REVIEW

Pharmacists can play a crucial role within surgical enhanced recovery pathways . This article discusses some of the strategies that can be employed in optimising long-term conditions peri-operatively to achieve the best possible patient outcomes

Neetu Bansal MRPharmS DipClinPharm IPresc MSc ( APP ) MClinRes Lead Enhanced Recovery Surgical Pharmacist and NIHR Clinical Doctoral research fellow , Manchester University Hospitals NHS Trust , Manchester , UK

The World Health Organization has estimated that approximately 234 million surgical procedures are performed worldwide each year . ¹ Although most of these procedures are uncomplicated , an increasing number of individuals are at risk of adverse outcomes because of comorbid conditions and poor functional capacity . At age 65 , 50 % of the UK population has multi-morbidity ( two or more long-term conditions ), and this proportion rises with age and deprivation . ² Complications which prolong length of stay occur after approximately 15 % of inpatient operations , which can be mitigated by optimising patients for surgery . ³

Optimising patients for surgery One of the key stages of enhanced recovery ( ER ) is optimising patients for surgery . The concept of ER was first pioneered in Denmark in the late 1990s for patients undergoing colorectal surgery . ⁴ Since their introduction in the UK in the early 2000s , ER pathways have been successfully implemented within various surgical specialities in the UK , the primary aim being to reduce the length of stay while still providing a high-quality package of care . Fundamental to all aspects of ER is that patients

FIGURE 1

Key areas for optimisation for surgery

Physical activity

Anticoagulation

Smoking cessation / alcohol intake

Key areas for optimisation

Cardiac function ( including hypertension )

Respiratory function are ‘ partners in their own care ’ and are kept fully informed throughout their surgical journey .

Pre-operative assessment It is crucial that assessment and preparation for surgery starts as soon as possible adopting a multimodal , trans-disciplinary approach . ² Primary care physicians can play a major role in identifying the modifiable causes of increased morbidity ; for example , smoking , reduced physical activity , excess alcohol and poor nutrition prior to referral for surgery .

Pre-assessment clinics ( nurse- , anaesthetist- and pharmacist-led ) are also crucial in identifying these ‘ high-risk ’ patients with multiple comorbidities at risk of post-operative complications : for example , pre-existing anaemia , diabetes , cardiovascular and respiratory disease .

Implementation of an ER pharmacist service : a local example In line with the ER initiative , a pharmacist-led Enhanced Surgical Medicines Optimisation Service ( ESMOS ) was implemented in a large 1200-bedded tertiary hospital in Central Manchester in September 2017 to mitigate the risks of post-operative complications and optimise post-operative care . ⁵ The goals of the ESMOS service are to identify high-risk surgical patients once they are listed for surgery and get them in the best possible state for surgery by focusing on optimising their pre-existing comorbidities .

During the pre-operative phase , patients are reviewed in a virtual pharmacist clinic whereby patients ’ pre-existing medical comorbidities are recorded by pharmacists along with any high-risk medication the patient is taking . ^{6 , 7} The goal at this stage is to optimise long-term conditions prior to surgery . The ESMOS was initially rolled out to four main general surgical sub-specialties : hepatopancreato-biliary ( HPB ); upper gastrointestinal ( GI ); lower GI ; and vascular surgery .

The results of the 12-month follow up study following implementation of the ESMOS service demonstrated a significant reduction in length of stay and post-operative complications . ⁶

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