Perioperative care refers to the time around a patient having surgery or a procedure. There are many steps and stakeholders involved.
The perioperative care journey includes the time from referral for a surgery or procedure through to discharge, rehabilitation and follow up with primary care providers. There are many considerations, including deciding to proceed with the surgery or procedure or not.
Perioperative care journey
The diagram below outlines the key stages of the patient perioperative care journey.
The perioperative care journey includes three stages:
perioperative
intraoperative
postoperative.
The components of the care journey fit across these stages, including:
Primary care: Including referral and follow up
Surgical and perioperative medicine team review: Including patient engagement, consent, risk assessment, pre-procedure preparation, medication management and alternative care plan
Optimisation: Including prehabilitation, high risk clinics and effective surgery preparation time
Operation: Including day of surgery processes
Recovery: Including safe recovery, pain management, rehabilitation and restoration of function and transfer of care and discharge planning
Post acute care follow up: Including primary care follow up, rehabilitation and readmission prevention programs
Primary care: Including transfer of care back to the primary care provider
The stages and components of the care journey are mostly sequential. However, the perioperative medicine team review may result in a decision not to operate. Care for the patient may then be transferred back to primary care.
Relevant to all stages and components of the care journey are:
clinical and corporate governance
quality improvement, benchmarking and reporting
shared decision making
patient engagement.
Perioperative care journey
Perioperative care team
The perioperative team includes a range of clinicians, together with the patient and their family and carers. Every circumstance is unique so the team may look slightly different for each patient.
In addition to the patient themselves, the team can include the following:
Family and carers
Primary care team: May include primary referrer, primary care physician or general practitioner and primary health networks
Allied health team: May include physiotherapists, occupational therapists, dieticians, social workers, Aboriginal liaison officers, psychologists, pharmacists, speech pathology and other non-medical support workers
Administration team: May include integrated bookings unit, waitlist manager, admissions department, administration officers, admissions clerks, patient liaison officer, patient reported measures officer
Nursing team: May include pre-admission clinic nurse, nurse screeners, day surgery nurses, perioperative nurse manager
Perioperative medicine team: May include consultants, e.g. anaesthesia, pain medicine, internal medicine, geriatric medicine, general practice, intensive care and other medical specialties
Surgical team: May include anaesthetist and proceduralist
Allied health
Physiotherapist
Occupational therapist
Dietitian
Indigenous liaison officer
Psychologist
Pharmacist
Speech pathologist
Other non-medical support workers
Administration
Integrated bookings unit
Waitlist manager
Admissions department
Administration officer
Admissions clerk
Patient liaison officer
Patient-reported measures officer
Perioperative medicine
Consultants:
Anaesthesia
Pain medicine
Internal medicine
Geriatric medicine
General practice
Intensive care
Other medical specialities
Nursing
Pre-admission clinic nurse
Nurse screener
Day surgery nurse
Perioperative nurse manager
Nurse practitioner
Primary care
Primary referrer
Primary care physician
General practitioner
Primary health networks
Surgical team
Anaesthetist
Proceduralist
Patient cohorts
Local and NSW Health policies and procedures inform perioperative care. There are specific considerations for some patient cohorts.
NSW Health aims to provide quality health services that are accessible, non-discriminatory and equitable. Vulnerable patient groups requiring supports and adjustments include:
The Aboriginal Chronic Conditions Network works to improve the experience and delivery of healthcare for Aboriginal people with chronic conditions in NSW.
Healthcare services should be culturally relevant and safe. Empower and actively involve Aboriginal families and carers in decision making. The perioperative care team:
coordinates with local health services or a patient’s usual doctor or healthcare worker to provide preoperative services close to home for rural and remote locations1
engages Aboriginal health workers, community workers or Aboriginal liaison officers where available, to foster understanding and trust and help coordinate care, for example, attendance at pre-admission clinics and travelling to hospital.1
Cultural Safety for Health Professionals A collection of resources on cultural safety and safe, accessible and responsive healthcare that is free from racism. Source: Australian Indigenous HealthInfoNet
‘Finding your way’ shared decision making model This is a holistic, two-way process where Aboriginal people and their healthcare professionals make decisions together – created with and for mob. Source: Agency for Clinical Innovation
NSW Health supports culturally responsive care that recognises and respects linguistic and cultural needs. This commitment includes providing access to care and supporting health literacy to enable shared decision making.
When supporting culturally appropriate care for a patient from a culturally and linguistically diverse background, the perioperative care team:1
accesses an interpreter if the patient does not speak English as a first language. This service can be by telephone or videoconferencing
provides accessible translated written communication.
Resources
NSW Health Care Interpreting Services Contact information for professional interpreting services available 24 hours a day, 7 days per week. Source: NSW Health
Frail or older patients may have difficulty attending a preoperative assessment face-to-face, particularly if they live in a residential aged care facility. Alternative options include:
conducting virtual preadmission clinics or other consultations1
performing assessments at their residential aged care facility1
using geriatric outreach services.
The perioperative care team considers age-related perioperative factors and complications, including:2
putting in place advance care directives and/or resuscitation plans at end of life
Locally adapted guidelines should inform perioperative care for children. The perioperative care team considers:1
factors including age, weight, size, developmental stage
possible special conditions, e.g. behavioural problems
reviewing results of assessment using a paediatric patient health questionnaire
minimising fasting times
providing education and support for families and carers.
Pregnant patients or patients with neonates or infants
Do not delay urgent and emergency surgery due to pregnancy. However, planned surgery should be postponed until after delivery. Pregnant patients should have an obstetrician as part of their perioperative care team.3
Support patients to continue breastfeeding following anaesthesia or sedation. Interruption to breastfeeding has short- and long-term risks and is generally not necessary. The perioperative care service provides:4
breast pumps and spaces for patients to express breastmilk
safe storage for breastmilk
access to breastfeeding support and maternity care
policies and procedures to limit periods of separation of the breastfeeding patient and the infant.
Rural and regional patients
The Rural Health Network works to improve information access and early identification of rural patients, their families and carers.
Surgery poses a challenge to people living in rural, regional and remote NSW, as they are often separated from home and their support networks.
A patient living in a regional or remote area may also need help with transport, accommodation and engaging local resources.
Perioperative support for rural and regional patients may include:
virtual assessments
phone-based pre-admission clinics
in-person assessments with local doctor or health care.
The perioperative care team liaises with the primary health network, local doctor or healthcare workers to:
assist with optimising the patient’s condition prior to surgery
organise any necessary tests or pre-work.
Resources
Friendly Faces Helping Hands Foundation Practical information and support for individuals and families from remote and regional rural areas. Source: Friendly Faces Helping Hands Foundation
Improving the Rural Patient Journey Resources to meet the social, emotional and practical needs of rural patients, carers and families. Source: Agency for Clinical Innovation
Patient engagement involves educating patients, giving them information, obtaining their informed consent and involving them in decision making with their healthcare team.
This improves their experience, outcomes and adherence to treatment.
Factors that influence patient engagement include, but are not limited to:
demographic characteristics1-3
access to convenient and responsive healthcare4
culturally safe and appropriate healthcare4
health literacy4
self-efficacy1-3
practical and emotional support4
health information and education in accessible formats.5
Actively engage patients, families, carers and clinicians to collaboratively consider information and needs throughout the perioperative process. This includes the risks and benefits of the surgery or procedure as well as the desired outcomes.
Patient engagement varies along a spectrum. The extent of engagement can shift depending on the circumstances.
Increasing level of engagement and influence
Empower
Consumers lead the development of activities, products and services with appropriate advice and support
Co-design
Consumers co-lead the development, design, implementation and evaluation of activities, products and services
Collaborate
Consumers are represented and can make recommendations and influence decisions
Consult
Consumers are invited to provide feedback about products and services developed
Inform
Consumers receive information about the group's activities (e.g. by being subscribed to the mailing list)
The spectrum of public participation. Adapted with permission: International Association for Public Participation.
Health literacy
Consider how well a patient and their family or carer understands health information, especially when communicating perioperative risks and engaging in shared decision making.
When caring for a patient, family or carer with low levels of health literacy:
use a healthcare interpreter when needed6
consider providing written instructions in multiple languages, e.g. top languages in the local health district, and/or in a format that includes pictures and words
consider using an online real-time editor to enhance the design of written materials, ensuring they follow principles of readability and use patient-centred language7
get guidance from the appropriate hospital/district multicultural or refugee health service, Aboriginal hospital liaison service or diversity health literacy committee.
Perioperative patient information
A booklet or checklist will help a patient, their family or carer to keep track of important information about their upcoming surgery or procedure. A perioperative patient information checklist could include the following:
Admission time
Fasting information
What to bring to hospital
Medication information
Expected length of stay
Discharge instructions
The surgeon or anaesthetist may also provide information or handouts relevant to the specific surgery or procedure.
Consent
Informed consent requires shared decision making between the healthcare team, the patient, and their family or carers. It is patient's decision to agree to the surgery or procedure, and the patient can give or withdraw consent at any time.
Consent must take place after the patient has:8
received accurate and relevant information about the surgery or procedure, and other options
adequate knowledge to consider the benefits and risks of the surgery or procedure
considered what to do if there are any complications9
collaboratively discussed their goals and wishes.
Further consent considerations are:
if a patient is unable to give consent, obtain consent from an appointed guardian or a ‘person responsible’10
an interpreter is essential for a patient who does not speak or read English.
consent must be documented and submitted with the request for admission.11
if a patient consents, consider the timing of surgery, including preoperative optimisation to enable best outcome.
If a patient decides not to have the surgery or procedure:
offer them alternative clinical options, e.g. specialist and allied health referrals to improve functional status
consider palliative and supportive care, if needed
communicate the decision with the primary referrer. Provide a deterioration plan to manage any decline in health.11
Shared decision making
Shared decision making means a patient, their family, carers and healthcare professionals work together to decide on the appropriate healthcare based on the patient’s goals, preferences and the best available evidence on treatment options.
Shared decision making is part of the entire perioperative journey. This supports patient autonomy and patient-centred care.12
Partnering with Consumers Standard A standard for providing clear communication and involving patients in their own care. Source: Australian Commission on Safety and Quality in Healthcare
Shared decision making A range of resources and tools to help clinicians implement shared decision making. Source: Australian Commission on Safety and Quality in Healthcare
Shared decision making, a short film A short film describing how shared decision making could help plan for surgery. Source: Peter MacCallum Cancer Centre
The SHARE Approach A five-step process for shared decision making. Source: Agency for Healthcare Research and Quality
Health literacy
Health literacy Information on health literacy, how it affects safety and quality of care and where action can be taken. Source: Australian Commission on Safety and Quality in Health Care
Gaffney HJ, Hamiduzzaman M. Factors that influence older patients' participation in clinical communication within developed country hospitals and GP clinics: A systematic review of current literature. PLoS One. 2022;17(6):e0269840. DOI: 10.1371/journal.pone.0269840
Bonetti L, Tolotti A, Anderson G, et al. Nursing interventions to promote patient engagement in cancer care: A systematic review. Int J Nurs Stud. Sep 2022;133:104289. DOI: 10.1016/j.ijnurstu.2022.104289
Vogel A, Guinemer C, Fürstenau D. Patients' and healthcare professionals' perceived facilitators and barriers for shared decision-making for frail and elderly patients in perioperative care: a scoping review. BMC Health Serv Res. Feb 24 2023;23(1):197. DOI: 10.1186/s12913-023-09120-4
Background
Method
An advisory group of expert medical and nursing representatives from various local health districts across NSW reviewed the updated toolkit.
A literature search, statewide consultation and consensus expert opinion of the advisory group provided data.
The project team conducted rapid, targeted literature searches of PubMed in November 2022, February 2023 and April 2023. These searches related to perioperative care and topics including: quality improvement, shared decision making, patient engagement, primary care, pre-admission processes, patient optimisation, high-risk clinics, safe recovery, discharge planning and patient cohorts. The review only included high-level evidence (systematic reviews and meta-analysis).
The toolkit was originally developed in 2007 and updated in 2016. Frontline clinicians and staff experienced in perioperative care were involved in the development and review.
Supplementary resources
We have created a SharePoint site as a supplementary resource for the Perioperative Toolkit. It is a repository for sharing local resources and tools to support implementation and operationalisation. Network members can request access.
Local health districts and specialty health networks
Australian and New Zealand College of Anaesthetists (ANZCA)
NSW Ministry of Health
Advisory group
Dr Arpit Srivastava, Anaesthetist, Royal North Shore Hospital and Co-Chair Anaesthesia and Perioperative Care Network
Dr Richard Halliwell, Anaesthetist, Westmead Hospital and Co-Chair Anaesthesia and Perioperative Care Network
Conjoint Associate Professor Dr Su-Jen Yap, UNSW Medicine and Health, Anaesthetist, Prince of Wales Hospital
Teresa Luczak, CNC Perioperative Services, Western NSW Local Health District
Primary care
Before surgery
Primary care provider to the perioperative service
At referral, the primary care provider:
supports the patient, family or carer in making decisions regarding the surgery or procedure
provides advice to the perioperative service on the patient’s condition, e.g. medical, cognitive, emotional, social, functional
provides advice to the perioperative service on the expectations of the patient, family, carer and other clinical specialists
collaborates with the perioperative service for diagnosis and optimisation of high-risk patients
provides investigations and test results.
Perioperative service to primary care
Supply the primary healthcare provider (including GP, Aboriginal medical service and/or community nurse) with information about the patient’s perioperative and optimisation goals. This enables the primary healthcare provider to support the patient with these goals.
Discharge
Perioperative service to primary care
Send the primary healthcare provider a written transfer of care referral within 48 hours of the transfer. Information includes:
a summary of the patient’s clinical episode of care
a list of medications on discharge with information about:
changes to medications
management of medications including a pain management plan
advice regarding follow-up arrangements, including need for additional services, e.g. rehabilitation, home care, residential care, mental health services, or drug and alcohol services1
pending tests or studies
results from pre-admission clinic (even if not directly impacting the surgery)
unexpected changes to baseline presentation
a contact number for questions or concerns after discharge.
Where appropriate and of benefit, consider a videoconference to support transfer of care. This may be particularly relevant for residential aged care facilities and out of area transfers.
Communicate critical or other important information, particularly regarding high-risk patients, directly via telephone.
Provide the primary healthcare provider (including GP, Aboriginal medical service and/or community nurse) with information about the patient’s perioperative and optimisation goals. This enables the primary healthcare provider to support the patient with these goals.
Primary care provider to the perioperative service
The primary care provider:
supports transfer of care following surgery or procedure
advises and refers patients to postoperative services
advises the perioperative service of adverse health outcomes related to the perioperative episode of care and other health outcomes, as appropriate.
Adverse event notification
The primary care provider and/or patient may contact the surgeon or surgical team to report any adverse events after discharge. Ideally, any adverse event notification should also go to the medical lead of the perioperative medicine team. Provide a phone number and/or email address with the transfer of care documentation.
Alternatively, the clinical governance unit or quality and safety directorates generally manage incident reviews. Provide a phone number and/or email address with the transfer of care documentation.
The patient may also attend a postoperative clinic or appointment with the surgeon or present directly to the emergency department.
The surgeon, medical lead of the perioperative medicine team or clinical governance unit should advise the primary care provider of the outcome of any incident review.
Encourage the patient and their family or carer to report any adverse events associated with the use of a medicine, vaccine or medical device directly to the Therapeutic Goods Association.
Perioperative pathways
A perioperative care pathway is a framework for treating patients with specific conditions or needs.
Perioperative care pathways are evidence-based and help standardise clinical practice. This supports better patient outcomes.2
Resources
HealthPathways A portal with clinical management information (pathways) for primary care providers during patient consultations. Source: NSW Health
Surgical clinical pathways A range of clinical pathways, screening tools, records and information for perioperative care. Source: Clinical Excellence Queensland
Patel J, Tolppa T, Biccard BM, et al. Perioperative Care Pathways in Low- and Lower-Middle-Income Countries: Systematic Review and Narrative Synthesis. World J Surg. Sep 2022;46(9):2102-13. DOI: 10.1007/s00268-022-06621-x
Pre-procedure preparation
Pre-procedure preparation involves:
identifying perioperative risks
supporting communication and management of risks
collaborating with nursing care, subspecialties and allied health
planning transfer of care from hospital
discussing and understanding the patient, family and carer expectations, as well as team expectations, to allow shared decision making and collaborative care.
Pre-admission review
All patients require pre-admission review including:
recommendation for admission (RFA) form
patient health questionnaire (PHQ)
transfer of care (discharge) from hospital planning questionnaire (TCPQ)
A patient may be clinically unfit and not ready for care. In this case, sites should develop pathways and designate responsible individuals to follow up and oversee case management.
provides a patient medical history for patients who may not require assessment in a pre-admission clinic
permits triage by a nurse screener to decide the level of further assessment required.
Other sources of information about a patient's medical condition include existing records from:
a previous hospital visit
primary healthcare provider
surgeons
specialist physicians.
Transfer of care planning questionnaire
Complete discharge planning and risk assessment before admitting the patient. The TCPQ identifies patients who have barriers to discharge from hospital. Address barriers to allow a safe discharge, e.g. modifications to the patient’s home, community support services, transfer to a subacute rehabilitation facility.
Virtual review (telephone or videoconference call) from a pre-admission clinic nurse can supplement the TCPQ.
Patients can complete a quality-of-life patient-reported outcome measures tool, e.g. PROMIS 29+, EQ5D, DASI, at pre-admission to help flag barriers to discharge. Patients can complete these virtually, saving time at a pre-admission clinic.
Triage
Appropriate triage involves development of local guidelines, screening processes, and delineated triage pathways to ensure optimal patient outcomes and efficient allocation of resources.
person responsible for reviewing and actioning results of investigations
standardised information for patients and/or carers
person responsible for communicating the information to patients and/or carers.
These guidelines should form part of the induction to a pre-admission clinic and pre-procedure processes for all staff.
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
Complete screening for triage within two working days of receiving the RFA, PHQ and TCPQ. This screening is generally done by nurse screeners with support from anaesthetic staff.
Complete triage at least two to four weeks prior to surgery (or several months prior for complex patients).
Triage questions provide information about the patient’s:
health history
required preoperative investigations
requirement for pre-admission clinic review
requirement for high-risk clinic referral.
Not all patients need preoperative investigations or to attend a pre-admission clinic.
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.
Personal or family history of malignant hyperthermia
History of anaphylaxis during anaesthesia
History of difficult airway
Cardiovascular
New or worsening chest pain
Heart failure with worsening shortness of breath or oedema
Arrhythmia requiring hospitalisation within last month
Ischaemic heart disease
Severe hypertension
Respiratory
Shortness of breath at rest or on minimal exertion
Respiratory disease requiring home oxygen
Hospitalisation for respiratory disease within last month
Chronic obstructive pulmonary disease, emphysema or bronchitis
Asthma
Sleep apnoea
Pulmonary embolism within three months
Neurological
Neurological illness with significant functional limitation
Stroke or transient ischemic attack within three months
Significant cognitive impairment, e.g. dementia
Anti-thrombotic agents
Cessation of anti-thrombotic therapy is required and patient has high thrombotic risk, e.g.:
Mechanical heart valve
Atrial fibrillation with CHADS 2 score of 5-6
Deep venous thrombosis or thromboembolism within three months
n/a
Endocrine
n/a
Type 2 diabetes
Renal
n/a
Dialysis-dependent renal failure
Renal transplant
Haematology and oncology
n/a
History of bleeding disorder
Current anaemia
Chemotherapy within two months
This list of red and orange flags is not exhaustive. Other factors to consider include malnutrition, frailty, dementia, past experience and trauma, emotional and psychological wellbeing, and poor functional capacity.
An example of how one hospital has categorised the most important and common medical problems pertinent to perioperative risk is available on the Perioperative Toolkit SharePoint site. Anaesthesia and Perioperative Care Network members can request access.
This triage pathway may apply to minor or intermediate grade surgical procedures for patients with additional needs and/or more significant illnesses .
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.
This triage pathway applies to patients at an increased risk of adverse perioperative outcomes. This includes patients having major surgery or presenting with significant medical complications. These patients should be reviewed in the pre-admission clinic and optimised prior to surgery.
Consider triage to a general pre-admission clinic for any patient who meets any of the following criteria:
all major surgery
intermediate surgery with red or orange flag, or poor physical capacity (metabolic equivalent or MET score less than or equal to four)4
planned minor surgery with red flag
communication barriers
people with an intellectual or significant physical disability
difficulty determining fitness for transfer of care from hospital
surgery requiring more than one surgical specialty.
The patient, family, carer or other member of the perioperative care team can request a pre-admission clinic review.
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.
An example of how to categorise the most important and common medical problems for perioperative risk is available on the Perioperative Toolkit SharePoint site. Anaesthesia and Perioperative Care Network members can request access.
Each facility should develop preoperative testing guidelines for planned surgery. Routine preoperative testing will depend on surgery grade and American Society of Anesthesiologists (ASA) physical status classification system grade.
additional information not obtained from patient history and physical examination
assessment of risk to reduce possible harm or increase the benefit of surgery
predicting postoperative complications
establishing a baseline measurement for comparison.
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.
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)
Preoperative Investigations Guideline A guideline on the management of preoperative investigations for adult patients undergoing elective surgery. Source: Statewide Anaesthesia and Perioperative Care Clinical Network (SWAPNet), Clinical Excellence Queensland
On the working day prior to the surgery or procedure the patient and family or carer should receive telephone education with the nurse including:
admission date and arrival time
directions and information on where to go on the day of the procedure
fasting instructions
current health status
reinforce medication instructions including:
If a patient has not ceased their anti-thrombotic medications and hypoglycaemic agents as instructed, escalate this to the surgical team.
Give patients taking insulin dosing instructions or check they are following their diabetic perioperative management plan.
Follow local and national guidelines for management of diabetes and hyperglycemia.7 For example, request that patients taking insulin commence second hourly blood glucose level (BGL) measurement from 0600 until hospital admission. If the BGL is less than 4mmol/L, then the patient may have 200ml of clear apple juice (up to the time of hospital admission).
things to bring to hospital (including medications, imaging, other equipment)
expected length of stay in hospital
post-discharge care
the requirement for discharge home in the care of a responsible adult following day only surgery.
Document the details of this phone call on the RFA or in the electronic medical record. Complete the Preoperative Screening Checklist, available within the electronic medical record, the day before surgery as part of this process.
If a patient is unwell in the days leading up to surgery, they should contact the hospital. Refer them to the nurse screener. Follow local processes if there is any concern about whether the surgery should proceed.
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.
References
NSW Ministry of Health. Elective surgery access. NSW, Australia: NSW Ministry of Health; 12 Jan 2022 [cited 28 Mar 2024].
Wijeysundera DN, Pearse RM, Shulman MA, et al. Measurement of Exercise Tolerance before Surgery (METS) study: a protocol for an international multicentre prospective cohort study of cardiopulmonary exercise testing prior to major non-cardiac surgery. BMJ Open. Mar 11 2016;6(3):e010359. DOI: 10.1136/bmjopen-2015-010359
The surgical team needs to discuss risks of the surgery or procedure with the patient and family or carer.
A perioperative risk assessment considers surgical complexity, the urgency of the surgery or procedure and individual patient comorbidities.
Surgical complexity categories include ‘minor’, ‘common and intermediate’, ‘major’ and ‘complex major’. An indicative list of surgery (minor to complex major) for both adults and children is available in the Guide to the Role Delineation of Clinical Services.
The perioperative risk assessment may have implications for informed consent and pre-procedure planning. It can help guide where the patient will go after their surgery or procedure, e.g. high dependency, close observation or intensive care unit placement.1
A patient who is identified as high risk for surgery can be referred to a high-risk clinic for multidisciplinary assessment and management, and to improve their perioperative care and outcomes.
Surgical Outcome Risk Tool Estimates the risk of death within 30 days of an operation. Source: Surgical Outcomes Research Centre UK
Surgical Risk Calculator Estimates a patient’s risk of postoperative complications. Source: American College of Surgeons National Surgical Quality Improvement Program
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.
Prehabilitation Key principles and case studies about prehabilitation and healthy behaviours before surgery, e.g. exercise, nutrition, education and psychological interventions. Source: Agency for Clinical Innovation
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.
Resources
Enhanced Recovery After Surgery A range of resources to support implementation of ERAS protocols including key principles, audit and feedback guide, and NSW local case studies showcasing various clinical specialities. Source: ACI
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
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
Day of surgery
Nursing staff admitting the patient will review the following.
A review of patient notes includes checking the following documents:
Recommendation for admission (RFA) form
Patient health questionnaire (PHQ)
Transfer of care (discharge) from hospital planning questionnaire (TCPQ)
Consent
A pre-admission clinic assessment review may include:
checking current medications
confirming any preoperative blood tests or imaging
reviewing any specialist or hospital discharge letters
A patient may have specific medication instructions or preoperative medication administration requirements.
Local and national guidelines exist to guide clinicians regarding specific medication management. For instance, the Australian Diabetes Society (ADS) and the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (ANZCA) developed the Perioperative Diabetes and Hyperglycaemia Guidelines (Adults) to manage patients with diabetes and hyperglycemia throughout the perioperative journey.
A review of pathology requirements may include confirming any preoperative tests or any tests required on the day of surgery.
On the day of surgery, nursing staff will complete the patient’s admission by:
confirming patient identification and verifying procedure
recording vital signs
confirming fasting times
confirming allergies and alerts
conducting a venous thromboembolism risk assessment
conducting a Waterlow Pressure Ulcer Scale assessment (only if not completed at a pre-admission clinic)
conducting a falls risk assessment for patients over 65 years of age with cognitive impairment or neurological disease (only if not completed at a pre-admission clinic).
Use surgical safety or preoperative checklists to improve a patient’s experience and outcomes in perioperative care.1-4
Adapt and modify checklists to fit your local processes.5
Resources
Clinical Procedure Safety Policy Directive A policy directive for clinical care and patient safety risks associated with clinical procedures. Source: Clinical Excellence Commission
Surgical Safety Checklist (Australia and New Zealand) A checklist of critical safety steps to be completed in operating rooms. The Royal Australasian College of Surgeons adapted their checklist from the World Health Organization Surgical Safety Checklist. Source: Royal Australasian College of Surgeons
Abbott TEF, Ahmad T, Phull MK, et al. The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis. Br J Anaesth. Jan 2018;120(1):146-55. DOI: 10.1016/j.bja.2017.08.002
Murphy K, Walker K, Duff J, et al. The collaborative development of a pre-operative checklist: An e-Delphi study. ACORN. 2016;29:36-43. DOI: 10.26550/2209-1092.1002
Royal Australasian College of Surgeons. Surgical safety checklist (Australia and New Zealand). Sydney, Australia: RACS; Oct 2009 [cited 27 Mar 2024].
Safe recovery
The perioperative medicine team supports multidisciplinary discharge planning and early rehabilitation. This is to reduce complications and improve patient outcomes.1
Safe recovery processes
Prioritise patients for regular postoperative review, e.g. flagged from pre-admission clinic
Identify high-risk patients requiring advanced monitoring in a higher care unit
Manage clinical deterioration for inpatients2
Screen and manage delirium
Prescribe postoperative analgesia safely and effectively
Manage outlying patients
Ensure early mobilisation in all patients (where appropriate)
Commence oral nutrition and hydration as soon as possible
Refer patients with postoperative functional or cognitive decline to restorative care such as geriatric medicine or rehabilitation medicine and allied health
High-risk patient groups require collaborative ward management, e.g. hip fracture, vascular surgery and emergency surgery.3, 4
When discharging a low-risk patient postoperatively, give them clear verbal and written instructions about:5
pain management
follow up
potential complications.
If clinically appropriate, remote patient monitoring and other forms of virtual care give patients the opportunity to recover at home.
Short-term restorative care
Short-term restorative care includes multidisciplinary subacute rehabilitation, geriatric evaluation and management and Commonwealth-funded transition care program (in Australia). Access to and choice of appropriate restorative care will depend on a patient’s needs and preferences as well as local factors.
Delirium Clinical Care Standard A standard to improve the prevention of delirium in patients at risk. Source: Australian Commission on Safety and Quality in Health Care
Position statement on the post-anaesthesia care unit A guide to post-anaesthesia care units that are designed, equipped and staffed to deliver safe patient care. Source: Australian and New Zealand College of Anaesthetists (ANZCA)
Principles to support rehabilitation care A guide for the establishment or development of rehabilitation services across NSW. Source: Agency for Clinical Innovation
Standards for rehabilitation services Seven standards for the provision of inpatient adult rehabilitation medicine. Source: Royal Australasian College of Physicians
Transition Care Programme A program to help older people recover after a hospital stay. Source: Australian Government Department of Health and Aged Care
Enhanced recovery after surgery
Enhanced Recovery After Surgery A range of resources to support implementation of enhanced recovery after surgery (ERAS) protocols including key principles, audit and feedback guide, and NSW local case studies showcasing various clinical specialities. Source: Agency for Clinical Innovation
Shaw M, Pelecanos AM, Mudge AM. Evaluation of Internal Medicine Physician or Multidisciplinary Team Comanagement of Surgical Patients and Clinical Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open. 1 May 2020;3(5):e204088. DOI: 10.1001/jamanetworkopen.2020.4088
Van Grootven B, Flamaing J, Dierckx de Casterlé B, et al. Effectiveness of in-hospital geriatric co-management: a systematic review and meta-analysis. Age and Ageing. 2017;46(6):903-10. DOI: 10.1093/ageing/afx051
Discharge planning is a multidisciplinary team effort and includes shared decision making with a patient and their family or carer.1, 2
When developing discharge instructions, consider:
how ready a patient is for discharge3
any extra supports they may need once discharged, e.g. assistance with cooking and cleaning, assistive technology and equipment, ongoing wound care2, 4
their postoperative goals
their living arrangements, as these can impact their postoperative recovery. For instance, a patient may live in a rural or remote area, they may be living alone or have primary carer responsibilities.4
Provide a discharge summary to the primary care provider or a patient’s general practitioner, including:
diagnosis
operation details, e.g. type of surgery, date
complications
active medical problems
pain management
changes to medication
post-discharge instructions, e.g. wound care, mobilisation, nutrition, driving restrictions
blood and other test results
contact details for escalation of care, e.g. general practitioner liaison service, if available.1
If relevant, include medical device information in the discharge summary and upload this to My Health Record.
Discharge education can influence a patient’s participation in self-care post discharge.3 A patient needs to:
understand what is in their discharge summary
be given verbal and written information about their postoperative recovery
be given contact details for escalation of care and any follow-up requirements.1
Consider different levels of health literacy and vulnerable patient cohorts requiring supports and adjustments.
Virtual care can support discharge planning, e.g. in-home assessments, and transfer from metropolitan to regional sites.
Re-Engineered Discharge (RED) Toolkit A toolkit for hospitals to improve discharge processes to reduce readmissions. Source: Agency for Healthcare Research and Quality
References
Bougeard AM, Watkins B. Transitions of care in the perioperative period - a review. Clin Med (Lond). Nov 2019;19(6):446-9. DOI: 10.7861/clinmed.2019.0235
Effective clinical and corporate governance underpins the perioperative process. This includes documenting the governance structure within each local health district or specialty health network supports.
Key roles and responsibilities
All NSW Health facilities offering surgical intervention aim to provide an integrated perioperative care service.
A qualified clinical champion will support and lead the perioperative service. They could be an anaesthetist, a physician or a general practitioner with a qualification in perioperative medicine.
Clinical and corporate governance requires coordination and investment. This takes place at the district, facility and service levels.
Provide executive sponsorship for development of perioperative services
Support the perioperative service director to engage local surgeons, anaesthetists, primary healthcare providers, general practitioners, primary and community health, and other key stakeholders
Ensure local structures, processes and tools meet clinical and administrative needs
Engage and support frontline clinical leaders
Invest in IT infrastructure for patient engagement and data collection
Identify a frontline clinician for the perioperative service director role
Partner a medical clinical leader with a nursing clinical leader
Support the perioperative service director to engage local surgeons, anaesthetists, primary healthcare providers, general practitioners and other key stakeholders
Support the establishment of a frontline perioperative service including anaesthetists, nurses, clerks along with the broader multidisciplinary team members
Support data collection to measure health outcomes and process indicators
Collaborate with nursing clinical leader
Coordinate perioperative multidisciplinary care
Develop service framework
Identify and manage perioperative patient risk
Enable case management of vulnerable, high-risk patients
Establish local guidelines, e.g. pre-admission clinic triage process, risk management, prehabilitation and rehabilitation
Measure and report outcomes
Initiate quality improvement
Contribute to statewide innovations for perioperative care and community health
Collaborate with medical clinical leader
Coordinate pre-procedure preparation process, day of surgery admission, ward care and transfer of care
Coordinate perioperative multidisciplinary care
Coordinate case management of vulnerable, high-risk patients with primary care and community health
Collate and distribute process indicators and health outcomes
Initiate quality improvement
Establish local guidelines, e.g. pre-admission clinic triage process, risk management, prehabilitation and rehabilitation
Engage health professionals, consumers and key stakeholders across NSW to develop perioperative services
Support implementation of the perioperative toolkit
Use relevant and up-to-date evidence to develop and update the Perioperative Toolkit
Encourage and support research and innovation in perioperative care
Promote a multidisciplinary approach to improve the quality, efficiency, effectiveness and safety of perioperative care
Quality improvement, benchmarking and reporting
Embed measurement and data collection in the perioperative process to support benchmarking, performance reporting and quality improvement.
Role of the perioperative service
Ensure each patient’s health and social status is documented and accessible (including self-reported outcomes and experiences).
Collect, manage and review data to ensure quality.
Use key metrics to empower changes and track improvements to patient care.
Create reporting schedules and provide regular reports (at least quarterly) to clinicians and managers to support continuous quality improvement.
Implement quality improvement initiatives where performance, trends or outcomes are unsatisfactory.
Collect indicators and outcomes and review regularly, e.g. monthly, as part of a process of continuous quality improvement. For example, the Ministry of Health Surgical Dashboard.
Complications or adverse events, e.g. unplanned reoperation, infections1-5
Unplanned readmission rates1, 2, 4-7
Unplanned admission to intensive care unit within 14 days of surgery5, 8
Unplanned reoperation within 30 days4
Process outcomes
Pre-admission preparation,8, 9 e.g. percentage of patients assessed in pre-admission clinic, percentage of patients receiving medication instructions, percentage of pre-admission clinic visits using virtual care, time of pre-admission clinic before surgery, duration of pre-admission clinic appointment, waiting times for physical clinic
Percentage of patients not ready for care
Operative time5, 8
Length of stay in hospital1, 2, 4, 5, 7
Procedure non-attendance or cancellation on day of surgery8, 9
Discharge, e.g. within 24 hours5 or unplanned delayed discharge9
Short-term recovery or discharge destination, e.g. own home, rehabilitation facility or care home, level of dependence, need for carers2
Post-discharge follow-up9
Patient-reported measures (PRMs)
Functional status, e.g. mobility, ability to perform specific activities
Symptoms and symptom burden, e.g. intensity, impact, frequency and duration
Longer-term recovery, e.g. overall health-related quality of life1
Patient-reported measures (PRMs) give patients the opportunity to provide direct, timely feedback about their health-related experiences and outcomes at the point of care. This feedback helps drive improvements in care across the NSW health system
Health Outcomes and Patient Experience (HOPE) is a purpose-built IT platform to capture PRMs. It was co-designed with consumers, clinicians and managers across NSW in partnership with the ACI, eHealth NSW and the NSW Ministry of Health. HOPE digitally enables consumers and clinicians to access real-time information and report on healthcare experiences and outcomes at the point of care.10
TheHOPE Platform is a secure website which requires a password. Patients receive access when a clinician invites them to participate in the Patient Reported Measures Program. They receive a secure code via email or text message to a mobile phone.10
References
Boney O, Moonesinghe SR, Myles PS, et al. Core Outcome Measures for Perioperative and Anaesthetic Care (COMPAC): a modified Delphi process to develop a core outcome set for trials in perioperative care and anaesthesia. Br J Anaesth. Jan 2022;128(1):174-85. DOI: 10.1016/j.bja.2021.09.027
Haller G, Bampoe S, Cook T, et al. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine initiative: clinical indicators. Br J Anaesth. Aug 2019;123(2):228-37. DOI: 10.1016/j.bja.2019.04.041
Abbott TEF, Ahmad T, Phull MK, et al. The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis. Br J Anaesth. Jan 2018;120(1):146-55. DOI: 10.1016/j.bja.2017.08.002
Tan YY, Liaw F, Warner R, et al. Enhanced Recovery Pathways for Flap-Based Reconstruction: Systematic Review and Meta-Analysis. Aesthetic Plast Surg. Oct 2021;45(5):2096-115. DOI: 10.1007/s00266-021-02233-3
Zacharakis D, Diakosavvas M, Prodromidou A, et al. Enhanced Recovery Protocols in Urogynecologic and Pelvic Floor Reconstructive Surgery: A Systematic Review and Meta-Analysis. Urogynecology (Phila). 1 Jan 2023;29(1):21-32. DOI: 10.1097/spv.0000000000001261
Cline KM, Clement V, Rock-Klotz J, et al. Improving the cost, quality, and safety of perioperative care: A systematic review of the literature on implementation of the perioperative surgical home. J Clin Anesth. Aug 2020;63:109760. DOI: 10.1016/j.jclinane.2020.109760
Queensland Health Clinical Excellence Division. Operating theatre efficiency guideline. Brisbane, Queensland: Queensland Health; Jan 2017 [cited 28 Mar 2024].
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Publication date 2024-04-23.
Accessed from https://aci.health.nsw.gov.au/projects/perioperative-toolkit
