Perioperative care in adults

Impact on NHS workforce and resources

This NICE guideline on perioperative care in adults has been reviewed for its potential impact on the NHS workforce and resources.

The guideline covers care for adults (aged 18 and over) having elective or emergency surgery, including dental surgery. It covers all phases of perioperative care, from the time people are booked for surgery until they are discharged afterwards. The guideline includes recommendations on preparing for surgery, keeping people safe during surgery and pain relief during recovery.

Recommendations likely to have an impact on resources

The following recommendation is most likely to have the greatest resource impact nationally (for England):

‘Provide postoperative care in a specialist recovery area (a high-dependency unit, a post-anaesthesia care unit or an intensive care unit) for people with a high risk of complications or mortality.’ [recommendation 1.5.1]

Context

Approximately 11 million people have surgery each year in the NHS. Over half are having elective (non-emergency) procedures. Although the standard of care during surgery is high, preventable complications and deaths still occur. Most of these are in high-risk patients, who make up 15% of all patients having surgery.

Perioperative care is a broad field covering an array of elective and emergency procedures across a varied population. The guideline focuses on aspects of perioperative care where practice varies. It brings together the available evidence and provides recommendations to standardise practice and improve surgical outcomes. It also highlights areas where research is needed to inform future guidance.

Surgical services are commissioned by integrated care systems / clinical commissioning groups and NHS England. Providers are NHS hospital trusts.

Resource impact

Due to high levels of local variation, we encourage organisations to evaluate their own practices against the recommendations in the NICE guideline and assess costs and savings locally.

Table 1 shows examples of the potential capacity impact per 100,000 population of recommendation 1.5.1 for the provision of specialist recovery. The table shows the impact in 3 scenarios. ‘Specialist recovery’ may also be referred to as ‘postoperative enhanced care’. In this text ‘specialist recovery’ is used in line with the guideline recommendations.

Table 1 Impact on capacity per 100,000 population

The main implementation costs will fall on providers if an increase in staffing is required to deliver specialist recovery. Providers may have capacity benefits arising from a decrease in the use of critical care facilities, a reduction in cancellations of procedures and a potential reduction in length of hospital stays. If there is a decrease in the use of critical care facilities, this may decrease the cost to commissioners, depending on the contract in place. Critical care activity may be paid for by commissioners at a locally negotiated bed day tariff or through a block contract.

For a population of 100,000 and assuming a 20% increase in specialist recovery activity, there is an estimated reduction of 224 people who go directly to a ward after major, complex or high-risk surgery and a corresponding decrease in the use of critical care bed days of 45 days.

Support to put the recommendations into practice

COVID-19

• See NICE’s COVID-19 rapid guideline on arranging planned care in hospitals and diagnostic services for guidance on minimising risk from COVID-19. Planned care covers elective surgery, including day surgery and inpatient stays.

Providing a point of contact within the perioperative team

• NICE recommends that when booking surgery, you should give people a point of contact within the perioperative care team who can be approached for information and support before and after their surgery. In larger hospitals the point of contact could be a specific team member such as a clinical nurse specialist. In smaller units the point of contact may need to be a team of people. The point of contact may change as people's needs change throughout the stages of perioperative care.

Audit and improvement programmes

• The Perioperative Quality Improvement Programme (PQIP) aims to improve patient outcomes after major non-cardiac surgery and reduce national variations in processes of care. It collects data on individualised risk assessment, postoperative destination and management of anaemia, diabetes, pain and compliance with enhanced recovery principles. It reports on complications, mortality and patient-reported outcomes. All hospitals undertaking major inpatient surgery are encouraged to take part and use their data to improve care. The PQIP annual reports detail successes and areas for improvement.
• The National Emergency Laparotomy Audit evaluates the care of adult patients in England and Wales undergoing this high-risk surgery. It measures compliance against improvement targets that are highlighted in the NICE guideline, including postoperative critical care admission and individualised risk assessment.
• The Getting It Right First Time (GIRFT) workstreams on anaesthesia and perioperative medicine and adult critical care began in 2017 and, following GIRFT methodology, have collected data and undertaken visits to NHS trusts. Reports on their findings and recommendations for improvement will be published and support the implementation of the NICE guideline.
• The Care Quality Commission (CQC) inspects elective and emergency surgery as an acute core service. The inspections cover all phases of perioperative care. The CQC inspection framework, which is currently under review, is in alignment with the NICE guideline.

Additional support

• The Centre for Perioperative Care (CPOC) is a cross-specialty initiative involving several healthcare organisations. They are interested in the development, advancement and promotion of perioperative care. As well as hosting a variety of resources in this area, they have also established a network of CPOC perioperative local leads who are committed to local implementation of perioperative care.
• The Faculty of Intensive Care Medicine’s guidelines for the provision of intensive care services specify minimum standards and supplementary recommendations to reduce geographical variation in the provision of critical care units. These guidelines are included as relevant professional standards in the CQC's core service framework for critical care, which is currently under review.
• The Faculty of Intensive Care Medicine and the Centre for Perioperative Care guidance on establishing and delivering enhanced perioperative care services supports services with the care of elective patients. These services allow for a higher level of care than the ward, while releasing critical care capacity. An established post-anaesthesia care unit may act as the basis for the development of an enhanced perioperative care service.

External websites and resources referred to in this statement have been identified as potentially useful resources to help implement specific recommendations from the guideline. NICE has not made any judgement about the methodology, quality or usability of the websites or resources.