Pre-procedure preparation

Develop triage criteria based on:

• the impact or complexity of the surgery or procedure
• patient medical and non-medical needs
• the local service and resources available
• consultation with anaesthetists, surgeons and other relevant departments
• best practice guidelines and continuous local feedback.

Screening for triage should consider:

• surgical complexity or surgery grades (minor, common or intermediate, major or complex major)^{2, 3}
• patient comorbidities
• patient medical and non-medical needs
• resources available within perioperative service
• consultation with anaesthetists, surgeons and other relevant departments.

Red and orange flags refer to serious medical conditions that would place a patient at a significantly increased risk ( red) or increased risk ( orange) while undergoing a surgical procedure. Information required to identify red and orange flags should be available in the completed PHQ or obtained from a comprehensive virtual interview.

Each local health district or facility should reach consensus on their red and orange flags locally.

Show examples of red and orange flags

Notify the patient and carers by telephone and provide them with written instructions including:

• planned admission date
• estimated length of stay in hospital
• medication instructions
• discharge requirements
• any required testing, e.g. urine cultures or methicillin-resistant staphylococcus aureus (MRSA) swabs
• contact details in case of cancellation, changes to medications or condition, or other concerns.

The virtual interview:

• will generally be nurse-led
• may require liaison with the perioperative medicine team and/or other specialists
• may identify medical conditions that are not optimised and/or any red or orange flags. Refer these patients to a pre-admission clinic for further review.

Patients with additional communication needs, e.g. language, hearing or other difficulties, may require a more comprehensive virtual interview. Obtain further information from the patient, family, carer and/or primary healthcare provider.

Give patients who are safe to proceed without further review verbal and written instructions about the planned procedure as outlined above. If the virtual review patient requires testing, e.g. blood tests, urine cultures, MRSA swabs, preoperative electrocardiogram (ECG), confirm the test results with the anaesthetic medical officer in the pre-admission clinic before proceeding to surgery.

Patients having minor surgery are generally not required to attend the pre-admission clinic, unless they have a red flag.

Patients scheduled for minor or intermediate surgery may not need to attend a pre-admission clinic if:

• they have had surgery within the last six months; and
• their health condition is unchanged.

A general pre-admission clinic is usually conducted by a team including an anaesthetist, nurse, medical officer (surgery team) and clerk.

Patients having more complex surgery and/or with more serious medical problems may require a multidisciplinary pre-admission clinic. In this case, the general pre-admission clinic team should liaise with other clinical and health disciplines including:

• subspecialty surgeons and nurses
• other medical specialists e.g. cardiologists, respiratory physicians, endocrinologists, renal physicians, geriatricians and rehabilitation physicians
• allied health professionals including pharmacists, physiotherapists, occupational therapists, speech pathologists, dietitians and social workers
• general practitioner and primary healthcare provider
• professional interpreter services, multicultural or diversity health units.

When assessment is required, give the patient and family or carer verbal and written instructions about the planned procedure.

Conduct a pre-admission clinic review via virtual care (telephone or videoconferencing), if appropriate. Consider the limitations of virtual care when assessing vulnerable and/or high-risk patients presenting for major or major complex surgery.

Fasting guidelines

Establish fasting guidelines and aim to minimise fasting of patients for extended periods of time. If there is no local protocol, general preoperative fasting advice is available in preoperative fasting and oral fluids.

The Australian and New Zealand College of Anaesthetists (ANZCA) Guideline on Pre-anaesthesia Consultation and Patient Preparation includes fasting guidance in Appendix 1.⁶

Perioperative management of medications

Establish guidelines for the perioperative management of patient medications. Obtain a complete medication history for over-the-counter, herbal and complementary and prescription medications including (but not limited to):

• anti-platelets or anti-coagulants
• diabetes mellitus medications (insulin and oral medications)
• immunosuppressants
• opioids
• supplements such as fish oil and Chinese herbs.

Theatre list requirements

Finalise the theatre list on the day prior to procedure. The perioperative care team should confirm:

• special requirements, e.g. bariatric, spinal cord injury patients, infection control
• preoperative medication requirements and availability of those medications. There may be standing orders for medication administration, e.g. eye drops for cataract surgery, enemas for bowel surgery, or specific prescriptions from the pre-admission clinic review.