Surgery is an inevitable and important part of health care that can offer individuals life-changing interventions for a range of medical conditions (Wicker, 2015). With increased developments in surgical techniques, such as laparoscopic approaches, and innovative strategies delivering better outcomes for surgical patients, surgeries that were once deemed high risk are now considered routine across a wider range of surgical specialties (Dejong and Earnshaw, 2015). As a consequence, the number of surgeries being performed rose by 27% between 2003/2004 and 2013/2014 (Royal College of Surgeons of England (RCS), 2020) and it is now estimated that more than 12 million surgical procedures are carried out in the UK every year (Abbott et al, 2017).
This article aims to provide the reader with clinical guidance for the care of a surgical patient from diagnosis to discharge. It will also examine some of the complications that can occur within the perioperative care continuum (see Glossary for definition of terms) and explore the management strategies that may be used. Because hernia repair has been identified as one of the most common procedures performed in the UK, with over 100 000 of these procedures carried out every year (RCS, 2013), a case study (Box 1) has also been included to help illustrate the care required across the patient journey.
Preoperative care
Initial investigation or contact
Preoperative care starts at the point of diagnosis and referral and is the first opportunity for health professionals to ensure that comprehensive preparation for the surgery begins. This should be from both a physical and psychological perspective because patients should be provided with the opportunity to ask questions about the surgery and aftercare to help reduce any fears and anxieties that they may have (Wicker and O'Neill, 2013). Consequently, primary care staff, including GPs and practice nurses, have a major role to play in the preparation of individuals for surgery, which can positively impact on postoperative outcomes, such as perceived levels of pain and behavioural recovery (Powell et al, 2016). GPs are also responsible for making the initial referral to a surgical specialty and ensuring that comprehensive background information (ie medical history and specific details of the condition) are communicated to the surgical team so that an outpatient consultation clinic appointment can be arranged (Royal College of General Practitioners, 2018).
Outpatient consultation
Delivering a high-quality clinic requires a holistic approach and the most effective and appropriate way to deliver this is to remain focused on the quality of service and ensure that the patient is treated as an individual with particular values, concerns and wishes (RCS, 2018). The surgeon may decide to go through the process of obtaining informed consent at this appointment, which incorporates discussion of the details of the surgical procedure and comprehensive exploration of the risks and benefits of having the procedure; however, the patient must have the capacity to understand the information given and competence to decide on whether to proceed (Anderson and Wearne, 2007). Following the consultation, the surgeon will list the individual for the required surgery and organise a preassessment appointment. In some cases, this could be on the same day, if the service incorporates one-stop clinics, which have been initiated in some areas to help streamline the service and ensure that most of the patient's preoperative care needs are addressed in a single visit (RCS, 2018).
Preoperative assessment
The process of preassessment is essential for identifying any underlying comorbidities that would increase the risk of complications when having a general anaesthetic, as well as anything that may influence the surgical procedure itself (Gray et al, 2018). However, it also provides the ideal opportunity for the early identification of, and attention to, individual patient needs, for patient concerns to be addressed before admission and for patient education about surgical preparation and aftercare (Association of Anaesthetists of Great Britain and Ireland (AAGBI) 2010; AAGBI and British Association of Day Surgery, 2011; Wicker, 2015; Martin, 2016) (Box 2). The investigations conducted at the preoperative assessment would usually include a full blood count (FBC), electrocardiogram (ECG), and lung function tests, but exactly which investigations are needed mainly depends on the level of the surgery (elective surgical procedures are classified as minor, intermediate or major (Table 1), and the comorbidities of the individual (Table 2) (National Institute for Health and Care Excellence (NICE), 2016a). The American Society for Anaesthesiologists (ASA) developed a Physical Status Classification System (often referred to as the ASA Grade) (ASA, 2019) which is also used to determine the level of investigations that need to be conducted at the preoperative assessment and communicate patient comorbidities to the anaesthetic and surgical team (NICE, 2016a).
| Grade | Examples |
|---|---|
| Minor | Excising skin lesion |
| Intermediate | Primary repair of inguinal hernia |
| Major or complex | Total abdominal hysterectomy |
| ASA 1 | A normal healthy patient |
|---|---|
| ASA 2 | A patient with mild systemic disease |
| ASA 3 | A patient with severe systemic disease |
| ASA 4 | A patient with severe systemic disease that is a constant threat to life |
| ASA 5 (Emergency surgery) | A moribund patient who is not expected to survive without the operation |
| ASA 6 (Emergency surgery) | A specific situation in which a declared brain-dead patient whose organs are being removed for donor purposes |
Hospital ward admission
On the day of surgery, the patient will be visited by a member of the anaesthetic team, either the consultant or a junior doctor, for a variety of assessments to be conducted, ie airway and pain assessment and the risk of developing venous thromboembolism (Royal College of Anaesthetists (RCOA), 2019) (Box 3). A member of the surgical team will also need to mark the site for surgery and complete consent procedures.
Surgical site marking is required in an attempt to reduce errors and must be performed only by an appropriate professional, undertaken with an indelible ink pen, using an arrow at or near the intended incision, which must be unambiguous and clearly visible because the site will be checked on three more occasions (leaving the ward, entering the operating department and prior to the incision) (World Health Organization (WHO), 2009a). Wherever possible, written consent must also be obtained before the surgery and anaesthetic, which needs to be clearly documented (no abbreviations) and retained in the patient's notes so they can be accessed by all the health professionals (NHS website, 2019).
Nursing and other healthcare staff will care for the patient in the immediate period leading up to the surgery and will ensure that venous thromboembolism prophylaxis, ie antiembolism stockings, are put into place, that preoperative medication (gastric acid suppression and pre-emptive analgesia) is administered, that the patient is showered or bathed and warmed, that protocols have been followed to minimise surgical site infections, jewellery and body piercings have been removed or taped and that the preoperative checklist has been fully completed (Dunn, 2016; WHO, 2016; NICE, 2016b; 2019; 2020) (Box 4).
Glossary of Terms
Intraoperative care
The safe surgery process continues within the operating theatre and begins with the perioperative team (ie surgeons, anaesthetists, nurses, operating department practitioners (ODPs) and healthcare assistants (HCAs)) discussing the surgical procedures that are listed for the day and any specific patient requirements, eg allergies and equipment requirements (Wicker, 2015). Once the patient arrives at the department a member of the team will admit the patient by checking the surgical safety checklist that was commenced by the staff on the ward, because the ‘check-in’ part of the form must be completed before the induction of anaesthesia (WHO, 2009a; 2009b) (https://tinyurl.com/yybrj4tl).
This checklist, which can be tailored to the needs of the clinical area, was created to reduce the number of adverse events by improving communication between the perioperative team and, since its introduction, there has been a marked improvement in the quantity of recorded adverse events within the operating theatre (Walker et al, 2012). This is supported by Tang et al (2014), who found, from their literature review, that effectively implemented surgical safety checklists can help in avoiding complications and reduce postoperative mortality.
The intraoperative process begins with the orientation of the patient to the anaesthetic room, the application of essential monitoring (ECG, pulse oximeter) and the induction of general anaesthetic, using a range of drugs to ensure that the patient is sedated, pain free and, if necessary, paralysed (AAGBI, 2012). On transfer to the operating room, the ‘time out’ element of the surgical safety checklist will be undertaken before the surgical incision in the patient's skin. All members of the team must be present and attentive at this stage because all areas of potential risks are discussed in detail and this is the last opportunity for adaptations to be made to the surgery to prevent unnecessary harm (WHO, 2009a). As well as the safe surgical checklist, several considerations also need to be addressed by the perioperative team (Box 5): surgical positioning, skin and nerve damage, patient warming.
Because patients, in most cases, are not able to advocate for themselves, all members of the intraoperative team must ensure that these elements of care are undertaken to reduce harm and achieve high-quality perioperative care (Cousley, 2016a). Surgical positioning is of particular importance, not only for ease of surgical access but also to minimise any adverse physiological effects, such as pressure ulcers and nerve damage, which can extend hospitalisation, delay patient recovery and increase costs to the patient and the NHS (Wicker, 2015). These can be avoided with the use of pressure-relieving equipment, use of safe moving and handling techniques and devices, frequent skin assessments and effective communication between the perioperative team (NICE, 2014). The importance of being an advocate for the surgical patient cannot be overstated, especially in an environment as complex as the operating theatre (Sundqvist et al, 2016). The health professional must fully consider any potential risks to the patient and develop a strategy to minimise these risks (Box 5).
Following the completion of the surgical procedure, the intraoperative team undertakes the ‘sign out’, which includes confirmation of the performed surgery, surgical counts of instrumentation, swabs and other supplementary items and any key concerns for recovery or postoperative care (WHO, 2009a). These details will be handed over to the post-anaesthetic care unit (PACU) specialist nurse, along with a record of the patient's vital observations while in theatre (Simpson and Moonesinghe, 2013). The PACU practitioner will regularly check the patient's condition, monitor their vital signs, ensure they are comfortable and, if necessary, warmed (Box 6) (Wicker, 2015). They will also pay particular attention to pain relief and the reduction of postoperative nausea and vomiting, which are often the elements of perioperative care that patients most fear before surgery; as a consequence, these must be minimised to increase patient satisfaction but also to promote recovery and reduce the associated postoperative complications (Liddle, 2013a).
Postoperative care
Before the patient is transferred back to the ward a comprehensive handover must take place between the PACU nurse and ward staff, including details of the procedure, the patient's condition, level of responsiveness, airway and breathing, oxygen therapy, circulation, wound dressings and drains, fluid output and input, pain levels, medication and any other special instructions (Liddle, 2013a; Wicker, 2015). As well as the standard nursing roles and responsibilities, nurses caring for surgical patients also need to have a deep understanding of the potential complications that can arise following surgery, such as surgical site infection, pain, hypothermia (Box 7) and how they can minimise risk or recognise early signs of development (Primiano et al, 2011; Liddle, 2013b; NICE, 2014; 2016b; 2019).
Nurses in primary and secondary care are therefore in a unique position and offer a valuable contribution to the care of the surgical patient because they have a major role to play in minimising the risk of harm and ensuring that the patient is returned to normal functioning as soon as possible, depending on the individual's condition and surgical intervention (Liddle, 2013b; Cousley, 2016b).
Conclusion
Due to the high level of iatrogenesis in surgery, patient safety poses a significant problem and almost half of all recorded adverse hospital events are related to surgical care (WHO, 2020). Consequently, because patient safety is ‘at the heart of quality care’ (Fisher and Scott, 2013: 6) it is paramount that health professionals minimise the risk of adverse events occurring by undertaking appropriate risk assessments and effective teamwork (AAGBI, 2010).