When should I refer a patient to a specialist for further evaluation before surgery?

Refer a patient to a specialist for further evaluation prior to surgery if:

• They have cardiac symptoms (such as breathlessness, pre-syncope, syncope, or chest pain) or signs of heart failure combined with a heart murmur, warranting resting echocardiography after ECG and anaesthetist discussion.
• They have diabetes and require recent HbA1c results included in the referral or need HbA1c testing if not done in the last 3 months.
• They have a known sickle cell disease managed by a specialist service, necessitating liaison with that team before surgery.
• The surgery planned is major or complex, where enhanced recovery programmes and preoperative optimisation may be considered.
• There are concerns about comorbidities that may limit functional capacity (ASA grade 3 or higher), requiring specialist assessment.
• There is a need for specific preoperative tests or assessments that cannot be managed in primary care, such as detailed cardiac evaluation or complex biometry for cataract surgery.

In all cases, ensure that preoperative test results and relevant clinical information are included in the referral to facilitate specialist evaluation and shared decision making.

Do not routinely refer for tests or specialist evaluation if there are no clinical indications, such as routine HbA1c testing in non-diabetics, routine chest X-rays, or urine dipstick tests without infection suspicion.

Always involve the patient in discussions about their surgery and referral, ensuring informed consent and shared decision making.

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