The importance of perioperative optimisation from a pre-operative assessment pharmacist's perspective

Imagine you struggle each night to get to sleep due to the pain in your hip, you can no longer run after your grandchildren in the garden, and now rely on a neighbour to walk your dog.  After waiting years for a hip replacement each month passes slowly with you gradually being less able to do the activities you enjoy and becoming more isolated from the outside world.

You finally get the call from the hospital, the wait is over, come for your pre-operative assessment and there will be an operation date very soon.  Fantastic news, or so you thought, until you receive a phone call the day after your assessment explaining the need to delay your surgery to improve your diabetes (or hypertension, or anaemia, or time your surgery around your three-monthly arthritis injection).

But it doesn’t have to be this way; it shouldn’t be this way. 

It’s frustrating, especially as over the past few years you’ve had numerous interactions with the wider healthcare team.  Appointments at your GP surgery about your painkillers and diabetes, at the outpatient department with the surgical team, an unplanned hospital admission with pneumonia and collecting your long-term medications each month from your local pharmacy. If only someone had used any of these opportunities to help you understand the importance of actively preparing for surgery.  Rather than passively waiting, after just a brief two-minute chat you might have paid better attention to your diet and blood sugar readings, tried to maintain some physical activity, been mindful of your alcohol consumption or stopped smoking.  It could have given you a positive focus whilst you ‘waited’ and you would have been in a better position now. 

Locally we have a fantastic pre-operative assessment service, which has evolved over the years to fire fight such situations. We treat iron-deficiency anaemia, usually with IV iron due to the timeframe, rapidly diagnose hypertension with ambulatory blood pressure monitoring, expedite sleep investigations with overnight pulse oximetry, refer to a smoking cessation service and provide pharmacist led perioperative management plans.

But pre-operative assessment can’t fix every problem, especially in a short timeframe, nor should it.  It can be all too easy to think pills are the answer - add in an antihypertensive or another diabetic medication as a quick fix - but polypharmacy creates more problems. Prevention is better than cure, and lifestyle approaches address the underlying cause rather than just treating the disease.  Lifestyle medicine may be a slower approach but even pharmacological approaches can’t optimise HbA1c overnight. 

That’s why I strongly believe that empowering patients to address lifestyle factors, identifying and optimising non-surgical comorbidities should be everyone’s remit and start as early as possible in the perioperative pathway, even at the point of contemplation of surgery.  After all what is there to lose? Better preparation leads to better outcomes, for the patient but also the wider NHS.   Stopping smoking, increasing physical activity, improving diet, reducing alcohol consumption and actively managing cardiovascular risk factors such as hypertension and diabetes, reduce perioperative complications, improving outcomes and utilisation of finite resources but also improve long-term health.

It is time to focus on health and not healthcare. The importance of preoperative preparation is gaining traction in policy. Last year Welsh Government launched ‘promote, prevent and prepare for planned care’, a similar initiative to NHSE’s ‘earlier screening, risk assessment and health optimisation in perioperative pathways’. However, the challenge in implementing these strategies is spreading the principles of universal prehabilitation to the wider healthcare team and public, not just those individuals working directly in pre-operative assessment. 

With so many patients waiting for elective surgery most healthcare staff will interact with patients on a waiting list on a daily basis regardless of their occupation, speciality or sector. Spreading awareness to this wider healthcare team will help further our goal of better perioperative care. That’s why over the course of this year, I’m hoping to raise awareness of CPOC’s aims within the wider pharmacy workforce.

• Why not raise awareness locally with colleagues working outside pre-operative assessment by sharing this infographic or our new preparation resources (stopping smoking, alcohol moderation, nutrition and exercise)?
• If you’ve redesigned local services to focus on early optimisation why not share it on our website to inspire others?

 

Claire Frank is the current CPOC fellow and has worked as a pre-operative assessment pharmacist in Wrexham Maelor Hospital, North Wales since 2009.  She also has a voluntary role on the development team for the UKCPA Handbook of Perioperative Medicines.