Optimisation

The perioperative care team assesses underlying conditions and comorbidities, e.g. heart failure, poor lung function and obesity. The team may suggest treatments or lifestyle changes to optimise a patient’s health before surgery.¹

Examples of patient optimisation initiatives include:^{1, 2}

• nutritional, e.g. diet, diabetes or anaemia
• respiratory, e.g. ceasing smoking
• physical, e.g. exercise, fitness training or progressive resistance training
• psychological
• preventive health care, e.g. vaccination
• oral hygiene.

Models for preoperative optimisation include prehabilitation, enhanced recovery after surgery (ERAS) and high-risk clinics.

Prehabilitation

Prehabilitation improves a patient’s physical and psychological function to support them before, during and after surgery. This can lead to faster recovery, better patient outcomes³ and cost savings for the health system. For some patients, prehabilitation can reduce the need for transfer to a rehabilitation facility after the procedure.

Examples of prehabilitation include:^{1, 4}

• exercise programs
• procedure and recovery education, e.g. postoperative breathing and mobilisation
• surgery school programs, e.g. programs that help a patient prepare for their surgery with an aim to improve physical, emotional, nutritional and general health.

Enhanced recovery after surgery

ERAS models are multimodal perioperative care pathways. They guide early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery.

High-risk clinics

A general practitioner or a surgeon can refer a patient who is identified as high risk for surgery to a high-risk clinic. The aim of a high-risk clinic is to improve the perioperative care and outcomes of high-risk patients. They do this using shared decision making, collaboration, optimisation and continuity of care.^{5, 6}

Referral criteria

Referral criteria for high-risk clinic assessment may include, but are not limited to⁶:

• age of patient, e.g. 65 years or older
• patient comorbidities and medical history
• patient functional status and frailty
• patient psychosocial factors
• type of surgery or procedure.

Patients who may benefit from a high-risk clinic assessment or another type of multidisciplinary assessment include:

• Aboriginal patients
• patients experiencing homelessness
• culturally and linguistically diverse patients.

Multidisciplinary assessment

A high-risk clinic provides a multidisciplinary assessment that may include:

• comprehensive pre-consultation medical examination including history, physical exam, laboratory tests and imaging
• frailty and comprehensive geriatric management assessment
• nutritional assessment
• cognitive impairment screening
• disability adjustments evaluation
• risk stratification including a cardiopulmonary exercise test
• rehabilitation assessment to identify post-procedure needs
• post-operative follow-up by anaesthetist.

Following a high-risk clinic assessment, communicate a patient’s results with the surgical team and send them to their general practitioner.^{5, 6}

References

1. Victorian Perioperative Consultative Council. Improving perioperative care before, during and after surgery: annual report 2020. Victoria, Australia: Safer Care Victoria; Mar 2021 [cited 28 Mar 2024].
2. Levy N, Grocott MPW, Carli F. Patient optimisation before surgery: a clear and present challenge in peri-operative care. Anaesthesia. 2019;74(S1):3-6. DOI: 10.1111/anae.14502
3. Victorian Managed Insurance Authority. Improving patient safety in Victorian perioperative care. Victoria, Australia: VMIA; 2022 [cited 27 Mar 2024].
4. Centre for Perioperative Care. Preoperative assessment and optimisation for adult surgery including consideration of COVID-19 and its implications. London, UK: CPOC; Jun 2021 [cited 27 Mar 2024].
5. Westmead Anaesthesia. Perioperative medicine. NSW, Australia: Westmead Hospital; 7 Sep 2018 [cited 27 Mar 2024].
6. Fullbrook AI, Redman EP, Michaels K, et al. A multidisciplinary perioperative medicine clinic to improve high-risk patient outcomes: A service evaluation audit. Anaesthesia and Intensive Care. May 2021;50(3):227-33. DOI: 10.1177/0310057X211017150