“In Shape for Surgery” - NHS Devon CCG

This document is to aid the launch of a recommended best practice pathway for routine surgery, initially applying to routine adult hip/knee arthroplasty and hernia referrals. The pathway is very strongly encouraged but not mandatory.

When a patient has poorly controlled chronic disease or certain risk factors including smoking, it can adversely affect the:

outcome of the operation
risks of complications during and after the operation
length of time spent in hospital
patient's recovery time
NHS costs, resources and health professional time needed to care for the patient in hospital and following discharge.

In view of this Devon STP is keen to promote the optimisation of patients prior to elective surgery with regard to smoking cessation and 5 medical markers:

HbA1c (in known diabetics, those with a BMI over 30 and others 'at risk of diabetes')
Haemoglobin
Blood pressure
Pulse check for atrial fibrillation
Detection and investigation of any heart murmurs

From August 2017 the STP will be launching it's "In Shape for Surgery" scheme. This will formally encourage both primary care and secondary care to ensure, where possible, that patients stop smoking before surgery and have these medical markers measured and optimised before routine elective surgery.

The message to patients is simple, and can be re-iterated at every opportunity in both primary and secondary care "surgery puts stress on the body, so the healthier you are, the better you'll handle it."

There is considerable evidence which shows that taking steps to improve a patient's general health and wellbeing before surgery greatly improves outcomes, shortens recovery time and significantly reduces the risk of complications.

Initially this recommended pathway will cover patients undergoing hip/knee arthroplasty and hernia surgery but in time is likely to be extended to other surgical procedures and specialities.

When patients are being referred for "likely surgery" primary care is asked to ensure that these medical markers are measured, and optimised where possible. It is accepted that due to patients' individual circumstances it might not be either possible or desirable to optimise some patients to the thresholds set out in the pathway. If it is not clear whether surgery is the likely outcome then referrals should be made but patients should be aware that optimisation may be encouraged later in the pathway should surgery be the outcome.

The thresholds that may require pre-referral intervention from primary care prior to referral are:

Hba1c greater than 69mmol/mol
Haemoglobin less than 120g/l for females and 130g/l for males
Blood pressure greater than 160/100
Atrial fibrillation rate greater than 100 beats per minute
Auscultation for new heart murmurs which should be considered for ECHO if detected

Smoking

For smokers it is requested that patients are:

Advised that 8 weeks smoking cessation prior to operation is optimal to reduce risks
Encouraged that it is a good time to consider quitting for good
Sign-posted to smoking cessation service

Smoking cessation should be initiated in primary care, with patients being signposted to existing cessation services for advice on nicotine replacement therapy and other methods of cessation. Patients should be made aware that carbon monoxide testing will take place during hospital appointments to give feedback and support for a successful quit attempt.

Patients who do not wish to attempt to stop smoking, despite an informed discussion with their clinicians about the risks involved will still be allowed to proceed to surgery. Patients will not be able to smoke whilst in hospital so they will need to consider how they will manage this during their stay.

Vaping and nicotine replacement therapies are accepted forms of pre-operative smoking cessation.

Alcohol and Substance Misuse

There is already rigour and professional guidance in pre-operative assessment of people with alcohol and substance misuse issues. No change of practice is planned beyond an added emphasis on screening patients judged or known to be at risk by their GP. Please communicate any known alcohol or substance misuse risk in the referral.

BMI

Patients with very high or very low body mass (BMI greater than 40 or lower than 18) are at additional risk in surgery, and this risk should be raised with them.

Patient information leaflets are available for practices to inform patients of the details of the scheme along with more information on the importance of quitting smoking and optimising any medical markers. If patients wish to feedback on the scheme or have any queries then they should be directed to