In Shape for Surgery

In Shape for Surgery

When a patient has poorly controlled chronic disease or certain risk factors including smoking, it can adversely affect the:

  • outcome of the operation
  • risks of complications during and after the operation
  • 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.

In view of this, the NHS in Cornwall is keen to promote the optimisation of patients prior to elective surgery with regard to smoking cessation and 5 medical markers:

  • Diabetes (HbA1c level in known diabetics, or 'at risk of diabetes')
  • Blood pressure
  • Pulse check for atrial fibrillation
  • Detection and investigation of any heart murmurs
  • Anaemia (for major surgery i.e. TKR/THR)

From December 2017 primary care is encouraged to follow these best practice guidelines. This will ensure, where possible, that patients stop smoking before surgery and have these medical markers measured and optimised before routine elective surgery.

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."

Initially this pathway will cover patients undergoing hip/knee arthroplasty and hernia surgery but in time is likely to be extended to other surgical procedures and specialities.

When patients are being referred for "likely surgery" primary care is asked to ensure that these medical markers are measured, and optimised where possible. It is accepted that due to patients' individual circumstances it might not be either possible or desirable to optimise some patients to the thresholds set out in the pathway. If it is not clear whether surgery is the likely outcome then referrals should be made but patients should be aware that optimisation may be encouraged later in the pathway should surgery be the outcome.

Medical Markers

The thresholds that may require pre-referral intervention from primary care prior to referral are:

  • HbA1c greater than 69mmol/mol
  • Blood pressure greater than 160/100mmHg
  • Atrial fibrillation rate greater than 100 beats per minute
  • Auscultation for new heart murmurs - ECHO should be obtained if there are concurrent symptoms and/or ECG abnormalities
  • Haemoglobin less than 130g/L (if not, investigate and treat to achieve minimum of 120 g/L- strongly recommended for major surgery i.e. TKR/THR)


For smokers it is requested that patients are:

  • advised that 8 weeks smoking cessation prior to operation is optimal to reduce risks
  • encouraged that it is a good time to consider quitting for good
  • referred to smoking cessation service

Smoking cessation should be initiated in primary care, with patients being referred to existing cessation services for advice on nicotine replacement therapy and other methods of cessation.

Patients who do not wish to attempt to stop smoking, despite an informed discussion with their clinicians about the risks involved will still be allowed to proceed to surgery. Patients will not be able to smoke whilst in hospital so they will need to consider how they will manage this during their stay.

Vaping and nicotine replacement therapies are accepted forms of pre-operative smoking cessation. 



Further information and resources:

Clinical Referral Guideline

Referral Form

Practice Pack

GP Briefing


Patient leaflets:

The following patient leaflets have information about each of the key risk factors and information to aid patients in taking care of their health so they are fit for surgery: 

A4 poster

Diabetes leaflet

General leaflet

Smoking leaflet

TV screens


Additional information, including patient leaflets is available on the NHS Kernow website