The importance of active preparation for surgery

Surgery is often regarded as a panacea; however, it can have consequences that the patient does not expect. Postoperative complications occur in 12.5% of patients and lead to increased healthcare costs, with 2.6% of patients requiring pharmacological intervention, 3.5% of patients returning to theatre and 1.1% of patients needing critical care^​1​. Prolonged morbidity of any aetiology is associated with increased mortality for up to three years post-operation^​2​. Surgical regret — when a patient regrets having a surgery — is experienced by 14.4% of patients, overall^​3​. However, the rate of surgical regret is higher in patients living with frailty at 30 days, 90 days and 365 days post-operation^​4​. The association between frailty and surgical regret is complex and varies by specialty. Regret is lowest for orthopaedic surgery^​4​ — possibly owing to the impact on pain and quality of life.

The surgical population is increasingly aged, obese and comorbid^​5​. Nearly half of all anaesthetics are administered to patients aged over 65 years^​6​, and nearly two-thirds of this age group have multiple comorbidities^​7​. In 2023, 43% of patients reported deteriorating health while they waited for elective inpatient surgery^​8​. This was an increase of 2% on the previous year^​8​, so it cannot be attributed just to deconditioning caused by the aftermath of the COVID-19 pandemic.

Elective surgery waiting lists are long; however, these wait times represent an opportunity for preparation and lifestyle change. Preparation is equally important when timescales are shorter for urgent and emergency surgery. Every day in community, primary and secondary care, pharmacists encounter individuals who are awaiting surgical treatment. Empowering patients to actively prepare for surgery and recovery, rather than passively waiting, benefits everyone: the individual by reducing complications and improving outcomes; the NHS by improving patient flow and theatre efficiency and reducing unwanted surgeries; and wider population health by utilising the teachable moment for sustained lifestyle change^​9​. The move from ‘waiting’ lists to ‘preparation’ lists requires consistency in communication from healthcare professionals and a shift in societal culture towards prevention, health behaviour change and ownership of health.

Perioperative care

Perioperative care is the integrated multidisciplinary care of patients throughout the surgical pathway — from the point when surgery is first contemplated until discharge and recovery (see Figure)^​10​.

Figure: Perioperative pathway

Centre for Preoperative Care, 2019

The Centre for Perioperative Care (CPOC) is a multidisciplinary initiative led by the Royal College of Anaesthetists to facilitate cross-organisational working on perioperative care. The CPOC has strong patient representation and works alongside high-value professional stakeholders and advisory group members, including the Royal Pharmaceutical Society and the UK Clinical Pharmacy Association, to break down silo working, streamline pathways, facilitate shared decision-making and encourage optimisation and preparation. This seamless perioperative approach reduces complications by 50% and length of stay by one to two days^​11​.

Prehabilitation

Prehabilitation is a growing concept in perioperative care. The aim of prehabilitation is to prepare patients for treatment or surgery by promoting healthy behaviours and optimising risk factors. This approach provides a positive focus for patients, rather than resigning them to passive waiting, while increasing physical and psychological resilience, which supports recovery, and improving long-term health. Prehabilitation interventions can be categorised as specialist, targeted or universal^​12​.

Specialist prehabilitation

Specialist prehabilitation is the most resource intensive, so it is reserved for patients undergoing major surgery (e.g. oesophagectomy and colorectal resection). Although there is no standard model, where services exist, they typically involve face-to-face or virtual group sessions, which focus on a tailored, high-intensity exercise programme alongside nutritional and psychological support. Services are typically delivered several times a week for approximately four weeks. Owing to the heterogenicity of interventions, it can be difficult to assess their impact; however, a systematic review has indicated that specialist prehabilitation reduces complications and might lead to clinically relevant improvements in health-related quality of life, length of stay and physical recovery after major surgery^​13​.

Targeted prehabilitation

Targeted prehabilitation focuses on needs identified by a healthcare professional during initial screening. This intervention may involve specific components of a specialist prehabilitation programme that are relevant to that individual — for example, a focus on psychological or nutritional support.

Universal prehabilitation

Conversely, universal prehabilitation is applicable to, and should be offered to, all individuals awaiting surgery. Universal prehabilitation aligns with several pillars of lifestyle medicine, including physical activity, minimising harmful substances, healthy eating and mental wellbeing^​14​. These simple, low-cost interventions are highly effective. The CPOC recommends seven top interventions to actively prepare patients physically, psychologically and practically for surgery and recovery^​15​. These same interventions reduce health inequalities and improve long-term health^​15​.

Making every contact count

‘Making every contact count’ is an initiative to equip healthcare, social-care and third-sector staff with the skills and confidence to use each of their interactions in the working day as an opportunity to influence positive health behaviour change^​16,17​. There are an estimated 1.7 million patient contacts with the NHS per day in England alone^​18​. With the addition of NHS patient contacts in the devolved nations, and also within community pharmacies, there are millions of opportunities to empower patients to actively prepare for surgery. Pharmacists are a trusted, accessible source of professional health advice in local communities and, through the expansion of the pharmacist role, are integrated within multi-professional teams in primary and secondary care. This makes the profession ideally placed to raise awareness of the benefits of actively preparing for surgery with both patients and other healthcare professionals.

Seven interventions for active preparation for surgery

1. Smoking cessation

Smoking prevalence among adults in the UK ranges from 11.6% in England to 15% in Scotland, with all nations reporting a higher prevalence in areas with greatest deprivation^{​19–22​}. Within the surgical population, smoking prevalence is thought to exceed this baseline rate^​15​ — possibly owing to smoking driving health inequalities^​23​. 

Smoking is associated with a 38% increased risk of postoperative mortality and a 50% increased risk of postoperative complications. Adverse effects include impaired wound and bone healing, cardiac and pulmonary complications, infection, increased requirement for critical care and increased length of stay^​24,25​.

Smoking cessation is the single most effective healthcare intervention — both preoperatively and long-term. The greatest benefit of smoking cessation is derived from quit attempts that commence four to eight weeks preoperatively and continue postoperatively^​24​. However, there are benefits of stopping regardless of the proximity to surgery, with improvements in wound healing noted after just four days^​15​. A systematic review, published in 2023, demonstrated increased abstinence, both at the time of surgery (NNT=7) and one year post-operation (NNT=9), in individuals receiving perioperative tobacco cessation interventions, representing an opportunity to influence population health^​26​.

Studies indicate approximately 55% of current smokers would like to quit, with 24% planning to quit in the next three months^​20,27​. Given the (re)introduction of nicotine analogues (e.g. varenicline and cystine), there are several options for pharmacological support. A combination of pharmacological and behavioural support is the most effective intervention^​15​.

2. Alcohol moderation

According to the ‘UK chief medical officers’ low-risk drinking guidelines’, published in 2016, it is safest if both men and women do not exceed 14 units of alcohol per week on a regular basis^​28​. The guidelines also recommend that consumption of 14 units of alcohol per week should be spread over at least three days^​28​. However, 24% of adults report drinking more than 14 units per week, while 4% of women and 6% of men report levels of consumption associated with a higher risk of alcohol-related harm, which are >35 and >50 units a week, respectively^​29​. 

Harmful alcohol intake is associated with a higher risk of postoperative complications, including infection, arrhythmias, bleeding and delirium. Complication rates increase by 50% with daily consumption of three units of alcohol and by 300% with daily consumption above five units^​30​.

Harmful alcohol intake is a continuum — from risky drinking through to dependence and addiction^​30​. The abbreviated ‘Alcohol Use Disorders Identification Test — Consumption’ (AUDIT-C) is a rapid screening tool comprising three self-report questions (see Table). Individuals who score ≥5 would benefit from a comprehensive screening tool (e.g. AUDIT) to establish those at increased risk, who should be given lifestyle advice, and those with harmful drinking or dependence, who are likely to require specialist support to reduce the risk of alcohol withdrawal^​31​.

Table: AUDIT-C screening tool scoring system^​31​

3. Physical activity

Exercise is considered a miracle cure that can improve wellbeing, reduce risk of long-term conditions, including dementia, type 2 diabetes and heart disease^​32​, and reduce postoperative complications by 50%^​33​. The ‘UK chief medical officer’s physical activity guidelines’, published in 2019, recommend 150 minutes of moderate activity per week, which is enough to raise the heart rate and get slightly out of breath^​34​. However, only 63% of adults meet these recommended levels, while, worryingly, 25% of adults are inactive (i.e. spend less than 30 minutes of moderate activity per week)^​35​. Activity levels vary by age, social deprivation and obesity. According to a report published by Sport England in April 2024, 38% of adults aged over 75 years, 53% of adults in the most deprived areas and 55% of obese individuals meet recommended levels of exercise^​36​.

The benefits of exercise outweigh any risks. It is more dangerous to be inactive than to do some activity, so routine medical clearance is not necessary^​37​. Resources such as ‘We are Undefeatable’ and low-impact or chair-based exercises help people with long-term health conditions introduce movement into their daily routine^​38,39​. Patients should be advised to: gradually build up duration, intensity and frequency of physical activity; to stop if they experience chest pain, irregular heartbeat, dizziness or changes in vision; and to avoid exercise if they feel unwell owing to infection^​15​.

4. Weight management and nutrition

Obesity is associated with reduced life expectancy, poor mental health and chronic conditions, including diabetes and cardiovascular disease. In England, the prevalence of adults who are overweight or living with obesity is estimated as 64%, which rises to 71.5% in areas with greatest deprivation^​40​. This is replicated in the surgical population, where both the prevalence and severity of obesity has increased in the past decade. Over one in four adults are estimated to be living with obesity^​40​, and this number rises to one in three adults in the surgical population^​5​. However, this data predates the COVID-19 pandemic, so these numbers are likely to be an underestimation of the current prevalence of adults who are overweight or living with obesity.

Obesity is associated with increased risk of anaesthetic complications, including accidental awareness under general anaesthesia, complications with airway management and complications owing to comorbidities, such as hypertension, type 2 diabetes and sleep apnoea^​5​. Working towards a healthy weight by addressing portion size, incorporating fruit and vegetables into a balanced diet and focusing on protein intake for satiety and postoperative wound healing can contribute to improved outcomes^​15​.

5. Mental wellbeing

Social isolation, living alone, caring responsibilities, ill health and poor mobility are risk factors for chronic loneliness, which is estimated to affect 7.1% of the UK population^​41​. Chronic loneliness and social isolation both adversely influence physical health, mental health and quality of life^​42​.

Understandably, many people feel apprehensive, anxious or stressed before surgery. Poor mental health can adversely affect postoperative outcomes, as anxiety and depression are associated with increased pain and stress with slower wound healing^​43​. Encouraging patients to get outside, make time for activities they enjoy, strengthen support networks, share concerns, increase physical activity, eat healthily and reduce alcohol intake can all positively affect mental wellbeing^​15​.

6. Assessment, optimisation and shared decision-making

Preoperative assessment in secondary care should identify modifiable risk factors and focus on action rather than simply documentation; however, as this often occurs late in the pathway, the time for optimisation of medical comorbidities is limited. NHS England’s ‘Earlier screening, risk assessment and optimisation in perioperative pathways’^​44​ and the Welsh Government’s ‘Promote, Prevent, Prepare for Elective Care’^​45​ initiatives seek to improve this by promoting lifestyle change and the optimisation of medical comorbidities (e.g. hypertension, diabetes and anaemia) from the first hospital contact. However, ideally, optimisation should begin in primary care when surgery is first contemplated in order to maximise the time for intervention and lifestyle change. 

Suboptimal glycaemic control in people with diabetes is associated with perioperative dysglycaemia, impaired wound healing, infection and increased length of stay. Delaying non-urgent elective surgery to facilitate further optimisation should be considered when HbA1c exceeds 69mmol/mol^​46​. Consequently, uncontrolled diabetes is one of the most common reasons for postponement of surgery in patients attending preoperative assessment^​47​.

Anaemia (i.e. haemoglobin <130g/L, irrespective of gender) is an independent risk factor for postoperative complications^​48​. Preoperative anaemia is associated with a reduced likelihood of drinking, eating and mobilising within 24 hours of surgery, which increases the risk of complications and length of stay^​49​. Early detection and treatment of anaemia reduces reliance on transfusion and associated harms; however, data indicates that 67% of patients with anaemia receive no treatment before surgery^​49​.

In the UK, 19% of older patients undergoing surgery are living with frailty^​50​. These patients are associated with at least a four-fold increase in postoperative complications^​6​. Comprehensive geriatric assessment can holistically optimise modifiable risk factors prior to surgery. In addition, following discussion with a geriatrician about alternative options, 14% of patients decide not to proceed with surgery^​51​. 

Shared decision-making is essential. A study conducted by the Personalised Care Institute in 2024, revealed that 19% of patients on waiting lists felt that with more choice and control over decisions, they might have decided against surgery^​52​. Encourage patients to use the Choosing Wisely UK^​53​ ‘BRAN’ mnemonic: 

• What are the Benefits?
• What are the Risks?
• What are the Alternatives?
• What if I do Nothing?

Similarly, encourage them to consider the recovery period, not just the day of surgery. This can help to inform patient choice and reduce decisional regret.

7. Practical preparation

Practical preparation prior to admission ensures a smooth transition on discharge. Patients may be provided with surgery-specific information via leaflets or surgery schools. However, all patients will benefit from thinking about practicalities, such as ordering repeat medicines, organising support for pets or caring responsibilities and considering how they can adapt their home or activities of daily living (e.g. personal hygiene, getting dressed and preparing meals), to make the days and weeks after discharge easier^​15​.