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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...

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...

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 patients undergoing elective procedures should be provided, prior to admission with information on their intended treatment pathway (day surgery or enhanced recovery) that is easy to understand.⁹⁶ This should include information on the operation, anaesthesia, recovery and postoperative pain relief. Provision of this information should be documented in the patient’s notes.⁹⁷ The written and verbal information given...