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When a patient has poorly controlled chronic disease or other risk factors, it can adversely affect the:
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."
From August 2017 primary care is requested to follow this "best practice" recommended Clinical Referral Guideline (CRG).
When referring patients who are likely to have hip arthroplasy, knee arthroplasty or hernia surgery, primary care is requested to measure the information below and, where possible, optimise any medical conditions prior to referral.
With regard to these measurements, prior to referral for surgery primary care is asked to investigate and optimise the conditions in the following circumstances:
Smokers who are willing to engage in attempting to quit should be signposted to stop smoking cessation services before, or at the time of surgical referral and should be advised that ideally they should be smoke free for 8 weeks prior to surgery in order to improve their outcomes.
This CRG covers patients who are being referred for "surgery likely."
Much of the work in this pathway already happens in practice prior to referral, but is now being formalised through this CRG. Without early intervention these issues frequently result in patients having their procedures deferred, cancelled or being put at avoidable risk.
There is no ban on surgery for people in the categories listed within the referral criteria and there is no blanket policy.
From August 2017, it is recommended that any adult referral for routine hip arthroplasty, knee arthroplasty or hernia repair should follow this recommended "In Shape for Surgery" guidance.
Patients referred for emergency surgery or clinically urgent or any other elective surgery
Patients who are being referred for a surgical opinion when the treatment is unclear
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
Criteria | Threshold for pre-referral intervention |
Medical Markers - chronic disease management | Medical Markers - chronic disease management |
Anaemia (for hip and knee arthroplasty only unless high anaesthetic risk) |
Hb less than 120g/L in females and 130g/L in males (excluding anaemia related to chronic disease) |
Blood pressure | BP greater than 160/100mmHg |
Diabetes - In known diabetics and - In those at risk of diabetes as identified by a BMI greater than 30. Diabetes UK risk tool is also recommended (here) |
HbA1c greater than 69mmol/mol |
Irregular Heart Beat (ECG if pulse rate greater than 100 or irregular) | Atrial Fibrillation with a rate greater than 100 beats per minute |
Auscultate for heart murmur |
Un-investigated heart murmur |
ALL MARKERS SHOULD BE CURRENT WITHIN 3 MONTHS OF REFERRAL | ALL MARKERS SHOULD BE CURRENT WITHIN 3 MONTHS OF REFERRAL |
Lifestyle Criteria | Lifestyle Criteria |
Smoking (Vaping and Nicotine Replacement Therapies are not restricted) |
Smoker. Advise patient: - 8 weeks smoking cessation prior to operation is optimal to reduce risks; - it is a good time to consider quitting for good; - and sign-post to smoking cessation service. |
ALL MARKERS SHOULD BE CURRENT WITHIN 3 MONTHS OF REFERRAL | ALL MARKERS SHOULD BE CURRENT WITHIN 3 MONTHS OF REFERRAL |
It is acknowledged that these 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 signposted to existing smoking cessation services for advice on nicotine replacement therapy and other methods of smoking cessation. This signposting should occur at the time of referral to secondary care. Carbon monoxide testing will take place during hospital appointments to support their quit attempt.
When patients who smoke are seen in secondary care and it is decided it is appropriate to operate for their condition the importance of being smoke free for surgery will be re-iterated to them. If they are unsuccessful in their quit attempt during that period they can still proceed to surgery.
There is already rigour and professional guidance in pre-operative assessment of people with alcohol and substance misuse issues. No substantial change of practice is envisaged at this time beyond an added emphasis on screening patients judged or known to be at risk by their GP.
Patients with very high or very low body mass index (BMI greater than 40 or less than 18) are at additional risk in surgery and this risk should be raised with them.
Patients who require health optimisation can be referred to the appropriate healthy lifestyles service using the resources available locally:
DRSS referral template - no merge fields
Guide to accessing GP clinical system specific referral templates
Please note there is an existing hernia policy and this policy includes advise on smoking cessation prior to incisional hernia repair.
N.B. if you have so far been unable to optimise your patient with regard to any of the above criteria, please include details of current/previous interventions in your referral. .
In Shape for Surgery - practice pack
In Shape for Surgery - stakeholder briefing
In Shape for Surgery - evidence summary
In Shape for Surgery - questions and answers
In Shape for Surgery - update for GPs
In Shape for Surgery - Patient website
NHS Devon patients
NHS Cornwall and Isles of Scilly patients
This guideline has been signed off on behalf of NHS Devon.
Publication date: August 2017
Updated: September 2024