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TABLE 3.3 Common preoperative comorbidities, presurgery considerations and potential postoperative risks.
Comorbidity Assessment tools Optimisation and investigations
Presurgery considerations for SFA
Potential associated postoperative
risks/concerns
Diabetes mellitus
(CPOC 2022a)
Blood sugars HbA1c <69 mmol/l
Test blood capillary (BM
6- 12 mmol/l) on admission
Test blood capillary (BM 6–12 mmol/l)
on admission
Minimise fasting – recommend first
case on operating list
Patient may require variable- rate
insulin infusion
Recent ECG
Pressure points
Neuropathy
Increased risk of infections
Reduced wound healing
Increased risk of ITU admission –
cardiovascular disease (MI, stroke)
Renal impairment
Urinary tract infection
Unstable blood glucose – may require
more intense monitoring
Hypertension
(Dillane 2021a)
Measuring systolic and diastolic
blood pressure
140/90 mmHg or higher
Compliance with medication
White coat syndrome- – allay anxiety
Recent ECG
Cardiac event
Renal failure
Increases risk of bleeding
Hypothyroidism/
hyperthyroidism
(Dillane 2021b)
Thyroid function tests (TFT)
Recent (ECG)
Cardiovascular assessment Airway compromise
Parkinson’s
(Finegan 2021)
and multiple
sclerosis
(Dillane 2021c)
Functional status – Duke Activity
Status (Dillane 2021c)
• Can climb a flight of stairs?
• Distance walked
Tissue viability:
Braden Scale, Waterlow Score,
PURPOSE- T (NICE 2022)
Nutrition – Malnutrition Universal
Screening Tool (MUST) Score
Communication strategies – allow
patient time
Spasticity and motor movements – be
aware for movement and positioning
Wound closure, dressing and drains
Recent ECG
Chest X- ray
Airway risk management
Investigate OSA
Tissue viability and positioning
Poor wound healing and potential
wound infection
Dysphagia – nutrition and hydration
postoperative
Ensure regular medication prescribed
and administer postoperatively –
consider nasogastric tube
Risks of falls postoperatively
Respiratory failure
(Continued)
TABLE 3.3 (Continued)
Comorbidity Assessment tools Optimisation and investigations
Presurgery considerations for SFA
Potential associated postoperative
risks/concerns
GORD/reflux
(Dillane 2021b)
Oeophagogastroduodenoscopy
(OGD)
Reflux Severity Score
24- hr pH manometry
Adjust positioning intra and
postoperatively
Antacid or proton pump inhibitor (PPI)
medication preoperatively
Respiratory aspiration
Chest infection, pneumonia
Obesity
(Dillane 2021c)
Body mass index (BMI) score
(weight in kilograms (kg) divided by
the square of height in meters (m
2
))
Girth measurement: body shape –
apple shaped: patients have more
central body fat. Pear shape: more
peripheral body fat (SOBA UK 2022)
OS- MRS (Obesity Surgery- Mortality
Risk) Score (Thomas and
Agrawal 2012)
Patient positioning
Check table/trolley chair loading
weights
Encourage patient mobilisation if
possible
Optimisation of weight – very low-
calorie diet (VLCD) two to three weeks
prior to surgery
Dietetic assessment
Failure to visualise organs and
proceed with surgery
Pressure sores
Cardiac/respiratory event
Poor wound healing
Difficulty undertaking urinary
catheterisation
Difficulty mobilising and transfer
Risk of VTE
Frailty (Finegan
and
Khadaroo 2021)
Surgical Outcome Risk Tool v2
(SORT)
Clinical Frailty Scale
6- item Cognitive Impairment Test
(6CIT)
Lung function tests
Pressure ulcer/injury assessment
tool such as Braden Scale, Waterlow
Score, PURPOSE- T (NICE 2022)
Hydration and nutrition
(MUST score)
Dementia screening (Montreal
Cognitive Assessment)
Consider use of hearing devices/
alternative methods of communication,
including sensitivity and patience,
involvement of guardian/relative
ECG
Chest X- ray
Care in patient positioning
Care in wound management including
closure, dressings and drains
Tissue viability
Poor wound healing
Postoperative confusion or delirium
Cardiac/respiratory event
Dehydration
Impaired vision/hearing
Risk of falls postoperatively
Venous Thromboembolism Risk Assessment 29
Therefore, it is essential to liaise with other healthcare professionals within both acute
care and primary teams to provide access to physiotherapy, nutritionists, dietitians,
stoma nurses, social workers, cardiology, acute pain services, pharmacists and
smoking and alcohol cessation services, as well as intensive care. Good communica-
tion between the preoperative assessment clinic and other healthcare professionals is
essential to ensure the effective use of resources and patient safety. The SFA is in a
unique position to ally the patient’s fears and communicate concerns reported on
admission to the theatre team during the WHO team brief.
VENOUS THROMBOEMBOLISM RISK ASSESSMENT
Venous thromboembolism (VTE) is a term that includes deep vein thrombosis (DVT)
and pulmonary embolism (PE) and is a significant safety concern for patients. Conse-
quently, NICE (2021) recommends that patients over the age of 16 years be risk-
assessed on admission, and in the United Kingdom (UK), these assessments are a
National Quality Requirement in NHS Standard Contracts.
Patients are at a high risk of VTE after surgery, major trauma and hospitalisation.
Whilst all types of surgery carry the potential risk of VTE, orthopaedic surgery, general
surgery, obstetrics and gynaecology have been reported to have a higher number of
VTE- related clinical negligence claims. Additionally, the risk of VTE increases with age,
previous VTE events, medical illnesses such as cancer, and pregnancy (Alsheef
et al. 2020; Zong et al. 2023). Therefore, assessing patients preoperatively to identify
contributory risks and initiate a treatment plan for postoperative management is crucial.
The SFA should be aware of the contributing factors associated with VTE
(see Table 3.4) and the preventative measures that can be utilised, such as graduated
TABLE 3.4 Contributing factors associated with VTE.
Individual factors Surgical factors
Age
Cancer
Obesity
Hormone therapy
Family history and personal
history of DVT/PE
Trauma
Acute abdomen
Reduced mobility
Pregnancy
Clotting diseases, such as
haemophilia
Acute stroke
Anticoagulation drugs
Length of surgery >60 minutes
Bleeding risk
Positioning during surgery, such as
lithotomy, reverse Trendelenburg, lateral
mobility postoperatively
Hypothermia (<36 °C)
Dehydration
Type of surgery, such as laparoscopic
Anaesthetic
30 Chapter 3 Preoperative Assessment
compression stockings, intermittent pneumatic compression devices, anticoagulation
pharmacotherapy, good positioning techniques to reduce venous compression,
oedema and mobilisation. However, some comorbidities may contraindicate the
useof mechanical devices, such as peripheral vascular disease, open fractures and
wounds, congestive heart failure, gangrene, dermatitis and neuropathy (Pavon
etal.2016). Using the WHO Surgical Safety Checklist for all surgical patients may sig-
nificantly improve VTE guideline compliance (Truran etal.2011).
The SFA is uniquely positioned to ensure the WHO Surgical Safety Checklist is
completed, ensuring the appropriateness and correct application of compression
stockings and intermittent compression devices to reduce complications such as
neuropathy and vascular impairment. Furthermore, the SFA can educate patients and
reinforce the importance of compliance with these devices. In addition, the SFA
should recognise the symptoms of DVT (swelling, redness and pain– commonly in
the calf but also in the thigh or arm) and PE (sudden chest pain, shortness of breath,
dry cough and haemoptysis) during pre- and postoperative consultations.
TISSUE VIABILITY
All patients are potentially at risk of developing pressure- related ulcers or injuries;
however, some patients are at significantly greater risk. In the UK, several risk
assessment tools are used to predict the risk of developing pressure sore injuries,
such as the Braden Risk Assessment Tool, Purpose- T (Pressure Ulcer Risk Primary or
Secondary Evaluation Tool), Norton Risk Assessment Scale and the Waterlow Score,
which are commonly applied in adults (NICE2022). For assessing children, the
Braden Q Scale is utilised. A variety of factors, such as significantly limited mobility
or neurological impairment, nutrition, weight (low and high BMI), continence,
diabetes, medications and length of surgery, can increase the risk of patients devel-
oping pressure ulcers or injuries. This information should be documented in a chart
that stratifies patients into risk categories. The chart should be completed upon
admission and updated weekly thereafter, focussing on pressure injuries or sores.
Complications of pressure ulcers include pain and distress (Angmorterh etal.2019),
as well as infections such as cellulitis or osteomyelitis, which can result in sepsis
(Long and Gottlieb2020). There is also an increased length of hospital stay, averaging
five to eight days longer (Wood etal.2019), along with increased mortality and mor-
bidity (OHID2022) and reduced quality of life (Gorecki etal.2012). For the SFA, this
risk assessment is essential, especially when the patient’s operation is lengthy and
requires movement, as these factors can cause injuries from traction, stretching and
compression. As the SFA is responsible for assisting in the patient’s positioning in
the operating room (PCC2018), they should be vigilant in correctly manoeuvring
and positioning the patient, giving special attention to the heel area and other
pressure points, including protection against fixed/static retractors (Greenwood
etal.2022). Additionally, the use of equipment, gel pads, supports and cushions is
vital in preventing injuries.
Ward Preparation– Patient Fasting 31
PATIENT MOBILITY
Given the ageing UK population, which currently includes over 10million people
aged 65 and over – a figure predicted to continue rising (The Centre of Ageing
Better2023)– frailty must be considered. A patient’s frailty can affect their mobility;
therefore, it is essential to assess this presurgery by undertaking assessments such as
the Clinical Frailty Scale and the 6- item Cognitive Impairment Test (6CIT), which can
determine cognitive function and dementia (Finegan and Khadaroo2021). Assessment
may reveal that the patient requires pre- and postoperative optimisation by a physio-
therapist. The preoperative mobility of a patient may also affect the type of anaes-
thetic given and the positioning of the patient during surgery. For example, a bilateral
above- knee amputee may require different positioning equipment for a lithotomy
position. Additionally, frailty can affect the patient’s mobilisation postoperatively,
increasing the potential for complications such as VTE, pressure ulcers/injuries and
chest infections. Patients should be encouraged to transfer themselves to a bed, trolley
or chair; the SFA can facilitate this discussion preoperatively and communicate these
needs to the wider perioperative team, thus reducing the risk of injury to both the
patient and staff. Patients should also be encouraged to reposition and move at least
every six hours for adults and four hours for children (NICE2022).
WARD PREPARATION– PATIENT FASTING
All patients undergoing elective general anaesthesia, sedation, regional, spinal or epi-
dural blocks should receive verbal and written information on the required fasting
instructions prior to elective surgery. These instructions are outlined below and
should be followed in line with local and national fasting guidelines. It is important to
note that these guidelines may differ for patients on an enhanced recovery pathway
(Smith etal.2011; Wobith and Weimann2021).
Fasting Instructions forAdult Elective Surgery Patient
Adults awaiting elective surgery should fast for
• Six hours– solid food.
• Two hours– tea and coffee with milk.
• Free access to water until the time of surgery ‘sips til send’ (National Day
Surgery Delivery Pack and Stocker etal.2020).
Fasting Instructions forAdult Emergency Surgery Patient
•
Follow the guidance for elective surgical patients, but communicate regularly
with ward staff.
• Continue with frequent drinks of water if clinically appropriate.
32 Chapter 3 Preoperative Assessment
• Patients unable to tolerate oral fluids may require intravenous fluids to main-
tain good hydration. Consider intravenous fluids if patients are fasted longer
than six hours (earlier in hot environments).
Fasting Instruction for Children
Children should be fasted for
• Six hours– solid food.
• Four hours – formula milk.
• Three hours– breast milk.
• Up to one hour – healthy children are encouraged to drink clear fluids,
including water with or without sugar, pulp- free juice and milk- free tea or coffee.
• Sip water till send (Frykholm etal.2022).
The patient should be encouraged to maintain clear fluids until sent for surgery
using the ‘sip til send’ guidance. SFAs should communicate with the ward staff
regarding the list order and actively encourage fluid intake to reduce postoperative
complications such as pain, nausea and vomiting (Lovejoy2020). Additionally, the
Malnutrition Universal Screening Tool (MUST) for adults should be completed on
admission to identify patients who are malnourished and at risk of malnutrition,
including those with obesity (Smith 2024). The MUST Risk Score is linked to
management guidelines, which can be used to develop a care plan to improve the
patient’s nutritional status. The SFA should be aware that the patient’s nutrition will
affect wound healing (Hirsch et al.2021), which may influence their skin closure
technique, for those SFAs undertaking extended skills.
SURGICAL SITE MARKING
Never Events are considered preventable safety incidents that should not occur if
national guidance and safety policies are followed. Wrong- site surgery is considered
as a never event (NHS England2021) and can cause significant harm to the patient.
NHS England reported 89never events from healthcare organisations, of which 39
cases were recorded as wrong- site surgery from April 2022 to June 2023. Every health-
care organisation should have a policy and clear guidance on correct- site surgery and
should complete the WHO Surgical Safety Checklist intraoperatively, which will be
further discussed in Chapter4.
The preoperative surgical site marking of a patient plays a significant role in sur-
gical safety and can prevent wrong- site surgery. RSCEng (2023a) recommends that
the operating surgeon or a nominated deputy, who will be present in the operating
Decision- Making andInformed Consent 33
room and during the checklist, undertake the surgical site marking with the patient
preoperatively.
Whilst the operating surgeon or clinician retains overall accountability, the sur-
gical site skin marking process must be completed robustly. Delegating this task to a
registered practitioner, nurse or Allied Health Professional (AHP) results in the nurse
or AHP retaining professional accountability for undertaking this task under their
own professional ‘duty of care’ to the patient (NMC2018; HCPC2023).
The CPOC (2023) NatSSIPs 2 document clearly outlines the steps and checkpoints
required to reduce errors in surgical site marking and consent. The surgical site mark-
ing should be undertaken prior to transferring the patient to the operating theatre.
The operative site mark should be recorded in the patient’s perioperative patient care
plan and corroborated against the consent, the patient ID band and, where appro-
priate, verbally with the patient. This will be reconfirmed as part of the ‘sign in’ step
of the WHO Surgical Safety Checklist. Additionally, the site mark must be re-
confirmed during the intraoperative ‘Time Out’ check.
The skin marker pen must be single- use to prevent cross- infection and permanent
to prevent removal after skin disinfection. The mark must be an arrow that extends
near the incision site, but not into the incision site, as this can result in permanent
‘tattooing’, and it should remain visible after the application of theatre drapes
(RCSEng 2023a).
However, some procedures do not require surgical marking, such as surgery on
teeth or mucous membranes, endoscopic procedures and cases of bilateral simulta-
neous organ surgery, such as bilateral hernia repair. The site does not need to be
marked in operations where laterality or pathology needs to be confirmed following
examination under anaesthesia.
DECISION- MAKING ANDINFORMED CONSENT
Within the UK, there is a fundamental right for patients and families to be involved in
their care and treatment (NICE2021). This is based on shared decision making (SDM)
and mental capacity; even patients who lack capacity should be involved (Mental
Capacity Act 2005). Additionally, the Montgomery v Lancashire (2015) case has
reinforced SDM by providing patients with the capacity information of all treatment
options and associated material risks.
From an SFA perspective, the NMC (2018) and HCPC (2023) regulatory bodies
provide clear guidance on the importance of obtaining consent (both verbal and writ-
ten). The SFA should follow the regulator guidance on valid consent, including
implied consent, which is necessary when performing treatments, examinations or
procedures such as urinary catheterisation, whilst also acting as the patient’s advocate.
The SFA must understand that the consent process starts with SDM. For elective
surgery, this will normally be initiated during an outpatient visit with the surgeon and
will continue throughout the patient’s surgical journey.
34 Chapter 3 Preoperative Assessment
The consent form is typically a generic document that records the discussion tai-
lored to the individual patient by documenting the risks based on the patient’s comor-
bidities and potential treatment interventions, including blood transfusions and other
investigations.
The SFA should also know the differences in consent for adults, young people and
children (RCOA2018). Patients aged 18 years and over are assumed to be competent
adults, capable of consenting to or refusing treatment unless other factors prevent
this. Whilst patients aged 16 and 17 years in England, Wales and Northern Ireland
have the legal capacity to consent, Scotland has different legislation for children and
young people regarding valid consent.
The SFA is not responsible for completing the consent form for an operative
procedure; this is the responsibility of the surgeon/practitioner providing the
treatment or someone who is actively involved in the provision of treatment (RSCEng
2023b). The person obtaining consent should be knowledgeable about the procedure,
including the potential risks, benefits and alternative treatment options.
After discussing the procedure with the patient, the consent form will be com-
pleted, including the site and side of surgery, and it will be signed by both the consul-
tant or nominated person and the patient. The patient should be given a copy for
reference and reflection. Preoperative assessment services will provide further
information to be discussed with and given to patients and their families. This
information may be available in various formats. Patients may also be referred to other
services, such as physiotherapy and smoking or alcohol cessation services, to reduce
operative risks (Eliasen etal.2013; Steffens etal.2019; WHO2020).
On the day of the surgery, the operating surgeon should review the patient’s
decision and clarify if anything has changed since the original consent discussion that
could potentially alter the treatment plan or associated risks. If there have been
significant changes or delays since the original signing, the consultant or nominated
practitioner will confirm the consent by signing it; a patient signature is not required
(General Medical Council2020). Additionally, any changes since the original consent
should be documented.
For consent to be valid (NHS2022), the patient must:
• voluntarily agree; the decision must be made by the person and not be influenced/
forced by medical staff, friends or family.
• be informed of all available treatment options, with sufficient information to
make a choice, balance the risks and benefits and reach a decision about a
treatment.
• have the capacity to make the decision, understand, remember and use the
information, whilst being able to communicate their decision.
For patients who lack the capacity to make decisions, either temporarily or per-
manently, the Mental Capacity Act (2005) gives medical professionals the ability to
provide carefully considered treatment that is in the patient’s best interests. Whilst
References 35
parents, guardians and family members may be involved in discussions regarding
treatment and care, they do not have the authority to give consent on the patient’s
behalf. The SFA can be instrumental in communicating the patient’s views in relation
to concerns, withdrawal of consent, resuscitation and transfusion (RCSEng 2023b)
and in supporting the patient’s family during the perioperative phase.
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