Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients 2024

Hospitals should have a clear and explicit strategy for developing a strong safety culture, which includes the following characteristics: recognition of the inevitability of errors, commitment to discuss and learn from errors, proactive identification of latent threats, and the incorporation of non-punitive, fair and transparent systems for reporting and analysing adverse events.^7,8,9

Hospitals should review their local standards to ensure that they are harmonised with the relevant national safety standards.^10,11,12 Organisational leaders are ultimately responsible for implementing local safety standards as necessary.¹³

The organisational culture should seek to empower health professionals to implement patients’ preferences, informed by discussions around risk and benefit. The ownership and decision making in healthcare should be in the hands of professionals and patients.^14,15

Information relevant to clinical staff concerning clinical outcomes, patient experience and productivity (such as theatre efficiency) should be readily available to staff.^15,16

The organisation should ensure that patient safety concerns are addressed and that the recommendations or changes that result are fed back to procedural teams.^13,17

Emergency and elective pathways should be separated (whenever practically feasible), to improve clinical care for patients.^18,19

There should be clarity of leadership and roles in the supervision of the day to day running of the anaesthetic department.

Elective theatres should offer spare capacity (such as that resulting from cancellations) to the emergency theatres.²⁰Elective cases may be cancelled, in accordance with agreed local procedures, to facilitate emergency work if required.

When members of the healthcare team are involved in a critical incident, the personal impact on individual team members can be significant.^7,21 Following a significant critical incident, the clinical director (see Glossary) or appropriate individual (head of service) should promptly review the immediate clinical commitments of the staff concerned. Relevant support for staff following a critical incident is outlined in GPAS chapter 1: Guidelines for the Provision of a Good Department.

Appropriate patient centred pathways should be in place linking through to primary care, clinical policies, checklists and standard operating procedures for operating theatres.

Generic policies covering the entire perioperative period should be held and easily accessible. These include but are not limited to:

• support for patients and staff of diverse religious beliefs and cultural backgrounds²²
• infection control, including personal protective equipment²³
• implementation of enhanced perioperative care²⁴
• management of death in the perioperative period.^25,26

The following policies covering the entire perioperative period should be held and easily accessible for the management of patients with additional clinical requirements including, but not limited to: 

• patients with obesity^27,28
• obstructive sleep apnoea
• allergies, including perioperative management of latex and chlorhexidine allergies
• management of complex cardiovascular disease including patients with cardiac pacemakers and implantable cardioversion defibrillators
• management of significant respiratory impairment including severe chronic obstructive pulmonary disease
• blood/component management for patients who refuse transfusion of blood or blood components^29,30
• thromboprophylaxis including the management of patients receiving any anticoagulant therapy^31,32,33
• diabetes management^34,35
• patients with sickle cell disease.³⁶ 

The following policies covering the entire perioperative period should be held and easily accessible for the management of vulnerable patient groups, including but not limited to:

• management of the older patient³⁷
• management of patients with learning disabilities, cognitive impairment and dementia²²
• management of complex acute pain (e.g. pre-existing opioid tolerance).³⁸

Policies for the management of children in accordance with GPAS chapter 10: Guidelines for the Provision of Paediatric Anaesthesia Services should be held wherever children are anaesthetised or sedated.³⁹

Access to paperless guidelines through a readily available hospital intranet repository is encouraged.

Anaesthetic departments should have a coherent and well managed governance structure with a clinical lead with time identified for the role within their job plan.

All critical incidents should be reported according to local governance procedures.⁴⁰

Hospitals must have systems in place to facilitate multidisciplinary morbidity and mortality meetings.⁶

Clinical governance is detailed in GPAS chapter 1: Guidelines for the Provision of a Good department.

Objective assessment of risk should be routine and the identification of increased risk should trigger advanced planning specific to that patient. Each hospital should have a consistent and where possible evidence based system in place to identify high risk surgical patients who require additional assessment.⁵⁰ This assessment should be based on:⁵⁴

• age
• comorbidity
• medication history and allergy status⁵⁵
• type of surgery including risk of severe postsurgical pain^56,57
• dementia and cognitive dysfunction⁵⁸
• frailty⁵⁹
• nutritional status
• lifestyle factors (i.e. smoking behaviour, excess alcohol consumption, drug use, obesity)
• psychological factors and anxiety
• functional status
• chronic pain.

As a minimum, all ASA 3–5 patients and those undergoing high risk surgery should have their expected risk of morbidity and mortality estimated and documented prior to an intervention, with adjustments made in accordance with national guidelines in planning the urgency of care, seniority of staff involved and postoperative care.^{16,54,60,61, 62}

There are validated general risk prediction tools available that assess the risk of 30-day mortality (and morbidity) following surgery, as well as procedure specific risk prediction tools for elective aortic aneurysm surgery.⁵⁹ There is also a wide variety of other screening and risk assessment tools that are useful in estimating the specific or additional risks accrued through the factors listed in recommendation 4.1. The focus is upon improving quality of outcomes through improved perioperative planning based on individual hospital case mix.^64,65 Where possible, risk quantification tools should be used to facilitate shared decision making conversations and to enable informed anaesthetic consent consistent with GMC requirements.^66,67 Quality improvement outcomes should be assessed through national and local audit. Appropriate tools for risk prediction in perioperative care can be found at www.CPOC.org.uk. 

Preoperative assessment should occur as early as possible in the patient’s care pathway. Greater than two weeks preoperatively is recommended as good practice and preferably as close to the point of contemplation of surgery as possible to allow for the optimisation of chronic health conditions and health behaviours, so that all essential resources and obstacles can be anticipated prior to the day of procedure, including discharge arrangements.⁴¹ If there are delays to surgery and a significant period of time has elapsed between preassessment and the date of surgery, a repeat preoperative assessment should be undertaken to ensure there are no changes to the patient’s co-morbidities.

Where possible, it is preferable for one stop arrangements to be implemented so that patients can attend preoperative assessment during the same hospital visit as their surgical outpatient assessment. Ideally, the frequency of high risk clinics should allow for one stop patient visits when appropriate. The volume of information may mean that the wrong details are prioritised or recollected. Patients should be given information to reflect on with their family at home, ideally beforehand and always afterwards. The patient should be encouraged to identify questions and be given a route for these to be discussed.⁶⁸

Each hospital should have agreed written preoperative policies or guidelines, following national guidelines where available, including but not limited to:

• preoperative tests and investigations^69,70
• preoperative ordering for potential blood transfusion
• preoperative fasting schedules and the administration of preoperative carbohydrate drinks^{41,42,71, 73}
• default to day surgery for suitable procedures
• escalation to higher levels of postoperative care (e.g. to a critical care unit) should the patient develop perioperative complications
• optimisation and continuation/ cessation of regular medication, including on the day or surgery, and including adjustments to monitored dosage systems^72,74
• referral of patients from a nurse led clinic to anaesthetic staff for further review
• pregnancy testing prior to surgery
• breastfeeding guidelines
• implementation of enhanced perioperative care.⁷⁵

Each hospital should have agreed protocols, following national guidance where available, including, but not limited to:

• management of anaemia including parenteral iron therapy to reduce the risk of allogenic blood transfusion^{75,76,77,78,79}
• antacid prophylaxis
• preoperative nutritional screening.

The secondary care preoperative service should liaise closely with primary care, other secondary care professionals and commissioners to promote a ‘fitness for referral’ process in line with best practice.

Agreed internal referral pathways to other specialties should be in place for the minority of cases in which this may be required to expedite further investigation and patient optimisation. This should be done in close collaboration between the preoperative assessment lead and nominated representatives from appropriate specialties (e.g. cardiology, diabetes, renal, respiratory and geriatric medicine).

Where the risk of an adverse patient outcome associated with surgery are identified as being high, the preoperative assessment consultation should facilitate a shared patient discussion, which may result in a well-informed individual opting for non-surgical management. Under such circumstances the decision making process should be endorsed through close collaborative discussion with surgical colleagues – this is ideally conducted and documented within a preoperative multidisciplinary team (MDT) meeting.⁸⁰

The output from consultations with patients at increased risk of mortality or morbidity must be documented in the patient’s medical notes. In addition, mechanisms for clear communication of these consultations to patients, anaesthetists, surgeons, general practitioners and other healthcare workers should be in place.^6,54

Consideration should be given to the use of formal prehabilitation pathways as well as services for nutritional assessment, smoking cessation, alcohol / drug addiction services and psychological support.^_81,82,83

Documentation and communication of information on preoperative preparation are essential. Electronic systems should be considered to enable the capture and sharing of information, support risk identification and allow data to be collected and available for audit and research purposes.^48,80,84

Discharge planning should ideally start as soon as the patient opts for surgery so that all essential resources and obstacles to discharge can be identified and dealt with, including liaison with primary care and social care services as required. This will minimise late cancellation of procedures.⁸⁵

A preoperative blood ordering schedule should be agreed with the local blood transfusion service for each procedure and appropriate system should be in place to facilitate timely provision of blood products.

Anticipated difficulty with anaesthesia should be brought to the attention of the anaesthetist as early as possible before surgery.⁸⁰ This includes planned admission to a critical care unit, the potential need for special skills such as fibre optic intubation, obesity, complex pain problems, a known history of anaesthetic complications or patients with learning disabilities who may require additional resources or theatre time. Local groups such as critical care MDTs or high risk MDTs could facilitate perioperative planning of patients where high risk is identified.⁸⁷

Where inpatient care is necessary, an enhanced recovery pathway should be followed as this is now considered to provide optimum perioperative care.^{86,88,89,90,91}The preoperative service should ensure that patients are clear about their own responsibilities and expected length of stay to support enhanced recovery pathways.^92,93

Consideration should be given to a designated pharmacist being available to provide advice and input into anaesthetic and preoperative assessment. This level of input may range from ad hoc advice through to designated preoperative assessment pharmacists, preferably with prescribing rights, who can undertake medicines reconciliation, produce perioperative medication plans and provide specialist advice.

All practitioners must follow the practices outlined in the GMC Decision making and consent guidance. Documentation of the risks discussed or the dialogue leading to a decision is required in accordance with paragraphs 50–55.⁶⁷ Equally, completion of a consent form is not a substitute for a meaningful dialogue tailored to the individual patient’s needs.

Ideally, as part of shared decision making, consent for surgical and anaesthetic procedures should be obtained prior to the day of surgery (see recommendation 4.3), allowing sufficient time for the patient to reflect on their consent discussion.⁶⁷ The competent patient has a fundamental right, under common law, to give, or to withhold, consent to examination, investigation and treatment.^66,67,99

Where a patient is seen prior to the day of surgery and shared decision making and discussion of anaesthetic conduct has taken place, the anaesthetist on the day of surgery has a responsibility to ensure the patient still understands and agrees with the perioperative plan.^66,67

The patient must be made aware of alternative treatment options, or the option for no treatment at all. It is acceptable to recommend one of the alternatives but as the GMC states ‘The doctor may recommend a particular option which they believe to be best for the patient, but may not put any pressure onto the patient to accept their advice’.^67,115

No other person can consent to treatment on behalf of any adult. If a health and welfare lasting power of attorney directive is in place, the attorney may be able to assent to treatment on behalf of the patient. There should be a local process and policy in place for patients who lack capacity that conforms to national guidance and the Mental Capacity Act, the Adults with Incapacity (Scotland) Act or the Mental Capacity Act (Northern Ireland).⁹⁹,111,112,113

The RCoA and Association of Anaesthetists currently do not support enhanced roles for AAs until the statutory regulation for AAs is in place and a scope of practice is defined. ^{118, 119}

AAs should always work within an anaesthesia team led by a consultant or other autonomously practising anaesthetist who has overall responsibility for the anaesthesia care provided for the patient and whose name should be recorded in the individual patient’s medical notes.¹¹⁸

The supervising anaesthetist should be easily contactable and should be available to attend within minutes of being requested by the AAs.¹¹⁸

The supervising anaesthetist should not be responsible for more than two anaesthetised patients simultaneously, where one involves supervision of an AA.¹¹⁸

Clinical governance of AAs should follow the same principles as that applied to medically qualified staff. This should include training that is appropriately focused and resourced, supervision and support in keeping with practitioners’ needs and practice responsibilities, and practice centred audit and review processes. AAs should always work within the remit and the educational curriculum of their training programme. 

There should be a dedicated trained assistant (i.e. an ODP, anaesthetic nurse or equivalent) who holds a valid registration with the appropriate regulatory body, immediately available in every location in which anaesthesia care is being delivered, whether this is by an anaesthetist or an AA.^41,118

Staff assigned to the role of anaesthetic assistant should not have any other duties that would prevent them from providing dedicated assistance to the anaesthetist during anaesthesia.⁴¹

Facilities for maintaining anaesthesia, monitoring, ventilation of patients’ lungs and for age-appropriate resuscitation, including defibrillation, should be available at all sites where patients are anaesthetised.^120,121,122

The following anaesthetic equipment is required for the safe delivery of anaesthesia, and should be immediately available at all sites where patients receive anaesthetic intervention:

• oxygen supply including an emergency back up supply
• self-inflating bag
• facemasks
• suction equipment
• airways (nasopharyngeal and oropharyngeal)
• laryngoscopes, including at least one type of video laryngoscope
• intubation aids (bougies, forceps, etc.)
• supraglottic airways
• appropriate range of tracheal tubes and connectors
• heat and moisture exchange filters
• trolley/bed/operating table that can be rapidly tilted head down
• method of delivering anaesthesia using volatile anaesthetic agents or infusions (including target controlled infusion algorithms).

Anaesthetic machines should never be able to supply a hypoxic gas mixture.¹²³

The recommended standards of monitoring, by instrument or otherwise, should be met for every patient.¹²¹ All monitors should be fitted with audible alarms, with preset but adjustable limits.^121,124 The following equipment should be available at all sites where anaesthesia is administered:¹²¹

• oxygen analyser
• device to display airway pressure whenever positive pressure ventilation is used, with alarms that warn if the airway pressure is too high or too low
• vapour analyser whenever a volatile anaesthetic agent is in use
• capnograph
• pulse oximeter
• non-invasive blood pressure monitor
• electrocardiograph
• a means of measuring the patient’s body temperature
• a nerve stimulator when neuromuscular blocking drugs are used.

All anaesthetic equipment should be checked prior to use in accordance with the Association of Anaesthetists’ published guidelines.¹²⁵ Anaesthetic machine checks should be recorded in a log and on each patient’s anaesthetic chart.

The following equipment is required for the safe delivery of anaesthesia and should be available at all sites where patients are anaesthetised in sufficient quantities for the case mix and workload:

• defibrillators and equipment for external cardiac pacing¹²⁶
• positioning equipment (stirrups for lithotomy, arm boards, head rest for prone positions, bariatric supports etc.)¹²⁷
• ultrasound imaging equipment for vascular access and regional anaesthesia
• equipment required for the administration of a volatile-free anaesthetic, including infusion pumps, volatile-free anaesthetic machine and/or activated charcoal filters
• adequate numbers and types of infusion pumps and syringe drivers available for high risk medicines¹²⁸
• at least one readily available portable storage unit with specialised equipment for the management of patients with a difficult airway in every theatre suite including video laryngoscopes and fibre-optic scopes^129,130,131
• active patient warming devices^132,133
• fluid warming devices, allowing the transfusion of body temperature blood products and intravenous fluids of body temperature^134,135
• rapid infusion device for the management of major haemorrhage
• regional anaesthesia equipment, including ultrasound and regional anaesthesia nerve stimulators
• cuff pressure monitors
• blood glucose measuring device

All equipment used for regional anaesthesia and analgesia should have NRfit connections.¹³⁶

Some patients may require additional monitoring equipment. The following should be considered based on case mix and workload:¹²¹

• invasive cardiovascular pressure monitoring
• Point of Care coagulation testing.¹³⁷
• cardiac output monitors
• depth of anaesthesia monitoring.¹³⁸

A named anaesthetist with time assigned in their job plan should oversee the provision and management of anaesthetic equipment.¹³⁹

All anaesthetists, AAs and anaesthetic assistants should receive systematic training in the use of new equipment. This should be clearly documented.¹³⁹ Anaesthetists should not use equipment unless they have been trained to use it and are competent to do so. The NHS Clinical Negligence Scheme for trusts and Healthcare Improvement Scotland require that hospitals ensure all personnel are trained to use and to check relevant equipment. This may take place at induction for new staff or at the introduction of new equipment. A record of training should be kept. The use of routine checks and associated checklists is an important part of training in anaesthesia and is part of the RCoA’s competency-based training.

User manuals should be available as required for anaesthetic equipment.¹³⁹

There should be a planned maintenance and replacement programme for all anaesthetic equipment.^139,140

As a minimum, services should be available for:

• blood transfusion
• radiological investigations
• haematology
• clinical pathology
• electrocardiography.

Near patient testing for blood sugar measurements should be readily available for theatres.

Near patient testing for haemoglobin, blood gases, lactate, ketones and coagulation measurements should be considered, particularly in areas where major blood loss is likely.¹⁴¹ If near patient testing is not available, laboratory testing should be readily and promptly available.

Decision support systems for crisis scenarios should be available, for example the Association of Anaesthetists Quick Reference Handbook, advanced life support algorithm, difficult airway guidelines and major haemorrhage protocols.^142,143,144

Real time alerts and recommendations (e.g. patient allergy or drug interactions) could be made available using electronic information systems.¹⁴⁵

Policies and equipment must be in place to protect patients and staff from cross infection, including the safe disposal of sharps and healthcare waste.^146,147

The separation of clinical and non clinical recyclable waste should be considered.¹⁴⁸

Up to 80% of patients having elective surgery (see Glossary) will be admitted through a day surgery unit. Provision of day surgery is detailed in GPAS chapter 6: Guidelines for the Provision of Day Surgery. All other patients should be admitted to a ward, admissions unit or similar facility with sufficient time before the operating list on which they are scheduled.

If used, the day of surgery admissions (DOSA) unit should ideally be located close to theatres to allow for efficient list management.

There should be a staffed reception desk or automated registration system to ensure the patient’s attendance is registered as they arrive in the DOSA unit, as well as sufficient seating for the patients throughout their stay.

There should be sufficient consulting rooms or privacy on the DOSA unit for preoperative checks or assessment by nursing, anaesthetic and surgical staff, including a secure environment to enable access to patients’ physical or electronic notes.

There should be equipment and facilities for basic day of surgery physiological monitoring checks, and near patient testing / laboratory blood tests as required for the patient case mix and surgery.

There should be sufficient space and changing rooms including toilets to allow for maintenance of patient dignity in the immediate period pre procedure. Suitable storage of personal effects including the patient’s own medication (e.g. secure storage lockers) should be available during transition through the perioperative pathway. Consideration should be given to providing an opportunity for basic entertainment while waiting for example wi-fi and / or televisions. Furniture should be appropriate to the patient population (e.g. for patients with obesity and those who are frail or older) to allow for their comfort and dignity.

The operating theatre, and anaesthetic room where used, should conform to Department of Health building standards and be appropriately maintained.¹¹⁷

There should be provision of an emergency call system, including an audible alarm.¹¹⁷ A visible indication of the location of the emergency should also be considered.

The geographical arrangement of theatres, emergency departments, critical care units, coronary care, interventional radiology and imaging facilities should allow for the rapid transfer of critically ill patients.¹¹⁷

Anaesthetic sites must have scavenging systems that meet the Health and Safety Executive’s occupational exposure standards for anaesthetic agents.¹⁴⁹

Appropriate blood storage facilities should be in close proximity to the operating theatre and should be clearly identifiable.¹¹⁷

Transport and distribution of blood and blood components at all stages of the transfusion chain must be kept under conditions that maintain the integrity of the product.¹⁵⁰

Facilities to allow access to online information, such as electronic patient records, local guidelines and clinical decision aids in the theatre suite should be considered.¹⁵¹

Appropriate facilities for rest breaks should be provided according to defined norms.^{116,152,153,154}

Facilities for medication storage should be located and designed in such a way that allows timely access when required for patient care, while maintaining integrity of the medicines and aiding organisations to comply with safe and secure storage requirements.^155,156,157

Access to theatres and associated clinical areas should be appropriately restricted.¹¹⁷

All staff involved in the prescribing, dispensing, preparing, administering and monitoring of medicines must be appropriately trained.^158,159

All theatre staff involved in any aspects of the use of medicines should have access to up to date resources on safe preparation and administration of medicines, and access to a pharmacy service for advice. ^125,138

There must be a system for ordering, storage, recording and auditing of controlled medicines in all areas where they are used, in accordance with legislation.^{159,160,161,162}

All drugs required for safe delivery of anaesthesia including emergency drugs, should be available. Some drugs such as dantrolene or intralipid may be held centrally rather than immediately to hand.

Robust systems should be in place to ensure reliable medicines management, including accurate medication history taking and documentation on admission, medication storage facilities, stock review and management, supply, expiry checks, and access to appropriately trained pharmacy staff to manage any medicine shortages.¹⁵⁸

All local anaesthetic solutions should be stored in a separate storage unit from intravenous infusion solutions, to reduce the risk of accidental intravenous administration of such medication.^158,163

All medication containing infusions and syringes should be clearly labelled and ideally colour coded in accordance with the anaesthesia recommended scheme.¹⁶⁴

Where possible, drugs should be made available as pre-filled syringes.¹⁶⁵

The following policies should be immediately and reliably available at sites where anaesthesia and sedation are provided:

• guidelines for the checking of anaesthetic machines¹²⁵
• guidelines for the management of anaesthetic emergencies, including anaphylaxis,^55,170,171malignant hyperpyrexia and major haemorrhage
• periarrest and cardiac arrest algorithms¹⁷²
• difficult airway management, including the ‘can’t ventilate, can’t oxygenate’ scenario.¹³¹

The following policies should be held and easily accessible for:

• WHO checklist, including time out⁴
• ‘Stop Before You Block’¹⁷³
• ‘Do not attempt cardiopulmonary resuscitation’
• death in the operating theatre²¹
• major incident
• infection control (including antibiotic prophylaxis, staff protection and post exposure prophylaxis)¹⁴⁶
• prevention of hypothermia¹³²
• major haemorrhage¹⁷⁴
• blood and blood products administration^175,176,177
• handover and continuity of clinical care⁸
• medicines management
• local anaesthetic toxicity
• perioperative care for breastfeeding mothers.

All institutions should have protocols and the necessary facilities for managing postoperative care and should review and update these regularly.¹⁹⁰

The following protocols should be held and easily accessible for:

• management of postoperative nausea and vomiting
• pain relief for patients with chronic pain¹⁹⁶
• hypothermia¹⁹⁷
• blood transfusion
• fluid therapy
• acute coronary syndrome
• respiratory diseases
• hypotension
• hypertension
• monitoring following central and peripheral neuraxial blockade¹⁹⁸
• escalation to higher levels of postoperative care (e.g. to a critical care unit) should the patient develop perioperative complications.

Patients should be transferred to the ward, the postoperative care environment or the critical care unit accompanied by two members of staff, at least one of whom should be suitably trained to locally agreed standards.¹⁹⁹ The anaesthetic record, recovery and prescription charts together with the postoperative plan, should accompany the patient and be clearly communicated to the receiving ward nurse.

Handover, including on moving to the postoperative care environment or to the ICU, should always be to a member of staff who is competent to care for the patient at that time, and this should be clearly documented.²⁰⁰

All handovers should be structured to ensure continuity of care.^8,201

Staff should complete urgent tasks before information transfer, limiting conversations while performing these tasks (adopting a ‘sterile cockpit’ approach see Glossary).^202,203

If responsibility for care is transferred from one anaesthetist to another, a ‘handover protocol’ should be followed, during which all relevant information concerning the patient’s medical history, medical condition, anaesthetic status, and plan should be communicated.¹⁸⁰

Standardisation of the handover process can improve patient care by ensuring information completeness, accuracy and efficiency (the use of checklists should be considered). Staff should comply with the local standardised handover processes.^190,204

There should be an established policy to ensure clear communication of continuing requirements at discharge (e.g. analgesia) to include communication with primary care. This should include written information about common concerns (restarting medication, driving, etc.) and how to contact the hospital when required post discharge. Surgical teams will ordinarily be responsible for most of this process.

The particular needs of children should be considered at all stages of perioperative care. Children should receive an appropriate preassessment from staff with appropriate paediatric experience.²⁰⁵

The child should be helped to understand events that are happening or will happen, with the use of age-specific and developmentally appropriate explanation and materials.^206,207 There are specific issues around consent for children that need to be understood, including the particular requirements for children who are not under the care of their parents.²⁰⁸

A parent or legal guardian should ideally be with the child up to the point of moving into the operating theatre.²⁰⁹

Consideration should be given to appropriate strategies for recognising and managing anxiety of children particularly at induction e.g. play specialists, counselling, psychological support and anaesthetic training around managing preoperative anxiety.

Anaesthesia for children should be undertaken or supervised by anaesthetists who have undergone appropriate training. In the UK, all anaesthetists with a Certificate of Completion of Training (CCT) or equivalent will have completed higher paediatric anaesthetic training or equivalent.²¹⁰ There will be anaesthetists who have acquired more advanced competencies, thus allowing provision of a more extensive anaesthetic service, and those competencies should be maintained. Unless there is no requirement to anaesthetise children, it is expected that competence and confidence to anaesthetise children will need to be sustained through locally organised clinical experience, continuing professional development and/or refresher courses, and should be considered within annual appraisal and revalidation.

Each hospital should have a written definition of age thresholds and the types of procedure for elective and emergency work, including imaging, which can be provided locally. Children undergoing complex surgical procedures or with significant comorbidity should be discussed with the carers and referred to a tertiary centre if the local infrastructure cannot meet their needs.^211,212

Children should be separated from and not managed directly alongside adults throughout the patient pathway, including in waiting rooms, preassessment clinic rooms and theatre areas, including anaesthetic and recovery areas, as far as possible.²¹³ These areas should be child-friendly and should be staffed by suitably trained and qualified practitioners within recovery.¹⁹⁹

Children undergoing surgery should be grouped into paediatric lists, or together at the start of mixed lists.^211,212

Preoperative fasting should be minimised as much as possible, especially for infants and younger children.²¹⁴

All clinical staff working with children should have up to date certification in safeguarding level 2.²⁰³

There should be a policy in place for pregnancy testing for young female patients under the age of 16 years. This policy should adhere to Royal College of Paediatrics and Child Health guidance.²¹⁶

Information on the risks and the common adverse effects of anaesthesia in children, and the long-term effects of anaesthesia, should be discussed and offered in writing to children, parents and guardians.^207,217

Where designated separate areas for children are not available, discrete segregated areas in the pre and postoperative pathways should be available. They should be made as child friendly as possible.¹¹⁷

Children should never be left unattended in the recovery area.²¹⁸

Children have an increased incidence of postoperative delirium. Recovery staff should have an increased awareness and there should be local protocols for the management of this condition.²⁰⁷

Children with learning disabilities should ideally be recovered in an area with lower levels of noise and lighting and a familiar presence, such as a parent or their carer.²⁰⁷

The presence of learning disability practitioners in recovery when a patient with learning disability is being recovered should be considered.²⁰⁷

All staff working in paediatric recovery should be trained and competent in protocols, and should be familiar with the relevant procedures and personnel if there are safeguarding or child protection concerns that arise while the child is in theatre.²¹⁵

There should be a minimum of one member of the recovery staff, or an anaesthetist with advanced training in paediatric life support on duty. All members of recovery staff should have up-to-date paediatric competencies including resuscitation.¹⁹⁹

Paediatric equipment to cover all ages should be available in recovery, including a full range of sizes of facemasks, breathing systems, airway adjuncts and tracheal tubes. Essential monitoring equipment includes a full range of paediatric non-invasive blood pressure cuffs and small pulse oximeter probes. Capnography should also be available.¹⁹⁹

Parents and children should be appropriately educated and equipped with information to address common issues they may face postoperatively, in recovery and on discharge. This information should include leaflets for common procedures highlighting risks and these should be developed locally with support from area networks.²¹⁹

Guidelines and commonly used algorithms for paediatric emergencies should be readily available and regularly rehearsed.¹⁹⁹

Guidelines for fluid management specific to children, and equipment for accurate fluid delivery, should be available.²²⁰

Pain assessment tools used should differ, depending on the age and ability of the child. Self-reporting tools should be used where possible, with behavioural or composite tools for those unable to self-report.^221,222

Protocols for the use of epidural infusions, morphine infusions, patient controlled analgesia infusions and nerve catheter local anaesthesia infusions should be available and specific for children.^221,222

A policy should be in place for the management of non-peripartum pregnant women. This should detail the involvement of the multidisciplinary obstetric team, including midwives, neonatologists and obstetricians, depending on gestational stage.²²⁴

A policy should be in place for the perioperative care of breastfeeding mothers. This should include guidance to staff on the requirements to facilitate breastfeeding, anaesthesia protocols for breastfeeding mothers, outline supportive measures and provide clear instructions for the patient pre and post anaesthesia or sedation.²²⁵

Multidisciplinary care improves outcomes. Protocol driven integrated pathways guide care effectively, but should be individualised to suit each patient, with emphasis on management of postoperative pain and avoidance of postoperative delirium.^{231,232,233, 236, 237}

Preoperative assessment, optimisation and shared decision making in patients with multiple comorbidities, frailty or cognitive impairment require a cross specialty approach involving anaesthetists, surgeons, geriatricians, pharmacists and allied health professionals. Liaison with a clinical pharmacist in the perioperative period will enable optimisation of medicines and improved management of the patients’ non-surgical comorbidities during this time. The development of such teams requires time and resources. These should be recognised and provided.^{54,231,234,235,238}

Care of the frail and older surgical patient starts at the contemplation of surgery and continues through the hospital stay and beyond. Models of care for frail and older patients should include multidisciplinary management between surgical teams, physicians with expertise in the assessment and management of frailty/delirium and allied health professionals providing consistent hands-on medical care, direction of rehabilitation goal setting and discharge planning until discharge at which point signposting to community services will occur.²³⁹

Models of care could include comprehensive geriatric assessment which may have potential to improve outcomes.²⁴⁰

Patients with frailty are at increased risk of adverse postoperative outcome. Older patients undergoing intermediate and high-risk surgery should be assessed for frailty using an established tool or scoring system.^241,242

Pathways of care providing proactive preoperative interventions for frailty, involving therapy services, social services, discharge teams and geriatricians or physicians with expertise in the assessment and management of frailty/ delirium should be developed.^231,243,244

Older patients should have access to a consultant or other autonomously practising anaesthetist experienced in the management of the older surgical patient to support shared decision making, patient optimisation and perioperative care. Opportunities for joint geriatric and surgical clinical governance should be considered as this model of care is superior to that delivered without this expert support. ^229,244,245

The risk of postoperative functional decline and complex discharge related issues should be considered. Procedures should be in place to identify complex patients at pre-assessment and complex discharge planning should begin then. This will require a multi-disciplinary team approach. Guidelines should be developed for the prevention, recognition and management of common postoperative geriatric complications and/or syndromes, including delirium, falls, functional decline and pressure area care.²⁵⁰

Mechanisms for the early recognition of patients requiring specialist postoperative input from geriatrician led services and/or critical care should be developed. These should include patients at risk of or presenting with delirium, multiple medical complications, functional decline or those requiring complex discharge planning.

There is a high prevalence of recognised and unrecognised cognitive impairment amongst older surgical patients. This has implications for shared decision making, the consent process and perioperative management. Older patients should have preoperative cognitive assessment using established screening or diagnostic tools.²⁴⁶

Multicomponent interventions which reduce the incidence of delirium in elderly patients undergoing surgery should be considered. These include early mobilisation, avoidance of dehydration and avoidance of delirium triggering medications.^195,247,248

Provisions should be made for the assessment and management of pain in older people, and more specifically in those with dementia.^249,251

All staff managing patients in the postoperative period must be familiar with the arrangements determining mental capacity in the part of the UK in which they are working and pathways of care for patients with dementia.^{111,252,253,254}

Each department of anaesthesia should have a lead anaesthetist for patients with cognitive impairment with sufficient time identified for the role in their job plan.²⁴⁶

There should be established liaison with social services for patients who need such support to prevent delay in discharge.

Every hospital should nominate an anaesthetic lead for patients with obesity undergoing surgery with time identified for this role in their job plan.²⁴¹

Medical records should include the patient’s weight and body mass index (BMI).²⁵⁶

Ideally, patients with morbid obesity should undergo preassessment by a senior anaesthetist.²⁵⁶

Advanced warning of elective patients with morbid obesity should be given to the appropriate ward/ theatre environment by the preoperative assessment team. Additional specialised equipment is necessary and should be available for every patient with morbid obesity at all stages of the perioperative pathway.²⁵⁶

Patients undergoing bariatric surgery should be considered for level 2 or 3 critical care postoperatively.²²

Patient dignity should be maintained preoperatively by ensuring appropriate theatre clothing is available in the day case suite or admissions area.

The safe movement and positioning of patients with obesity may require additional staff and specialised equipment.^257,258 An operating table, hoists, beds, positioning aids (including for induction of anaesthesia) and transfer equipment appropriate for the care of patients with obesity should be available in appropriate quantities for the caseload, and staff should be trained in its use.^256,259 Additional members of staff should be available where necessary, and manual handling should be minimised where possible.

Operating lists should include the patients’ weight and BMI to highlight additional or alternative equipment requirements. Equipment and manual handling issues should be highlighted at the team brief element of the WHO Surgical safety checklist.^4,256

In view of the increased technical and clinical risks posed by patient with morbid obesity, senior anaesthetic and surgical staff should manage these patients.²⁶⁰

In the postoperative period, the safety of patients with obesity may be improved by the use of supplemental oxygen, non-invasive ventilation (continuous positive airway pressure), monitoring of sedation, and ideally continuous pulse oximetry.²⁶¹

Patients with obstructive sleep apnoea have a higher incidence of postoperative complications including hypoxia, renal failure, unplanned critical care stay, and delayed discharge. Therefore, consideration should be given to monitoring such patients in a critical care environment postoperatively.²⁶²

Critically ill patients should only be held in the recovery area because of a lack of availability of appropriate facilities elsewhere if recovery staff are appropriately trained, and the recovery unit is appropriately equipped to enable monitoring and treatment to the standard of a level 3 intensive care unit (ICU). In some circumstances, such as a viral pandemic or a major incident involving mass casualties, this may not be possible because of a huge surge in demand. This situation should be seen as exceptional rather than the accepted norm. Non-critical transfer to another hospital should be considered where necessary. It cannot be assumed that it is safe to use the recovery facility as an extension of ICU, and local policies and procedures should govern this issue.²⁶⁴

Where postoperative care is delivered outside of a main ICU (e.g. a level 2 high dependency unit (HDU) or specifically developed PACU), nurse-led, protocol driven care of frequently occurring problems for high risk surgical patients (such as pain, fluid imbalance, nutrition and mild cardiorespiratory compromise) can ensure good patient outcomes.²⁵⁰ Protocols and policies should be agreed between nursing staff, critical care, surgeons and anaesthetists.

Where the postoperative destination is not a main ICU (e.g. a level 2 HDU or specifically developed PACU), the patient should remain in PACU until they are stable and are no longer likely to require immediate support from an anaesthetist. This is of particular importance when transferring patients from recovery to level 2 critical care units that are not staffed by doctors skilled in airway management.

All hospitals should have a clear policy describing the safe triage of surgical patients considered to require postoperative critical care, with guidance on which patients should be admitted immediately to ICU, and which can wait in a standard recovery area for a short period while an ICU bed becomes available. Staff in critical care and recovery units should develop procedures to ensure safe and effective patient care during this transition. While the patient remains in the recovery unit, their care should be the primary responsibility of the staff and doctors working in that location. 

Hospitals should have written policies on the management of surgery that is sufficiently urgent that it proceeds when postoperative critical care is desirable but not available; this situation should be considered exceptional.

Preoperative assessment, optimisation, manipulation of patients’ normal drugs and shared decision making in patients with diabetes requires a cross-specialty approach based on national guidance involving anaesthetists, surgeons, diabetes physicians, diabetes inpatient specialist nurses and pharmacists. The development of such teams requires time and resources. This should be recognised and provided.^267,268

Patients with diabetes are at increased risk of adverse postoperative outcomes. Pathways of care providing proactive preoperative interventions to promote day of surgery admission and day surgery should be developed.²⁶⁷

Patients with diabetes are at increased risk of concurrent morbidity. These conditions should be identified and optimised where and when possible.²⁶⁷

Patients with diabetes are at increased risk of drug errors and medication interactions. Pathways should ensure medication reconciliation is performed, as this is vital to these at risk patients. ²⁶⁷ Insulin errors including overdoses occurring due to abbreviations or use of incorrect devices are classed as a never event by NHS Improvements.^269,270

Consideration should be given to scheduling patients with diabetes at the start of the operating list, to minimise disruption to the patient’s glycaemic control.

Hospitals should provide the services and resources required for the management of the surgical patient with diabetes, including explicit managerial and clinical policies.^33,267,268

Hospitals should consider appointing a lead anaesthetist for diabetes with appropriate time for the role identified in their job plan.²⁶⁸

Hospitals should have clinical guidelines, including:³⁴

involving patients in the management of their own diabetes

• ensuring that surgical patients with diabetes have an individualised explicit plan for the management their diabetes during periods of starvation and surgical stress; this may require the involvement of senior anaesthetic staff and the availability of equipment to continue or institute variable rate intravenous insulin infusions
• ensuring the prevention, and prompt recognition and treatment of hypo and hyperglycaemia, and hospital-acquired diabetic ketoacidosis
• surgical patient with diabetes have an increased risk of pressure ulcers and policies should be in place to prevent them.

In patients with learning disabilities or special needs, there should be close co-operation with other specialists. A learning disability liaison nurse could be available to support patients and carers while attending the hospital either for outpatients, day surgery or as inpatients. If patients lack capacity and are unaccompanied, then the involvement of an independent mental capacity advocate (IMCA) should be sought.²⁷¹

Departments should have a policy on how to care for patients with additional needs including those covered under the Equality Act, and consider appointing an assigned lead anaesthetist with time in their job plan for the role.^272,273 The policy should incorporate preassessment, deprivation of liberty assessment, consent, pathways to minimise anxiety and considerations for analgesia and discharge planning.²⁷⁹

Some patients who are unable to leave their homes and have difficulty in accessing primary or secondary care may benefit from a home visit for their preoperative assessment and preparation. The same may apply to prisoners detained in HM Prison Service.

Translators or interpreters should be available for patients who do not speak or understand English and those who use sign language. Written information also needs to be available in different languages.