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Referral
In Shape for Surgery
Ensuring patients are In Shape for Surgery – what this means in practice
When a patient has poorly controlled chronic disease or other risk factors, it can adversely affect the:
- outcome of the operation
- risks of complications during and after surgery
- length of time spent in hospital
- patient's recovery time
- NHS costs, resources and health professional time needed to care for the patient in hospital and following discharge.
The message to patients is simple, and can be re-iterated at every opportunity in both primary and secondary care "surgery puts stress on the body, so the healthier you are, the better you'll handle it."
From August 2017 primary care is requested to follow this "best practice" recommended Clinical Referral Guideline (CRG).
When referring patients who are likely to have hip arthroplasy, knee arthroplasty or hernia surgery, primary care is requested to measure the information below and, where possible, optimise any medical conditions prior to referral.
- HbA1c (in known diabetics, those with pre-diabetes and those with a BMI greater than 30)
- haemoglobin
- blood pressure
- pulse check for atrial fibrillation
- auscultation of heart for new heart murmur
With regard to these measurements, prior to referral for surgery primary care is asked to investigate and optimise the conditions in the following circumstances:
- HbA1c greater than 69
- haemoglobin less than 120g/l for females and 130g/l for males
- blood pressure greater than 160/100
- atrial fibrillation rate greater than 100
- heart murmur – consider referral for ECHO in newly detected heart murmur
Smokers who are willing to engage in attempting to quit should be signposted to stop smoking cessation services before, or at the time of surgical referral and should be advised that ideally they should be smoke free for 8 weeks prior to surgery in order to improve their outcomes.
This CRG covers patients who are being referred for "surgery likely."
It is recognised that it is not always clinically desirable or possible to optimise patients to the thresholds set out in this pathway. Should this be the case then referrers are requested to state this in the referral letter in order to assist any decision making in secondary care.
Much of the work in this pathway already happens in practice prior to referral, but is now being formalised through this CRG. Without early intervention these issues frequently result in patients having their procedures deferred, cancelled or being put at avoidable risk.
There is no ban on surgery for people in the categories listed within the referral criteria and there is no blanket policy.
Scope
From August 2017, it is recommended that any adult referral for routine hip arthroplasty, knee arthroplasty or hernia repair should follow this recommended "In Shape for Surgery" guidance.
Out of scope
Patients referred for emergency surgery or clinically urgent or any other elective surgery
Patients who are being referred for a surgical opinion when the treatment is unclear
Any surgical interventions that may be required as a result of pregnancy
Vulnerable patients where the likelihood of achieving optimisation and benefits from it are low will require individualised consideration. This includes patients with learning disabilities, significant cognitive impairment or severe mental illness
Referrals of a diagnostic nature
Children under the age of 18
| Criteria | Threshold for pre-referral intervention |
| Medical Markers - chronic disease management | Medical Markers - chronic disease management |
| Anaemia (for hip and knee arthroplasty only unless high anaesthetic risk) |
Hb less than 120g/L in females and 130g/L in males (excluding anaemia related to chronic disease) |
| Blood pressure | BP greater than 160/100mmHg |
| Diabetes - In known diabetics and - In those at risk of diabetes as identified by a BMI ≥ 30. Diabetes UK risk tool is also recommended (here) |
HbA1c greater than 69mmol/mol |
| Irregular Heart Beat (ECG if pulse rate greater than 100 or irregular) |
Atrial Fibrillation with a rate greater than 100 beats per minute |
| Auscultate for heart murmur | Un-investigated heart murmur |
| ALL MARKERS SHOULD BE CURRENT WITHIN 3 MONTHS OF REFERRAL | ALL MARKERS SHOULD BE CURRENT WITHIN 3 MONTHS OF REFERRAL |
| Lifestyle Criteria | Lifestyle Criteria |
| Smoking (Vaping and Nicotine Replacement Therapies are not restricted) |
Smoker. Advise patient: - 8 weeks smoking cessation prior to operation is optimal to reduce risks; - it is a good time to consider quitting for good; - and sign-post to smoking cessation service. |
| ALL MARKERS SHOULD BE CURRENT WITHIN 3 MONTHS OF REFERRAL | ALL MARKERS SHOULD BE CURRENT WITHIN 3 MONTHS OF REFERRAL |
It is acknowledged that these thresholds are not achievable, or even desirable, for a small number of patients due to their co-morbidities. If your patient doesn't meet these thresholds, but you feel they are as well optimised as possible ("best optimised") for surgery, with their risks from surgery minimised as much as reasonably possible, then this should be stated in the referral letter.
Smoking cessation should be initiated in primary care, with patients being signposted to existing smoking cessation services for advice on nicotine replacement therapy and other methods of smoking cessation. This signposting should occur at the time of referral to secondary care. Carbon monoxide testing will take place during hospital appointments to support their quit attempt.
When patients who smoke are seen in secondary care and it is decided it is appropriate to operate for their condition the importance of being smoke free for surgery will be re-iterated to them. If they are unsuccessful in their quit attempt during that period they can still proceed to surgery.
There is already rigour and professional guidance in pre-operative assessment of people with alcohol and substance misuse issues. No substantial change of practice is envisaged at this time beyond an added emphasis on screening patients judged or known to be at risk by their GP.
Patients with very high or very low body mass index (BMI greater than 40 or less than 18) are at additional risk in surgery and this risk should be raised with them.
Patients who require health optimisation can be referred to the appropriate healthy lifestyles service using the resources available locally:
Referral form
DRSS referral template - no merge fields
Guide to accessing GP clinical system specific referral templates
Please note there is an existing
hernia policy and this policy includes advise on smoking cessation prior to incisional hernia repair.
- Initiate anaemia treatment promptly (investigate as appropriate - see NHS Devon Anaemia in adults guidance)
- Optimise diabetes medications (see Exeter diabetes Handbook)
- Optimise hypertension medications (see NHS Devon Hypertension diagnosis and management guidance)
- Optimise AF rate control (investigate new AF as appropriate (see NHS Devon AF assessment and management guidance)
- Request echocardiogram if heart murmur previously un-investigated (see NHS Devon direct access echo guidance)
- Refer promptly to smoking cessation services as indicated
N.B. if you have so far been unable to optimise your patient with regard to any of the above criteria, please include details of current/previous interventions in your referral. .
Further information & resources
In Shape for Surgery - practice pack
In Shape for Surgery - stakeholder briefing
In Shape for Surgery - evidence summary
In Shape for Surgery - questions and answers
In Shape for Surgery - update for GPs
Patient information
In Shape for Surgery - Patient website
Patient Leaflets
- In Shape for Surgery leaflet
- In Shape for Surgery video
- Information for Smokers
- Information for Diabetics
Patient feedback contact details
NHS Devon patients
- Telephone: 01392 267665 or 0300 123 1672
- Text us for a call back: 07789 741099
- Email pals.devon@nhs.net or complaints.devon@nhs.net
Evidence
- British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia. Alwyn Kotze et al British Journal of Haematology 2015; 171: 322–331
- Type 2 diabetes: prevention in people at high risk. NICE Public health guideline (PH38). July 2012
- Peri-operative management of the surgical patient with diabetes. Association of Anaesthetists of Great Britain and Ireland Anaesthesia 2015; 70: 1427–1440
- Management of adults with diabetes undergoing surgery and elective procedures: improving standards. Joint British Diabetes Societies for Inpatient care (JBDS-IP). Revised September 2015.
- The measurement of adult blood pressure and management of hypertension before elective surgery. Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society. Anaesthesia 2016; 71(3): 326–337
- Major complications of airway management in the United Kingdom, Chapter 20: Obesity. NAP 4: 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society. Report and findings March 2011
- Body mass index and risk of perioperative cardiovascular adverse events and mortality in 34,744 Danish patients undergoing hip or knee replacement. Thornqvist C. et al Acta Orthopaedica 2014; 85 (5): 456-462
- Perioperative Outcomes among Patients with the Modified Metabolic Syndrome Who Are Undergoing Non-Cardiac Surgery. Glance L.G. et al Anesthesiology 2010; 113(4): 859-872
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: August 2017
Updated: May 2023
