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The aim of perioperative care is to deliver the best possible care for patients before, during and after major surgery. Perioperative care is a natural evolution in healthcare using existing skills and expertise within the NHS to provide an improved level of care throughout the perioperative period.

Multi-disciplinary perioperative teams

The perioperative team can be led by doctors from various specialties, including anaesthesia, surgery, acute medicine, cardiology, and care of the elderly. They will provide evidence-based perioperative care, driven by robust audit data. GPs and surgeons will have a single point of contact to ensure the individual needs of complex patients are carefully coordinated from the decision to offer surgery, through to the weeks and months after the procedure.

Perioperative care teams will lead the assessment and preparation of patients for surgery to optimise the treatment of co-existing medical disease. Teams will plan care in hospital, provide advice and support during the days after surgery, and review patients in clinic when they return home to ensure all harmful consequences of surgery are fully resolved.

The perioperative team would provide an additional level of care for those patients who need it. This would include assessment and treatment before surgery, as well as individualised care in the days, weeks and months afterwards.

Perhaps most importantly, this team provides a single point of contact for surgeons and GPs coordinating the care of these complex patients.

The complete model

This complete model of care does not yet exist in the NHS, but there are numerous examples of hospitals, which have successfully implemented some of its key components. In the pages that follow, we describe some of these success stories, as well as identifying the gaps in care and exploring how a joined-up pathway would work.

Click here to see some of our Case Studies on current pathways.

Major surgery may trigger a deterioration in long-term illness and delay patient recovery. We must use the time between the decision to perform surgery, and the procedure itself to assess the needs of individual patients, and to optimise treatment of long-term disease. There are many examples that show how we modify perioperative care to the benefit of both the patient and the healthcare system.

The needs of each patient

Most patients make a quick recovery after surgery, but not all. Medical complications such as pneumonia and myocardial infarction are an important cause of poor outcomes after surgery. As a cause of acute illness, surgery has one major advantage over sepsis, trauma and other conditions – we know when and where it is going to happen. This provides an opportunity to assess the needs of each individual patient, to determine the risks of the proposed surgery, and to optimise treatment of any long-term disease.

Taking this opportunity will allow both patient and doctor to make fully informed decisions about whether to proceed with surgery, and to plan the necessary care. Many patients who present for surgery have undiagnosed long-term illnesses such as lung disease or diabetes.

The decision to perform surgery

It is essential to make the most of the time between the decision to perform surgery, and the procedure itself. Delivering high-quality care in this limited time frame may be challenging, but there are many examples of it in the NHS today, which show how we can modify perioperative care to the benefit of both the patient and the healthcare system. We need to build on these models of care to embed planning before surgery into a pathway of care that continues until all the consequences of surgery have been addressed.

Assessing patient risk before surgery

Assessing the risk of complications following major surgery is a key part of perioperative care. All NHS hospitals provide nurse-led preoperative assessment, and four out of five also provide consultant anaesthetist led clinics to assess complex patients before surgery. This ensures all relevant medical problems are identified and treated in advance, so there are no surprises for the team on the day of surgery.

The approach to risk assessment is becoming increasingly sophisticated. Many hospitals offer Cardiopulmonary Exercise Testing (CPET) to assess physical fitness. This accurately quantifies exercise capacity, which has been used for many years as a guide to perioperative risk. Other forms of risk assessment include simple blood tests used elsewhere to assess heart failure, kidney disease and other acute and chronic conditions.

In one hospital in the south-west of the UK, risk-assessment data are used to generate survival curves using a statistical model. Surgeons and anaesthetists use this to help in deciding which patients require postoperative critical care, as well as other support. Early evidence suggests that patients who are assessed in clinics like these, have a higher rate of survival, although this may also be affected by other aspects of care.

The obvious benefit of preoperative assessment is the opportunity to optimise treatment of existing disease, and plan for care during and after surgery. However, these assessments also inform the discussions between doctor and patient, on whether surgery is the best option if the risks outweigh the benefits.

Multi-disciplinary teamwork in cancer surgery

Despite steady improvements in outcomes, patients undergoing major gastrointestinal surgery are still exposed to a significant risk of complications. Oesophageal and pancreatic surgery have some of the highest mortality rates for elective surgery. These procedures therefore need careful planning.

In many hospitals, anaesthetists now attend multi-disciplinary meetings with surgeons, oncologists, radiologists and specialist cancer nurses. The presence of a diverse group of experts allows the risks and benefits of different treatments to be carefully discussed. In some patients with serious co-morbidity, the risks of surgery may outweigh the benefits, and other less invasive treatments are considered.

Referrals for more detailed assessment and optimisation before surgery are made on the basis of these discussions and shared with patients. With the increasing use of neo-adjuvant chemotherapy before surgery, the need to tackle the problem of patient frailty is growing. In some centres, this multi-disciplinary approach is extended further to include a Care of the Elderly physician for all patients older than 65 or 70 years.

The inclusion of perioperative care within the cancer multi-disciplinary team is an excellent example of how we can broaden the view of the surgical team to focus not just on the index disease for which the patient is having surgery, but also on the harm associated with surgery itself.

Safe surgery is one of the greatest successes of modern healthcare. The challenge of care during surgery is now to improve the quality of patient care, as well as preventing medical error. The presence of an experienced anaesthetist supported by a multi-disciplinary team, provides an opportunity for the delivery of treatments which need significant medical input, without disrupting the surgical care pathway.

Maintaining standards, improving quality

Permanent harm caused by technical errors during surgery is now considered to be rare. Whilst the need to maintain the highest safety standards will never cease, the greatest challenge of care during surgery has now become the need to improve the quality of patient care. There are numerous examples of developments in perioperative care which are based on interventions started in the operating theatre.

The presence of a highly-trained anaesthetist, supported within a multi-disciplinary team, provides an easy opportunity for the delivery of treatments which are complex or need significant medical input, without disrupting the surgical care pathway. It is increasingly necessary to see the care provided during surgery, not as an isolated episode, but as part of a continuum starting with the decision to operate.

Reducing the impact of acute pain after surgery

Despite the efforts of doctors and nurses, many patients still experience acute pain after surgery. For these patients, pain is much more than an unpleasant experience. Severe pain delays patient recovery, and prevents adequate breathing leaving patients more at risk of pneumonia and myocardial infarction, and in some cases it develops into chronic pain which can cause life-long disability. As many as one in ten patients having a knee replacement experience long-term pain afterwards.

Perioperative physicians are ideally placed to prevent and treat pain following surgery. The anaesthetist takes primary responsibility for assessing the risk of acute and chronic pain and for developing a robust plan for pain management. In almost all NHS hospitals, patients at risk of severe pain are reviewed on the surgical ward by a multi-disciplinary acute pain team, providing expert advice and training for the doctors and nurses from the surgical team. This approach to effective pain management helps to reduce the risk of complications such as pneumonia, and speeds patient recovery. It also reduces the risk of debilitating chronic pain problems.

The prevention and treatment of pain is an excellent example of perioperative care. Whilst not a fundamental part of treating the index disease (such as cancer or arthritis), we all recognise that it is essential to treat this consequence of surgery in order to give the patient the best chance of a safe and speedy recovery. Acute pain teams also offer a model of care for the multi-disciplinary perioperative medicine team early after surgery. Whilst not leading the care of every patient, they provide expert advice and guidance as well as seamless continuity of care from surgery to patient discharge.

Simple tools to make surgery safer

Although harm due to medical error during surgery is now rare, it remains important. There is growing recognition that safety and quality of care are at two ends of a single continuum that ensures the best possible outcomes for patients. Research led by the World Health Organisation (WHO), suggested that adverse incidents in the operating theatre may be reduced by a simple checklist to confirm that basic safety procedures are complete before surgery begins. The Department of Health then directed that the WHO Surgical Safety Checklist was to be used in all NHS hospitals.

During implementation, local variation of the layout and content of the checklist allowed hospitals to tackle their individual needs, promoting a sense of ownership, and improving adoption. The three core components of the checklist are: the sign in before anaesthesia, time out before surgery begins and sign out before any member of the surgical team leaves the operating theatre. Participation in the WHO checklist is now included in the curriculum for anaesthesia, in good practice guidelines and in the Anaesthesia Clinical Services Accreditation (ACSA) standards.

Recent research across Europe has shown significant international variation in use of the surgical checklist, and vitally that exposure to a checklist is associated with reduced mortality after surgery. Compliance with the checklist in the NHS is greater than 90% although regulators sometimes report some variability. We don’t know whether the checklist itself prevents frequent harm, or that it is used more commonly where the quality of care is higher. However, it is clear that the need to improve the quality of perioperative care is as important as maintaining high standards of safety.

Surgeons are increasingly diversified in their technical expertise, whilst care of acute and long-term medical disease is ever more sophisticated. It is no longer realistic to expect surgeons to have an in-depth knowledge of recent advances in the management of patients with complex needs, who develop acute medical problems. Improving the quality of care early after surgery represents a major challenge.

All hospitals deliver a package of perioperative care that is focused on the needs of the individual patient, as determined by the specific surgical procedure. Specialised surgical wards are a historic feature of the NHS, delivering expert management of the common problems that may occur after surgery.

Multi-disciplinary input

However, as surgeons become more diversified in their technical expertise, and the care of acute and long-term medical disease becomes ever more sophisticated, a clear gap has opened in terms of the ability of the surgical team to provide care to the surgical patient with complex medical needs, such as heart failure or pneumonia. Physicians are well trained in the management of acute and chronic medical disease, but may have less insight into how major surgery may modify such conditions. Anaesthetists have an excellent understanding of how complications develop after surgery, but are rarely given the time to review and assess patients on the general surgical ward.

Improving the quality of care early after surgery is perhaps the biggest challenge we face as we work to make perioperative care a reality. But again, we can identify many examples of care within the NHS today which convince us that effective change is worthwhile and achievable. 

Caring for long-term disease after surgery

Twenty years ago, it was very common to find that patients were not offered surgical treatments because of increased risk due to co-morbid disease. As perioperative care has improved, we find that these patients are now offered surgery as a matter of routine, with the same expectations of success as the wider surgical population. Maintaining high standards of care for patients with long-term diseases, becomes a major challenge as they undergo surgery.

Diabetes care is an important example. This disease is associated with increased rates of cancellation before surgery, complications such as wound infections, and prolonged hospital stay after surgery. Patients are now routinely admitted on the day of surgery, even for major procedures, creating particular challenges for diabetic patients. One NHS trust in the south of England has set up a service to tackle this. All diabetic patients are offered an additional screening test called HbA1c as part of their routine preoperative assessment. Those with high values are seen by the diabetic team within ten days, to review their diabetic medication in the context of surgery, as well as to offer other routine care that diabetic patients need.

This service provides important support, but requires on average only one day each week from the diabetic nurse specialist to accommodate referrals. The service promotes communication between diabetes experts, surgeons and anaesthetists to ensure high quality care within an efficient surgical service. Importantly, colleagues in primary care have also commented on the utility of this approach which provides a valuable model of care for the short-term management of surgical patients with long-term disease. The introduction of perioperative care teams would help us to ensure that all long-term diseases are managed in this way during the perioperative period.

Extra care for the high-risk patient

Many patients need extra care immediately after surgery, particularly if they need major surgery. For many years, we have admitted these patients to a Critical Care Unit for 24–48 hours after surgery. However, despite increased resources the demands on these services remain high. When critical care beds are not available, clinicians must decide between cancelling surgery, or proceeding with less care than they believe the patient needs. This situation is bad for patients, bad for the NHS and very stressful for hospital staff.

However, surgical patients don’t need all the facilities that a modern intensive care unit offers. In fact, a much simpler facility would be more efficient and still offer the care patients require. After cardiac surgery, all patients are admitted to critical care as standard. However, in most hospitals this is part of a nurse-led, protocol-driven form of care known as ‘fast-track’ cardiac surgery.

One hospital in London has for many years admitted all high-risk patients to an ‘Overnight Intensive Recovery’ unit which functions much like a normal post-anaesthetic care unit. Patients are admitted for up to 24 hours before they are discharged to the ward or to a fully-equipped intensive care unit, depending on need. This provides a facility for the provision of cardiac or respiratory organ support (much like a critical care unit), as well as a focus on pain management and other common postoperative problems (much like a post-anaesthetic care unit). Patient flow is not a problem because places in the unit are not considered to be hospital ‘beds’.

There are now several NHS hospitals that use this model of care for patients who would traditionally be admitted to a critical care unit after surgery. This ensures all patients receive the level of care they need whilst avoiding the need to cancel procedures when critical care beds are not available.

Main role

The anaesthetist's major role lies in providing anaesthesia during surgery, but this role is ever widening. For example anaesthetists are leading the development of preoperative assessment of surgical patients and the quantification of risk. They are leading the development of acute pain teams for the relief of post-operative pain, and providing anaesthesia and pain relief in obstetric units.

Anaesthetists often lead the clinical management of intensive care units alongside other specialties, and work closely with Emergency Physicians to treat emergency patients. They provide care for patients in chronic pain clinics, provide anaesthesia in psychiatric units for patients receiving ECT, as well as the provision of sedation and anaesthesia for patients undergoing interventional radiology and radio-therapy.

Trends in perioperative care must mirror those of the wider NHS. Our reliance on care in hospital is unsustainable, inefficient and frequently fails to meet patients’ hopes and expectations.

Communication between primary and secondary care

As we work to ensure patients recover quickly after surgery, the number of days they spend in hospital will steadily decrease. This in turns places demands on the system to communicate more effectively between primary and secondary care, an interface that most agree does not function as well as it should.

As we offer surgery to more older patients, and to those with long-term disease than we ever have before, it is vital that we consider the impact of major surgery in the context of patients’ long-term health. Primary care services need support and excellent communication from a team of experts who understand the impact major surgery has on their individual patients, advising on specific medical problems that have arisen after surgery, coordinating onward referrals if specialist input is needed, and ensuring the GP is fully informed of their patient’s progress in the weeks and months following surgery.

Kidney injury after major surgery

Acute kidney injury (AKI) is a serious clinical problem which has a significant impact on both short and long-term patient outcomes after surgery. As we offer major surgery to more and more patients with risk factors for kidney disease, more patients experience damage to their kidneys as a result of the systemic inflammatory response to surgery. The rising prevalence of risk factors such as older age, chronic kidney disease, diabetes and hypertension indicates that surgery will have a growing impact on the long-term health of patients.

We now recognise that even mild episodes of AKI trigger step-wise deteriorations in renal function, eventually leading to chronic kidney disease. This in turn results in a dramatic increase in cardiovascular risk, reduced survival, and of course increased NHS resource use. For technical reasons, it is very difficult to predict a patient’s risk of kidney disease at the time of hospital discharge. This partly relates to the reliability of routine kidney blood-tests in patients who have major surgery. Local and national collaborations between clinical teams in nephrology, perioperative medicine, intensive care and biochemistry have led to more effective screening systems for AKI and pathways for follow-up.

A major NHS trust in London has taken this a step further by creating an AKI follow up clinic. This is a collaborative venture between several hospital departments, offering patients at risk an expert assessment and screening for the presence or worsening of chronic kidney disease in the months following surgery. This creates key opportunities to improve long-term health by reducing the progression of kidney disease and its cardiovascular consequences. We now realise that many acute illnesses have an important impact on long-term disease. In time, we expect to see routine screening of patients for acute myocardial, kidney and other organ injuries triggered by major surgery. This will allow us to minimise the long-term effects of short-term harm.

High quality training will be required to deliver integrated perioperative care in the NHS. Postgraduate medical training shapes careers that will span 30 years or more and it is essential that this training reflects the organisation and conduct of clinical practice that will provide the best possible care for patients. Much of the infrastructure and mechanisms are already in place, and many of the skills required are already identified in the various medical CCT (Certiificate of Completion of Training) programmes.

Setting standards

Royal Colleges are responsible for defining the curricula for training, and ultimately for setting standards in the provision of perioperative care for patients. These curricula are currently under review and some, like the CCT in Anaesthetics, have already changed to incorporate more perioperative elements.

Training is embedded in the work of all hospitals in the UK, and underpins clinical standards, academic quality and innovation. By developing training in perioperative care, the colleges will support the development of a future consultant workforce that is able to provide the best possible care for patients in the NHS. Trainees themselves recognise this and its importance. Colleges also recognises the importance of training in perioperative care at undergraduate and Foundation level and we hope to work with medical schools and the Foundation Programme to develop this.

Workforce

In terms of workforce training, perioperative care provides both challenges and solutions. The Centre for Workforce Intelligence (CfWI) in-depth review on anaesthesia and intensive care medicine identifies a 25% under supply of anaesthetists and intensivists up to 2033. This projection does not include the need for perioperative positions, which may create further strain on workforce supply.

Conversely, improved patient pathways present an opportunity to use the acute care workforce more effectively. The work of the perioperative care team may reduce demand for anaesthesia and intensive care medicine in the future although this is difficult to model. CPOC will work together with its partner colleges and specialties, and workforce planners in Health Education England (HEE) and the devolved nations, to explore perioperative care solutions to create a better workforce for the future.

The challenges we are currently facing in perioperative care are:

• £16billion is spent on elective surgical care in England each year.
  
   
• 10 million patients have surgery every year, and this number is rising.
  
   
• Long-term conditions: 25% of the population in England have one.
  
   
• An aging population: it is great news that people are living longer, but this does leave us with challenges.
  
   
• Intensive care capacity: less than 1 in 5 non-cardicac surgery patients are admitted to ICU.
  
   
• High-risk patients are a minority, but account for 4 in 5 deaths after surgery.
  
   
• Screening patients for long-term harm: there is currently no system in the UK to screen patients in this manner, for issues such as heart failure or deteriorating kidney function.

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. 

Prevention in the NHS operates in different ways, at different times, and at different levels. This makes cross-sector action challenging to operationalise at the scale required to improve population health outcomes and reduce health inequalities.

There is currently no common thread from national to system/organisational level prevention strategies, with accountability mechanisms.

A recent survey of 310 NHS leaders on what they think the NHS’s prevention priorities should be in their local areas has revealed three key priorities:

• delivering a systems approach to prevention (64%)
• embedding prevention into routine practice, eg Make Every Contact Count (45%)
• embedding prevention into clinical and/or patient pathways (43%).2

The NHS can make the most of its existing assets and interactions by building prevention into clinical pathways and working across organisations to ensure services are joined up. Perioperative care offers a means of supporting primary and secondary care organisations to deliver system wide prevention interventions that operate at both individual and population health level.