Equity and Perioperative Care

The COVID-19 pandemic, with its disproportionate impact on historically marginalized populations, highlighted underlying inequities in society that can lead to disparate health outcomes and increased attention to the need to address health disparities. Although different countries may have different issues relating to health disparities, this chapter describes approaches that can be broadly applied to improve health equity and reduce disparities in perioperative care. © 2023 Elsevier Inc. All rights reserved.

The post-anaesthetic care unit re-imagined: Whipps Cross Hospital's COVID-19 recovery initiative

The surgical demand upon the NHS was of concern prior to the COVID-19 pandemic, it has now worsened. The waiting list may rise from 6 to 14 million. One in five of these patients require admission and potential access to more than level 1 care [1]. The anaesthesia and perioperative medicine Getting It Right First Time (GIRFT) report made recommendations for the introduction of enhanced care to minimise cancellations due to lack of critical care beds, reduce the burden placed upon the intensive care unit (ICU) and help the future recovery of elective surgery. Enhanced care lies between level 1 and level 2/3 care. It facilitates closer observation, monitoring and interventions than is offered on a general ward. It is multidisciplinary, integrating the anaesthetic, surgical and enhanced recovery teams [2]. Whipps Cross Hospital introduced a post-anaesthetic care unit (PACU) in a green recovery in line with these recommendations. Methods We reviewed the records of all patients with PACU admissions between April 2021 to April 2022. We looked at engagement in pre-operative pathways, pre-operative interventions and postoperative enhanced care interventions, engagement by the multidisciplinary team (MDT), outcomes and escalations to intensive care. Results Fifty-four patients admitted to the PACU were identified. All were seen in the pre-operative assessment clinic, 51 were seen in the pre-operative planning clinic. Twenty-five received pre-operative optimisation. In the PACU, 44 received blood gas analysis, four received cardiac output monitoring, one received vasopressors and 29 received additional pain management. All patients were reviewed by the anaesthetic registrar and consultant, 98% by the surgical team and 78% by the enhanced recovery team within 24 h of admission to the PACU. Four were escalated to the ICU. Discussion Our analysis shows the successful application of the GIRFT report's recommendations, demonstrates the effectiveness of enhanced care and shows a successful reduction of the burden on ICU. High-risk patients were identified, optimised and received enhance cared. MDT engagement was high and only four patients were escalated to the ICU. We delivered our model in recovery, showing it is the mental approach that matters, not the physical location. This model also helps us deliver care tailored to each patient's unique risk profile. The GIRFT report estimates financial opportunities from the reduction of critical care bed days. We aim to do a local cost analysis. (Figure Presented).

The Swedish Perioperative Register (SPOR): description, validation of data mapping and utility.

BACKGROUND: Since 2013 surgical units in Sweden have reported procedures to the national Swedish Perioperative Register (SPOR). More than four million cases have been documented. Data consist of patient ID, type of surgery, diagnoses, time stamps during the perioperative process (from the decision to operate to the time of discharge from the postoperative recovery area), and quality measures. This paper aims to describe SPOR and validate data mapping. Also, we wished to illustrate the utility of the SPOR in assessing variations in national surgical capacity during the Covid-19 pandemia years 2020-2021. METHODS: After a detailed description of SPOR, we report on the validation of data performed by comparing data from local databases with data stored in the central SPOR database, assessing missing values and accuracy. Effects of the pandemic on surgical capacity were described by developing an index, based on the number of performed surgical procedures per week during four production weeks in January 2020. Subsequent weeks were then compared with this baseline. RESULTS: The validation effort demonstrated nearly 100% data accuracy for the number and type of surgical procedures between local and central data. Missing data was a problem for some parameters. The number of performed surgical procedures decreased dramatically from week 11 in 2020 compared to normal production on a national basis, mainly impairing elective surgery. DISCUSSION: Data validation revealed good agreement between local and central databases. The changes in national surgical capacity during the pandemic were illustrated by an index based on the reported surgical production. This article is protected by copyright. All rights reserved.

Information Technology-Enhanced Telehealth Consultations Reduce Preoperative Evaluation Center Visits in a Bariatric Surgery Population.

Background: Preoperative patient evaluation and optimization in a preoperative evaluation center (PEC) has been shown to improve operating room (OR) efficiency and patient care. However, performing preoperative evaluation on all patients scheduled for surgery or procedure would be time- and resource-consuming. Therefore, appropriate patient selection for evaluation at PECs is one aspect of improving PEC efficiency. In this study, we evaluate the effect of an enhanced preoperative evaluation process (PEP), utilizing a nursing triage phone call and information technology (IT) optimizations, on PEC efficiency and the quality of care in bariatric surgery patients. We hypothesized that, compared to a traditional PEP, the enhanced PEP would improve PEC efficiency without a negative impact on quality. Methods: The study was a retrospective cohort analysis of 1550 patients from January 2014 to March 2017 at a large, tertiary care academic health system. The study was a before/after comparison that compared the enhanced PEP model to the traditional PEP model. The primary outcome was the efficiency of the PEC, which was measured by the reduction of in-person patient visits at the PEC. The secondary outcome was the quality of care, which was measured by delays, cancellations, and the need for additional testing on the day of surgery (DOS). Results: The enhanced PEP improved the primary outcome of efficiency, as evident by an 80% decrease in in-person patient visits to the PEC. There was no reduction in the secondary outcome of the quality of care as measured by delays, cancellations, or the need for additional testing on the DOS. The implementation of the enhanced PEP did not result in increased costs or resource utilization. Conclusions: The enhanced PEP in a multi-disciplinary preoperative process can improve the efficiency of PEC for bariatric surgery patients without any decrease in the quality of care. The enhanced PEP process can be implemented without an increase in resource utilization and can be particularly useful during the COVID-19 pandemic.

Obstructive sleep apnoea and perioperative medicine: a growing concern.

Obstructive sleep apnoea represents a sizable public health and economic burden. Owing to rising obesity rates, the prevalence of obstructive sleep apnoea is increasing, and it is a condition that is significantly underdiagnosed. Exacerbated by the COVID-19 pandemic, the backlog of elective surgeries is also sizable and growing. A combination of these factors means that many patients due to have surgery will have obstructive sleep apnoea, either diagnosed or otherwise. Patients with obstructive sleep apnoea have a significantly increased risk of operative complications, but the evidence base for optimum perioperative management of these patients is limited. This article reviews sleep apnoea, its prevalence and its impact on operative management and perioperative outcomes for patients. The evidence base for screening and treating undiagnosed obstructive sleep apnoea is also comprehensively assessed. Finally, a pathway to manage patients with possible undiagnosed obstructive sleep apnoea is proposed, and areas for further research identified.

A Description of Interventions Prompted by Preoperative Comprehensive Geriatric Assessment and Optimization in Older Elective Noncardiac Surgical Patients.

OBJECTIVES: Comprehensive Geriatric Assessment (CGA), a multicomponent, complex intervention, can be used to improve perioperative outcomes. This study aimed to describe the actions and interventions prompted by preoperative CGA and optimization in elective noncardiac, older, surgical patients. DESIGN: Retrospective observational study. SETTING AND PARTICIPANTS: Five hundred consecutive patients aged over 65 years attending a preoperative CGA and optimization clinic in a single academic center. METHODS: A retrospective review of electronic clinical records was undertaken. CGA prompted actions and interventions were categorized a priori and examined according to the perioperative pathway and frailty status. RESULTS: Patients received a median of nine interventions (IQR 6‒12, range 0‒28). Long-term condition medication changes were made in 375 (75.0%) patients, lifestyle advice provided in 269 (53.8%), therapy interventions delivered in 117 (23.4%), shared decision making documented in 495 (99.0%) with individualized admission plans documented in 410/426 (96.2%). Following CGA, 74/500 (14.8%) patients did not undergo surgery and were more likely to have benign pathology (69% vs 53%, P = .01), higher frailty scores (Edmonton Frail Scale 8 (IQR 5‒10) vs 4 (IQR 2-6), P < .001), lower functional status (Nottingham Extended Activities of Daily Living 33 (IQR 16‒47) vs 57 (IQR 45‒64), P < .001) or cognitive scores (Montreal Cognitive Assessment 19 (IQR 14‒24) vs 24 (IQR 20‒26), P < .001). CONCLUSIONS AND IMPLICATIONS: This study provides a description of actions and interventions prompted by preoperative CGA at one center. Such a detailed exploration of the CGA process and the clinical skills necessary to deliver it, should be used to inform future multicenter studies and the development and implementation of perioperative services for older patients.

The Impact of Perioperative Remote Patient Monitoring on Clinical Staff Workflows: Scoping Review.

BACKGROUND: Remote patient monitoring (RPM) interventions are being increasingly implemented in health care environments, given their benefits for different stakeholders. However, the effects of these interventions on the workflow of clinical staff are not always considered in RPM research and practice. OBJECTIVE: This review explored how contemporary RPM interventions affect clinical staff and their workflows in perioperative settings. METHODS: We conducted a scoping review of recent articles reporting the impact of RPM interventions implemented in perioperative settings on clinical staff and their workflow. The databases accessed were Embase and PubMed. A qualitative analysis was performed to identify the main problems and advantages that RPM brings to staff, in addition to the approaches taken to evaluate the impact of those interventions. Different themes were identified in terms of the challenges of RPM for clinical staff as well as in terms of benefits, risk-reduction strategies, and methods for measuring the impact of these interventions on the workflow of clinical staff. RESULTS: A total of 1063 papers were found during the initial search, of which 21 (1.98%) met the inclusion criteria. Of the 21 included papers, 15 (71%) focused on evaluating new RPM systems, 4 (19%) focused on existing systems, and 2 (10%) were reviews. CONCLUSIONS: The reviewed literature shows that the impact on staff work experience is a crucial factor to consider when developing and implementing RPM interventions in perioperative settings. However, we noticed both underdevelopment and lack of standardization in the methods for assessing the impact of these interventions on clinical staff and their workflow. On the basis of the reviewed literature, we recommend the development of more robust methods for evaluating the impact of RPM interventions on staff experience in perioperative care; the adoption of a stronger focus on transition management when introducing these interventions in clinical practice; and the inclusion of longer periods of assessment, including the evaluation of long-term goals.

COVID-19 in the perioperative setting: A review of the literature and the clinical landscape.

The COVID-19 pandemic has dramatically affected societies and healthcare systems around the globe. The perioperative care continuum has also been under significant strain due to the pandemic-tasked with simultaneously addressing surgical strains and backlogs, infection prevention strategies, and emerging data regarding significantly higher perioperative risk for COVID-19 patients and survivors. Many uncertainties persist regarding the perioperative risk, assessment, and management of COVID-19 survivors-and the energy to catch up on surgical backlogs must be tempered with strategies to continue to mitigate COVID-19 related perioperative risk. Here, we review the available data for COVID-19-related perioperative risk, discuss areas of persistent uncertainty, and empower the perioperative teams to pursue evidence-based strategies for high quality, patient-centered, team-based care as we enter the third year of the COVID-19 pandemic.

Role of Dexmedetomidine in Perioperative Management of Pheochromocytoma

The prevalence of Pheochromocytoma in pat ient with hypertension is 0.1 -0.6%. These types of tumours are known for unpredictable perioperative course and hemodynamic instability. Various different drugs and anaesthesia techniques can be used to tackle these situations. Dexmedetomidine is emerged as newer agent with better hemodynamic stability, reducing requirement of other anaesthesia drugs, blunting of sympathoadrenal response in resection of Pheochromocytoma. We report four cases operated between January 2021 to June 2021.Preoperative preparation was done with α and β blockade. Dexmedetomidine was used during induction as 1 mcg/kg over 10 mins followed by 0.7mcg/kg/hr intraoperatively. Combination of Dexmedetomidine, Fentanyl, NTG, Isoflurane and Epidural analgesia was used. IF needed boluses of Esmolol and Labetalol were used during tumor manipulation. All the patients had an uneventful perioperative course. Dexmedetomidine with pre-operative α and β blockade reduce the need of other drugs intraoperatively and can be used as anaesthetic adjunct to maintain steady hemodynamic.

Telemedicine improves Anesthesia Pre-operative Evaluation Appointment Adherence: A Retrospective Analysis

Background/Introduction: Amidst the COVID-19 pandemic, the sudden demand for virtual medical visits drove the drastic expansion of telemedicine across all medical specialties. Current literature demonstrates limited knowledge on the impact of telehealth on appointment adherence particularly in preoperative anesthesia evaluations. We hypothesized that there would be increased completion of preoperative anesthesia appointments in patients who received telemedicine visits. Methods: We performed a retrospective cohort study of adult patients at UCLA who received preoperative anesthesia evaluations by telemedicine or in-person within the Department of Anesthesiology and Perioperative Medicine from January to September 2021 and assessed appointment adherence. The primary outcome was incidence of appointment completion. The secondary outcomes included appointment no show and cancellations. Patient demographic characteristics including sex, age, ASA physical status class, race, ethnicity, primary language, interpreter service requested, patient travel distance to clinic, and insurance payor were also evaluated. Demographic characteristics, notably race and ethnicity, are presented as captured in the electronic health record and we recognize its limitations and inaccuracies in illustrating how people identify. Patient reported reasons for cancellations were also reviewed and categorized into thematic groups by two physicians. Statistical comparison was performed using independent samples t test, Pearson's chi-square, and Fischer's exact test. Results: Of 1332 patients included in this study, 956 patients received telehealth visits while 376 patients received in-person preoperative anesthesia evaluations. Compared to the in-person group, the telemedicine group had more appointment completions (81.38% vs 76.60%, p = 0.0493). There were fewer cancellations (12.55% vs 19.41%, p = 0.0029) and no statistical difference in appointment no-shows (6.07% vs 3.99%, p = 0.1337) in the telemedicine group (Figure 1). Compared to the in-person group, patients who received telemedicine evaluations were younger (55.81 ± 18.38 vs 65.97 ± 15.19, p < 0.001), less likely American Indian and Alaska Native (0.31% vs 1.60%, p = 0.0102), more likely of Hispanic or Latino ethnicity (16.63% vs 12.23%, p = 0.0453), required less interpreter services (4.18% vs 9.31%, p = 0.0003), had more private insurance coverage (53.45% vs 37.50%, p < 0.0001) and less Medicare coverage (37.03% vs 50.53%, p < 0.0001). Main reasons for cancellation included patient request, surgery rescheduled/cancelled/already completed, and change in method of appointment. Conclusions: In 2021, preoperative anesthesia evaluation completion was greater in patients who received telemedicine appointments compared to those who received in-person evaluations at UCLA. We also demonstrate potential shortcomings of telemedicine in serving patients who are older, require interpreter services, or are non-privately insured. Knowledge of these factors can provide feedback to improve access and equity to telehealth for patients from all backgrounds, particularly during the COVID pandemic as virtual evaluations increase. (Table Presented).

Can patients with asymptomatic SARS-CoV-2 infection safely undergo elective surgery?

Current or recent infection with SARS-CoV-2 increases the risk of perioperative morbidity and mortality. Consensus guidelines recommend delaying elective major surgery after acute SARS-CoV-2 infection for 7 or 8 weeks. However, because of the growing backlog of untreated surgical disease and the potential risks of delaying surgery, surgical services may be under pressure to reduce this period. Here, we discuss the risks and benefits of delaying surgery for patients with current or recent SARS-CoV-2 infection in the context of the evolving COVID-19 pandemic, the limited evidence supporting delays to surgery, and the need for more research in this area.

Preoperative Anxiety among Adult Patients Undergoing Elective Surgeries at a Tertiary Teaching Hospital: A Cross-Sectional Study during the Era of COVID-19 Vaccination.

Anxiety in the perioperative period has significant impact on both the flow of surgery and the post-operative recovery process. The aim of this cross-sectional study is to determine the prevalence of preoperative anxiety among adult patients undergoing elective surgical procedures at a tertiary teaching hospital and the effect of COVID-19 and COVID-19 vaccines on preoperative anxiety. We used the Amsterdam Preoperative Anxiety and Information Scale (APAIS) to assess patients' anxiety toward surgery and their need for more information. Patients with APAIS about anesthesia and surgery (APAIS-A-T) total score <10 were considered as the low preoperative anxiety group, while patients with APAIS-A-T ≥11 were considered as the high preoperative anxiety group. The overall APAIS-A-T score of the 794 included patients was 8.5 ± 4.5. The mean APAIS-A-T score was 7.0 ± 3.8 among males and 9.6 ± 4.6 among female patients (p < 0.001). The APAIS-A-T score for those who had previously underwent surgery under anesthesia was 8.3 ± 4.4, compared to 9.5 ± 4.8 for those who had not (p = 0.002). No significant difference was found between those with a previous history of COVID-19 and those without (p = 0.105), nor between those who were vaccinated and those who were not (p = 0.550). Sixty-four (26.8%) highly anxious patients were afraid of becoming infected with COVID-19 during their hospital stay (p = 0.009). This fear of COVID-19 in-hospital transmission made 19 (7.9%) highly anxious patients and 36 (4.5%) of the total sample hesitant to undergo this surgery (p = 0.002). In conclusion, this study demonstrated that 30.1% of patients had high preoperative anxiety, with fear of pain after surgery being the most common factor related to anxiety on the day of surgery. Controlling the spread of COVID-19 can play a crucial role in decreasing preoperative anxiety during this pandemic.

A quality-improvement project on perioperative electrocardiography pathways

The COVID-19 pandemic has increased the pressure on pre-operative services to assess and optimise patients undergoing elective surgery [1]. Electrocardiography (ECG) is one of the most common investigations performed in pre-operative clinics, providing a stable baseline for postoperative comparison. In our unit, most pre-operative appointments are now done virtually, making the ECG more important in supporting cardiac risk assessment. We present preliminary findings from our multispecialty quality-improvement project on peri-operative ECGs. Methods The research team received quality-improvement training. We audited 3 months of pre-operative clinic activity, including number of ECGs performed, the proportion referred to consultant anaesthetists and onward to cardiology, and referral outcomes. We designed a process map. We surveyed consultant anaesthetists on the current system for ECGs and collated the results. We engaged stakeholders and formed a core group of consultant anaesthetists and cardiologists to attend a meeting. During this, we identified key areas for improvement and designed a driver diagram. We are now conducting interventions and will reaudit our progress in 6 months. Results In 3 months, 170 patients were seen in consultant pre-operative clinics (13% face-to-face) and 170 patients required notes reviews. ECG was performed for 197 patients (58%) based on symptoms or indications from our hospital protocol. Of these, 108 were referred to consultant anaesthetists (55%) for further risk assessment. Consultant anaesthetists referred nine patients to cardiology (8%), the majority using the cardiology on-call bleep system. All surveyed consultants agreed that the pathway needs to be improved and identified issues with referral guidance and pathways. Our four key areas for improvement are timely ECG availability, assessment and referral guidelines, referral pathway to cardiology and advice follow-up after referral. Discussion Multispecialty working is the cornerstone for good peri-operative medicine. Our project has brought both departments together to work on a common issue. We focused on ensuring that robust quality-improvement methodology was employed to maximise the likelihood of success. We hope that our project will improve patient and staff experience in the peri-operative period and will improve the quality of assessment and optimisation for high-risk patients undergoing surgery.

Are Non-Contact Thermometers an Option in Anaesthesia? A Narrative Review on Thermometry for Perioperative Medicine.

Measurement of core body temperature-clinical thermometry-provides critical information to anaesthetists during perioperative care. The value of this information is determined by the accuracy of the measurement device used. This accuracy must be maintained despite external influences such as the operating room temperature and the patient's thermoregulatory defence. Presently, perioperative thermometers utilise invasive measurement sites. The public health challenge of the COVID-19 pandemic, however, has highlighted the use of non-invasive, non-contact infrared thermometers. The aim of this article is to review common existing thermometers used in perioperative care, their mechanisms of action, accuracy, and practicality in comparison to infrared non-contact thermometry used for population screening during a pandemic. Evidence currently shows that contact thermometry varies in accuracy and practicality depending on the site of measurements and the method of sterilisation or disposal between uses. Despite the benefits of being a non-invasive and non-contact device, infrared thermometry used for population temperature screening lacks the accuracy required in perioperative medicine. Inaccuracy may be a consequence of uncontrolled external temperatures, the patient's actions prior to measurement, distance between the patient and the thermometer, and the different sites of measurement. A re-evaluation of non-contact thermometry is recommended, requiring new studies in more controlled environments.

Emotional status and fear in patients scheduled for elective surgery during COVID-19 pandemic: a nationwide cross-sectional survey (COVID-SURGERY).

BACKGROUND: Fragmented data exist on the emotional and psychological distress generated by hospital admission during the pandemic in specific populations of patients, and no data exists on patients scheduled for surgery. The aim of this multicentre nationwide prospective cross-sectional survey was to evaluate the impact of pandemic on emotional status and fear of SARS-CoV-2 contagion in a cohort of elective surgical patients in Italy, scheduled for surgery during the COVID-19 pandemic. RESULTS: Twenty-nine Italian centres were involved in the study, for a total of 2376 patients surveyed (mean age of 58 years ± 16.61; 49.6% males). The survey consisted of 28 total closed questions, including four study outcome questions. More than half of patients had at least one chronic disease (54%), among which cardiovascular diseases were the commonest (58%). The most frequent type of surgery was abdominal (20%), under general anaesthesia (64%). Almost half of the patients (46%) declared to be frightened of going to the hospital for routine checkups; 55% to be afraid of getting SARS-CoV-2 infection during hospitalization and 62% were feared of being hospitalised without seeing family members. Having an oncological disease and other patient-related, centre-related or perioperative factors were independently associated with an increased risk of fear of SARS-CoV-2 infection during hospitalization and of being hospitalised without seeing family members. A previous infection due to SARS-COV-2 was associated with a reduced risk of worse emotional outcomes and fear of SARS-CoV-2 infection during hospitalization. Patients who showed the most emotionally vulnerable profile (e.g. use of sleep-inducing drugs, higher fear of surgery or anaesthesia) were at higher risk of worse emotional status towards the hospitalization during COVID-19 pandemic. Being operated in hospitals with lower surgical volume and with COVID-19 wards was associated with worse emotional status and fear of contagion. CONCLUSIONS: Additional fear and worse emotional status may be frequent in patients scheduled for elective surgery during COVID-19 pandemic. More than half of the participants to the survey were worried about not being able to receive family visits. Psychological support may be considered for patients at higher risk of psychological distress to improve perioperative wellbeing during the pandemic.

Towards integrated perioperative medicine: a survey of general practitioners' attitudes, beliefs and behaviours regarding perioperative medicine for older people.

BACKGROUND: Perioperative optimisation can improve outcomes for older people having surgery. Integration with primary care could improve quality and reduce variability in access to preoperative optimisation. AIM: Our aim was to explore attitudes, beliefs and behaviours of general practitioners (GPs) regarding the perioperative pathway, and evaluate enablers and barriers to GP-led preoperative optimisation. METHODS: Stakeholder interviews (n=38) informed survey development. A purposive sampling frame was used to target delivery of online and paper surveys. Results were analysed using descriptive statistics. RESULTS: We had 231 responses (response rate 32.7%). Enablers included belief among GPs that optimisation improves postoperative outcomes (86%) and that they have a role discussing modifiable risk factors with patients (85%). Barriers included low frequency exposure to older surgical patients, minimal training in perioperative medicine and rare interaction with perioperative services. CONCLUSION: This survey illustrates the importance of interprofessional education, cross-sector training opportunities and collaboration to deliver integrated preoperative optimisation for older people undergoing surgery.

Toward Smart Monitoring with Phones, Watches, and Wearable Sensors.

Smartphones are increasingly powerful computers that fit in our pocket. Thanks to dedicated applications or "Apps," they can connect with external sensors to record, analyze, display, store, and share multiple physiologic signals and data. In addition, because modern smartphones are equipped with accelerometers, gyroscopes, cameras, and pressure sensors, they can also be used to directly gather physiologic information. Smartphones and connected sensors are creating opportunities to empower patients, individualize perioperative care, follow patients during their surgical journey, and simplify clinicians' life.

The Effect of Orthostatic Hypotension Detected Pre-Operatively on Post-Operative Outcome.

BACKGROUND: Exacerbation of or new onset orthostatic hypotension in perioperative patients can occur. There is complex underlying pathophysiology with further derailment likely caused by acute cardiovascular changes associated with surgery. The implications for post-operative recovery are unclear, particularly in frail and older patients. We retrospectively explored patient notes for evidence of post-operative orthostatic intolerance in relation to pre-operative orthostatic hypotension. METHODS: Supine and 1-minute and 3-minute standing blood pressure measures obtained from adult patients before mainly general, orthopedic or uro/gynecology surgery were compared to post-operative outcome, specifically, evidence in patient notes about falls, feeling dizzy/unsteady and/or fearful to stand. Orthostatic hypotension was defined as a 20 mmHg or more and/or 10 mmHg or more fall in systolic and diastolic blood pressure, respectively, within ~3 minutes of standing after lying supine for an electrocardiogram. RESULTS: Whilst all patients included had a 1-minute standing blood pressure assessment (N = 170), 3-minute assessment was performed less commonly (N = 113). Nevertheless, one-quarter (23.5%; N = 40) of 170 patients had pre-operative orthostatic hypotension. This was not clearly explained by cardiac or neurological disease or by common medications, but did occur more frequently in older patients and in those aged 65 years or more with higher clinical frailty scale scores. The COVID-19 pandemic reduced the number of patients progressing to surgery within the planned study timescale (N = 143/170; 84.1%). Nevertheless, patients with orthostatic hypotension stayed longer in hospital post-operatively and were more likely to have an episode of fall, unsteadiness and/or dizziness documented (un-prompted) in their notes. CONCLUSIONS: These data provide further impetus for research into modifiable perioperative risk factors associated with orthostatic hypotension. These risks are not confined to those with a pre-existing dysautonomia diagnosis.