Trust Policy and Guideline for Pre-Operative Investigations
Version
5
Name of responsible (ratifying) committee
Anaesthetic Department Governance Group
Date ratified
25th June 2014
Document Manager (job title)
Dr Frances King, Consultant Anaesthetist
Date issued
24th October 2014
Review date
23rd October 2016
Electronic location
Clinical Policies
Related Procedural Documents
Key Words (to aid with searching)
Preoperative investigations, preoperative tests
Version Tracking
Version
Date Ratified
1
2004/5
2
2007
3-5
2009, 2012 2014
Brief Summary of Changes
Author
Portsmouth Anaesthetic Department Guideline updated
in response to NICE guideline CG3 - Preoperative
tests: The use of routine preoperative tests for
elective surgery. Published 2003
F. King
Amended details regarding Sickle testing and cervical
spine x-rays.
F. King
No significant amendments. Awaiting outcome of
updating National NICE guideline – Guideline
Development Group – set up April 2014.
F. King
Preoperative Investigations : Issue Number 5, Issue Date 24/10/2014
(Review Date: 23/10/2016)
Page 1 of 5
CONTENTS
1. Introduction
2. Purpose
3. Scope
4. Definitions
5. Duties and responsibilities
6. Process
7. Training requirements
8. References and Associated Documentation
9. Equality Impact Assessments
10. Monitoring Compliance with Procedural Documents
11. Appendices
1. INTRODUCTION
This guidance has been developed to assist in the implementation of NICE Guidelines with
regard to a rational approach to preoperative investigations. Following the publication of NICE
guideline CG3 - ‘Preoperative tests: The use of routine preoperative tests for elective surgery’
in 2003, existing Portsmouth Anaesthetic Department guidance for preoperative blood tests, xrays and ECGs (electrocardiograms) was updated in line with the new recommendations. The
original NICE guidance was assessed by the preoperative teams and found difficult to use in
practice, as it consists of a number of different tables and for many tests the advice to
‘consider’ rather than yes/no was difficult to put into practice. A single table to set out basic
tests to be recommended in elective patients was produced.
2. PURPOSE
The Policy is aimed at introducing a rational and evidence based approach to preoperative
investigations.
3. SCOPE
The guidance refers to all patients over the age of 16 years, being prepared for elective surgery
in all surgical specialties within the Trust. Patients having minor procedures under local
anaesthetic are excluded from the requirements of this policy.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
.
4. DEFINITIONS
Preoperative investigations: Tests that are performed prior to surgery to assist in the
assessment of fitness for surgery. e.g blood tests, electrocardiograms, X-rays and lung function
tests.
Preoperative Investigations : Issue Number 5, Issue Date 24/10/2014
23/10/2016)
(Review Date:
5. DUTIES AND RESPONSIBILITIES
All professionals (medical or nursing) practicing preoperative assessments have a responsibility
to refer to these guidelines when organising preoperative investigations for patients being
prepared for elective surgery.
6. PROCESS
See Appendix 1.
7. TRAINING REQUIREMENTS
This will form part of the induction for all new clinical staff in working in preoperative
assessment, surgical specialties and anaesthetics.
Preoperative assessment clinic staff and their line managers are responsible for training for use
of this policy.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
References:
1. NCCAC. Preoperative Tests, The Use of Routine Preoperative Tests for Elective Surgery Evidence, Methods and Guidance. London: NICE, 2003
2. Carlisle J, Langham J, Thoms G. Guidelines for routine preoperative testing. Editorial,
British Journal of Anaesthesia 2004; 93: 495-97.
3. Munro J, Booth A, Nicholl J. Routine preoperative testing: a systematic review of the
evidence. Health Technology Assessment 1997; 11: number 12.
4. Garcia-Miguel F J, Serrano-Aguilar P G, Lopez-Bastida J, Preoperative Assessment. The
Lancet 2003; 362: 1749-57.
5. American Society of Anaesthesiologists Task force on Preanaesthetic Evaluation. Practice
advisory for preanaesthesia evaluation: a report by the American Society of
Anaesthesiologists Task Force on Preanaesthesia Evaluation. Anaesthesiology 2002; 96:
485-96.
9. EQUALITY IMPACT STATEMENT (Appendix N)
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
All policies must include this standard equality impact statement. However, when sending for
ratification and publication, this must be accompanied by the full equality screening assessment
tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy
Documentation
Preoperative Investigations : Issue Number 5, Issue Date 24/10/2014
23/10/2016)
(Review Date:
Appendix 1 – see enclosed:
Surgery
Grade 1
Grade 2
Grade 3
Grade 4
Age
ECG
FBC
U&Es
Grade of surgery: examples
16-59
No
No
No
1 - Minor Surgery: Excision skin lesion /
>60
YES
No
No
breast lump, drainage abscess,
cystoscopy.
16-59
No
No
No
2 - Intermediate Surgery: Hernia
>60
YES
No
No
repairs, excision varicose veins,
tonsillectomy, arthroscopy.
16-59
No
YES
>60
YES
YES
YES
hysterectomy, TURP, thyroidectomy,
lumbar discectomy.
16-59
No
YES
YES
4 – Major+ Surgery: Total joint
>60
YES
YES
YES
replacement, bowel resection,
oesophagectomy, radical neck dissection.
3 – Major Surgery: Abdominal
The above table forms the minimum preoperative investigations to be carried out in all adults, including healthy
patients (ASA 1). Clotting studies, random glucose, urinalysis and CXR are not indicated routinely. Tests need not be
repeated where there is a NORMAL test result available, (and there have not been any changes to medications or
new health problems) within 12 months of the date of surgery.
PREOPERATIVE INVESTIGATIONS - based on Intercurrent Disease
In addition to the above, preoperative tests are recommended in patients with co-morbidities as listed below
- ALL ages, for ALL grades of surgery.
Cardiovascular Disease e.g. hypertension or angina.
Diuretic therapy.
Respiratory Disease ASA 3/4 - i.e. significantly limiting
activity
Renal Disease
Diabetes
Liver Disease / bleeding disorders/ anticoagulant therapy
Anaemia / symptoms of/ myelosuppression/ malignancy
Lithium therapy
Rheumatoid Arthritis
Sickle Cell Disease susceptibility
(African/ Afro-Caribbean origin or positive family history)
Pregnancy possible
ECG, U&Es, FBC
CXR if new symptoms
Consider FEV1/FVC
Consider blood gas on air for
Grade 3-4 surgery.
ECG, U&Es, FBC
ECG, U&Es, glucose, HBA1C
LFTs, U&Es, FBC,
Clotting studies
FBC
Lithium levels, U&Es
Cervical spine x-ray –
flexion/extension views.**
Sickle test
Pregnancy test
** Where C.spine X-ray, flexn/ extn views are required, write ‘Report Please’ on X-ray form and indicate urgency.
ASA Score (American Society of Anaesthesiologists ‘Fitness’ Score)
ASA 1
ASA 2
ASA 3
ASA 4
Normal healthy patient
Patient with mild systemic disease e.g. Controlled angina, hypertension or asthma where activity is not
limited.
Patient with severe systemic disease e.g. Unstable angina, hypertension requiring multiple therapies,
poorly controlled diabetic with complications, respiratory disease that limits activity.
Patient with severe systemic disease that is a constant threat to life.
(NICE recommendations 2003 / Portsmouth Anaesthetic Department 2014)
Preoperative Investigations : Issue Number 5, Issue Date 24/10/2014
23/10/2016)
(Review Date:
MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to
be monitored
Lead
Tool
Frequency of Report
of Compliance
Annual sample audit of
preoperative investigations in
one
or
more
surgical
specialties.
Lead nurse for
preoperative
assessment.
Lead
anaesthetist for
preoperative
assessment.
Audit – normally case
note review
Annual
Reporting arrangements
Policy audit report to:

Anaesthetics

Preoperative assessment nurses

Relevant surgical specialty.
Lead(s) for acting on
Recommendations
Mrs Tanya Mapp
Dr Shirley Lobo
Dr Frances King
This document will be monitored to ensure it is effective and to assurance compliance.
The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being
achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.
The details of the monitoring to be considered include:






The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);
The lead for ensuring the audit is undertaken
The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
Frequency of the monitoring e.g. quarterly, annually;
The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required.
In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on
the Trust Intranet Trust Intranet -> Policies -> Policy Documentation
The lead(s) for acting on any recommendations necessary.
Preoperative Investigations : Issue Number 5, Issue Date 24/10/2014
(Review Date: 23/10/2016)