Heatherwood hospital is the elective surgical hub for Frimley Health.

There are certain patient conditions and surgical procedures that are not suitable for Heatherwood hospital as it is a stand-alone, elective site with limited resources, unlike an acute hospital

Careful patient selection is crucial to deliver safe care to as many patients as possible in this setting and reduce the risk of cancellation prior to day of surgery.

This document is to help medical teams, managers and booking teams select suitable patients for surgery at Heatherwood.

Patients offered surgery at Heatherwood hospital should be informed, as early as possible, that this site is an elective surgical hub and it is not appropriate for all patients to have their procedure there.

Due to the multiple, complex medical histories seen for patients, an early referral for anaesthetic assessment in the High Risk Anaesthetic Clinic (HRAC) before listing for surgery will be imperative to enable the correct patient journey at the suitable hospital site.

If in doubt, refer first to HRAC.

The goal remains inclusivity in terms of admissions, to maintain the Trust’s commitment to reducing surgical waiting lists and the GIRFT accreditation achieved by Heatherwood Hospital.

The guidelines below should help facilitate this, while managing risk.

Weekend Surgery

• There is a difference in staffing levels and skill mix available onsite at Heatherwood at the weekend

• Therefore, even more careful consideration must be given to patient selection for all procedures which are undertaken at Heatherwood over the weekend

• The acuity of patients, complexity of surgery and potential complications must all be evaluated prior to booking cases.

• Clinicians must be familiar with working practices at Heatherwood and the processes for dealing with unanticipated complications and/or transfer of a patient to an acute site

• Note inappropriate patient selection leading to complications or transfer of patients can impact on limited on-call services at the acute sites.

Patients requiring extended recovery care

• The use of an extended recovery will not substitute for Level 2 or 3 care in ICU. It is designed to offer daytime post op Level 1.5 care only.

• Close liaising with the booking teams is essential so the more complicated patients are operated on in the morning, to ensure the patient can benefit from several hours if needed in PACU, before a decision is made whether to transfer out or not.

• Ideally these patients should be scheduled earlier in the week

• Please refer to the Extended Recovery in PACU guideline for further details

There may be certain types of surgery amenable to a regional technique/sedation or LA, but not for General Anaesthesia.

Suitability for surgery at Heatherwood will depend on both the procedure and anaesthetic options, rather than solely on blanket exclusion criteria.

This requires close understanding between the anaesthetic and surgical teams.

It is important that teams are comfortable with this new way of working.

Types of surgery:

• Minor – e.g., pain injections, cystoscopy, hysteroscopy, biopsy

• Intermediate – e.g., arthroscopies, simple mastectomy, surgery for prostatic hyperplasia, laparoscopy

• Major – e.g., joint replacements, spinal surgery, total hysterectomy, cholecystecomy, mastectomy with reconstruction

Age: 16 years and above. Patients must be psychologically prepared to be treated on the adult pathways. No upper age limit.

There is no paediatric cover at Heatherwood.

Pregnancy: Pregnant patients are unsuitable for surgery at Heatherwood

BMI: BMI 40 and plus require anaesthetic opinion first before determination of suitability.

Weight limit: determined by restrictions to bed/ operating table/ trolley limits

ASA Grades: definitions: https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system

ASA1 – fit and well, non-smoker

ASA2 – chronic medical condition with no restrictions to day-to-day activity or complications, e.g., treated hypertension, mild asthma, NIDDM without complications; smoker; BMI >30; well controlled epilepsy; GORD; controlled AF

ASA 3 – chronic medical condition with restrictions to daily activities or complications, e.g., ischaemic heart disease/ angina, systemic arthritis (e.g. rheumatoid); CKD stage 3; BMI >40, moderate/severe asthma, IDDM, poorly controlled epilepsy; CVA; COPD; unable to lie flat due to breathing issues, dialysis

ASA 4 – unstable cardiac disease, recent (<3 months) MI or CVA, severe valve dysfunction, end-stage renal failure not on dialysis, clinical frailty score 7-9, severe respiratory disease (SOB minimal exertion), severe dementia such as Alzheimer’s disease

Table 1 provides a quick reference guide using a traffic light approach to assess patient suitability for admission to Heatherwood. This applies to patients planned for general anaesthesia, regional anaesthesia, or sedation. There are no exclusion criteria for local anaesthesia.

Pathway for the perioperative management of patients with obstructive sleep apnoea hypoventilation syndrome (OSAHS) requiring CPAP or NIV

NB: Perioperative patients with chronic respiratory failure requiring NIV should be managed in ITU or MADU.

Obstructive sleep apnoea hypoventilation syndrome” (OSAHS), formerly known as “obstructive sleep apnoea”, refers to a condition associated with more than 5 episodes of apnoea and/or hypopnoea witnessed per hour (AHI) during polysomnography.

Preoperative

Elective cases: Patients not compliant with prescribed CPAP should be advised to comply with treatment prior to surgery at pre op assessment. Discuss with anaesthetist as required.

Patients should be advised to bring CPAP machine on day of surgery.

Final decision of appropriateness for day case surgery by anaesthetist on day of surgery

Emergency cases: Do not delay surgery. Individualised care as necessary

Intraoperative

Use Sleep Disordered Breathing Safe anaesthetic. (Maximise use of regional anaesthesia, limit opiate/ sedative use, appropriate dose neostigmine with nerve stimulator)

Postoperative

During an extended recovery period of up to 4hrs, patients should be observed for:

• Bradypnoeas (<8 breaths /minute; >2 episodes),

• Apnoeas (>10 seconds; at least 1 episode)

• Desaturations with nasal cannulae oxygen (<90%; >2 episodes)

• Pain-sedation mismatch with on-going opioid requirements

PACU Discharge criteria (see below)

• Physiological stability (cardiac, respiratory, neurological)

• Non-major surgery (laparotomy, bowel resection)

• Physical and mental ability to manage their own CPAP therapy with minimal assistance

• Free of respiratory events without stimulation (as highlighted above)

• No need for major opioids (i.e. parenteral or oral causing excessive sedation)

• O2-dependance ≤4L nasal O2

If above criteria not met- to stay in PACU or admit to high acuity area for continuous SpO₂ monitoring

PACU Discharge

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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