Ensuring patients are In Shape for Surgery – what this means in practice

Purpose

We have had informal communications with you about the introduction of the new "In Shape for Surgery" pathways – an initiative to ensure patients are as fit as possible before surgery in order to improve outcomes, shorten recovery time and significantly reduce the risk of complications. The purpose of this document is to formally notify you of the imminent launch of the scheme and to describe the actions we are asking general practice to undertake prior to referring patients for some surgical procedures. It also describes the longer term ambition of developing a community based pre-assessment service, in line with the Five Year Forward View for care redesign.

Introduction & Background

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.

The message to patients is simple, and should 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."

In view of this, NHS Kernow Clinical Leadership Group (CLG) and Governing Body (GB) are giving their support to proposals to emphasise pre-operative fitness for patients undergoing non-urgent, planned operations.

The In Shape for Surgery programme was originally developed by Devon STP who invited Cornwall to collaborate. Devon STP launched their project over the summer; in Cornwall and Isles of Scilly the scheme is due to launch this winter.

Initially the pathways in Cornwall and Isles of Scilly will apply to hip arthroplasty, knee arthroplasty and hernia surgery, and will promote patient optimisation with regards to smoking cessation and five medical markers (see table one).

Table 1: From December 2017, any adult patient being referred for hip arthroplasty, knee arthroplasty or hernia surgerywill be subject to the following RECOMMENDED CRITERIA:

Exclusions:

Please note this exclusion list includes specialities/procedures that are not covered at the launch of this pathway

• Bariatric surgery
• Any surgical interventions that may be required as a result of pregnancy
• Vulnerable patients where the likelihood of achieving optimisation and benefits from it are low will require individualised consideration. This includes patients with learning disabilities, significant cognitive impairment or severe mental illness
• Referrals of a diagnostic nature
• Children under the age of 18
• Emergency surgery or clinically urgent need for example:
  • Cholecystectomy
  • Surgery for arterial disease• Hernias at high risk of obstruction
  • Deterioration/acute hospital admission. Includes infection, impending per-prosthetic fracture, gross implant loosening, severe ligamentous instability
  • Revision hip surgery which is clinically urgent and where delay could lead to significant deterioration/acute hospital admission. Includes infection, recurrent dislocation, impending peri-prosthetic fracture, gross implant loosening or implant migration
  • Revision knee surgery which is clinically urgent and where delay could lead to a significant Nerve compression where delay will compromise potential functional recovery of the nerve
  • Surgery to foot/ankle patients with diabetes or other neuropathies that will reduce the risk of ulceration or severe deformity
  • Orthopaedic procedures for chronic infection
  • Primary hip or knee surgery which is clinically urgent because there is rapidly progressive or severe bone loss that would render reconstruction more complex
  • Acute injuries that may benefit from early intervention
  • Patients receiving treatment for cancer or the suspicion of cancer

Impact in General Practice

Much of this work currently happens in General Practice prior to referral, but this is now being formally encouraged within the In Shape for Surgery programme by recording the relevant information (HbA1c, haemoglobin, blood pressure, pulse and smoking status) on the updated referral form for any patient who are likely to have surgery as outlined above. This information is already included on many referrals, but the pathway recommendation is that this information should be current within 3 months of the referral.

It is acknowledged that the medical marker thresholds are not achievable, or even desirable, for a small number of patients due to their co‐morbidities. If your patient doesn't meet these thresholds, but you feel they are as well optimised as possible ("best optimised") for surgery, with their risks from surgery minimised as much as reasonably possible, then this should be stated in the referral letter.

Smoking cessation should be initiated in primary care, with patients being referred to existing stop smoking services for advice on nicotine replacement therapy and other methods of smoking cessation. Patients who do not wish to attempt to stop smoking, despite an informed discussion with their GP about the significant risks involved, are still able to access specialist assessment and diagnostics.

There is no ban on surgery for people in the above categories and there is no blanket policy. People who do not wish to access the support services or fail to meet the criteria will not automatically be denied their elective procedure. Decisions about what is in the best interests of an individual's health are made on a case‐by‐case basis.

Future Scope

Learning from the first phase of the In Shape for Surgery programme will be used to inform the planning for future phases, which could include extending the range of procedures/specialties; extending the range of markers to include BMI/ metabolic syndrome; or even centralising phlebotomy services.

Ultimately, in line with the Five Year Forward View on care redesign, it is hoped the In Shape for Surgery programme will be a stepping stone to developing a community pre-assessment service. Practices will be engaged to establish how these ideas can be made to work.

Support for Practices & Patients

In order to support practices with these changes we have produced a practice pack including a summary of the markers and thresholds, along with an outline of the patient flows for medical markers. An updated referral form will be produced for each clinical system.

A leaflet has been developed for patients explaining why optimising their health prior to surgery is important. Specific leaflets for diabetes and smoking are also available for patients. These will be available on the referral web site to print off and give out to support discussions with patients.

Making Every Contact Count – giving patients the same message across primary and secondary care

As a frontline clinician, you have an incredibly important role to play in helping people improve their health before surgery.

As well as the immediate benefits to surgical outcomes, there are also longer-term positive impacts of controlling chronic disease and avoiding risky health behaviour. These are significant for individual patients and their families and they are also important for the NHS and for social care.

While people are living longer, many are living longer with increasing, avoidable ill-health that makes their quality of life worse. This may create an added stress to families and requires more and more of stretched health and social care services.

Please take every opportunity to discuss with your patient the changes that they can make to help ensure that they have a safe and successful operation and are able to recover quickly.

Evidence:

• British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia. Alwyn Kotze et al British Journal of Haematology 2015; 171: 322–331
• Type 2 diabetes: prevention in people at high risk. NICE Public health guideline (PH38). July 2012.
• Peri-operative management of the surgical patient with diabetes. Association of Anaesthetists of Great Britain and Ireland Anaesthesia 2015; 70: 1427–1440
• Management of adults with diabetes undergoing surgery and elective procedures: improving standards. Joint British Diabetes Societies for Inpatient care (JBDS-IP). Revised September 2015.
• The measurement of adult blood pressure and management of hypertension before elective surgery. Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society. Anaesthesia 2016; 71(3): 326–337
• Major complications of airway management in the United Kingdom, Chapter 20: Obesity. NAP 4: 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society. Report and findings March 2011
• Body mass index and risk of perioperative cardiovascular adverse events and mortality in 34,744 Danish patients undergoing hip or knee replacement. Thornqvist C. et al Acta Orthopaedica 2014; 85 (5): 456-462
• Perioperative Outcomes among Patients with the Modified Metabolic Syndrome Who Are Undergoing Non-Cardiac Surgery. Glance L.G. et al Anesthesiology 2010; 113(4): 859-872