HNY Policy and Pathway Repository - North Yorkshire

People being considered for/awaiting elective surgical interventions

Previous policies across Humber and North Yorkshire, including criteria relating to BMI or smoking for ANY planned non-urgent surgical interventions, including hip and knee replacement, are withdrawn.

Clinicians should offer referral to relevant health optimisation services for all who could clinically benefit.

When there is a clinical indication for referral to any surgical service for potential surgical intervention:

If BMI is >40 consider referral for weight loss management alongside referral to a surgical service. To minimise risk, it will usually be preferable to reduce BMI to below 40 before surgery, unless the patient:

• has red flag symptoms OR
• has an urgent need for surgery (infection, tumour, is likely to go off legs etc) OR
• has already engaged with weight loss management for at least 6 months but failed to achieve a BMI <40

but referral to a surgical service should not be delayed on the grounds of BMI.

If BMI is 35.1-40, consider referral for weight loss management alongside referral to a surgical service.

If BMI is 30-35 AND waist-height-ratio is 0.5 or higher, consider referral for weight loss management alongside referral to a surgical service.

If the patient is a smoker, consider referral to smoking cessation alongside referral to a surgical service.

If a patient comes under the care of a surgical service without referral from primary care, referral for health optimisation measures should be considered by the responsible surgical service.

Smoking cessation prior to surgery has been found to significantly reduce the relative risk of post operative complications in orthopaedic and abdominal surgery. Whilst the evidence around BMI reduction is weaker, with very litle significant effect on post operative outcomes, there is strong evidence that obesity increases the risk of anaesthetic complications. Smoking cessation interventions and weight loss interventions delivered in the pre-operative period have a success rate comparable to use in the population generally.

BMI is not a direct measure of central adiposity and for a BMI <35, assessing waist to height ratio is recommended to give a practical estimate of central adiposity, to assess associated health risks.

There is a risk that using blanket BMI and smoking criteria to restrict access surgical interventions may worsen health inequalties, given that health and ill health is highly socially stratified, and it is likely that certain sections of society in age, gender, socioeconomic status and ethnicity will experience greater ill health and have a greater demand for surgery. There is also a risk of further health deterioration (social, physical, mental health) because of the condition requiring surgical intervention while waiting for surgery.

The ethics commitee in HNY also concluded that the balance of ethical argument does not support the blanket application of health optimisation, as it is unjustifiably restrictive.

The decision whether to proceed with surgery and, if so, whether to delay until health optimisation measures have been atempted, should be on a shared basis with the patient, considering their individual risk of adverse outcomes from anaesthesia and surgery and their risks from delaying or not having the surgical intervention.

Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation | British Journal of Surgery | Oxford Academic (oup.com)

NAP4: Major Complications of Airway Management in the United Kingdom | The Royal College of Anaesthetists (rcoa.ac.uk)

Preoperative assessment and optimisation guidance (CPOC) Commissioner, clinician, and patient experiences of a pre-surgical health optimisation programme – a qualitive study | BMC Health Services Research | Full Text (biomedcentral.com)

CG198 Obesity: identification, assessment and management (NICE)