Clinical update

Pre-operative tests

Updated NICE guidance aims to reduce unnecessary pre-operative testing

Essential facts

The NHS in England performed 10.6 million operations in 2012/13, compared with 6.61 million a decade before – a rise of 60%, says Health and Social Care Information Centre data.

Over the same period, pre-operative assessment has changed radically, with most people seen well in advance of their surgery in a pre-operative assessment unit. While the number of routine tests for young, healthy people having minor surgery has reduced significantly, there remains a concern that some unnecessary tests continue to be requested, says the National Institute for Health and Care Excellence (NICE).

In April, NICE updated its 2003 guidance on routine pre-operative tests for those aged 16 and above. The aim is to reduce unnecessary testing by advising which tests to offer people before minor, intermediate and major or complex surgery. It takes into account specific comorbidities including cardiovascular, renal and respiratory conditions, diabetes and obesity.

To reduce any risks during or following surgery, experienced nursing staff in a pre-operative assessment clinic should carry out a structured patient history – including any medications – and a targeted examination. The kinds of tests needed depend on the person’s health, the type of anaesthetic and the surgery they will be having.

Many apparently healthy people are tested before surgery to check for any undetected conditions that may affect their treatment. NICE says this can provide a benefit where test results yield extra information that could not be gathered from their patient history or physical examination. But excessive pre-operative testing can cause anxiety, delays in treatment and unnecessary, costly and possible harmful treatments where false positive results are obtained. Even genuinely abnormal results often do not lead to any significant change in peri-operative management in relatively healthy people, says NICE.

Good communication is key. Healthcare professionals should explain any tests, why they are needed and what they entail, involving the patient in making decisions about what is best for them. They should also make sure that any pre-operative tests undertaken in primary care are included. Alongside being ready physically, nursing staff should help to ensure patients are emotionally prepared, allaying any fears or anxieties they may have about their forthcoming surgery. Patients should be provided with as much information as they want or need.

Expert comment

Michael Pritchard is an advanced nurse practitioner at Wirral University Hospital NHS Trust

‘This new guidance is a step forward. I’d like to think that most pre-operative assessment units are already carrying out some, if not all, of these recommendations. It will help to raise standards by ensuring all patients having an operation receive the same high standard of care.

‘These guidelines make the job of the pre-operative assessment nurse easier, guiding them to which tests are essential. They also act as a resource if patients ask questions about why they have not had a certain test.’

‘The recommendations also make clear when to consider tests for patients who have not had any recent investigations, and when to seek further advice regarding tests such as lung function.’

Find out more

NICE guidance: Routine preoperative tests for elective surgery (2016)

NICE guidance: Surgical site infections: prevention and treatment (2008)

Royal College of Surgeons

Royal College of Anaesthetists

ASA physical status classification system

Nursing Standard: Pre-operative assessment of elective surgical patients (2012)

Nursing Standard: Identifying and assessing anxiety in pre-operative patients (2009)

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