bluuebunny/crossref_metadata_2025 huggingface dataset:
722 Audit on Improving the Management of Pre-Operative Medication Prior to Elective Surgery
Authors: Ong W , Choo J H
Published: August 2023

Aim

Patients presenting for elective surgery frequently omit one or more regular medications. Inappropriate management of some medication classes may lead to pre or perioperative complications. Our objective was to assess if preoperative patients are receiving their prescribed medications correctly preoperatively.

Method

A 2 staged PDSA cycle was conducted. All patients admitted to the elective surgical ward were sampled. Patients’ drug chart was retrospectively reviewed to determine if their preoperative medications have been correctly prescribed. Our interventions included posters to be displayed in elective surgical wards following the first wound and local departmental teaching during the second cycle of the audit. This 1ST and 2nd cycle were re-audited at 2 month and 4 months interval respectively to assess compliance and monitor for improvement.

Results

In the first cycle, 50 patients were included in the first round and 45 in the re-audit. 19/50 (38%) patients received their medications correctly. Post implementation of the posters, this improved to 56% (n = 25/45). During the second cycle, the baseline data reported 55% (n = 33/60) of the patients had their medications correctly managed preoperatively. The reaudit statistics demonstrated a rise to 71% (n = 35/50).

Conclusions

This quality improvement audit shows that our interventions between audit cycles have made a significant improvement in patients receiving their medications and therefore this has a direct positive impact on patient safety and outcomes. Work to introduce an electronic record of drug chart to this NHS trust is still underway.
731 Acute Pancreatitis: The Experience of a District General Hospital Following the Introduction of a New Care Pathway
Authors: Raby-Smith W , Manley L
Published: August 2023

Aim

Acute pancreatitis is a common surgical condition associated with significant morbidity and mortality. Outcomes depend on establishing disease severity, identifying complications and prompt initiation of management. Despite the recognised complications and mortality, the management of acute pancreatitis is often found to be highly variable. This study aimed to examine the effect of a new care pathway on the documentation and management of patients admitted with acute pancreatitis at a district general hospital (DGH).

Method

This clinical audit measured the compliance of a general surgical department at a DGH with NICE (National Institute of Care and Health Excellence) and IAP (International Association of Pancreatology) guidelines. Through a retrospective case note review, documentation and management were assessed for patients admitted with acute pancreatitis over two four-month periods before and after the introduction of a new care pathway.

Results

Following the introduction of the care pathway, we observed that compliance with guidelines improved across all measured outcomes including admission documentation, the use of diagnostic imaging, nutritional recommendations, and the use of the Modified Glasgow score to predict severe pancreatitis.

Conclusions

Based on these findings, we advocate for the use of a comprehensive care pathway, such as the one introduced in this audit, to standardise the documentation and management of patients admitted with acute pancreatitis and improve compliance with NICE and IAP guidelines.
760 Single Centre Evaluation of the Risk of Bleeding Following Cutaneous Skin Surgery in Patients with Long-Term Antithrombotic Drugs
Authors: Gujjuri R R , Nagra R S , Salibi A
Published: August 2023

Aim

The peri-operative management of antithrombotic drugs for skin surgery remains heterogenous with varying practice regarding the interruption of these drugs. This audit aimed to evaluate the risk of bleeding following cutaneous surgery in line with the British Society for Dermatological Surgery (BSDS) guidance on antithrombotic and skin surgery.

Method

All patients undergoing cutaneous surgery in a single centre were identified following a retrospective review of electronic health records between September to October 2022. Patients were included if they were on antithrombotic therapy in the operative period. Data were collected on demographics, operation type and site, reconstruction, antithrombotic agent and post-operative complications. The primary outcome was the rate of postoperative bleeding. Secondary outcomes included post-operative infection rate, bleeding risk of the cutaneous procedure and other surgical complications.

Results

This audit included a total of 71 patients who underwent surgery while on antithrombotic drugs, with 55, 12 and 4 procedures being determined as low-, moderate- and high-risk as per the BSDS classification. Of all patients, 8.5% experienced bleeding as a post-operative complication and 50% of these patients were on direct oral anticoagulants (DOACs). In moderate- and high-risk procedures, 37.5% of patients experienced either bleeding or infection.

Conclusions

Patients on antithrombotic drugs undergoing cutaneous skin surgery may be at an increased risk of post-operative bleeding and infection. Patients who are due to undergo moderate to high-risk cutaneous surgery and are established on DOACs or potent antiplatelet drugs should have these agents paused prior to surgery in an effort to minimise complications.
802 Are Patients with Malignant Melanoma Operated on Within National Cancer Waiting Time Standards?
Authors: Khatun A , Clark S
Published: August 2023

Aim

This audit evaluated the performance of the local melanoma referral pathway against national cancer wait times, to identify limiting factors and find solutions to deliver service in a safe and streamlined manner.

Method

Patients with malignant melanoma referred to general surgeons between March and June 2022 were identified retrospectively. Patients with other skin cancers, concurrent malignancy, metastatic melanoma, or those declining surgery were excluded.

The date of each step of the referral pathway was noted for each patient using Microsoft Excel, and the difference between the dates was calculated. The percentage of compliance with the 31-day and 62-day wait was compared against the national operational standard.

Results

During the audit period, 59 patients with malignant melanoma were referred to the general surgeons, 22 of these were excluded for the aforementioned reasons. Of the remaining 37 patients, 65% were male and the average age was 66 years old. 83% of patients received their first treatment from diagnosis within 31 days, falling short of the 96% target. Only 60% of patients received surgery within the following 31 days. On average it took 56.8 days from diagnosis to surgical treatment, with wait time to operation varying from 15 days to 101 days.

Conclusions

Overall, the average time to surgery for patients with malignant melanoma was less than the target 62 days, however there was notable variation in the number of days patients waited for their operation. Further detailed analysis of cases with long wait times is required to reduce the risk of delaying vital cancer treatment.
804 Audit of Hand-Written Consent Form Documentation for Skin Lesion Excisions in the Plastic Surgery Procedure Room
Authors: Egbuji O , Zengin H , Saad M , Rosich-Medina A , Sheppard N
Published: August 2023

Aim

To audit the hand-written consent forms for elective excision of skin lesions in the Procedure Room.

Method

The notes and consent forms from 11 Procedure Room sessions were analysed. The total number of notes reviewed were 24. Our audit standards focused on the consenter and the completion of sections of the audit form. There are no standard guidelines for the complications of skin lesion excision, therefore a consensus from the general consultant body was used.

Results

Our patient demographic mostly consisted of male patients (15, 63%) with a mean age of 50 (range 17 – 75). 83% of the procedures required no reconstruction, 8% were biopsies and 8% required a full thickness skin graft (FTSG). 75% of the consenting clinicians were Registrars. The rest were Senior House Officers. All the consenters documented their job title, signed and dated their signature. All were trained in consenting and each consenter performed the procedure. 100% of clinicians used the correct consent form, documented the proposed procedure, clearly documented the site and risks and placed a label on every page. 83% completed the ‘intended benefits’ section. 58% wrote the procedure name in full. Every clinician documented bleeding and infection as a risk factor. 54% pain, 75% re-excision of margins, 71% recurrence and wound breakdown, 96% scarring, 46% injury to surrounding structures and 0% anaesthetic risk. All patients who received a FTSG, had graft loss documented as a risk.

Conclusions

The quality of hand-written consent forms is user dependent. A pre-filled consent form is proposed to increase compliance.
807 Lower Limb Pathological Fracture Audit
Authors: Nawaz S M , Karayiannis P , Heyes G
Published: August 2023

Aim

To minimise the delays in surgical management and differentiate among patients with suspected and not suspected pathological fracture.

Method

Review of all patients admitted since January 2022 with pathological fracture or suspected Pathological fracture. Reviewed gospels (previous recorded/saved files) and then ECR/radiology systems for outcomes. All spinal patients and all upper limb patients were excluded as they are ambulatory.

Results

Initially identified 24 patients, 10 excluded and 14 patients included. 10 were females and 14 were males. Mean age was 69 (range 45 – 90). Majority site of lesions were on hip (with 11 patients). Majority of investigations were CT scan, MRI and bone scan which took mean time of 14 days for completion and mean time to theatre was 26 days.

Mean length of stay – 21 days (range 3 – 77, mean 16 with outliers excluded). 50% patients died at 6 months follow up. 1 patient passed away as inpatient and 1 dislocated Pelvic floor repair but was not suitable for further surgery whereas 1 requiring return to theatre for washout and debridement.

Conclusions

A patient with a suspected pathological fracture is at risk of hugely significant delay to life saving or life prolonging operation. Patient who requires biopsy at present will not get to theatre within 3 weeks of injury.
843 Asymptomatic Bacteriuria at Flexible Cystoscopy- Can We Reduce Cancellations?
Authors: Jeevanandan P , Baby A , Mahesan T
Published: August 2023

Introduction

At our trust patients with nitrite positive urinalysis attending for flexible cystoscopy (FC) are rescheduled, placing a heavy burden on over stretched NHS resources. It is accepted that asymptomatic bacteriuria (AB) affects up to 20% of patients over 70. Catheters, stents, and recent antibiotics for a urinary tract infection also significantly increases this risk.

Recent evidence suggests that proceeding to cystoscopy in patients with AB is safe, and we evaluated our cohort of patients to identify what proportion of our patients it would be safe to proceed in.

Method

We reviewed all outpatient FC over a four-month period. We interrogated cancelled FC procedures where patients were cancelled for a nitrite positive urinalysis. Information recorded included result of urine culture, whether an antibiotic was prescribed and risk factors for AB.

Results

1241 FC were performed. Mean age was 78.4. In a total, 61 patients (4.9%) were postponed due to nitrite positive urinalysis. 58 (95.1%) patients were asymptomatic, of which 31 (53.4%) demonstrated bacterial growth on culture. Risk factors for AB included catheters (n = 14), a ureteric stent (n = 2), regular antibiotics for recurrent UTIs (n = 27).

Conclusions

Data collected confirms our cohort is at high risk of AB. Based on the findings from Trail et al, we propose that proceeding to FC in patients with asymptomatic bacteriuria is safe and intend to implement this change in our department. This will reduce demand on FC waiting lists and improve time to diagnosis.
858 The Effect of a ‘Rib Fracture Pathway’ on the Efficiency of Rib Block Delivery at a UK Major Trauma Centre
Authors: Bethel J , Christodoulou A , Smart Y W , Emer N , Fernando K , Vasireddy A
Published: August 2023

Aim

Rib fractures carry a mortality rate of 10% which is doubled in the elderly population. They are common following blunt thoracic trauma and are a marker of injury severity. Timely delivery of regional analgesia is crucial to prevent secondary respiratory complications. We compare the time taken from admission to administration of a regional block in patients with >2 rib fractures before and after the implementation of a rib fracture pathway.

Method

Retrospective data was collected from 22 pre-pathway and 47 post-pathway patients who were given a regional block after suffering >2 rib fractures. Demographic data, ISS, length of stay and respiratory complications were collected. Need for block was determined by clinical factors including uncontrolled pain and limited respiratory effort.

Results

Time to block from admission was longer in pre-pathway patients (41.9±33.8 vs 23.9±21.2 hours, p = 0.03). There was no significant difference in length of stay (21.6±14.2 vs 19.9±14.5, p = 0.3).

Pre-pathway patients were significantly younger (54.6±15.0 vs 66.8±17.4 years, p = 0.006) and had fewer rib fractures (5.4±2.3 vs 7.4±3.5, p = 0.02).

The mean ISS was 24.1±10.3 and 18.1±8.5 in the pre- and post-pathway patients, respectfully (p = 0.02). There was no significant difference in post-admission chest infection rates (18.2% vs 23.4%, p = 0.4).

Conclusions

The time taken from admission to block in patients with multiple rib fractures significantly reduced following the implementation of a ‘Rib Fracture Pathway’ at a UK Major Trauma Centre. Further work is required to determine whether this will affect length of stay or patient outcomes.
877 Utility Value of Colonoscopy in the Over 80's
Authors: Challapalli P , Gokul K , Artiuokh D
Published: August 2023

Aim

To audit the rationale and efficacy of colonoscopy in the over 80’s over a year period at Southport hospital which caters to a geriatrically skewed population. Currently protocol driven diagnostic pathways often lead to direct triaging of patients to endoscopy preventing assessment of biological age of patient, practicalities of the procedure and risk-benefit ratio.

Method

A retrospective audit with data in 105 patients over the age of 80 who underwent colonoscopy in 2021 January – December 2021 was collated. An audit proforma looking at pre-, during- and post -colonoscopy data was evaluated using the hospital endoscopy records and clinical records.

Results

Pre-colonoscopy demographics showed that anaemia (31%) and change in bowel habit (26%) were the most common indications for colonoscopy. Completion rates, diagnostic yield and complication rates were evaluated. Completion rate was 73%. Positive findings were diverticulosis (52%), polyps (9%), colitis (3%) and malignancy in 15%. Mitigating factors for non-completion and poor efficacy were discomfort, angulation, poor bowel prep as well as incriminating polypharmacy and comorbidity.

Conclusions

Based on the audit findings targeted endoscopy in this age group is a better management rather than its usage as first line investigation to achieve maximum efficacy.
887 Developing Patient Information Leaflets for Patients Undergoing Emergency Laparoscopic Appendicectomy & Cholecystectomy
Authors: Finch B , Imran H , Wakefield C
Published: August 2023

Aim

Appendicectomy and Cholecystectomy operations are the two most common general surgical emergency operations performed at Royal Hampshire County Hospital. Despite this, patient information leaflets (PILs) about these emergency operations are unavailable, compromising standards of care and uncompliance with Trust policy and National guidelines. The project aimed to establish levels of written information offered to patients undergoing an emergency appendicectomy or cholecystectomy, and to assess the impact on patient’s understanding regarding all aspects of their operation after the development of PILs.

Method

Baseline data was collected via prospective analysis of all patients undergoing an emergency appendicectomy or cholecystectomy between December 2021 – February 2022. Questionnaires were given to patients post-operatively to assess their understanding on all operative domains. A PIL was designed and approved by the Trust’s Communications-Team, published online via Trust Extranet and distributed onto surgical wards with staff education. A re-audit was completed between April-June 2022.

Results

0% (0/14) of patients were offered written information at baseline, despite 86% reporting PILs would have been useful. PIL compliance rose substantially to 80% (12/15) in our re-audit. Implementation of a PIL led to greater understanding of the operative complications and the recovery-period, as well as an overall improved hospital experience.

Conclusions

This project indicates that provision of written information is poor despite it being highly valued by patients. Implementation of PIL for emergency operations led to greater patient understanding and hospital experience, thus improved compliance to National guidelines. However, continued education of staff is essential to embed good practice over the long term.
899 Administration of Fascia-Iliaca Blocks for Hip Fracture Patients on Admission to the A&E Department at Southport DGH
Authors: Moss M , Sha S , Sangani C , Gledhill P
Published: August 2023

Aim

Fascia-iliaca block (FIB) is regional anaesthetic used in A&E for hip fractures; they’re performed under landmark guidance in Southport A&E. NICE recommend FIBs for hip fractures if PO/IV paracetamol/opiates provide insufficient relief; it’s shown to provide superior analgesia and reduce opiate consumption. RCEM state FIBs should be administered promptly in A&E by trained personnel and are a listed ACCS competency.

The audit aim was to review the number/percentage of hip fracture patients receiving FIBs, with documentation, in Southport A&E. Hip fracture patients should have documented FIBs, the standard for the audit was ≥90% patients.

Method

This audit was a retrospective analysis of the 6-week period 08/08/2022-20/09/2022 for hip fracture patients at Southport DGH. Data was collected from the National Hip Fracture Database. Patients weren’t delayed to surgery on FIB administration. Online inpatient/A&E notes and drug charts were analysed for FIB documentation.

Results

The sample included 46 patients, 8 male and 38 female. 13 had documented FIBs on admission, 33 had no documented FIB, meaning 28.2% of patients received FIBs in A&E over 6-weeks.

Conclusions

This audit shows too few hip fracture patients are receiving FIBs in Southport A&E as analgesia, with 28.2% documented compared to the desired ≥90% standard. Patients are either not receiving FIBs or not having them documented. FIB use can be improved by clinical audit, and interventions are being implemented to improve use in Southport A&E, including posters, hip fracture proforma additions, and department education.
900 Assessing the Use of GIRFT Guidelines and the Role of a Natural Language Processing Artificial Intelligence System for Operation Note Documentation in Emergency General Surgery – a Closed Loop Prospective Audit & Comparative Study
Authors: Karki B , Rossi L , Peckham Cooper A , Burke J
Published: August 2023

Aim

4.6 million NHS operation notes (ONs) are generated annually. The Getting it Right First Time (GIRFT) Initiative created procedure-specific guidelines for ON documentation. Natural Language Processing (NLP) Artificial Intelligence systems have the potential to improve documentation quality. This audit aimed to test the potential of GIRFT guidelines (P1) and a novel NLP programme against surgeons (P2) to improve ON documentation quality.

Method

P1: The five most recent, consecutive ONs from a tertiary-centre CEPOD list for Laparoscopic Appendicectomy (LA), Laparoscopic Cholecystectomy (LC), Open Inguinal Hernia (IH), Emergency Laparotomy and Small Bowel Resection (ELS) were collected, anonymised, and assessed against GIRFT guidelines by two independent reviewers. All surgeons were then educated on the four guidelines (intervention) and the audit loop was closed. P2: NLP ONs using ChatGPT (OpenAI-USA-Ver.15/12/22) were produced using five iterative response generations.

Results

P1: 40 ONs were assessed across 2200 marking points. Post-intervention, median documentation scores improved by +12.3% [p = 0.033] (LA), +0.6% [p = 0.500] (LC), +25.5% [p = 0.006] (IH) and +9.5% [p = 0.030] (ELS). The most accurate documentation was LA in cycle 2, median score 72.7% [IQR = 8.5].

P2: ChatGPT performance improved by a median of +29.7% [IQR = 9.4] between response generation 1 to 5. ChatGPT scores were inferior to cycle 2 surgeon scores: -37.4% [p = 0.006] (LA), -47.7% [p = 0.002] (LC), -39.6% [p = 0.002] (IH) and -32.3% [p = 0.006] (ELS).

Conclusions

Using GIRFT documentation guidelines can improve the quality of ON documentation. ChatGPT performed significantly worse than surgeons across four EGS procedures. However, average NLP scores improved by 1/3, by the fifth-generation response, indicating promise as a future adjunct.
901 Assessing Adherence to RCSEng Standards for Operation Notes in Patients With Neck of Femur Fractures: A Closed Loop Audit
Authors: Bull D , Cai J , Ensor D , Greenfield M , Boardman D
Published: August 2023

Aim

To determine the accuracy with which Royal College of Surgeons of England (RCSEng) standards for documenting surgical procedures were met within a defined patient group, with the goal of improving patient safety, and improving documentation for medicolegal purposes.

Method

We conducted a closed loop audit on adherence to RCSEng standards for operation notes. We calculated the percentage adherence for each measurable standard and overall note, and presented the data at a local clinical governance meeting. We implemented autotext templates for operations to improve quality of operation notes in following RCSEng standards. We collected data retrospectively after 3 months to complete the audit cycle.

Results

We included 24 patients in the first cycle and 16 patients in the second cycle. Prior to intervention, the overall percentage of measurable standards met was 69.4%, which increased to 76.4% after intervention. The five least adherent standards all improved in percentage, with the largest increase from 33.3% to 93.8%.

Conclusions

In the first cycle, 3 of the measurable standards were met 100% of the time, which increased to 4 in the second cycle. Along with the general improvement of standards met, the interventions improved patient safety and surgeon documentation. Operation notes using templates generally recorded higher percentages of standards met than those without templates, but further work is needed to ensure more standards meet the 100% ideal.
932 Provision of a 7 Day Radiology Service for Emergency Laparotomy Patients: Are We Compliant with Current Standards?
Authors: Mirtorabi N , Ikram S , Aain H , Ali D , Dilworth M
Published: August 2023

Introduction

According to “NHS services, Seven Days a week Forum”, a radiological scan should be reported within 1 hour for “critical” requests and within 12 hours for “urgent “ones. Requests are considered critical when the test will alter patient’s management at the time; and urgent if the test will alter management but not necessarily that day.

Aim

The aim was to audit whether the above standards were met for urgent and critical requests for patients undergoing emergency laparotomy.

Method

A single centre retrospective audit of adults undergoing emergency laparotomy between 01/02/2014 to 30/12/2021 was performed. Data was collected from the National Emergency Laparotomy Audit database. A total of 1748 patient records were analysed out of which 1309 were included. Patients who underwent pre-operative CT scan in the same admission were included. Patients who had CT prior to admission for laparotomy and those who had more than one operative intervention were excluded. CT time was calculated as time taken from CT examination to reporting.

Results

Standards were met for 27.5% of all investigations ordered. 0.16% of Critical, and 53% of urgent scans were reported within required times. There was no difference in standards met between weekends and weekdays.

Conclusions

Limitations include the retrospective nature of data collection and amendment time being recorded instead of original reporting time for some scans. Recommendations include allowing time frames for standards and retaining interim report times.
971 Audit of Consent Documentation for Emergency Hand Surgery in the Ambulatory Procedure Unit
Authors: Egbuji O , Zengin H , Saad M , Sheppard N
Published: August 2023

Aim

To audit the handwritten consent forms for emergency hand surgery in the unit.

Method

The notes and consent forms from a selection of 8 days were analysed (total 25). Our audit standards focused on the consenter and the completion of sections on the consent form. There are no published standards for hand surgery complications, therefore a consensus from the general consultant body was used.

Results

80% of our patients were male with a mean age of 48 (range 20 – 71). 60% were tendon repairs, 20% debridement, 20% digital nerve repairs, 12% nail-bed repairs, 12% excision of lesion, 8% terminalisation, 8% incision and drainage, 8% manipulation under anaesthesia, 4% carpal tunnel decompression and 4% plating of fracture.

68% of the consenting clinicians were Registrars, 16% Senior House Officers and 8% Consultants (8% illegible). 92% of the consenters performed the procedure. All the consenters signed and dated their signature and were trained in consenting. 88% documented their job title.

100% of clinicians used the correct consent form, documented the proposed procedure, site and risks. 92% completed the ‘intended benefits’ section, 96% wrote the procedure name in full and 88% placed a label on every page.

Every clinician documented bleeding and infection as a risk factor. 92% documented complex regional pain syndrome, 68% stiffness, 48% wound dehiscence, 40% delayed healing, 84% scarring, 36% injury to surrounding structures and 56% further procedures.

Conclusions

The quality of hand-written consent forms is user dependent. A pre-filled consent form and discussion in clinical governance is proposed to increase compliance.
987 Audit of Prophylactic Antibiotic Prescriptions in Oral and Maxillofacial Surgery and Adherence of Surgeons to Local Trust Guidelines
Authors: Al-Balah A , Bayoumi S
Published: August 2023

Aim

To investigate the adherence of Oral and Maxillofacial surgeons in a district general hospital to local trust prophylactic antibiotic guidelines. Trust antimicrobial guidelines are available freely on the MicroGuide mobile application - https://tinyurl.com/MAXFACS.

Method

A retrospective audit conducted in a district general hospital. The list of patients attending follow up clinic in November post operation was used for the patient sample in this audit. The important information was collected from the trust’s electronic patient record using a predesigned Pro forma.

Results

A total of fifty-two patients (patients with penicillin allergy; n = 2, 3.8%) were identified from the outpatient clinic list in November. 100% of patients were given prophylactic antibiotics. Types of operations performed as per the categorisation system on MicroGuide: Dentoalveolar or salivary gland surgery (complex) (n = 10, 19.2%), fractured mandible (n = 10, 19.2%), malignancy (n = 9, 17.3%), osteotomies and bone grafting (n = 6, 11.5%), upper aerodigestive (n = 6, 11.5%), dentoalveolar or salivary gland surgery (uncomplex) (n = 5, 9.6%), fractured maxilla/zygoma (n = 3, 5.8%), intracapsular TMJ joint (n = 3, 5.8%). Dentoalveolar or salivary gland surgery (uncomplex) had the highest compliance to antimicrobial guidelines (100% of patients had no antibiotics prescribed as per guidelines) followed by fractured mandible surgery with 20% compliance. The remaining types of surgery had 0% compliance with trust antimicrobial guidelines.

Conclusions

The first cycle of this audit demonstrated poor compliance with trust antimicrobial guidelines. Increasing awareness of the MicroGuide app as well as presenting the findings to the Oral & Maxillofacial surgery department could help improve adherence in the future.
1009 Improving Accuracy and Extractability of Electronic Operative Documentation Data in a Hand Trauma Unit
Authors: Cook H , Aggarwal A , Kanapathy M , Davison E , Ioannidi L
Published: August 2023

Aim

Accurate and thorough operative documentation is essential for continuity of patient care, audit purposes, and the medicolegal protection of patients and doctors. In a hand trauma department in central London, challenges to this include a fast turnover of junior doctors, busy trauma lists, and complex, multidisciplinary cases.

‘Pathpoint’ is an online system with functionality for operative note templates and pre-filled data. However, it is unclear how much this is utilised in the department.

This project aimed to evaluate operative documentation for hand trauma and the utilisation of templates for data input.

Method

All hand trauma cases performed in a one-month period were requested from Pathpoint. Operation notes were initially screened for directly extractable data in template-form then manually checked for free-text data entry using prior-agreed criteria.

Results

The initial search yielded 51 procedures.

Nerve repairs were best documented (18% data missing), terminalisation procedures were worst documented (38% data missing). Overall, only 18.3% of all data were directly extractable; 0% data were extractable for dressings, post-operative antibiotics, follow-up and movement restrictions.

Best documented topics were hand trauma findings, skin closure, and follow-up. >90% of data in each of these were freetext.

Worst documented topics were CEPOD category, ASA grade, intra-operative antibiotics, and tourniquet details.

Conclusions

Despite overall good documentation, multiple important omissions are noted. Furthermore, the majority of data is not recorded in an extractable format. Templates have been distributed within the department. Re-auditing in subsequent months will assess whether accuracy of documentation and ease of data extraction have improved.
1024 Current Adherence to Local Health Board Guidelines for Venous Thromboembolism Risk Assessment in Orthopaedic Trauma Lists
Authors: Todd-Hems A , Duguid A , Cervenak R
Published: August 2023

Aim

This audit aims to assess the current adherence to the local health board guidelines for Venous Thromboembolism (VTE) risk assessment in Orthopaedic Trauma lists.

Method

Data was collected for all patients who underwent operation on trauma lists between 1st June 2022 and 31st June 2022. Data collected included the operation type, if VTE risk assessment was completed on admission and pre-operatively. Plan post-operatively and on discharge was also noted as well as the length of VTE prophylaxis prescribed.

Results

There were 172 patients in total, 117 lower limb procedures and 55 upper limb procedures. Of these procedures 42 lower limb patients and two upper limb patients had risk assessments on admission. 110 patients with lower limb injuries received VTE prophylaxis on admission compared to eight of the non-day case upper limb. Seven lower limb patients and five upper limb did not have a VTE plan post-operatively. There was variation in length of prophylaxis prescribed post-operatively in relation to procedure and guidelines ranging from nine days to six weeks.

Conclusions

As per local health board guidelines all patients that are admitted or undergo operation as part of the Orthopaedic Department should have VTE assessment carried out. This audit concludes that approximately 25% of VTE assessments on admission are clearly documented. Despite the lack of formal assessment most patients receive VTE prophylaxis but questions whether prescription is appropriate. We also conclude that most patients have a well-documented post-operative VTE plan. Re-audit with intervention is due to end 4th January 2023.
1039 Preventing Avoidable Harm with Safe IV Fluid Therapy – a Closed Loop Audit
Authors: Hassan S W U , Alam S N , Shoaib M , Ibrahim M
Published: August 2023

Aim

The National Institute for Health and Care Excellence (NICE) states that one in five people on intravenous (IV) fluids suffer from complications or morbidity due to their inappropriate administration. We aimed to compare our Trust’s current IV fluid prescription practices to standards set out in the NICE CG174 guidelines.

Method

We retrospectively reviewed 50 case notes for patients admitted to the Acute Medical Unit. We evaluated if hydration status was assessed comprehensively, and if resuscitation and maintenance fluids were prescribed appropriately, according to the NICE CG174 guidelines. The findings were presented at a local meeting and interventions were implemented by putting up posters and conducting regular teaching sessions on safe IV fluid prescription. To close the audit loop, data from a further 50 patients was collected post-intervention.

Results

The first audit cycle showed poor overall compliance with the guidelines; however a significant improvement was noted post-intervention. Pre-intervention, only 10% of patients had regular hydration assessments, 32% of patients received fluid resuscitation appropriately, and while 52% of our sample received maintenance fluid when indicated, 0% received the correct composition. Post-intervention, these figures rose to 28%, 66%, 84% and 15% respectively.

Conclusions

Inappropriate fluid administration is a risk to patient safety. This audit highlighted several areas for improvement regarding IV fluid prescription, and although a significant change was noted, further work is needed to increase compliance. We hope to incorporate the topic of IV fluids into the hospital’s regular teaching programmes to sustainably improve IV fluid prescription practices across the Trust.
1041 Audit of Enhanced Recovery After Surgery (ERAS) Protocol in Elective Colorectal Surgery (A Loop Audit)
Authors: Akhtar M A B , Zeeshan S
Published: August 2023

Aim

Audit of current adherence to the ERAS guidelines for all elective colorectal surgical procedures in our hospital.

Comparison was made with first audit which was done in 2018 and subsequently improvement was done in second loop in 2019.

Method

Retrospective review of all elective patient’s admitted for Colorectal surgery between January 1st 2019 – December 31st 2019. Inclusion Criteria: All elective colorectal surgeries including right hemicolectomy, extended right hemicolectomy, left hemicolectomy, anterior resection, and abdominoperineal resections. All colorectal surgeries after either adjuvant or neoadjuvant chemotherapy or radiotherapy 37 patients were identified for the audit. Every component of Enhanced recovery after surgery (ERAS) was carefully noted in patient's records. All the data was collected and collaborated manually in excel sheet. The data was then presented in graphical manner. Exclusion Criteria:Emergency colorectal procedures.

Results

Audit in 2018:Percentage adherence:Pre-admission – 59.2%Pre-operative – 73.9%Intra-operative – 70.1%Post-operative – 52.7%No ERAS Anaesthetic component was includedOverall Adherence to guidelines – 63.9%Mean Length of Stay – 9.8 days

Loop Audit in 2019:Percentage adherence:Pre-admission – 88 %Pre-operative – 80.25%Intra-operative – 76.8%Post-operative – 79.6%All ERAS Anaesthetic components includedOverall Adherence to guidelines – 81.1%Mean Length of Stay –7.1 days

Conclusions

Very Good compliance to ERAS. Improved as compared to previous audit.
1045 A 6-Year Cohort Study Assessing Outcomes Following Calf Fasciotomies at a Single Tertiary Vascular Trauma Centre
Authors: Gnanasundaram A , Laloo R , Bailey M , Scott J
Published: August 2023

Background

Acute compartment syndrome (ACS) is a surgical emergency.Delayed diagnosis and fasciotomy can result in irreversible muscle necrosis causing permanent disability and major amputation.This study compared outcomes following prophylactic (Group1) versus therapeutic calf fasciotomies (Group2), as well as early (within 6 hours) versus delayed fasciotomies (>6 hours) at a single tertiary vascular trauma centre.

Method

All patients undergoing calf fasciotomies between 1st January 2017 and 31st November 2022 were identified from a prospectively collected vascular departmental database.The primary outcomes included foot drop, amputation and mortality while infection, wound debridement,neuropathic pain and negative-pressure dressing were secondary outcomes.Statistical analysis with SPSS was performed using Fisher’s exact test.

Results

88 patients (65 men, 23 women) of median age (IQR) 67 (56-74) underwent calf fasciotomies.Of these, 43 (48.9%) were therapeutic (Median age = 62) and 45 (51.1%) were prophylactic (Median age = 67).Ischaemia was more prevalent among Group1 while trauma among Group2.There were no significant differences among outcomes between both groups apart from higher 30-day mortality rate (26.7% vs. 7.0%, p = 0.014)and incidence of neuropathic pain (22.2% vs. 4.7%, p = 0.027)in Group1 versus Group2.Most patients (79.5%) underwent early calf fasciotomy with no significant differences in primary and secondary outcomes between early and delayed fasciotomy groups.The delay was attributed to theatre unavailability (n = 6) and on-going resuscitation (n = 5) .

Conclusions

Higher rates of neuropathic pain and 30-day mortality in group1 may be attributed to co-existing lower limb ischaemia.Further work is required to establish the impact of neuropathic pain.Pathways should be developed to ensure rapid access to theatres for patients with suspected ACS.
1054 The Use of Tranexamic Acid in the Wythenshawe Plastic Surgery Department
Authors: Reid G , Bedford J
Published: August 2023

Aim

This audit aimed to benchmark current practice of the use of tranexamic acid (TXA) in the Wythenshawe plastic surgery department against the recent recommendations from the Joint Royal Colleges Tranexamic Acid in Surgery Implementation Group. The new guidance recommends that one gram of TXA should be given intravenously at the start and end of all inpatient surgery. TXA is routinely given in the plastic surgery department and is protocol for all the breast reconstructive surgeries however current practice is to administer this only at the start of the operation.

Method

30 general anaesthetic operations were reviewed retrospectively. The inclusion criteria were as follows: age >18 years old and must be admitted to hospital (at least 1 overnight stay).

Results

The first cycle demonstrated a 0% compliance. Following the intervention of all consultants being made aware of the new recommendations the second audit cycle demonstrated that a 13% compliance was achieved. It was noted that all breast reconstructions received the new recommended dosage regime however uptake amongst the other subspecialties was variable.

Conclusions

Simple education had a significant impact on increasing compliance. Further education amongst all junior doctors has been given to try and further increase uptake of this new guidance.
1094 Pre-Operative Prescribing Practices for Patients Undergoing Emergency General Surgical Operations
Authors: Nair K , Gill M , Sri-Pathmanathan C , Balasubramaniam D
Published: August 2023

Aim

To identify if pre-operative prescribing has improved over time within the general surgery department as identified within the NCEPOD 2002 report on pre-operative drug treatment. This multi-cycle audit aims to achieve 100% compliance when administering essential drugs and omitting certain drug classes.

Method

Data for the current cycle of this audit was collected retrospectively. The drug charts of 131 patients who had an emergency general surgical operation in CEPOD theatre between August and October 2022 were analysed. The drug classes to be collected were based on the NCEPOD 2002 report, local trust and European anaesthesiology/cardiology guidelines. The data was compared to previous cycles collected over multiple years.

Results

For a total of 236 essential drug classes prescribed, 181 were given pre-operatively (76.7%). Compared with previous cycles, results have improved (67% in 2021, 68% in 2018 and 56% in 2015). A frequent reason charted for holding essential medications was “nil by mouth”. Of the 9 medications that should have been withheld on the day of surgery, 7 were held appropriately (77.8%), which was similar to previous results (78% in 2021, 50% in 2018, 75% in 2015).

Conclusions

Although the results have shown improvement over time, there is still a significant proportion of patients who are not receiving essential medications pre-operatively. There also remains ongoing misconceptions about what “nil by mouth” means and how this impacts medication administration. More education is required for both doctors and nursing teams with information on which drug classes should still be given pre-operatively and which should be omitted.
1120 Time to Revascularisation for Chronic Limb Threatening Ischaemia – Audit of a Major UK Vascular Service
Authors: Shea J , Ko I , Onida S , Boyce R , Mohamed A , Shalhoub J
Published: August 2023

Aim

Chronic Limb Threatening Ischaemia (CLTI) is severe peripheral arterial disease where arterial supply is sufficiently compromised to threaten tissue viability. CLTI has a prevalence of 1-2% and carries significant morbidity and mortality. Early revascularisation is essential for tissue preservation. Recent guidance from CQUIN 2022/23 set national targets for time to revascularisation based on VSGBI guidelines. This audit assessed one major vascular centre’s compliance.

Method

Audit standards were taken from VSGBI Peripheral Arterial Disease Quality Improvement Framework (PAD-QIF 2019). Data from Imperial College Healthcare NHS Trust was collected from February-April 2022 for inpatients and outpatients presenting with new CLTI. The primary outcome was time to revascularisation from referral. Secondary inpatient outcomes included time to referral, specialist reviews, imaging and discussion at MDT.

Results

59 inpatients and 33 outpatients were included. 54% of inpatients and 83% of outpatients who were candidates for revascularisation breached targets: 5 days and 14 days respectively. Of those breaching most inpatients were re-vascularised within 6-10 days; whilst for outpatients the majority were re-vascularised within 46-75 days. At the time of data collection 7 outpatients were awaiting revascularisation, all >5 months since CLTI onset.

Conclusions

A significant portion of patients are breaching revascularisation targets, increasing risk of poor outcomes. In both pathways delays are multi-factorial. Contributing factors for inpatients include delays in pre-surgery optimisation and bed/theatre slot pressures. For outpatients’ pre-assessment, surgical optimisation, MDT discussion and/or investigations all contribute to delays. Implementation of early anaesthetic optimisation or outpatient one-stop clinics could be considered.
1121 Evaluating the Practice and Post-Procedural Outcomes of Endoscopic Retrograde Cholangiopancreatography in United Lincolnshire Hospitals Trust in 2019
Authors: Marei O , Shenbagaraj L , Sivanesan N , Vojtekova K , Keralia S , Kanade C , Pervaiz F , Morra M , Andrew D , Perry M , Babu S
Published: August 2023

Aim

To evaluate the performance of ERCPs within our trust through exploring the rates of post-procedural complications and outcomes.

Method

Data was collected from multiple databases including EndoWeb, which had all the reports of ERCPs performed, including indications, diagnosis and whether there were any complications during the procedure. We used WebV to look at post-procedural blood results and any tests from readmission that could be consistent with a complication. We also used CarePortal to look at clinic and discharge letters post-ERCP to identify whether readmission was necessary. The data collected was entered in an Excel Spreadsheet and analysis was performed in Microsoft Excel.

Results

We collected data for 248 ERCP procedures and there were 37 patients with repeat ERCPs in the same year. The most common indications were gallstones (34%) and jaundice with dilated ducts (36%). 81% ERCPs were successful, diagnostically and therapeutically and the complication rate was 6% with acute pancreatitis and bleeding being the most common complications. Finally, we noted a 30-day mortality rate of 2.8% but none of the deaths were related to ERCPs and were mostly due to co-morbidities.

Conclusions

The British Society of Gastroenterologists published a standards framework in 2014 concluding that the UK requires a national system to check ERCP practice similar to that of the US, the ERCP Quality Framework. Our post-ERCP pancreatitis rate is within the standards set by the BSG. This audit is a step in developing a national standardising system, however, there is a requirement of 100% engagement from all centres within the UK.
1129 LaCON: A Quality Improvement Project on Laparoscopic Cholecystectomy Operation Notes
Authors: Kapsampelis P , Prce D , Saunders J , Bezzaa S , Gerogiannis I
Published: August 2023

Aim

Accurate and comprehensive operation notes are crucial for patient care, quality assurance and medico-legal purposes. Laparoscopic cholecystectomy (LC) is one of the most common procedures in General Surgery, either in an Elective or Emergency setting. Therefore, there is a need for an accurate and standard way to document the operation notes for a safe immediate and late post-operative care, including follow-up. The LaCON project aims to evaluate and improve the quality of the operation notes.

Method

A retrospective review of operation notes of LCs performed at our institution between August-November 2022. Electronic notes were assessed against the Royal College of Surgeons’ Good Surgical Practice standard, consisting of 18 items.

Results

A total of 80 operation notes were reviewed. There was 100% compliance in surgeon’s name, operation procedure, incision, port sites, and closure technique. Other high-scoring items were indication (98%), operative findings (98%), operation date (91%) and assistant’s name (90%). Among the lowest-scoring items were detailed postoperative instructions (46%), designation as elective or emergency (38%), operative diagnosis (16%) and estimated blood loss (EBL) (8%).

Conclusions

We identified several areas for improvement in LC operation notes, such as a detailed and robust post-operative plan, a precise intraoperative diagnosis and information about EBL. The LaCON project highlighted the need to implement an electronic evidence-based proforma to standardise notes. This proforma will be accessible through a secure online app, in line with the local Hospital policies, and will allow accurate and contemporaneous record keeping and efficient extraction of operative data for analysis.