Frailty Tier 2b.
2. British Geriatrics Society (BGS) Frailty Hub (multiple resources) https://www.bgs.org.uk/resources/resource-series/frailty-hub
3. BGS e-learning courses (costs vary depending on BGS membership or if CPD certificate required): https://www.bgs.org.uk/e-learning
a. Frailty: identification and interventions
b. Perioperative Care of Older People Undergoing Surgery
4. BGS Hospital-Wide Comprehensive Geriatric Assessment (HoW-CGA) https://www.bgs.org.uk/resources/how-cga-introduction-to-the-service-level-toolkit
British Journal of Anaesthetisia - Preoperative assessment of the older patient (2021)
Medications (Consider polypharmacy and deprescribing of inappropriate medication)
5. STOPP/START criteria (Screening Toll of Older Persons’ Prescriptions, Screening Tool to Alert to Right Treatment)
6. NHS Scotland Polypharmacy Guidance. Realistic Prescribing 2018. https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf
7. Anticholinergic Burden Calculator http://www.acbcalc.com/
Alternative colleagues/sources of help
8. Trust frailty lead – may be able to help with local training for yourself/other members of the team
9. Pharmacists – may be able to help with medications review/polypharmacy eg preoperatively or postoperatively on the ward.
10. Geriatricians – even if they cannot provide regular input they may be able to advise on local pathways and how to access these eg rehab at home.
11. Discharge services – patients who are likely to need increased care postoperatively (eg frail, live alone, only just coping) can end up waiting in hospital as their needs are arranged, prolonging their length of stay. Early communication with local discharge services may reduce these problems
12. Use the induction time for surgical and anaesthetic rotating trainees to educate and highlight the importance of frailty, how to screen for it, how to manage it, where to get help etc
13. Make frailty scoring a prerequisite eg for surgical bookings of emergency laparotomy/laparoscopy patients
What to do with the results of preoperative screening tests
14. Cognitive screen indicates possible cognitive impairment:
a. Discuss with your local geriatricians what referral pathways there are eg memory clinic or refer back to the GP if there are no internal pathways
b. Such patients are at higher risk of delirium postoperatively. Warn them and their family about this to try and limit the distress it can cause. Give practical suggestions such as bringing in a clock, glasses, hearing aids, eyemasks/ear plugs to improve sleep on noisy wards
15. Frailty score indicates frailty
a. Discuss with your local geriatricians – can they see the most frail? Is there a frailty service in the community that the patient can be referred to?
b. Use the identification of frailty in shared decision making discussions – the risk of mortality and morbidity will be higher but, at least as important but often not discussed, is the risk of not being able to return home/having increased care needs. If a patient is frail and only just managing as they are, they may not fully recover from the insult of surgery
c. ‘Frailty’ is not a single entity – it is made up of several components, some of which it may be possible to improve:
i. cognition may benefit from referral to memory clinics
ii. continence issues may benefit from referral to continence clinic
iii. low mood may benefit from self referral to talking therapies or referral back to the GP for consideration of medications
iv. malnutrition may benefit from referral to dieticians either internally in the hospital or externally in the community. It may be possible to arrange a local protocol eg starting high calorie/protein drinks from preop clinic
v. polypharmacy may benefit from pharmacist input or rationalisation using eg anticholinergic burden calculator, STOPP/START tool.
Whole Perioperative Pathway
The Modernising Patient Pathways Programme is dedicated to improving patient journeys by delivering sustainable changes to support safe, effective, and person-centred care.
The programme has over twenty one areas of focus all across medical specialites and is undertaking projects in this area.
To find out up to date information on the work please view the MPPP on twitter,
FPM, RCoA, RCGP, RCSEng, RCN, CPOC, RPS & The British Pain Society
This document represents the work of a multi-professional and multidisciplinary collaboration and sets out the guiding principles in opioid management in the perioperative period. This guidance is intended for use by clinicians, nurses and allied healthcare providers, patients, pharmacists and policy makers.
CPOC, BADS, GIRFT
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. 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.
The pack aims to support trusts in considering reconfiguration or redevelopment of services to increase the level of day surgery for at least the 200 procedures identified by BADS and to provide advice to clinical communities on developing safe and effective day surgery pathways.
The COVID-19 pandemic has had a huge impact on patients, healthcare and the public. Dramatic changes to people’s lives and across NHS organisations have occurred swiftly. From this disruption and the emergence of the 'new normal' comes the opportunity to improve patient care, the design of services and the power perioperative care and multidisciplinary working has on the effectiveness and optimisation of the workforce.
CPOC has developed 'Delivering on Opportunities for Better Health and Perioperative Care in the COVID-19 Era' to highlight the need for a rethink moving forward and to make the case for perioperative care in a COVID-19 world.
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.
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.
CPOC has not tested these sites and does not partner with the mentioned organisations or promote the effectiveness of any of the products listed. CPOC is simply providing links to these resources.
Please contact us at CPOC@rcoa.ac.uk if you would like us to include another example.
Medify has 10 years experience in digital pre-operative assessment across Europe.
- Improving patient compliance
- Reducing administrative burden
- Creating a standardised digital record
Medify's high quality 3D animations and localised audio visual explanations guide, reassure and educate patients, who, in turn, provide pre-assessment and consent from the comfort of their own homes.
The aim is to reduce administration burden and therefore capacity is created.
- Important risk stratified information is collated early in the patient pathway, allowing for efficient procedural planning
- Medify can be integrated with EMR to send out modules automatically and receive responses direct to the patient record.
- PREMs and PROMs can be gathered
- All in a standardised format
Patient-driven online preoperative assessment
Ultramed has developed MyPreOp®, a cloud-hosted programme, enabling patients to enter, own and share their preoperative assessment information. A report is electronically provided to the hospital to integrate into the Electronic Patient Record. Complex algorithms suggest which preoperative tests and actions should be considered. MyPreOp® empowers patients and saves nursing time.
Before an operation a person’s fitness needs to be assessed by a registered nurse. A lot of time is spent collecting information from the patient. Many hospitals have paper-based systems which cannot automatically process the information or give guidance to the nurses about what preoperative tests and actions might be needed.
MyPreOp® provides a patient-owned, cloud-hosted solution to these problems. Through the programme, the patient completes a comprehensive assessment of their general health and medical history, which is then digitally submitted to the healthcare provider. By facilitating one-stop preoperative assessment, MyPreOp® helps patients potentially avoid a further hospital appointment and saves time for healthcare professionals.
- 30% of patients completing MyPreOp® avoid having a face-to-face appointment
- In the NHS this could save 1m outpatient appointments per year
- 78% of patients said they would be extremely likely or likely to recommend MyPreOp®
- Avoiding an appointment saves mileage, carbon and patient transport costs
LifeBox is a digital pre-operative assessment ePOA tool which supports pre-op patient assessment, hospital decision-making and personalised patient care.
LifeBox (ePOA) offers patients a platform to complete part of their pre-operative assessment in their own time, at their own pace. The information provided is then available for clinicians to securely access, allowing for early triage and risk stratification which streamline workflows and support personalised patient care.
The Low Carb Program is empowering people living with type 2 diabetes, prediabetes and obesity to improve their health and wellbeing through reassuringly impactful behaviour change.
The resource aims to help people lose weight, improve their HbA1c, reduce medications and place type 2 diabetes into remission.
Managing Post-Op Patients at Home During COVID-19
Covid-19 has meant most patients who have had a recent surgery/procedure or have one in the coming months will not be able to come to outpatients for their post-surgery follow-ups.
These patients are often elderly, have other underlying conditions and are our most at risk and vulnerable.
Go Well Health enables hospitals to provide patients timelined care plans to safely self manage their rehab at home.
It digitally monitors their progress and provides secure 2 way messaging to escalate care if required avoiding face-to-face contact.
Health providers can broadcast targeted messages at any time to different groups of patients to keep the message relevant and engaging.
It enables volunteers in the community to help those that might find digital solutions difficult.