bluuebunny/crossref_metadata_2025 huggingface dataset:
50 Ward Round Documentation in Vascular Surgery – a Closed Loop Audit Cycle
Authors: White A. , Hyde-Baker C. , Elahwal M. , Caruana M.
Published: February 2022

Introduction

Ward Rounds are a fundamental part of multidisciplinary team assessment, planning patient care and co-ordinating management decisions. Accurate documentation of patient assessment, relevant history and investigations, discussions with the patient and decisions made is crucial for continuity of patient care, medico-legally and overall patient safety. Despite the variety of record-keeping methods used throughout the NHS, it remains imperative that documentation remains accurate, contemporaneous, and can be used as a reliable source of reference throughout the patient’s journey.

Method

We used Royal College of Physician’s Ward Round Audit Standard 2015, with Cycle 1 of data collection from 17/5/21-23/5/21, followed by introducing interventions from 24/5/21-30/6/21. Interventions consisted of a Ward Round Proforma, displayed in each set of patient notes and communal ward areas. We completed Cycle 2 (31/5/21-6/6/21) using the same standard following which our results were analysed both individually and in respect to each other.

Results

Overall documentation improved by 14% across all domains from 67% to 81% following our interventions, in the 230 entries analysed (109 Cycle 2, 121 Cycle 2). Key areas included: Patient identification improving 25%, from 68% to 93%; Operation name and date improving 28% and 24% respectively and documentation of abnormal observations improving by 48%. Antibiotics and Thromboprophylaxis improved by 25% and 30% respectively, however remained under 50% in Cycle 2.

Conclusions

We conclude that simple, cost-effective interventions such as proformas & memory aids can significantly improve the documentation of ward rounds, thereby leading to improved patient care and safety and cohesive patient management throughout the multidisciplinary team.
51 Restructuring of the UK Vascular Services: Does the Hub and Spoke Model Affect Patient Mortality in Ruptured AAAs?
Authors: Nyamedom-Bonsi T. , O’Malley O. , Abbud N. , Safar M.
Published: February 2022

Aim

Ruptured Abdominal Aortic aneurysms (rAAA) are a fatal vascular condition. In 2018, The Get It Right First Time Programme (GRIFT) recommended the restructuring of vascular services in England to a Hub and Spoke model where AAA repairs should be performed in higher volume centres, the hub sites. This study aims to assess the mortality rates in patients presenting at hub versus spoke sites in the Merseyside region.

Method

We conducted a retrospective review, 1st January 2017 to 31st December 2020, recognising 110 patients with a rAAA presenting to hub and spoke sites in the Merseyside Region. We determined if there was any association in mortality and the presenting site. We also assessed the mean time to theatre for both Hub and Spoke patients.

Results

41 patients presented to Hub site and 69 patients to the spoke sites. 81% underwent operative intervention and 19% died in A+E or were palliated. 57% of those who underwent an intervention survived. Overall mortality rate in hospital was 53% (58 patients). There was no association between mortality and transfer from a spoke site (p = 0.58). The median time to theatre for Hub patients was 160 minutes from presentation and 315 minutes from Spoke sites. Time to theatre had no overall effect on mortality (p = 0.1)

Conclusions

This study indicates that the GRIFT programme does not have a negative effect on mortality irrespective of time taken to theatre. Therefore, transferring patients to a specialist hub site will positively influence patient outcomes.
55 Laparoscopic Cholecystectomy Consent Form Analysis Audit
Authors: Manson D. , McKnight G. , Alessandri G. , O’Reilly D.
Published: February 2022

Aim

To assess consent forms in the new urgent laparoscopic cholecystectomy theatre (ESAC) list in the University Hospital of Wales. With procedure-specific consent forms becoming more regularly utilised, we assess the need for them in our Trust.

Method

We prospectively assessed the consent forms of the first 20 patients who were enrolled in ESAC. We measured the complications list against national standards to assess completeness, including any use of abbreviations and the overall legibility. To complete our assessment and for posterity, we called each patient and gave them an official questionnaire to ensure their understanding before, during and after surgery.

Results

We found that of the complications included in the ESAC consent forms, there was a high degree of variability. For example, 75% contained ‘bile leak’ and 55% ‘post-cholecystectomy syndrome’; both named examples in national guidelines. Additionally, while the vast majority were legible, 50% of the consent forms utilised abbreviations in their written sections. Lastly, patient understanding surrounding the details of the operation was sound, with the majority correctly identifying their surgery, what it entailed and what they were expected to do post-operatively. However, just over half were able to provide a moderately detailed list of the associated complications that may have occurred.

Conclusions

That the trust would benefit from a procedure-specific consent form (PSCF) to provide exhaustive information on procedure details, complications, and their rates, as well as mortality rates. Additionally, this would eliminate issues of legibility and usage of abbreviations. We anticipate that it will also improve patient understanding.
60 Neoadjuvant Imatinib Mesylate – an Ace of Spaces for Surgical Management of an Oesophago-Gastric Junction Gastro-Intestinal Stromal Tumour
Authors: Arora A. , Arkle T. , Sreedharan L. , Kumar B.
Published: February 2022

Introduction

Oesophageal gastro-intestinal stromal tumours (GISTs) are rare, accounting for less than five percent of all GIST, with the majority of these occurring at the oesophago-gastric junction (OGJ). Due to the anatomical location and size of these tumours at presentation, surgical resection is often a major undertaking.

Neoadjuvant treatment with tyrosine kinase inhibitors, such as Imatinib mesylate, have the potential to downstage such tumours, thereby limiting the extent of subsequent surgical resection. This may therefore reduce any potentially associated morbidity and mortality.

Case Description

We report the case of a 75-year-old gentleman who presented with a large OGJ GIST, which presented with dysphagia. The tumour was deemed too large for local excision due to the risk of compromising the lumen at the OGJ in attempting to obtain a clear resection margin. Given the patient’s co-morbidity, oesophagectomy or total gastrectomy was deemed too major an undertaking. Therefore, endoscopic biopsies were obtained with a view to possible neoadjuvant therapy. These confirmed DOG-1 and Exon-11 mutations, suggesting sensitivity to Imatinib mesylate. A standard dose regime of 400mg daily for a planned 36-month course was commenced. Subsequent imaging showed a substantial decrease in tumour bulk and the decision was made to perform a local excision. A local enucleation procedure was performed, and the patient made a sound recovery.

Post-operative histology of resected tumour showed almost complete tumour regression.

Discussion

This significant response to neoadjuvant Imatinib mesylate therapy demonstrates clear potential for its use in similar cases, where radical resection would cause significant morbidity and risk mortality.
72 Transperineal Prostate Biopsies: Has the Change in Technique Been Effective?
Authors: Horn C. , Fordyce W. , Daggamseh A.
Published: February 2022

Aim

In March 2020 Derriford Hospital Urology Department changed its technique for biopsying prostates, going from a transrectal (TR) approach to a transperineal (TP) one. This method is now used for initial biopsies as well as when taking template biopsies. Our aim was to demonstrate whether either technique was more effective at diagnosing cancer, with a secondary aim of ensuring we were selecting the right patients to undergo template prostate biopsies after initially inconclusive results.

Method

We obtained a list of all patients who had undergone procedures coded under General Anaesthetic Prostate Biopsies between March 2019 and March 2021. We discounted patients who appeared on this list as they could not tolerate biopsies under local anaesthetic. We looked at initial biopsy technique and initial histology results, as well as number of template biopsies taken, histology results and subsequent management.

Results

Our sample size was small with 26 patients in total, with an even split between the 2 techniques, with 13 patients in each group. Following template biopsies, 15 patients were diagnosed with prostate cancer. 11 of these 15 patients had undergone TR biopsies initially. As a result, the management for all these patients changed. Incidentally we did also note that there was a wide variation in the amount of template biopsies taken.

Conclusions

It appears that TP biopsies are more effective than TR biopsies at not missing cancer. It also appears that the Derriford MDT has been selecting the correct patients to undergo further template biopsies.
73 Computed Tomography Imaging to Determine Reduction in Intracrainal Pressure Before & After Posterior Vault Expansion in Apert Syndrome
Authors: Khera B. , van de Lande L. , Sidpra J. , Knoops P. , Borghi A. , Ong J. , James G. , Hayward R. , Schievano S. , Mankad K. , Dunaway D. , Jeelani N.u.O. , Breakey W.
Published: February 2022

Introduction

Apert syndrome is an autosomal dominant malformation syndrome, accounting for 4.5% of all craniosynostoses. Raised intracranial pressure (ICP) in Apert syndrome has a multifactorial aetiology, with an incidence of up to 45% if left untreated [1, 2]. Raised ICP can be determined clinically, with non-invasive and invasive methods. In this study, we want to assess whether the use of CT scans is reliable in identifying changes in ICP.

Method

Pre and postoperative CT scans for 13 Apert syndrome patients who had posterior vault expansion were assessed and graded for severity of intracranial pressure (ICP). The grading system used was departmental specific and the assessment was carried out by a single clinician on different brain structures. This process was repeated on the same patients, using the same CT scans, 4 months later to determine consistency and repeatability. The relationship between the pre and postoperative scans was explored using the chi squared test. Intra-observer variability was assessed using Kappa statistics [SS1].

Results

There was no statistically significant difference between the pre and postoperative CT scan grading. Across instances, only one assessed structure had a p-value <0.05. The Kappa interobserver reliability test did not identify a strong agreement in the comparison of the two instances of data analysis.

Conclusions

Assessment of CT scans is not a reliable method to determine changes in intracranial pressure in Apert syndrome patients who have had a posterior vault expansion.
78 Hand Injury and K – Wire Related Infection Rates in the Plastic Surgery Department – Closed Cycle Audit
Authors: Kandil M. , Abdul Z. , De La Cruz Monroy M. , Abdelaty M. , Shariff Z.
Published: February 2022

Aim

To identify the rate of K-wire infection in hand injuries and ascertain compliance with NICE guidelines on antibiotic prophylaxis and surgical skin preparation.

Method

Retrospective audit/service evaluation – EPR Operations first cycle (August – December 2019), and the second cycle (August – November 2020). Included all cases (adult and paediatric) of hand injuries managed with K – wire fixation – Plastic Surgery Trauma theatre lists.

Results

After the first cycle recommendations, the infection rates fell from 15 % to 11 %.

Conclusions

Infection rates were lower in the group of patients who had antibiotics on induction and on discharge.
79 Yellow Nail Syndrome Management with Nail Ablation and Reconstruction with a Full-Thickness Skin Graft
Authors: Kandil M. , Rahman S. , Abdul Z. , Abelaty M.
Published: February 2022

Aim

Yellow nail syndrome is a very rare and complex syndrome associated with aberrant nail growth multiple digits, in this case, the report we offer this as a solution to a challenging and rare condition.

Method

A 56-year-old lady underwent nail ablation and reconstruction with a full-thickness skin graft (FTSG).

Results

The patient had good cosmetic results.

Conclusions

Yellow nail syndrome is a rare but complex condition that is not yet fully understood. Nail plate deformity and discoloration are on the way the disease can manifest itself. Although not often encountered by plastic surgeons; The role of surgical excision for patients affected by dystrophic nails in yellow nail syndrome was given more emphasis within the literature. It is an effective technique that can be adapted as a standardized treatment modality
80 “To Freeze or Not to Freeze, That Is the Question”: A Case of Septic Arthritis in a Finger Resulting from Cryotherapy for Warts
Authors: Kandil M. , Sarwar U. , Abdul Z. , Shariff Z. , Abdulaty M.
Published: February 2022

Aim

Cryotherapy is a common treatment for a variety of skin conditions; however, it has to be performed with care due to the risks of inadvertent tissue damage including burns, damage to healthy tissue, and scarring. We report on the first case of septic arthritis developing post cryotherapy to a digit.

Method

A 57yr-old female retired podiatrist who five days prior received cryotherapy, by a Dermatologist, for a long standing presumed viral wart on the dorsum of her hand.

Results

septic arthritis to the distal interphalangeal joint.

Conclusions

-The delicate skin and tissues over the dorsum of the fingers and hand can result in significant trauma. Care must be exercised in these areas to prevent full-thickness wounds that involve the joint and result in septic arthritis and functional disability.
82 Timely Prescribing of Regular Medications in General Surgery
Authors: Barter R. , Harrison B.
Published: February 2022

Aim

It’s crucial that regular medications are prescribed in a timely manner for hospital inpatients. Missed or delayed doses of critical medications (insulin, anti-parkinsonian medication, antiepileptics and steroids) can compromise patient safety. This audit, with two closed-loop cycles, aimed to improve prescribing on surgical wards.

Method

Data was gathered from >48 adult non-elective general surgery patients pre- and post-intervention with four outcomes measured, listed in results. Data was re-collected after one month and the cycle repeated one year later.

Interventions:

Results

Average time for prescribing regular medications improved from 13hrs to 11.2hrs in the first cycle and 22.5hrs to 13.1hrs in the second cycle.

Percentage of patients with critical medications prescribed on admission improved by 50% in the first cycle and remained at 100% pre- and post-intervention in the second cycle.

Percentage of patients who missed medication due to delayed prescribing reduced by 11% in the first cycle and 16% in the second cycle.

Percentage of patients who had regular medications prescribed before pharmacy medicines reconciliation improved by 9% in the first cycle and 28% in the second cycle.

Conclusions

In both cycles, all measurements experienced improvements. Largest improvements were in the 2nd cycle with the addition of educational posters. SCR access improves ability to prescribe regular medications. Educational posters act as effective visual aids. Both can be recommended.
85 A Closed Loop Audit of Consent for Trauma and Orthopaedic Surgery in the COVID-19 Pandemic
Authors: Goh J.Y. , Neary C. , Razii N. , Little K. , Leach W.
Published: February 2022

Aim

Surgical patients with perioperative SARS-CoV-2 infection have increased risks of morbidity and mortality. The primary aim was to audit the inclusion of COVID-19 as a specified risk on trauma and orthopaedic consent forms. The secondary aim was to calculate the indicative risk of acquiring COVID-19 in the perioperative period.

Method

Case notes were reviewed for 193 patients, including 160 consent forms, over one-week data collection periods in February 2021 and April 2021, at a Major Trauma Centre. Following the initial audit, data were presented at a departmental governance meeting and an infographic was disseminated to all clinicians. 33 patients, comprising 24 Adults with Incapacity (AWI) and 9 others who had been consented prior to departmental guidance, were excluded from the primary analysis but included in the secondary analysis, where all SARS-CoV-2 RT-PCR test results up to 2 weeks postoperatively were reviewed.

Results

In the initial audit period, 91 patients underwent surgery (79 consent forms), whilst 100 patients underwent surgery in the re-audit period (81 consent forms). Following our intervention, 70% of patients had COVID-19 specified as a risk on the consent form, representing a statistically significant improvement from 49% in the previous cycle (p = 0.007). During the initial audit, 2 patients tested positive for COVID-19 postoperatively, whilst there were no positive tests during the re-audit.

Conclusions

The consent process for the risk of perioperative COVID-19 significantly improved following our intervention. The indicative risk of acquiring perioperative COVID-19 reduced from 2.15% to less than 1%, which likely reflects the impact of the vaccination programme.
86 Adherence to Best Practice Tariffs (BPT) for Neck of Femur (NOF) Fracture Admissions During the COVID-19 Pandemic
Authors: Basha A. , Singh A. , Barmpagianni C.
Published: February 2022

Introduction

For patients with fragility hip fractures, care needs to be promptly organised to undertake a holistic assessment and preparation for surgery. The aim of the Best Practice Tariffs (BPT) is to promote hip fracture programmes that provide best practice in the care and secondary prevention of fragility fractures.

Method

Results

Conclusions
88 Blood Cultures on a Cardiothoracic Surgery Ward- a Quality Improvement Project
Authors: Brown J. , Zamvar V.
Published: February 2022

Aim

Blood cultures are an important practice when patients spike temperatures, allowing treatment to be targeted and rationalised. However, often it is missed or forgotten about when a patient is unwell. The aims of this project were: to look at the rate of blood cultures being taken after patient’s spiked temperatures and to try and improve on these rates with education.

Method

All patients on the ward had their observation charts examined. Any patient with a temperature of 38 degrees or more was noted down and seen whether blood cultures had been taken. Nurse led education then occurred between each cycle of data collection. Three cycles of data of 10 patients were collected.

Results

In the first cycle only 20% of patients had blood cultures taken. After nurse led education, this improved to 30% of patients. A crib sheet on when/why blood cultures should be taken was then distributed to nursing staff on the ward. The final cycle of results showed an improvement to 60% of patients having blood cultures taken.

Conclusions

Educating ward staff on when blood cultures should/shouldn’t be taken and why has led to a significant improvement on the proportion of pyrexic patients having blood cultures taken on the ward. However, there is still room for improvement and future work should be done to continue to improve compliance rates on the ward.
89 Covid-19 and the Impact on Oncological General Surgery at a District General Hospital
Authors: Brown J. , Dick L. , Berlansky M.
Published: February 2022

Introduction

Covid-19 has had a significant impact on all aspects of healthcare. We aimed to characterise our experience of oncological general surgery during the first 4-months of the pandemic and compare with the same period in 2019.

Method

A prospective cohort study was performed from 23/03/20 to 08/07/20. All elective oncological operations were included. Data on patient demographics, waiting times, inpatient characteristics and oncological outcomes were recorded. Statistical analysis was used to compare with retrospective data from 2019.

Results

78 patients were included in total, 38 in 2019 and 40 in 2020. There were no differences in length of stay (2.5 vs 3.5 days, p = 0.355) or waiting list time (27.2 vs 24.2 days, p = 0.574).

Oncological outcomes were comparable with no statistical difference in clear resection margin status (94.4 vs 84.6%, p = 0.168) or positive nodal status (24.1 vs 37.1%, p = 0.298).

The percentage of staging CT scans requested externally was higher in 2020 (4 vs 32%, p = <0.05).

There was no difference in time from urgent referral to first assessment (30.5 vs 26.4 days, p = 0.384) or time to operation (96.6 vs 85.7 days, p = 0.618).

Conclusions

Oncological surgery during Covid-19 can be performed safely with favourable oncological outcomes. The longer-term effects from delayed diagnoses remain to be evaluated.
96 Adult Nasal Chondromesenchymal Hamartoma: A Rare and Benign Tumour with Aggressive Malignant Transformation
Authors: Collins R. , Lafford G. , Meghji S. , Burrows S.
Published: February 2022

Nasal chondromesenchymal hamartoma (NCMH) is an extremely rare benign tumour of the nasal cavity predominantly described in infants. To date, a total of 59 cases have been described. We report a case involving a 48-year-old female who had been diagnosed with NCMH a year earlier and now represented with a short history of progressive nasal blockage, recurrent epistaxis, and orbital apex syndrome.

Histopathology was suggestive of malignant transformation into sinonasal sarcoma. However, following multi-disciplinary team (MDT) discussions including a second and third opinion from external departments, the histological diagnosis was revised to ‘NCMH with bizarre stromal cells. Despite this, clinically the lesion demonstrated malignant features with rapid, invasive growth and was treated with palliative radiotherapy. The patient later developed radiological signs of lung and liver metastases and subsequent pulmonary emboli. Shortly after this she passed away. This case is unique in its diagnostic challenge, with ambiguous histopathological findings, and highlights the importance of an MDT approach when managing complex sinonasal tumours.
97 Paralysis From an Ear Infection: A Severe Case of Otitis Externa Leading to Acute Complete Cervical Cord Syndrome
Authors: Collins R. , Lafford G.
Published: February 2022

We report a case of a generally fit and well 54-year-old gentleman who presented with a two-day history of worsening left sided ottorhea, headache, neck stiffness, vomiting and pyrexia on the background of a seven-week history of OE. His condition progressed dramatically as he developed symptoms consistent with acute complete cervical cord syndrome with radiological evidence of skull base osteomyelitis, parapharyngeal, retropharyngeal and paravertebral abscesses and sigmoid sinus thrombus. Ultimately, he made a significant, although not complete, recovery.

This case is unique in demonstrating how OE can develop into a potentially life-threatening condition. It emphasises the importance of early diagnosis and treatment of OE, the recognition of ‘red flag’ symptoms and highlights the importance of a multi-disciplinary team (MDT) approach when managing complex complications of OE.
98 Developing Minor Operation Services in Plastic Surgery to Reduce Theatre Burden and Improve Time to Surgery
Authors: Peberdy D.
Published: February 2022

Aim

The primary aim was to assess safety of a single centre minor operations service run by plastic surgery over the course of one year with data collected for over 100 procedures.

Method

Data was prospectively gathered using our electronic trauma database to record date of referral, date of procedure, and type of procedure. Complications were checked for 6 weeks post procedure by review of patient notes. Comparison of time to surgery and complication rate were made using similar cases performed in dedicated theatres in the same time period.

Results

We found that 6 weeks post procedure complication rates were less than 5%. In addition to this we found that the minor operations service significantly reduced the burden on plastics trauma lists as well as reducing the time to surgery when compared to the same types of procedures listed in our main theatres.

Conclusions

Our data shows that the minor operation service is a safe way to increase the trauma capacity of plastic surgery units. We feel a minor operation service is an integral part of an efficient plastic surgery department with better patient service and reduced costs.
103 Antibiotics Prescription Pattern and Resistance Profile of Common Isolates at Soba University Hospital, Sudan 2018
Authors: Mohammed O.A.A. , Ahmed F.A. , Koko A.I. , Mohamed M.E.A. , Abdelaziz H.A.M. , Elhag R.Y.
Published: February 2022

Aim

Antimicrobial resistance is an increasingly global public health threat. Antimicrobial stewardship programs have been introduced to tackle this problem. In this study we aim to determine the pattern of antibiotics prescription and resistance profile of common bacterial isolates at Soba university hospital, Sudan.

Method

A retrospective cross-sectional study that was conducted at the medicine and surgery wards in a tertiary care hospital. Records of all patients who were admitted during the study period were included. A pretested data collection form was used to collect information.

Results

Records of 269 patients were reviewed, the most frequently reported diagnosis on admission was cerebrovascular accidents (10.6%). The mean duration of hospital stay was 6.6 ± 6 days. Almost 81.8% of admitted patients received antibiotics with No documented indication in about 40.5% of them. Most antibiotics were administered intravenously (82.1%). More than one-third of the prescribed antibiotics (38%) were 3rd generation cephalosporin (38%). The main reason for stopping antibiotics was the patients’ discharge (63.6%). Of patients receiving antibiotics, only 5 (1.9%) had undergone culture. A total of 100 cultures were performed during the study time. Most of them were urine cultures (64%). Escherichia coli was isolated from 14 (29.2%) cultures. Resistance percentage was highest for erythromycin, and oxacillin (100% for both).

Conclusions

The study shows a trend of antibiotic misuse. Most patients received antibiotics without documented indication. Antibiotics sensitivity results showed high levels of resistance among isolated organisms. We recommend a wider study and formulation and implementation of clear guidelines to regulate antibiotic use.
104 The Assessment of the Clinical Frailty Scale in Emergency Department (Quality Improvement Project)
Authors: Aung M. , Khalil A. , Abdelaal M.
Published: February 2022

Aim

To enforce clinicians to use clinical frailty scale (CFS) in the elderly population which can guide the management pathway i.e., suitable for ITU admission or surgical intervention

Method

As part of the QIP, an audit was carried out which looked at two criteria:

The above criteria are based on NICE guidelines NG191 and the specialized Clinical Frailty Network website.

The inclusion criteria are patients older than 80 years of age. The first cycle looks at 50 randomized patients presented to A&E in July 2021, followed by the implementation of change. The target for all criteria is 75%. The second cycle looks at 50 randomized patients presented to A&E in August 2021.

Results

Initial audit data suggests the following:

Crit 1: 40%

Crit 2: 2%

This suggests we are performing less than the national standard. Therefore, an implementation that involves a change in a software system, poster and teaching session was done. This approach improves our performance immensely.

Crit 1: 100% (now mandatory due to software system i.e., sustainable change)

Crit 2: 40%

The third cycle was currently underway with a plan to undertake CFS awareness month.

Conclusions

This QIP helps not only the emergency team but also admission teams particularly ITU and surgical speciality to reach the management decision for the elderly population.
106 Laparoscopic Cholecystectomy Following an Episode of Cholecystitis: Are We Meeting the NICE Guidance?
Authors: Singh P. , Pufal K. , Robinson S.J.
Published: February 2022

Aim

On average, acute cholecystitis is responsible for 3% of admissions to emergency general surgery wards. NICE Guideline [QS104] states that adult patients admitted with acute cholecystitis should be offered a laparoscopic cholecystectomy within one week of diagnosis. This study aims to assess adherence to this guideline in a medium size district general hospital.

Method

Data was gathered retrospectively from contemporaneous electronic-based patient record system. Patients with a first case of cholecystitis within a 486-days’ time period were included; incorrect coding or repeat admissions within our time period were excluded. Data was gathered on admission length, aetiology, investigations undergone and procedure type (open vs laparoscopic). Additionally, for those that underwent a cholecystectomy, the length of time between diagnosis and operation was calculated.

Results

72 adults were admitted with acute cholecystitis in the 486-day study period. The median length of stay was 3 days. The commonest aetiology was either gallstones or unknown (47.2% of cases each), followed by bacterial infection (5.6%). 9 patients (12.5%) underwent laparoscopic cholecystectomy, and 10 (13.9%) were placed on a waiting list. The remaining 53 (73.6%) had no mention of being listed for surgery in their notes. Of those undergoing laparoscopic cholecystectomy (n = 9), none were within the recommended one-week period from time of diagnosis.

Conclusions

Over 486 days, no patients diagnosed with acute cholecystitis in our unit were being treated according to NICE guidance. We therefore recommend reinstating the hot gallbladder list at this hospital, which will enable surgeons to deliver the biliary emergency service advocated by the national guidelines.
108 Improving the Quality of General Surgery Operation Notes
Authors: Hammenga C. , Ekowo O. , Altaf K. , Nada H. , Bhardwaj R.
Published: February 2022

Introduction

As outlined in Good Surgical Practice by the Royal College of Surgeons (RCS), accurate, comprehensive, legible, contemporaneous, and preferably electronic operation notes are fundamental in maintaining effective communication, patient safety and overall quality of patient care.

Aim

To improve the quality of general surgery operation notes by increasing the documentation of the 18 key criteria recommended by the RCS, and increasing the quantity of operation notes completed electronically.

Method

Operation notes were reviewed for the documentation of the 18 key criteria. Initial audit aimed to gather baseline after which five actions aimed to increase the use of electronic notes were undertaken (including implementation of electronic operation notes proforma, presentation in the surgical morbidity and mortality meeting). Thereafter, a re-audit reviewed operation notes for the documentation of the same 18 criteria. As handwritten notes continued to be used in the re-audit, we took the initiative to also compare documentation between handwritten and electronic notes. For this purpose, 158 operation notes were randomly selected (80 handwritten, 78 electronic) and documentation of key criteria were compared.

Results

Use of electronic notes increased by 59%. There was an overall increase in documentation between the initial audit and the re-audit. On comparison of handwritten vs electronic notes, the total relative risk of not completing key criteria 0.461 (95%CI 0.417-0.509), p<0.0001.

Conclusions

The audit was successful in increasing the documentation of key criteria. When comparing handwritten vs electronic notes, the data show that electronic notes significantly reduce the risk of not completing key criteria.
112 Improving Neonatal Vascular Access in Surgical Patients
Authors: Rupra R. , Loveday R. , O’Sullivan B. , Soccorso G. , Arul S.
Published: February 2022

Aim

Many neonatal surgical patients require intravenous (IV) access for >1 week. Technical, organisational, and cultural factors reduced placement of peripherally inserted central catheters (PICCs). Most babies requiring parenteral nutrition/central medications undergo central venous line placement under general anaesthetic (GA). Repeated bedside cannulation causes distress to patients and parents, with workload burden resulting in extravasation injuries. We aim to reduce these factors by increasing PICC usage in a ward setting.

Method

We followed a Plan, Do, Study, Act cycle over 4 months.

Results

Final results pending. The intervention has occurred, in 1 month we will re-measure:

We will measure risks of increasing PICC placement (through an iterative process), including:

Conclusions

The initial message yielded perceptions that ‘the department is doing things wrong’. The message of PICCs adding an ‘extra string to our bow’ was clearer, non-judgemental and with strong rationale for change.

Training non-rotating staff promotes sustainability but required senior clinician agreement to procure equipment, delaying our timeline – target completion is in 1 month.
119 Evaluating the Quality and Readability of Online Information on Unspecified Kidney Donation
Authors: Stavropoulou-Tatla S. , Awal D. , Fardanesh A. , McCaig F. , Hossain M.A.
Published: February 2022

Introduction

Living kidney transplantation from donors bearing no genetic or emotional relationship with the recipient, is known as unspecified kidney donation (UKD). UKD can create multiple living donor transplantation opportunities and shorten the national waiting list for cadaveric organs. Consequently, the UK Living Donor Kidney Transplantation 2020 Strategy, has prioritised maximising UKDs.

The Internet has an established role in raising awareness, offering support, and potentially influencing the decision for or against UKD. This is the first study assessing the quality and readability of online material related to UKD.

Method

Google was used to search for the following terms: ‘kidney donation’ and one of ‘unspecified’, ‘altruistic’, ‘non-directed’, ‘anonymous’ or ‘good Samaritan’ as well as ‘giving or donating a kidney to a stranger’. Two independent assessors reviewed the top 100 websites and assessed their quality using the Journal of the American Medical Association (JAMA) criteria, the DISCERN instrument and HONcode (Health on the Net Code) certification. Readability was assessed using the Flesch Reading Ease (FRE), Flesch-Kincaid Grade (FKG) and Simple Measure of Gobbledygook (SMOG) scores.

Results

Only 6% of websites displayed a HONcode stamp. The mean (± SD) JAMA and DISCERN scores of 1.96 (±1.00) and 32.34 (±11.19) respectively, indicate poor quality. The mean (± SD) FRE, FKG and SMOG scores of 52.92 (±13.62), 10.60 (±2.72) and 9.64 (±2.22), respectively, reveal poor readability.

Conclusions

Transplant centres and medical organisations should prioritise improving the standards of online material on UKD. This enables informed and ethical decision-making when attempting to expand the living donor pool.
122 Tetanus Prophylaxis for Injuries Referred to a Plastic Surgery Service
Authors: Stark D. , Nagrath N.
Published: February 2022

Aim

To ascertain whether there is appropriate documentation of tetanus immunisation status. To determine whether appropriate tetanus prophylaxis is offered to those with an incomplete or unknown immunisation history for tetanus prone and high-risk tetanus prone wounds. To improve adherence to the green book of immunisation tetanus guidance.

Method

We performed an audit of wounds referred to plastic surgery in a 3-week period to ascertain whether the green book guidance was satisfied. A poster intervention for junior colleagues that illustrated the guidance was implemented. Re-audit was performed.

Results

Tetanus immunisation status was documented in 17 (34%) patients. Of 22 with tetanus prone wounds, 11 (50%) had an incomplete tetanus immunisation, but only 3 (27%) received a booster vaccine. Of the 11 high risk tetanus prone wounds, 10 (91%) had an incomplete tetanus immunisation status, but only 5 (50%) received a booster vaccine and none were offered tetanus immunoglobulins.

Following intervention, tetanus immunisation status was documented in 23 (46%) patients. In the re-audit, 12 (24%) sustained a tetanus prone injury and 4 (33%) of these had complete immunisation. Of the remaining 8, 7 (88%) received a booster vaccine and 1 patient refused. Of the 4 high risk tetanus prone wounds, 3 (75%) had an incomplete tetanus immunisation status, all of whom received a booster vaccine and 1 (25%) was offered tetanus immunoglobulins.

Conclusions

We observed greater engagement with the tetanus immunisation guidance and improvement in the assessment and management of tetanus prone injuries.
123 Effectiveness of the “Emergency Neurosurgery Referral Card”
Authors: Baig A.A. , Lo W.B.
Published: February 2022

Aim

The recording of patient and clinical information is important during the neurosurgery referral process, as time-critical communication with the referring teams and appropriate clinical decisions are dependent on the accuracy and completeness of the information recorded. A ‘Neurosurgery Emergency Referral Card’ was introduced to assist the process for the on-call registrars/consultants.

Method

Following the first audit cycle was carried out over 52 weeks (1st January 2020 – 31st December 2020), which assessed the percentage of incomplete data entry in the referral database, a ‘Neurosurgery Emergency Referral Card’ was introduced. Data entry was then re-audited (12 weeks; 21st May 2021 – 21st August 2021).

Results

Referral type (emergency, urgent, semi-urgent, non-urgent) is the most inadequately recorded data field, with a completion rate of 68%. Following the implantation of the card, it improved to 89%. The pre- and post-implementation completion rate for patient age was 82% and 98% respectively, and 85% and 96% respectively for time of referral. The completion rates for the remaining data fields in the 1st cycle (e.g., referring doctor, diagnosis, gender) were generally above 94% but still improved with the usage of the card. The average improvement in referral taking after implementation is 6%.

Conclusions

Even in the digital age, a ‘low-technology’ yet simple physical card can be an effective adjunct to improve referral accuracy and efficiency.
124 Administration of Fascia Iliaca Block to Patients Who Have Suffered a Neck of Femur Fracture
Authors: West C. , Wright C.
Published: February 2022

Aim

Hip fractures are the most common serious injury affecting elderly people and are associated with a total cost to the health and social services over £1 billion per year. This injury takes approximately 1% of the NHS budget. Furthermore current 30-day mortality rate is 6.5% so has serious implications for patients. NICE recommend that nerve blocks should be used to help perioperative pain and limit the use of opioids. We audited our use of analgesia, especially fascia iliaca blocks (FIB), to see whether training could improve the management of these patients.

Method

We conducted a retrospective cohort study in which a total of 188 patients, who had sustained a hip fracture, were audited during 4 discrete periods between March 2021-July 2021. The primary outcome assessed was whether they had received a FIB preoperatively. Improvements were implemented between audit cycles to see if they achieved desired outcomes.

Results

Implementation of good quality teaching to orthopaedic juniors and emergency department registrars and juniors successfully improved rate of FIB from 2.5% to 47%. The rate of FIB was not sustained over time and declined to 22%. Factors thought to influence this decline included regular rotation of junior doctors and increasing time pressures in the emergency department.

Conclusions

Our data suggested that low rates of FIB resulted in high opioid use in the emergency department. Allocated teaching sessions on administration of FIB were a successful way to improve use of blocks and reduce opioid use.
127 Optimum Treatment for Sigmoid Volvulus Remains Elusive but Surgery May Provide Considerable Benefit: Results of a 5-Year Audit
Authors: Issa M. , Nair D. , David B. , Banks J. , Lewis E. , Monk C. , Griffin A. , Guy R.
Published: February 2022

Background

Sigmoid volvulus is a surgical emergency and patients are often elderly with significant comorbidities. Whilst endoscopic decompression is easy and effective in the short-term, recurrence and repeated admissions are common with surgery generally being reserved for non-resolution or complications. Consensus an optimum management is lacking.

Method

A retrospective audit of all patients admitted with sigmoid volvulus to a DGH General Surgery service between 01/01/2015-20/10/2020 was undertaken. Patient demographics, comorbidities, clinical findings, investigations, and treatment were recorded.

Results

Sixty-three patients were identified (median age 71.5 years; 58.7% male]. Some 50.8% had more than one previous presentation (range 1–6), 19% presented after 3 days of symptoms and 3.2% presented with perforation. Plain radiography and CT scanning was undertaken in 90.5% and 54%, respectively.

Endoscopic detorsion was performed in 77.77% and repeated in the same admission for 33.3% of cases. Flatus tubes and rigid sigmoidoscopy was used in 47.6% with a 59.6% success rate. Seventeen patients (27%) underwent sigmoid resection, 14 having open surgery and 3 laparoscopic. Primary anastomosis was undertaken in 64.7% (11 patients), with only one anastomotic leak; the remaining 6 patients had a colostomy. The re-admission rate was 30.1% (19% non-operated patients, 11.1% operated patients).

Conclusions

Most patients with sigmoid volvulus are managed non-operatively with endoscopic detorsion which may be associated with a considerable healthcare burden and high readmission rates. Selective resection can be associated with low morbidity and good outcomes. Clinicians could reasonably adopt a lower threshold for surgical intervention, particularly for recurrent volvulus.
128 Thickness and Porosity of the Human Calvarium Layers: A Systematic Review
Authors: Cheong J. , Bhumitrakul J.
Published: February 2022

Introduction

With the advent of 3D printing in surgical training, producing realistic cranial bone models can benefit cranio-surgical training greatly. This includes the measurements of the individual layers of the skull. Hence, we have done this systematic review to identify the calvarial thickness measurement in the literature, if the different modalities affect the thickness and if calvarial thickness in human and cadaveric samples differ.

Method

Our literature search explored the terms, “Calvarium thickness” and “Cranial thickness” on PubMed and Google Scholar databases. A total of 6871 papers were identified and following the implementation of the PRISMA criteria, 7 papers were included in this review. Our inclusion criterias are studies that report on thickness, density and porosity, samples obtained from people greater than 20 years old and studies that included parietal bones and frontal bones.

Results

Our review identified inconsistent results with the thickness of the inner and outer table in the frontal bone. The results for the parietal bone were more consistent, which shows that the diploe is the thickest, followed by the outer table then the inner table. The porosity for the different layers in both parietal and frontal bones were consistent with the highest in the diploe and lowest in the outer table. CT scans showed similar measurements across different studies and are more accurate than ultrasound. However, the lack of standardised protocol could have resulted in the heterogeneous results obtained.

Conclusions

Our findings from this systematic review will provide insight into some of the improvements needed for future studies and applications.
130 Paediatric Hand Fractures Requiring Surgery – the Results of a Bespoke Hand Surgery Service
Authors: Donnachie D. , Yim G. , Watts A.
Published: February 2022

Aim

To evaluate the management of The Royal Devon and Exeter Hospital (RD&E) bespoke hand surgery service on paediatric closed hand fractures. In particular, an assessment against The British Society for Surgery of the Hand (BSSH) closed fracture standards on treatment timelines and national guidance compliance.

Method

A retrospective review of all paediatric patients requiring plastic surgery seen at the RD&E plastics trauma clinic from 1st Nov 2020 to 28th Feb 2021 was performed. This was compared to two previous audit cycles completed during winter 2019 and summer 2020. Health informatics was collated via our IT department and thoroughly reviewed using departmental notes. Exclusion criteria included: all non-fracture injuries, patients > 18 years old and open fractures.

Results

In winter 2020–21 all patients were referred the same day of injury and 92% were seen by a Plastic Surgeon within 24 hours of injury. This was an improvement from the mean time from referral to clinic of 5 days in winter 2019 and 1.33 days in summer 2020 respectively. 85% of cases are now operated within 48 hours of review and 92% of cases were operated within 72 hours of the decision to operate where conservative management had failed.

Conclusions

The introduction of a ‘rapid-access’ musculoskeletal unit with early senior review and a dedicated theatre has created ‘gold-standard’ compliance with national standards for the operative management of closed paediatric fractures. We should continue to focus on improving and increasing capacity of this service as it has likely improved both the patient journey and outcomes.
138 Using Peer-to-Peer Induction to Improve the Confidence of Incoming Surgical FY1s During Changeover
Authors: Smitheman M. , Zafar A.Q.
Published: February 2022

Aim

The benefits of peer-led teaching are well evidenced, as are the benefits of interactive over passive learning in a clinical setting.

This project aimed to create an FY1-led induction model that could be reproduced across departments, cost-effectively boosting junior trainee confidence, and improving continuity of care during quarterly changeover periods with minimal pressure on senior clinicians.

Method

Areas for focus were identified by consultants and departing FY1s to produce an FY1-led, presentation-based induction for December and April changeovers.

Incoming FY1 confidence was assessed using pre-induction and post-induction surveys to identify areas for improvement in future.

An interactive e-learning induction replaced the presentation for the new FY1s in August, again using surveys assessing trainee’s confidence versus previous cycles.

Results

The first two inductions both showed a complete reduction in trainees rating themselves overall ‘not so confident' or below.

Four of the six targeted areas showed increased improvement in confidence in April versus December.

The August e-learning induction showed a 71% increase in newly qualified FY1s rating themselves as overall ‘confident’ or ‘very confident’, an improvement on previous inductions. ‘Confident’ and ‘very confident’ ratings for focused areas increased by 62% on average, versus 37% and 27% previously.

Conclusions

This induction greatly increased FY1s’ confidence, with feedback citing peer-gained insights as the main positive addition to the consultant-led induction.

Combining the evidence-based methods of peer-led teaching and interactive e-learning resulted in a replicable, cost-effective, and time-efficient template for improving confidence and continuity of care in the changeover period. This could be implemented in any department nationwide.