Preoperative anaemia toolkit

This toolkit is for healthcare professionals to identify and optimise patients with preoperative anaemia.

Optimisation of preoperative anaemia improves patient outcomes including reduced post-operative infection risks, better post-operative mobilisation and reduced length of stay. It also reduces the chance of needing a blood transfusion and the associated transfusion risks.

The NHS Standard Contract now requires early screening and health optimisation for all surgical inpatient pathways. Preoperative anaemia requires collaborative service development to embed it fully into the surgical pathway, to achieve the best patient outcomes.

In this section

Pages in the 'Identify and manage anaemia' section

The preoperative anaemia pathway

An illustration of a pathway, with icons depicting the five steps involved in optimising patients with preoperative anaemia

Optimisation starts at the point of referral, involves all staff groups and departments across the whole surgical patient pathway and includes the following steps:

Pathways for identification and treatment
Education and resources for staff
Patient information and involvement
Quality improvement and audit

Guidance

The following guidance supports preoperative optimisation of anaemia.

National guidance

The National Institute for Health and Care Excellence (NICE) provides the following guidance:

In 2024, the British Society for Haematology published an update to their guideline on identification and management of preoperative anaemia in adults.

The Centre for Perioperative Care (CPOC) published an update to their guideline on anaemia in the perioperative pathway in 2025. This is a collaborative guideline, developed using a whole pathway approach.

There are several supporting resources on the CPOC guideline page, including:

guidance for specific staff and patient groups
example GP letters
patient group directives for prescribing
patient information

The CPOC guideline also includes:

NHS guidance and programmes

The National Perioperative Care Programme is one of many workstreams covered by Getting It Right First Time (GIRFT), a national NHS England programme.

It built on the CPOC's preoperative assessment and optimisation for adult surgery guidance, clinical guidance developed by a cross disciplinary, multi-specialty working group.

Following changes in the requirements for perioperative care in the NHS Standard Contract, early screening and health optimisation has been required for all inpatient pathways since April 2024.

The National Perioperative Care Programme has developed guidance to support this: Earlier screening, risk assessment and health optimisation in perioperative pathways: guide for providers and integrated care boards.

Developing and improving your service

Service development

This section includes practical tools and guidance for service development and avenues for collaboration.

The Centre for Perioperative Care (CPOC) provides the following guideline: Recommendations for organisations where surgical services are provided for people who may have anaemia (PDF 38.2 KB).

The patient blood management (PBM) toolkit contains useful resources for perioperative PBM. It includes an information leaflet on 'Preoperative optimisation of iron deficiency anaemia' to guide your identification and management of anaemia in patients undergoing surgery.

The FutureNHS Collaboration Platform hosts workspaces for collaboration, including perioperative forums within the GIRFT programme. (A FutureNHS account is required to access this content. It is free for NHS staff to join.)

Audit and improvement

Use the following resources to help promote continuous improvement.

QS138 Quality Insights is a quality improvement audit tool, enabling users to regularly self-assess compliance to the National Institute for Health and Care Excellence (NICE) Blood Transfusion Quality Standard 138. This includes preoperative iron supplementation and the use of tranexamic acid for adults undergoing moderate blood loss surgery.

The National Comparative Audit of Blood Transfusion is a national rolling programme of clinical snapshot audits that evidence appropriate use of blood components and alternatives, comparing practice to guidelines in surgical and medical settings.

The Perioperative Quality Improvement Programme (PQIP) includes preoperative anaemia. They have also produced the following guidance: 'Addressing preoperative anaemia: Ten top tips, practical advice and the evidence base'.

The PQIP report for March 2024 to March 2025 includes data on perioperative anaemia.

Examples of good practice

How patient-level costing (PLICS) can support quality improvement: this webinar by The Healthcare Financial Management Association discusses how clinicians and members of the costing team created a tool to improve preoperative anaemia management in elective surgical pathways.

The Patient Blood Management England YouTube channel contains an Anaemia playlist. The channel is regularly updated with presentations.

The Wales Blood Health National Oversight Group has developed a preoperative anaemia programme.

Royal Marsden Hospital Policy for Oncology Pre Operative Anaemia Management

North Bristol Trust Guideline on Management of Pre Operative Anaemia.

Research and publications

Preoperative intravenous iron to treat anaemia before major abdominal surgery (PREVENTT) trial full report - The Lancet

Download supplementary information about the PREVENTT trial below:

Summary of the PREVENTT trial (PDF 757KB)
PREVENTT trial secondary analysis - published in Anaesthesia, on the Association of Anaesthetists website

Alternate day oral iron dosing in iron deficiency anaemia - published in Haematologica, on the National Library of Medicine website

Current concepts in the evaluation and management of preoperative anaemia - published in Current Opinion in Anaesthesiology

International consensus statement on the perioperative management of anaemia and iron deficiency - published in Anaesthesia, on the Association of Anaesthetists website

Anaesthesia and Perioperative Medicine (PDF 5MB) - Getting It Right First Time (GIRFT) September 2021 report

Results from a type two hybrid-effectiveness study to implement a preoperative anemia and iron deficiency screening, evaluation, and management pathway - PubMed

Optimizing the screening and management of preoperative anemia prior to gynecologic oncology surgery (OPRA1): A quality improvement initiative - PubMed

Design and Staged Implementation of a Multidisciplinary Preoperative Anemia Clinic at a Tertiary Care Medical Center - PubMed

Early detection and correction of preoperative anemia in patients undergoing colorectal surgery-a prospective study - PubMed

Preoperative anemia in cardiac surgery patients: how to achieve clinical optimization - a narrative review - PubMed

Information for the public

Our patient information leaflets are available to help inform patients and support shared decision making, including leaflets on anaemia and iron in your diet.

Ferinject R Intravenous Iron Infusion patient information leaflet

Monofer R intravenous iron infusion patient information leaflet (LINK)

The Centre for Perioperative Care (CPOC) has a patient information leaflet for surgical patients with anaemia: Recommendations for people with anaemia and their carers (PDF 465 KB).

They also have a webpage for patients on perioperative care: For patients - CPOC.

For additional resources and infographics for iron deficiency, please see our iron deficiency toolkit.

Share your learning

Tell us about your preoperative anaemia projects, highlighting your successes or where things didn't go so well, and we'll include them on this page.

Page last reviewed: June 2026