Anaesthesia and Perioperative Medicine

Ensure that day case surgery is the default for all suitable elective surgical procedures. a Ensure patients are made aware in primary care at time of referral for possible surgery that their procedure is likely to be conducted as a day case. b Confirm or establish a dedicated preoperative assessment and preparation process for the day case surgery pathway. c Ensure there is an appropriate trust infrastructure to deliver effective day case surgery. d Confirm or appoint an effective trust day case management team that includes clinical and nursing leads, an operational manager and a named executive trust board member responsible for the provision of day surgery. e Educate all trust staff in the importance of promoting day surgery (over inpatient surgery), to ensure consistent messaging to patients and families. f Separate day case surgery pathways from inpatient surgical pathways, to ensure the continuation of day case surgery during surge conditions. g Develop generic and procedure-specific day case guidelines and pathways, consistent with GIRFT surgical pathways. h Develop emergency ambulatory surgical pathways.

Ensure that metrics are appropriately recorded and monitored using available tools to inform successful day case delivery. a Ensure day case surgery is coded as a surgical procedure on day case pathway. b Record when day case patients have converted to inpatients and the reason for that conversion. c Review day case metrics monthly. d Disseminate data on successful day surgery, cancellations on the day of surgery and unplanned admissions to all staff involved in the day surgery pathway. e Benchmark day case success rates using British Association of Day Surgery (BADS) and Model Hospital metrics. Integrated Care Systems (ICSs) to benchmark provider trusts as part of a Quality and Efficiency dashboard. f Conduct follow-up for all day case patients with a next-day telephone call to audit postoperative pain, nausea and vomiting, patient satisfaction and patient feedback. g Provide all day case surgical patients with a telephone contact number for postoperative advice. h Ensure ICSs assume a leadership role* where required, to ensure that day surgery becomes the default option unless an inpatient stay is unavoidable. (*Trusts to retain responsibility for the delivery of day-to-day services.)

Deliver enhanced recovery across all elective inpatient surgical pathways. a Develop (or reinvigorate) an enhanced recovery culture, driven by a team-wide approach covering nurses, doctors, anaesthetists, surgeons, dieticians, physiotherapists and everyone involved in the perioperative pathway. b Ensure quarterly review and feedback of the appropriate metrics related to enhanced recovery. c Join the Perioperative Quality Improvement Programme (PQUIP) in order to improve patient care. d Ensure that patients undergoing a caesarean section are on an enhanced recovery pathway.

Admit patients for elective inpatient surgery on the day of surgery. a Ensure that the appropriate preoperative assessment and preparation processes are in place to facilitate day of surgery admissions and to avoid day-of-surgery cancellations. b Use 'patient hotels' for patients travelling long distances for surgery.

Record the rates of and reasons for day-of-surgery cancellations for elective surgical patients. a Capture and monitor surgical cancellation data in real time and act on it to improve pre- and postoperative processes. b Ensure that the rates of and reasons for cancellations are collected and fed back to the appropriate clinicians and managers in a timely manner.

Ensure effective multidisciplinary input into all emergency surgery pathways. a Ensure a timely approach, with multidisciplinary input, to all emergency procedures. b Provide appropriate information to patients and their relatives around outcome in emergency surgery to enable shared decision-making. c Assess and record frailty and delirium before emergency surgery. d Ensure accurate and timely communication of clinical information between primary, secondary and tertiary care. e Ensure that trusts use appropriate triage to facilitate timely access to emergency theatres.

Develop and provide enhanced care to the appropriate elective and emergency surgical patients. a Develop enhanced care as described in the recent guidance from the Faculty of Intensive Care (FICM) and the Centre for Perioperative Care (CPOC). b Develop a local process to identify patients who would benefit from enhanced care. c Ensure that enhanced care is multidisciplinary. d Integrate enhanced recovery with enhanced care. e Ensure enhanced care does not prevent the appropriate development of Level 2/3 intensive care.

Audit all patients on surgical pathways that involve enhanced and intensive care. a Ensure optimal flow of surgical patients through enhanced care and intensive care pathways. b Audit and review planned admissions, unplanned admissions and readmissions to enhanced care and intensive care. c Review and improve the appropriate use of enhanced and intensive care on an ongoing basis using audit data.

Integrate perioperative care across all surgical pathways. a Develop a local multidisciplinary and multi-specialty team to deliver perioperative care. b Ensure regional-level standardisation of perioperative care through clinically-led networks. c Incorporate best practice as described by the Royal College of Anaesthetists (RCoA) guidance to deliver perioperative medicine that is aligned with Integrated Care Systems (ICS).

Ensure that shared decision-making (SDM) takes place throughout the surgical pathway. a Incorporate SDM across all surgical pathways. b Ensure SDM is linked to the 'Choosing Wisely' recommendations. c Ensure all staff involved in perioperative care are trained in SDM in line with NICE guidelines (update document awaited). d Triage all identified high-risk surgical patients (those with a predicted 30-day mortality risk >1%) from the pre-assessment clinic to ensure they receive a medically-led SDM consultation. e Make certain that SDM consultations deliver decisions around choice, alternative treatments (including no surgery) and realistic expectations for outcome, recovery and rehabilitation based on clearly delivered information. f Obtain informed consent from patients in line with the ruling of the Montgomery Judgment.

Deliver generic preoperative assessment with expansion to perioperative medicine clinics for higher-risk patients. a Develop a generic, nurse-led preoperative assessment system. b Provide a unified pre-assessment team (not defined by individual surgical specialty) to avoid siloed working and mitigate resistance to standardised pathway organisation. c Provide medically-led perioperative clinics to optimise patients' medical conditions (clinic time should be formally job planned). d Develop virtual, telephone or face-to-face consultation options as appropriate. e Use formal frailty assessment where appropriate to guide referral to geriatrician, occupational therapist and discharge co-ordinator. f Ensure the pre-assessment team includes targeted involvement from other healthcare professionals, such as pharmacists, physiotherapists, dieticians and specialist nurses. g Ensure healthy patients undergoing minor or intermediate surgery are not routinely given unnecessary preoperative tests, as recommended by NICE guideline NG45. h Develop pathways to enhance preoperative risk assessment by including use of validated risk scoring systems or survival prediction models and availability of more advanced perioperative testing procedures (e.g. cardiopulmonary exercise testing). i Employ digital solutions for pre-assessment documentation with full integration across both trust and primary care electronic patient record systems. j Establish effective communication links with primary care teams to facilitate and support optimisation of acute and chronic medical conditions before surgery. k Provide preoperative support for patients to engage in change activities, including lifestyle factors (e.g. weight loss, smoking cessation, alcohol reduction and increased physical activity). l Ensure all staff are trained to incorporate 'Making every Contact Count' principles into pre-assessment pathways.

Ensure effective perioperative care for patients with diabetes. a Implement the recommendations set out in recent publications from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), GIRFT Diabetes National Specialty Report recommendations and the forthcoming Centre for Perioperative Care (CPOC) document to improve perioperative care of patients with diabetes. b Ensure a recent HbA1C (glycated haemoglobin) measurement is available within three months of surgery for all patients with diabetes. c Promote and develop effective lines of communication between the perioperative team and the diabetes specialty teams. d Ensure all staff managing surgical patients are fully educated on appropriate perioperative management pathways for patients with diabetes.

Optimise the use of blood products through effective perioperative blood management. a Encourage perioperative teams to collect data on perioperative blood and blood product transfusions with three monthly review of usage in conjunction with a transfusion committee. b Ensure that all current national guidelines on perioperative blood management are followed (NICE guideline NG24 and Mueller et al. (2019)). c Establish early access to haemoglobin levels through primary care and preoperative assessment clinics. (A low haemoglobin measurement should trigger simultaneous access to haematinics to assess cause of preoperative anaemia.) d Ensure that effective pathways exist for further investigation of anaemia if there is a suspicion of malignancy. e Establish a process whereby perioperative teams audit anaemia management through levels of blood transfusion, readmission rates and post-discharge anaemia rates. f Develop local guidelines for anaemia levels that would benefit from treatment in different surgical procedures. g Establish oral and IV iron pathways in primary and secondary care with agreed shared responsibilities. h Ensure cell salvage systems are available when required in all surgical specialities through infrastructure, staff training and audit of use. i Educate all staff on the wards regarding postoperative transfusion triggers.

Develop and implement perioperative pathways and protocols for managing pain medication. a Follow the Royal College of Anaesthetists (RCoA) 'Opioids Aware' guidance on pain management and ensure both staff and patients are educated as to the risks and signs of opioid addiction. b Ensure that preoperative initiation of a pain management pathway is followed for all patients. (In more complex patients, referral to a pain specialist may be required.) c Establish systems to identify patients early in the perioperative pathway who have pre-existing opioid use for pain issues related to surgery (e.g. hip pain) or unrelated to surgery (e.g. chronic myalgia), or patients who have had a previous poor experience with postoperative pain. d Ensure all staff have a clear understanding that inpatient pain management is integral to perioperative care and that a specialist pain team is available as required. e Review discharge prescribing and ensure patients on opioid medications are followed up. f Ensure patients are discharged with no more than five days' supply of opioids, GPs are informed and the patient is given a copy of the Opioids Aware leaflet 'Taking Opioids for Pain'.

Ensure that the workforce reflects the needs of a rapidly developing anaesthesia and perioperative service. a Continue to examine the future staffing requirements for anaesthesia and perioperative care teams. b Ensure that all work undertaken by anaesthetists, whether or not it is within the theatre environment, is accurately recorded. c Ensure that anaesthetists' job plans reflect the entire spectrum of work being delivered. d Implement electronic rota systems in all anaesthetic departments. e Consider how best to deploy Anaesthetic Associates, matching their skills and competences to the tasks required to ensure optimal functioning of the perioperative team. f Identify tasks that do not need to be undertaken by an anaesthetist but could be assigned to other staff.

Mandate a specific dataset which effectively captures the hospital activity and input for the anaesthetic and perioperative medicine team as a priority. a Ensure surgical pathway coding is appropriate, especially concerning admission on an intended day case pathway, to be differentiated from elective inpatient admission. b Investigate the need for inclusion of codes to record perioperative activity. c Ensure that there is collaboration between GIRFT and NHS England and NHS Improvement to develop a list of new mandated data items for currently uncoded anaesthetic care in theatres with a view to this being implemented by NHS Digital. d Review and improve processes for clinical data capture and code assignment to ensure that no clinical factors that can be captured using the clinical classifications are missed (with particular reference to pre-admission data/co-morbidities and the operation record). e Use all relevant data captured within theatre systems to produce information on the volume and quality of anaesthetic activity conducted, and use the electronic patient record to improve coding wherever possible. f Investigate and improve the accuracy of procedural coding for caesarean sections as necessary, using a regular process of data validation involving a responsible named clinician and a clinical coding team representative.

Use data on sustainability of surgical and anaesthetic practice to drive down the environmental impact of surgery. a Develop strategies to reduce the use of volatile anaesthetic agents and nitrous oxide in anaesthesia. b Develop sustainable procurement of anaesthetic consumables, including waste recycling.

Reduce litigation costs by application of the GIRFT programme's five-point plan (this is the standard litigation guidance that applies to all GIRFT reports). a Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts will have received this information in the GIRFT 'Litigation data pack'. b Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c Once claims have been verified, clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d Claims should be triangulated with learning themes from complaints, inquests and serious untoward incidents (SUI)/serious incidents (SI)/Patient Safety Incidents (PSI) and where a claim has not already been reviewed as SUI/SI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clinical staff in a structured format at departmental/directorate meetings (including Multidisciplinary Team meetings, Morbidity and Mortality meetings where appropriate). e Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional hubs to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.