Below outlines best practices involved in the entire hospital treatment process
Pre-operative assessment (POA) and planning, carried out prior to treatment, ensures that the patient is fully informed about the forthcoming procedure and the post operative recovery. It ensures the patient is in optimum health and has made arrangements for admission, discharge and postoperative care at home. 1
PAO avoids last minute cancellations on the day of surgery due to unforeseen medical conditions. 2
In the POA clinic and with the patient’s permission he has his blood pressure, pulse and oxygen saturation measured. 3
His chest is examined and in addition he has blood drawn, with his consent, from a vein, which is sent for laboratory analysis. 4
This role of preoperative assessment was formally the duty of junior surgical doctors though the final arbiter of a patient’s fitness to proceed is always the anaesthetist who will anaesthetise the patient. Financial considerations and theatre utilization considerations now ensure patients are seen in the PAO but the anaesthetist should also see them on the day of admission. 5
This role cannot be delegated. 6
Day of admission
On the day of admission the operating surgeon who will speak to the patient again will review the case. He or she will identify the site of the operation and specifically note the side (left or right) of the proposed procedure. 1
The National Patient Safety Agency (NPSA) and the Royal College of Surgeons of England (RCS) strongly recommend pre-operative marking to indicate clearly the intended site for elective surgical procedures. The surgeon will also obtain the patients consent to proceed, provided they are competent, after fully explaining the proposed procedure with the benefits and risks. Patients must be informed of any rare but significant risks that may influence a patient’s decision to proceed.
“Obtaining proper consent from patients for any planned investigation or treatment is a fundamental principle of medicine, recognising the importance of patient autonomy. Valid consent must of course be voluntary and “competent” – that is patients must have the maturity and mental capacity to freely make a decision. It must also be informed and this is perhaps the one aspect of consent that leads most to discussion and debate.” 2References
During the pre-op visit the anaesthetist will deal with the following elements: 1
- They will provide patients information about anaesthesia and pain relief 2
- Confirm they have been fully worked-up in the pre-admission clinics according to agreed protocols for preoperative investigation 3
- Review and manage chronic medication 4
- Assess the airway and neck movement to determine if any difficulty is anticipated 5
- Ensure an adequate period of preoperative fasting is ordered or has taken place 6
- Discuss and order premedication 7
- Identify thrombosis risk and order appropriate thromboprophylaxis 8
- Determine the likelihood of intraoperative bleeding and arrange cross-matching of blood appropriately 9
- Discuss the choice of anaesthetic technique – general, local or regional anaesthesia 10
- Obtain consent to the proposed anaesthesia, discussing risks when appropriate 11 12 13
- 1. Royal College of Anaesthetists https://www.rcoa.ac.uk/system/files/CSQ-ARB-section1.pdf
- 2. Raising the Standard: Information for Patients. Royal College of Anaesthetists 2003. (see: www.youranaesthetic.info
- 3. Kinley H et al. Extended scope of nursing practice: a multicentre randomised controlled trial of appropriately trained nurses and pre-registration house officers in pre-operative assessment in elective general surgery. Health Technology Assessment 2001;5:1–87.
- 4. Kennedy JM et al. Polypharmacy in a general surgery unit and consequences of drug withdrawal. Br J Clin Pharmacol 2000;49(4):353–362.
- 5. Mallampati SR et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can J Anaesth 1985;32:429–434.
- 6. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications (Cochrane review). The Cochrane Library, Issue 4. Wiley, Chichester 2003.
- 7. Leigh JM,Walker J, Janaganathan P. Effect of preoperative anaesthetic visit on anxiety. Br Med J 1977;2:987–989.
- 8. Scottish Intercollegiate Guidelines Network. Prophylaxis of venous thromboembolism. Guidelines No 62. SIGN, Edinburgh 2002 (www.sign.ac.uk/guidelines/fulltext/62/index.html).
- 9. Scottish Intercollegiate Guidelines Network. Perioperative blood transfusion for elective surgery. Guideline No. 54. SIGN, Edinburgh October 2001 www.sign.ac.uk/pdf/sign54.pdf and review www.sign.ac.uk/pdf/2005bloodtransfusionreport.pdf
- 10. National Institute for Clinical Excellence Guidelines: Preoperative Tests – The use of routine preoperative tests for surgery. NICE, London June 2003 www.nice.org.uk/page.aspx?o=56818 Association of Anaesthetists of Great Britain and Ireland. The anaesthesia team. AAGBI, London 2005
www.aagbi.org/pdf/the_anaesthesia_team.pdf. Association of Anaesthetists of Great Britain and Ireland. Risk management. AAGBI, London1998 ( www.aagbi.org/pdf/27doc.pdf).
- 11. Association of Anaesthetists of Great Britain and Ireland. Consent for anaesthesia. AAGBI, London 2006 (www.aagbi.org/pdf/Consent.pdf)
- 12. Department of Health. Good practice in consent implementation guide. DH, London November 2001 (www.dh.gov.uk/assetRoot/04/01/90/61/04019061.pdf)
- 13. Department of Health Circular: Good practice in consent. HSC 2001/023. DH, London November2003 (www.dh.gov.uk/assetRoot/04/01/22/86/04012286.pdf).
It is the responsibility of the theatre manager or other appropriate person to ensure that there is sufficient staff to run an operating room and recovery service for the proposed operations list.1
Despite strong representation to the government, mandatory nurse to patients staffing levels of staffing have not been adopted in the UK.2 3
This means that if any concerns exist it is down to the clinical judgment of the anaesthetist and the surgeon as to whether to proceed or not. Mandatory staffing levels are enforceable under law within certain US states. 4
“This is a searing indictment of the hospital industry’s illegitimate attempt to deny patients safe care as required by the legislature, the Governor, and the Department of Health Services- and a huge victory for RNs and patients.” said Rose Ann DeMoro, executive director of the California Nurses Association on the group’s Web site.
Provided all is in order the planned surgery may now proceed.
Drugs, equipment and Machine checks
Meanwhile in theatres the anaesthetist and their assistant will be checking their drugs and equipment. 2 Their roles include:
- Preparation of the anaesthetic room
- Checking the anaesthetic machine
- Preparing and checking your basic anaesthetic equipment
- Preparing your drugs for induction and those to use in case of an emergency
- Preparation of the theatre itself
- Checking the anaesthetic machine
- Additional and specialist equipment checks
- Checking of the anaesthetic machine may be delegated to a qualified assistant.3
Duty of care and medical negligence
Failure to comply with some “best practices” may result in successful criminal prosecutions and a custodial sentence for the doctor and an additional GMC fitness to practice hearing. Examples include non-adherence to established practice guidelines and failing to keep good records. This outcome however is not likely without evidence of serious harm to the patient that arose from a negligent medical act. A negligent medical act may result in a civil action by the injured party (claimant) or a criminal prosecution by the state if the act was so bad that the doctor represents a danger to the public.
All components of the three-part test need to be established if medical negligence is to be proven. In a civil suite these need be proven only on the balance of probabilities or for a criminal prosecution, beyond reasonable doubt. The three-part test establishes that the doctor owed a duty of care to the patient, the duty of care was breached, and as a direct result of the breach the patient suffered harm. Successful civil actions result in monetary compensation to the injured party or dependents. The employing trust or the doctor’s defence organization may pay monetary compensation in such cases.
Despite this requirement to adhere to guidelines, guidelines in themselves do not protect a doctor from being successfully sued if, in following a guideline, a patient is harmed by a doctor. 2 Under UK common law, minimum acceptable standards of clinical care derive from responsible customary practice, not from guidelines. It is important for doctors to realise that should a faulty guideline be followed it is they, and not the authors, of the guideline who will be held accountable. The existence of a guideline cannot be used to mandate, authorise or outlaw treatment options.3
- 1.Daniele Bryden, Ian Storey. Duty of care and medical negligence. Contin Educ Anaesth Crit Care Pain (2011) 11 (4): 124-127.
- 2.Early v Newham Health Authority. 1994 5 Medical Law Review 215-17.
- 3.Brian Hurwitz,Legal and political considerations of clinical practice guidelines. BMJ 1999;318:661