Search

Perioperative care means reviewing the surgical perioperative pathway, our patient flows and how we prepare our patients for surgery, and how and who decides they are optimised for surgery. It means changing the postoperative course with increased emphasis on enhanced recovery after surgery and re-designing our discharge processes so it is planned and arranged in advance of the surgical event.

And, it means designing care pathways that embed important patient discussions – true shared decision-making where the focus changes from a technically possible surgical procedure, to the delivery of perioperative care designed and wrapped around the patient.

The final decision is therefore one where the patient is at the centre of decision making, and that they, along with the various stakeholders, agree to the appropriate course of action for their condition.

This will ensure patients understand the risks and outcomes and allows clinicians from various specialties to empower patients to get in the best possible physical shape before surgery.

These ‘teachable moments’ provide us an opportunity to ensure that we can really start to address the prevention agenda around smoking, diabetes, obesity and exercise.

Current NHS priorities are largely risk factor and single-issue based. The NHS prevention programme has been shaped by the key risk factors causing premature deaths, eg smoking, diet, blood pressure, obesity, alcohol and drug use. This focus is very welcome.

However, individual interventions alone will not achieve the change we need to deliver at a population level. NHS and public health leaders alike think the NHS should prioritise a systems approach to prevention. The perioperative care pathway, because it is cross-specialty and multi-disciplinary nature, is an ideal approach to deal with the co-morbidities that many of the high risk surgical patients present with.

In this context, with half of all primary and secondary care consultations and admissions for patients with multiple long term conditions, perioperative care is a natural enabler for the treatment of this cohort of patients and CPOC would be keen to see the development of an explicit national strategy to address multimorbidity.

The shift to ICSs and primary care networks will help bring together commissioners, providers and local authorities to make decisions in the interests of the entire health economy, based on clusters of disease profiles across populations.

Cross-sector partnerships with local authorities, community and voluntary organisations

and statutory bodies are enablers of prevention.

Around 10 million patients undergo surgery each year in the NHS

Any healthcare pathway catering for a population of this size must be simple, safe and efficient. However, problems arise when we identify individual patients on this pathway who have complex medical needs. This simple care pathway can then feel inflexible, as we attempt to address different medical problems for each patient we see.

Fortunately, the great majority of patients are well served by existing NHS surgery pathways. However, there is a growing body of evidence that the needs of the high-risk surgical patient are not being met. As a result, patients who are older or have significant medical problems are offered major surgery in a system that cannot adapt to minimise their risk of complications.

Around 250,000 high-risk patients undergo surgery each year in the NHS. This is approximately 15% of all those who need surgery as a hospital inpatient. We believe these patients need extra care to ensure they have the best possible recovery after surgery, but any solution to this problem must function well within the existing high volume NHS surgical service.

Traditionally, the care of patients undergoing major surgery has been tailored to the operation itself and the index disease being treated by the procedure. However, the majority of complications, which occur after surgery are not due to technical errors or failures by the surgical team, but are medical complications such as pneumonia or myocardial infarction. The prevention and treatment of these medical complications requires a broader approach than we currently take to the care of the surgical patient.

Unmet need

The scale of this unmet need is becoming increasingly clear, and with 10 million patients undergoing surgery each year in the NHS, even a low rate of avoidable harm will be associated with many preventable complications and deaths. The long-term impact of this short-term postoperative harm is also increasing.

Some surgical specialties have already made good progress in improving the quality of perioperative care. Cardiac surgery provides an excellent example of an efficient patient-centred care pathway led by a multi-disciplinary team, achieving better outcomes than many other types of major surgery. We need to take a similar approach for patients undergoing all forms of surgery. To achieve this, we need to define an integrated agenda for healthcare policy around the challenge of providing healthcare to patients undergoing major surgery.

We believe that perioperative care provides a solution to the unmet need, using existing skills and expertise within the NHS to reduce variation and improve patient outcomes after surgery.

There are many steps we can take to create solutions for perioperative care.

• 8 in 10 hospitals offer anaesthesia assessment before surgery.
   
• Integrated care for elderly patients happens in several NHS trusts, reducing complications and length of hospital stay.
   
• Exercise testing - 2 in 5 hospitals use this to assess risk for patients
   
• Participating in perioperative research - there are multiple ongoing research projects and initiatives which you can get involved in to drive perioperative practice.  These include: 
  
  Perioperative Quality Improvement Programme (PQIP)
  National Emergency Laparotomy Audit (NELA)
  UK Perioperative Medicine Clinical Trials Network (POMCTN)
   
• Over 90% of surgical procedures in the NHS involve the WHO Surgical Checklist. 

Changing clinical pathways is one of the biggest challenges in moving to a population health approach. It requires not only development of new care models, but clinical roles and adoption of new ways of working.

While the specialty of anaesthesia is seeing an evolution of the anaesthetist into the ‘perioperative care physician’, this new role cannot work in isolation and the ‘prehab to rehab’ model will only be successful with the buy in of ICSs, their leaders and staff across all providers.

We believe that the implementation of this model of care across system providers can provide the tools needed to help ICSs achieve their goal of improving the health of local populations.

A Teachable Moment

The RCoA’s report A Teachable Moment – Delivering Perioperative Medicine in Integrated Care Systems contains a detailed analysis of the first ten ICSs and offers a series of practical solutions for each to embed perioperative best practice to support their identified clinical priorities and develop related pathways.

 CPOC will strive to facilitate greater collaboration between specialties to improve perioperative care pathways, and we look forward to working with Government and arms-length bodies to support them as they play a key role as catalysts of the culture change needed to achieve this.

The time available to patients to prepare for surgery is a ‘teachable moment’, where a patient can be encouraged by their GP, surgeon and perioperative team to make positive and lasting changes to their lifestyle. The ‘Making Every Contact Count’ (MECC) approach recognises that ‘the opportunistic delivery of consistent and concise healthy lifestyle information enables individuals to engage in conversations about their health at scale across organisations and populations’.

Fitter Better Sooner

The RCoA has launched Fitter Better Sooner, a toolkit to help patients make the most of the perioperative care period and to equip them with the information they need to get fitter for surgery, reduce postoperative complications and adopt a healthier lifestyle.

Prehabilitation

Prehabilitation of surgical patients through exercise has been proven to be particularly effective in reducing postoperative complications and helping patients to return to a full functional state quicker. A structured programme of exercise ahead of surgery improves cardiovascular and muscular conditioning and helps the patient better withstand the physiological stresses of surgery.

As well as making the patient more resilient for surgery, this prehabilitation phase offers an opportunity for patients to experience the benefits of exercise and gives them the tools and knowledge they need to stay physically active long after the postoperative period.

The case study below offers an example of the benefits that comprehensive prehabilitation ahead of surgery and discussions with patients about their lifestyles can bring to patients and their long term health. This type of initiatives are effectively ‘prevention in action’.

Patients with cancer

Prehabilitation is also particularly important for cancer patients. 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, a partnership between the RCoA, the National Institute for Health Research and Macmillan Cancer Support, contains evidence that when services are redesigned so that prehabilitation is integrated into the cancer pathway the quality of life and long-term health of patients is considerably improved.

Engaging with patients

The perioperative approach of engaging in conversations with patients about their lifestyle and providing the tools and information they need to make meaningful changes should be embraced across all care settings and healthcare professions.

Lifestyle change can be daunting for patients and complex for healthcare professionals to deliver. It requires a truly multidisciplinary approach and collaboration between specialties. The greatest success is achieved when patients are encouraged to start changing their lifestyle as soon as they are told they will require surgery by their GP, health assistant or specialty consultant.

We know that coming into hospital for surgery can be a worrying time. Talk to your family and friends about going into hospital and tell them how they can help you. Don’t underestimate how tired you may be afterwards.

Give the below checklist some thought well in advance of the operation.

• How will I pass the time? Have some headphones and music, books, tablet computer or puzzles.  Don’t forget chargers.
• What can I do to relax? Learn some breathing techniques, try yoga or listen to relaxing music. Read about mindfulness.
• What do I need to prepare at home? You may find it difficult to move around when you return from hospital – consider sleeping on the ground floor and getting mobility aids.
• Who can look after my elderly relatives? If friends and family cannot help, contact your local council and your local carer service.
• How will I get to and from the hospital? Can someone drive you? If you are eligible for hospital transport, the hospital may be  able to organise transport for you.
• Do I have enough easy-to-cook meals and healthy snacks for when I get home?  Think who might be able to help prepare meals or help with your shopping afterwards.
• Who can look after my children or pets? Don’t underestimate how tired you might feel after the operation. Ask friends and family to help or to be on standby. To help you with childcare, they may need to arrange time off work too. If you have significant difficulties looking after your children following an operation, talk to your local council or your health visitor.
• Do I have enough medication and batteries for my hearing aid to last me in hospital and when I get home? Remember to take your usual medication into hospital with you.
• Do I have some over-the-counter painkillers at home? You may need to take some during your recovery as instructed by the hospital.
• What do I need to pack? If you are staying in hospital overnight you should think about toiletries, nightwear and comfortable clothes and footwear. It is important to get out of bed, get dressed and start to move as soon as your operation allows – those who do this get home sooner and recover quicker. Temperatures in hospital can vary so some layers of clothing can be useful. See CPOC's practical preparedness resources
• What else would be helpful to do? Get your house and garden in order. Get up to date with your general affairs and finances. This will mean you do not have to worry about these whilst you recover.
• Whom should I let know I am going into hospital? Friends and family can usually give you practical support. It is also good to have people to talk with whilst you are at home recovering. Many people will want to help your recovery, so let them know how they can help in plenty of time.
• Make sure I have a shower/bath before going to hospital to minimise the risk of infection.

Members of the perioperative team at the hospital will discuss your anaesthetic, surgery and recovery period. They will discuss any particular risks you have from both your anaesthetic and surgery and any choices you have. They will give you information to read at home. There will be a
contact number to ring if you need to ask more questions.

The better prepared you are, the easier the process is likely to be.

Below are some questions that you might want to ask the perioperative  team.

• What time do I need to stop eating and drinking before surgery?
• What medication should I take on the day of my surgery?
• What do I need to pack for the hospital?
• Do I need to remove nail varnish, gels or piercings?
• Can I have visitors? When are the visiting times?
• Will someone at the hospital shave me if needed before my surgery?
• When can I expect to go home?
• What help can I expect to need at home afterwards?
• How long will it be before I can shower/bathe again?
• Are there any important ‘dos’ and don’ts’ for my recovery?
• Will I have stitches or staples that need to be taken out?
• How much time will I need to arrange off work?
• Who will give me a fit/sick note for my employer?
• Will I have a check up afterwards?
• How long might it be before I can walk/swim/play golf/run again?
• When can I drive afterwards?
• How long will it be before my life is roughly back to normal?

Depending on what surgery you are having, recovery may take many weeks.

Don’t worry if some days go better than others, as this is normal. It can be useful to keep a recovery diary which you can continue after you go home.

Try and get into a routine and get up in the morning at a regular time. A list of daily goals can give structure to your day and help monitor your progress.

Visits and phone calls from family and friends can cheer you up and encourage you to reach your goals. Be careful though that you don’t tire yourself out from too many visitors.