bluuebunny/crossref_metadata_2025 huggingface dataset:
291 Virtual Classroom Proficiency-Based Progression for Robotic Surgery Training (VROBOT): A Prospective, Cross-Over, Effectiveness Study
Authors: Nathan Arjun , Patel Sonam , Georgi Maria , Mullins Will , Fricker Monty , Asif Aqua , Ng Alexander , Hang Man Kien , Light Alexander , Francis Nader , Kelly John , Collins Justin , Sridhar Ashwin
Published: November 2022

Aim

Robotic surgical training has historically lacked evidence-based standardisation. The Fundamentals of Robotic Surgery (FRS) curriculum addresses this by incorporating proficiency-based modules which certify trainees’ skills. However, the curriculum is self-directed and non-interactive. We aim to determine the effectiveness of interactive virtual classroom training (VCT) as an adjunct to the FRS curriculum for robotic skills training.

Method

11 novice surgical trainees were randomly allocated to two groups. Both groups completed a one-week robotic skills induction. In week two, Group A received training with the FRS curriculum and adjunctive VCT; Group B only received access to the FRS curriculum. In week three, the groups received the alternate intervention. The primary outcome was measured using the validated robotic-objective structured assessment of technical skills (R-OSAT).

Results

11 participants completed the training curriculum; all were included in analyses. Both groups demonstrated significantly improved proficiency upon completion of the training. At time point 1 (end of week two) Group A achieved a statistically significant greater mean proficiency score compared to Group B (44.80 vs 35.33 points, p=0.006). At time point 2 (end of week three), there was no significant difference in Group A's mean score from time point 1. In contrast, Group B showed significant improvement in mean proficiency by 9.67 points from time point 1 (95% CI 5.18–14.15, p=0.003).

Conclusions

VCT is an effective training adjunct to the FRS curriculum for the learning of basic robotic skills. With the steep learning curve in robotic surgery training, VCT offers interactive learning and can increase training effectiveness.
388 Patient-Specific 3D Printed Talus Truss Cage with Hindfoot Nail Arthrodesis – a Novel Salvage Procedure for Complex Post-Traumatic Talus Avascular Necrosis
Authors: Morris Richard , Cheruvu Manikandar Srinivas , Lingnau Leonie , Mumtaz Haroon
Published: November 2022

Background

Post-traumatic avascular necrosis (AVN) following talus fracture can be a devastating injury, with subsequent destruction of the tibio-talar-calcaneal articulations resulting in joint degeneration and compromised mobility.

Tibio-talar-calcaneal arthrodesis is a salvage procedure where large bone voids can present significant challenges. Whilst a range of arthrodesis techniques have been described, we present a unique case of patient specific 3D-printed talus truss cage with navicular articulation and hindfoot nail fusion.

Case Presentation

We present a case of an 80-year-old fit and well gentleman who was a delayed presentation with a Hawkins 3 talar neck fracture and a Mueller AO / OTA C3 talar body fracture. The patient opted for a trial of conservative management over primary fusion, but at 3 months post-injury there was talar body collapse and progression of subtalar degeneration, therefore he underwent talus fixation with subtalar fusion.

At 6 months post-injury, there was collapse of the tibio-talar joint with AVN of the talus. The patient had ongoing discomfort and a decision was made to proceed with custom implant arthrodesis. At 7 weeks post-operatively the patient's wounds have healed without complication and talus height is maintained. Follow-up is ongoing.

Discussion

The mainstay of treatment for severe post-traumatic talar AVN has been arthrodesis of the hindfoot and ankle with complication rates as high as sixty percent, including mal-union and loss of bone height. This case highlights the potential of a patient specific 3D-printed talus truss cage to manage complex bone defects and these challenges of arthrodesis.
946 Transforming the Morbidity and Mortality Review Process: Customised Digitalisation Helps Us Learn from Mistakes
Authors: James Eleanor , O'Shea Kathryn , Kwok Chun , Partridge Roland , Taylor Josef , Almond Sarah
Published: November 2022

Aim

Morbidity and Mortality (M&M) review is an important component of clinical governance in surgical practice. Constructive discussions are crucial for improving patient outcomes and quality of care. We aimed to transform the M&M review process within the paediatric surgical department of our tertiary referral centre.

Method

A critical assessment of our previous system identified weaknesses which we addressed by sequential changes in software and meeting organisation. Clinical staff developed a customised web-based reporting platform, followed by a more sophisticated mobile application for smart phones/tablets, allowing users to explore all reported cases and discussions, and to monitor actions from previous cases. The introduction of triage meetings structured the agenda and content for M&M meetings and monitoring of agreed recommendations/proposed actions ensured service improvement.

Results

The introduction of the reporting platform increased case reporting (11 vs 21 cases/month). The subsequent development of our mobile application standardised the recording of case discussion with contributing factors recorded for 100% of cases discussed. Recommendations are logged and tracked within the app's dashboard which shows every report coded by key words so case series can be identified, and audits easily facilitated.

Conclusions

M&M meetings are crucial in improving patient safety and quality of care and are pivotal to surgical training. Our mobile application simplifies, and encourages, case reporting and provides a platform to facilitate structured M&M conferences. This project demonstrates innovative uses of technology can facilitate quality improvement from M&M meetings, support audits and enhance education of surgical trainees.
200 Online Trauma Care Learning Helped Young Myanmar Doctors Managing War-Wounded
Authors: Oo Khaing Khant , Soe Aung Pyi
Published: November 2022

Aim

Myanmar military's brutal crackdowns on pro-democracy protestors after Feb-2021 coup resulted in a staggering number of death and wounded. An on-line trauma care series was launched in March 2021 for general practitioners and young medical graduates with limited trauma care experience.

Method

A pilot study was conducted to assess the effectiveness of online learning and address the demands of the medical personnel in the frontline areas. Pre- and post-assessments were sent out via anonymised Google forms and analysed.

Results

Among 106 participants, 65% graduated between 2011 and 2020. 46% worked in a hospital setting before the coup while 19.2% were GPs. Trauma first aid (70.8%), wound ballistics (68.8%) and ATLS updates (62.5%) were the most demanded topics. Average confidences grew in managing all 4 components (24.3% to 85.4% in Trauma First Aid, 23.5% to 72.9% in Trauma Wound Management, 12.5% to 81.3% in Wound Ballistics and 27.2% to 85.5% in Red Cross Wound scoring).

Conclusions

This pilot study highlighted an urgent demand for training and education in trauma care among young Myanmar doctors. With ongoing public hospital closures due to civil disobedience movement, care of war-wounded would still be largely dependent on makeshift casualty care chain in community setting.
792 Association of Dietary and Obstetric Factors with the Type of Gallstone
Authors: Arham Muhammad , Arish Muhammad , Khan Jahangir Sarwar , Malik Jamal Nasir , Malik Ahmed Mujtaba , Humayun Talha
Published: November 2022

Aim

Dietary and many other factors have been shown to increase the risk of gallstones, but their association with stone type is poorly understood. This study aims to assess the association of dietary and obstetric factors with the type of gallstone.

Method

116 consecutive patients requiring cholecystectomy due to gallstone disease, admitted in our hospital, from January 2019 to December 2020 were included in this study. Demographic details, medical history, lifestyle and dietary habits, obstetric history and laboratory parameters were recorded using a data collection form developed by the researchers. Removed gallstones were classified as being cholesterol or pigment by gross visual inspection.

Results

Cholesterol gallstones were found in 76 (65.5%) and pigment stones in 40 (34.5%) of 116 total patients. Drug use was significantly higher in pigment stone group as compared to cholesterol group (p=0.002). Patients with cholesterol stones consumed significantly higher beef, fish and confectionery items than patients with pigment stones with a p-value of 0.043, 0.017 and 0.041, respectively. Parity was significantly higher in patients with pigment stones as compared to patients with cholesterol stones (p=0.023). A logistic regression model to assess the effect of beef, fish and confectionery item consumption and age at first pregnancy with the likelihood of having cholesterol gallstone was statistically significant (p=0.017) and showed that risk is higher in patients with age ≤ 20 years at first pregnancy [OR 6.89 (95% CI 1.24–38.15), p=0.027].

Conclusions

This study concludes that diet and obstetric factors can influence the type of gallstone.
835 F.I.T for Discharge? Role of Faecal Immunochemical Testing (FIT) in Ruling Out Primary Bowel Cancer: A Review of Current Outcomes
Authors: Krishna Arun , Ferrara Giovanni , Edwards Joshua , Lala Anil
Published: November 2022

Aim

NICE recommends a FIT <10 may not warrant an Urgent Suspected Cancer(USC) Referral. We aim to assess current outcomes at a local level. Secondary aims included whether a high FIT(>100) determines increased cancer risk and whether a moderate FIT(10–100) warrants a USC referral.

Method

We retrospectively looked at patients who received a FIT between June-December 2020 in North-West Wales. These were divided into 3 groups: negative FIT(<10), moderate FIT(10–100) and high FIT(>100). They were followed-up for a year to determine the result of further investigations such as Endoscopies, CT Colons or CTs. The histology results from polyps/biopsies/specimens from Endoscopy/Surgery were recorded.

Results

A total of 909 patients received a FIT, 180 excluded due to no result. 557 were negative, 125 moderate and 47 high. 2 of 557(0.36%) in the negative FIT group had cancer, however histology of both showed Squamous Cell Carcinoma from Anal Cancer. 4 of 125(3.2%) in the moderate FIT group and 10 of 47(21.27%) in the high FIT group had cancer. Polyp histology demonstrated high-grade dysplasia in 1(2.13%) in the high, 3(2.4%) in the moderate and 0 in the negative Group.

Conclusions

Inappropriate investigations and delayed diagnosis can both have drastic clinical and financial implications. Our results show that a negative FIT, with a thorough history and examination, should prevent a need for a USC referral for primary bowel cancer. Patients with high FIT could proceed to investigation, while moderate FIT may need further assessment.
255 International Variation in Intraperitoneal Drain Placement and Outcomes After Elective Colorectal Surgery: A Matched, Prospective, Cohort Study
Authors: Collaborative EuroSurg
Published: November 2022

Background

Currently, many surgeons place intraperitoneal drains after elective colorectal surgery. However, Enhanced Recovery After Surgery (ERAS) guidelines recommend against their routine use due to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice.

Method

COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) was a prospective, international, cohort study which enrolled consecutive adult patients undergoing elective colorectal surgery (February-March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time-to-diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time-to-discharge; 30-day major postoperative complications (Clavien–Dindo grade ≥3). After propensity-score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement.

Results

Overall, 1805 patients from 22 countries were included (798 [44.2%] female; median age 67.0 years). The drain insertion rate was 51.9% (n=937). After matching, drains were not associated with reduced rates (OR 1.33, 95% CI: 0.79–2.23, p=0.287) or earlier detection of collections (HR 0.87, 95% CI: 0.33–2.31, p=0.780). Although not associated with worse major postoperative complications (OR 1.09, 95% CI: 0.68–1.75, p=0.709), drains were associated with delayed hospital discharge (HR 0.58, 95% CI: 0.52–0.66, p<0.001) and increased risk of SSIs (OR 2.47, 95% CI: 1.50–4.05, p<0.001).

Conclusions

Intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of collections but were associated with prolonged length of stay and increased SSI risk.
67 Does a National Lockdown Affect the Characteristics of Deep Vein Thromboses in Patients in the Community?
Authors: Aden N , Shahid A , Howard M , Narayanamoorthi S , Khan T
Published: November 2022

Aim

Has lockdown and COVID-19 led to a change into the characteristics of DVT's and patients who have them alongside a review of the DVT service.

Method

Data was collected retrospectively from electronic patient records system for the following periods: 1st April until 30th June 2019 and 1st April until 30th June 2020. These were the key months during the first United Kingdom national lockdown. Data was analysed for patient demographics, risk factors, characteristics of the DVT, management and DVT reoccurrence. Statistical analyses were preformed using GraphPad Prism 8.

Results

227 patients sustained community DVT's in 2019 and 211 patients in 2020 during the study period. 13 of these patients in 2020 were COVID-19 positive. There was a difference in gender distribution (p= 0.0128) with 128 males and 99 females in 2019, 93 males and 118 females in 2020. No significant difference was noted for the incidence of thrombophilia with 9 in 2019 and 3 in 2020 (p=0.1437). Fewer long-haul journeys were made (p=0.012) with 16 in 2019 and only 2 in 2020. Fewer patients had immobility as a risk factor with 79 in 2019 and 55 in 2020 (p=0.0494). However, there were more patients using the contraceptive pill (p=0.0086) with 1 in 2019 and 9 in 2020.

Conclusion

There is no significant difference in the characteristics, extent, and management of DVT's prior to and during Lockdown during COVID-19. National Lockdowns do not affect community DVT's however it is important to highlight the surrounding inpatient numbers.
106 Local Anaesthetic Toxicity and its Treatment in the Plastic Surgery Minor Op Theatre
Authors: Shah R , Herieka M , Dalal M
Published: November 2022

Objectives

Local anaesthetics (LA) are frequently used in Plastic Surgery; hence knowledge of the recognition and treatment of LA toxicity is vital amongst all staff members. Our study aimed to identify and improve the understanding of local anaesthetic toxicity and its treatment amongst plastic surgery staff in our minor operations theatre.

Method

The BNF and AAGBI guidelines on LA toxicity were used as our audit standards. In the initial cycle, we performed 1–1 interviews, using an 11-point questionnaire, with 11 doctors and 7 nurses over two days. Interventions to improve our service included organising a structured departmental teaching on LA toxicity; displaying official AAGBI posters around the department; and including information on LA toxicity in the junior doctor's handbook. A re-audit was performed 1 month later.

Results

After the interventions, the knowledge on safe doses of LA improved from 57% to 100%. All staff knew signs and symptoms of LA toxicity (up from 67%). An improvement was also seen in the knowledge about monitoring and treatment of LA toxicity, from 39% to 100%. Surprisingly, only 17% knew the location of intralipid within the department during the initial cycle, however this figure improved to 100% after the interventions.

Conclusions

Knowledge of LA toxicity and its treatment is vital for all Plastic Surgery staff, especially in a minor operations theatre. The use of structured teaching sessions, posters about LA toxicity, and information in junior doctor's handbook, are useful interventions in improving the know-how amongst all staff members.
113 Prevention, Diagnosis, and Management of Fracture Related Infections in Accordance with the BOA FRI Guidelines
Authors: Lu V , Zhang J , Thahir A , Krkovic M
Published: November 2022

Aim

Fracture related infections (FRI) are common and serious complications of musculoskeletal trauma. With average hospital health care costs for infected patients being 6.5 times higher than uninfected patients, FRI poses a significant social-economic burden to the patient and healthcare system.

We aim to audit current practice in preventing and diagnosing FRIs and improve management of infections in patients with fractures. The guidelines covered are the British Orthopaedic Association (BOA) FRI guidelines.

Method

Our sample included patients who suffered an infection as a direct consequence of fracture and/or subsequent surgical management procedures over a seven-year period. Surgical procedures were performed for fractures in 8826 patients. In total, 102 patients with an FRI were reviewed. Audit results and recommendations have been presented at a clinical governance meeting.

Results

Seven out of sixteen items had poor compliance (<80% compliance). Ultrasound-guided aspiration was done in 21.6% (22/102), even if debridement surgery is delayed. 1.96% (2/102) received adequate advice about responding to a suspected FRI. 56.9% had recommended 2-week antibiotic-free duration before sampling. Our recommendations include pre-written template in discharge documentation providing guidance on responding to a suspected FRI, better communication between microbiology, surgical team, and GPs regarding antibiotic prescription timing, including weekly bone and joint infection MDT review for FRI patients.

Conclusions

Lowering FRI-related burden requires a three-pronged approach: uniform set of standards for infection prevention in trauma and orthopaedic surgery, robust diagnostic workup for suspected FRI cases, effective management scheme for confirmed FRI cases. These systems should be a key element of orthopaedic trauma service.
193 Audit on Effectiveness of Theatre Handover to the Critical Care Team
Authors: Bushra R , Shahjahan S , Salaunkey K
Published: November 2022

Aim

Immediate handover of a postoperative patient to a critical care team is vital for in-patient management. Smooth and accurate exchange of information avoids unnecessary clinical incidences. Local trust guidelines direct towards 100% completeness of handover sheet in the electronic system. Goal to achieve 100% completeness of theatre handover form. To receive all relevant information from personnel involved in care.

Method

A total number of 100 post-cardiac surgery patients were admitted to Critical Care immediately after surgery in both cycles from June to July and October. Data were collected retrospectively, which includes both elective and emergency procedures.

Results

In 1st cycle, information from surgeon to CCA doctor accounts for around 50%. Information from anaesthetists and theatre nurses were 88% and 90%, respectively. In the 2nd cycle, handover from the surgeon, anaesthetist, and theatre nurse was approximately 60%, 95% and 90% gradually. Specific postoperative instruction was recoded 30% for 1st round, whereas it was around 45% in reaudit.

Conclusions

A proper handover is crucial for managing postoperative cardiac surgery patients because inadequate pre-and postoperative information can lead to a serious error. Considering the audit finding, it seems advisable to take a more multidisciplinary approach to improve the standard of postoperative patient handover care with complete information transformation.
199 An Audit Cycle of Antibiotic Prophylaxis for Laparoscopic Cholecystectomy
Authors: McMaster D , Shaikh M , Singh S , Elghazaly H , Dahaghin P , Sheth H
Published: November 2022

Aim

Due to the lack of clinical benefit and the risks of unnecessary antimicrobial use, current national guidelines do not recommend prophylactic antibiotic use in low-risk elective laparoscopic cholecystectomies, reserving their use for high-risk patients only. The aim of this audit was to assess compliance with local and national guidelines for antibiotic usage for laparoscopic cholecystectomies, to identify areas of improvement, implement change and re-audit to assess the effectiveness of this change.

Method

Data was collected retrospectively between 01/05/2021 and 01/08/2021 for patients undergoing elective laparoscopic cholecystectomies. Following the initial data collection, we implemented change by attaching pre-printed stickers of local antibiotic prophylaxis guidance to pre-operative notes. We prospectively re-audited between 01/11/21 and 01/12/21 to assess the effectiveness of this change.

Results

In the initial three-month period, 24.4% (10/41) of elective cases received correct antibiotic prophylaxis, with 58.5% of patients prescribed unnecessary post-operative antibiotics in the post-operative plan. Following the implementation of change, in the re-audit period there was a significant improvement, with 55% (11/20) of elective cases receiving correct antibiotic prophylaxis, and only 25% prescribed unnecessary post-operative antibiotics.

Conclusions

We show that pre-printed stickers are a simple intervention that can improve adherence to local guidance and reduce injudicious use of antibiotics in the pre- and post-operative periods. Improving antibiotic prescribing for laparoscopic cholecystectomies, one of the United Kingdom's most common surgical procedures, highlights the potential for significant cost savings and improved antimicrobial stewardship. We will re-audit again in the coming months to assess if this improvement has been sustained.
201 Compliance to New BOAST's Guidelines for Paediatric Supracondylar Fractures in the Middle of COVID Pandemic
Authors: Oo KK , Richards T , Khurana A
Published: November 2022

Aim

Amid COVID pressures, standards of surgical practices need constant reviewing to maintain patient safety and streamline care pathways. Newly published BOAST (British Orthopaedic Association Standards for Trauma and Orthopaedics) guidelines for paediatric supracondylar fractures became a benchmark against which a restructured DGH trauma unit's performance can be appraised.

Method

Theatre records were analysed between April-2020 and September-2020. Data were collected to reveal time to theatre, operative techniques, documentations of ulnar nerve protection, complications, follow-up plans, time to first post-op radiograph and to wire removal.

Results

90% of patients underwent operations within 24–48 hour. Although there was no incidence of iatrogenic nerve injury, documentation of ulnar nerve protection was not identified in 45% of crossed wire fixations. Wire size was not mentioned in 14%. 33% did not have first follow-up with radiograph within 4–10 days, and 43% of patients did not have the wires removed till 4 weeks post op.

Conclusion

This re-audit highlights the need to improve in documentation for ulnar nerve protection and to identify the delays in follow-up appointments. Although BOAST no longer recommends a fixed timeframe for follow-up plan, first radiograph within 4–10 days and wire removal within 4 weeks are still reasonable locally.
205 A Closed Loop Audit of CT Hip Scanning at Our District General Hospital
Authors: Gompels B , Limb R , Ralte P
Published: November 2022

Aim

This audit aimed to determine whether there was a delay beyond 36 hours in theatre cases due to delayed neck of femur fracture diagnoses for non ambulatory patients with no diagnostic abnormality identified on plain film. We examined the indications for CT scans to ensure a full examination had been documented and a trial of mobilisation had been attempted.

Method

CT hip scan requests audited retrospectively against whether they delayed surgery, if the scan was discussed with the T&O team, hot reporting prior to the scan request and if there was a full examination with documented weightbearing status. Data was compared with NICE guidelines on hip fracture management (CG214) and expected compliance was 95%. Following the initial audit cycle, teaching was given at A&E induction on the referral process and pathway and subsequently re-audited.

Results

Documented full examination improved from 85 to 93%. Weightbearing status was documented in 33% initially and 76% following the re-audit. There was a 44% improvement in the number of patients who had scans hot reported prior to CT scan occurring. In 95% of patients CT scan did not delay surgery beyond 36 hours.

Conclusion

CT scan delays did not lead to a delay in the 95% of patients going to theatre. However, with normal plain films it is crucial to have a documented attempt to weight bear prior to the CT request being made. Hot reporting of hip radiographs can be useful prior to requesting CT scans though reporting times and clinical workload can limit this factor.
239 Neurovascular Assessment in Fracture Patients Admitted in a Major Trauma Centre, a Comparison of Emergency Department and Orthopaedic Admission Documentation
Authors: Gilmore C , Toner E , McHenry S
Published: November 2022

Aim

The December 2021 British Orthopaedic Association Standards for Trauma for peripheral nerve injuries clearly state “An examination to assess all the functions of a peripheral nerve should be performed and recorded in sufficient detail to allow confident comparison with preceding and subsequent examination”.

Early accurate neurovascular assessment should first be performed to identify patients requiring urgent surgical intervention, clear documentation is essential to facilitate monitoring over time. The aim of this study was to evaluate the neurovascular documentation in trauma patient's presenting to a Major Trauma Centre and compare quality of Emergency doctors (ED) documentation against Orthopaedic surgeons.

Method

A retrospective analysis of A&E and orthopaedic admission proforma paperwork was performed, 77 patients were identified over 4 weeks from Nov – Dec 2020. Following the introduction of vascular examination section to the admission paperwork a repeat cohort of 75 patient notes were reviewed in Oct – Nov 2021.

Results

Orthopaedic surgeons were more compliant with neurovascular assessment than ED (96% vs 77%), this was maintained in 2021 (96% vs 70%). Orthopaedic surgeons were more specific when documenting components of vascular, motor function and sensation examination (75% vs 39%). Significant numbers of patients had only ‘neurovascularly intact’. Poor documentation post manipulation/splinting was noted, with no documentation in 63% of cases.

Conclusions

Neurovascular documentation remains a challenge in the care of orthopaedic trauma patients. Orthopaedic surgeons were consistently more compliant at documentation compared to Emergency doctors. Many patients had a gross assessment with only ‘neurovascularly intact’ documented, falling below the BOAST standard.
252 Plastic Surgery Venous Thromboprophylaxis for Abdominal and Thigh Based Free Flap Breast Reconstruction Surgery
Authors: Bahadori D , Eiben I , Eiben P
Published: November 2022

Aim

Correct Venous Thromboprophylaxis (VTE) assessment and prescription is at basis of patient safety when considering patient hospital admission. Current local Guy's and St Thomas Hospital guidelines are in keeping with National Institute for Health and Care Excellence (NICE) guidelines recommending all patients to be assessed and prescribed VTE prophylaxis within 24 hours of admission. There are no specific local or national guidelines however that would recommend VTE prophylaxis specific to free flap breast reconstruction surgery.

We assessed therefore adherence to VTE prophylaxis guidelines for patients undergoing abdominal and thigh based free flap breast reconstruction surgery. Patient outcomes were reviewed and VTE prophylaxis proforma was recommended.

Method

Patients who underwent abdominal or thigh based free flap breast reconstruction surgery between October 2017 and February 2019 were identified. Data was collected retrospectively and analysed via SPSS Statistics (IBM, USA).

Results

51 patients were included in the first audit cycle; 50 patients in the re-audit. Overall improvement and 100% of patients received LMWH on admission. The timings of correct prescription versus actual administration of LMWH decreased however from 71% to 49%.

Conclusion

There is good adherence to assessment and administration of VTE prophylaxis across the patients. Unfortunately, the prescription of VTE prophylaxis itself is mostly incorrect. It is therefore with gratitude to the ward staff VTE is administered correctly. Further improvements in the communication therefore between theatre, ward and surgical staff and implementation of VTE prophylaxis proforma need to be considered.
276 Documentation for Follow Up ENT Outpatients at University Hospital of Wales
Authors: Lam CM , Owens D
Published: November 2022

Aim

Clinic appointment documentation for follow up patients in ENT may not meet BMA Ethics documentation standards for health records. This is important as dictated clinic letters can lack sufficient information or be subject to technical errors. Our audit aim was to determine if follow-up patient consultations in ENT clinics at University Hospital of Wales are being appropriately documented.

Method

Retrospective audit. All ENT outpatient clinic documentation for follow up patients over a one-week period in January 2020 were reviewed. New patients to the clinic were excluded. The documentation was audited to see if all relevant clinical findings, the decisions made, information given to patients, and drugs or treatment prescribed were included. This was the audit gold standard and was taken from the BMA ethics Access to health records (2014) publication. The audit target was 100% on all categories.

Results

Clinic appointment records for 133 patients met the inclusion criteria. 73.7% of records included all relevant clinical findings, 80.5% included the decisions made, 23.3% included the information given to patients and 65.4% included the drugs or treatments provided. 21.8% of clinic appointment records were compliant with all 4 of the above categories.

Conclusions

The majority of clinic appointment note documentation were not compliant with all 4 of the categories advised by the BMA publication. A stamp was designed to provide a template for clinic appointment documentation for follow up patients to make the process easier for clinicians.
317 Preoperative Fasting in Adults – A Quality Improvement Project at Macclesfield District General Hospital
Authors: Saad D , Mughal H
Published: November 2022

Aim

Our primary endpoint was to evaluate staff awareness of preoperative fasting guidelines. Our secondary endpoint was to evaluate patient preoperative fasting times.

Method

Data were collected using online close-ended survey questions from surgical ward nurses and healthcare assistants before and after implementing a multimodal campaign to raise awareness. Data were collected for patient fasting times before and after the same interventions.

Interventions:

Results

Staff: Our interventions increased staff awareness of preoperative fasting guidelines for food by 20.6% (from 50% to 70.6%) and for clear fluids by 28.8% (30% to 58.8%).

Patients

Average preoperative fasting times for food before and after intervention were 12.7 and 12 hours respectively (p=0.736). For clear fluids, average fasting times before and after intervention were 6.2 hours and 4.5 hours (p=0.415).

Conclusions

Staff were generally unaware of the guidelines and viewed preoperative fasting solely as a safeguard against aspiration, causing adoption of a risk-averse attitude. The benefits of adequate hydration and nutritional support before surgery were overlooked. Our interventions helped raise awareness in the short term.

For our next cycle, we plan to assess the efficacy of implementing long-lasting changes such as local trust guidelines and improved staff training to drive a change in attitude and awareness of preoperative fasting.
338 Establishing Ceilings of Care in Elderly Frail Patients with Acute Fractures
Authors: Madden-McKee C
Published: November 2022

Aim

The British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) document ‘Care of the Older or Frail Orthopaedic Trauma Patient’ advocates early discussion and documentation of ceilings of care. The aim of the study was to assess whether cardiopulmonary resuscitation (CPR) status was being discussed and documented at the time of admission in this patient cohort.

Method

At two separate time points (September and October 2021), a sample of current inpatients admitted under the acute fractures service were selected who met inclusion criteria of having sustained a low-energy fracture and having a clinical frailty score of 5 or greater. Patient notes were examined to determine whether any decisions or discussions regarding CPR status had been documented at the time of admission. Between time points, a teaching presentation was sent to all FY2-CT2 doctors who covered acute fractures admissions and a reminder box was added to the fracture's admissions sheet template.

Results

The mean age was 82 years (range 65 to 97 years) and 85 years (range 70 to 94 years) at the first and second time point, respectively. Successful documentation regarding ceiling of care at the time of admission improved from 26% (5/19) to 64% (14/22) between study periods.

Conclusions

Early discussion and documentation of ceilings of care in elderly frail patients sustaining acute fractures is important to avoid unsuccessful, undignified attempts at resuscitation in the event of deterioration.
345 Not Just Metal Hips: Correcting Peri-Operative Anaemia and Iron Levels in Emergency Neck of Femur Surgery
Authors: Cai W , Daneshmend A , El Rhermoul FZ
Published: November 2022

Aim

Method

44 orthogeriatric patients’ records who underwent NOF surgery between December 2019 and March 2020 were examined in the first round. The following data were extracted from the electronic records: age, pre- and post-operative haemoglobin, uptake of pre- and post-operative haematinics, blood, and iron transfusions throughout the surgical period. Subsequently, two more rounds of data collection were undertaken, and they followed the same method. These involved 58 patients between January and April 2021 and the 26 patients between May and June 2021, respectively.

Results

Our first cycle saw uptake of pre-operative haematinics increase by 31% (from 20% to 51%). The final round saw uptake of pre-operative haematinics decrease to 27%. In addition, more than 1/3 patients (37%) who received blood had not met transfusion criteria according to NICE guidelines. Almost half of patients (46%) who received iron transfusion did not have confirmed iron deficiency anaemia.

Conclusions

Pre-operative anaemia continues to be poorly investigated despite an initial increase in haematinics uptake. This could be attributed to the changeover of teams in April. To sustain the level of previous improvement, a hospital-wide educational session for clinicians is needed and this is best incorporated into the induction programme.
350 Nutritional Management of Emergency and Elective Surgical Patients – Are We Doing Enough?
Authors: Hern D , Desai C , Rao V
Published: November 2022

Aim

Malnourished patients make poor surgical candidates, with an increased risk of post-operative complications. We assessed the peri-operative nutritional status of patients undergoing elective and emergency general surgical operations.

Method

Data was collected from 1 September 2021 to 1 November 2021. The inclusion criteria included: underwent surgery for gastro-intestinal pathology, length of stay ≥5 days, and high risk of malnutrition as per the Malnutrition Universal Screening Tool (MUST).

Results

50 emergency patients were identified. In the pre-operative to post-operative period, these patients had a mean albumin decrease from 30.5 to 23.7, against a decrease in CRP of 146 to 105.5, suggesting worsening nutrition rather than worsening inflammation. 48% of these patients had dietician referrals in-place with 54% of these on oral supplementation. Post-surgical complications increased in these patients without a dietician referral, with wound infection the most common cause (n=4).

50 elective patients were identified. 40% of these patients had dietician referrals in-place with 70% of these on oral supplementation. Post-surgical complications increased in these patients without a dietician referral with the most common complication being acute kidney injury followed by wound infection.

Conclusions

Optimal nutrition is key to optimal recovery. Most patients with dietician referrals had a plan of oral supplementation. This intervention can be commenced by the immediate surgical team. 56% of patients meeting the MUST tool criteria for high risk of malnutrition had no dietician referral. This can be addressed through early consideration for dietician referral, teaching sessions and educational posters distributed across surgical wards.
377 Audit of Barts Health NHS Trust Virtual Fracture Clinic
Authors: Stimler B , Banhidy N , Parducci M , Panagopoulos G
Published: November 2022

Aim

The British Orthopaedic Association recommends that all patients should be seen in a new fracture clinic within 72 hours of injury. The Virtual Fracture Clinic (VFC) at Barts Health NHS Trust was audited to assess compliance with the BOAST 7 Fracture Clinic Services guidelines, and to identify areas requiring improvement.

Method

All VFC referrals between 10/05/2021 to 28/05/21 were analysed across the Barts Health NHS Trust. Data was collected on discharge rates, type of injuries seen, inappropriate referrals, time to be seen, and time to further imaging.

Results

A total of 1,039 patients were reviewed in VFC. 54% included upper limb injuries and 46% lower limb injuries. 51% of patients were discharged following initial VFC review by an orthopaedic consultant. Mean time from injury to VFC review was 2.33 days. Mean time VFC to face-to-face review was 15.17 days, and mean time to advanced imaging was 30 days. 9% of injuries did not match pre-existing injury diagnosis codes (including hand injuries and injuries without enough clinical detail provided).

Conclusions

This audit of the VFC at Barts Health NHS Trust identified several areas requiring improvement. Waiting times for investigations were often unacceptably long. Inappropriate referrals frequently led to delayed, or otherwise avoidable face-to-face appointments. Following these findings, the Orthopaedic department plans to address these identified weaknesses through means of increased funding and staffing; educational support to A&E staff; and updated VFC protocols. A re-audit will subsequently follow to assess the impact of these interventions.
385 Service Evaluation of the Management of Acute Cholecystitis in the Royal Gwent Hospital Pre and During the COVID-19 Pandemic
Authors: Mukhopadhyay S , Taylor L , Rasheed A
Published: November 2022

Aim

NICE guidelines set out the criteria for the treatment of patients with acute cholecystitis and the operative timescales for cholecystectomy. These targets were greatly affected during the Covid-19 pandemic. Therefore, we aimed to assess the impact that COVID-19 had on patients presenting with acute cholecystitis at a busy district general hospital. June 2020, compared with patients who presented with the same in June 2019.

Method

Patient cohorts were identified for matching seasons pre- and post-covid-19 (June 2019 and June 2020). Data of all patients who presented with acute cholecystitis was obtained using an electronic patient management system. Statistical analyses were performed using a Wilcoxon test.

Results

The results of the study indicate that waiting times post-covid are going down (p<0.05). Thus, days until cholecystectomy have decreased but the number of patients being operated on too has decreased thus further worsening waiting times for elective patients. The median and IQR's of days to surgery post-covid are 198 (121.5–278) and pre-covid are 251 (89.5–586.5). Presentations of gallstone complications almost doubled post-covid and the percentage of patients operated on decreased by over 20%.

Conclusions

It is clear from the data that the NICE guidance on the management of acute cholecystitis has been difficult to adhere to during the pandemic. While the time from diagnosis to operation has reduced post-covid the total number of operations has decreased drastically, putting further strain on elective waiting lists. This, inevitably, will result in further presentations of complications from gallstones and adverse patient outcomes.
431 Writing the Right Way! Improvement of Operation Notes in an Orthopaedic Ward – a Closed Loop Audit
Authors: Ijaz O , Waqar Bhatti H , Ahmed R
Published: November 2022

Introduction

Operation notes are recognized as standard for documentation of details of operation but still it's often neglected. Proper documentation is necessary as it is correlated with good patient care, quality assurance, future decisions, and medico-legal issues.

Aim

The objective of this study is twofold: one to compare the documentation of notes against standard RCS (Royal College of Surgeons) guidelines and secondly making sure that surgeons follow these by educating them through presentations, brochures, aide memoires and introduction of proformas.

Method

We prospectively studied 50 post-op notes against standard RCS guidelines consecutively both pre and post intervention. Asymmetric data was analyzed after 4 weeks using the Fischer-Exact Test and statistical significance was set as <0.05.

Results

A total of 18 guidelines were audited. First loop showed deficiencies in fields of elective/emergency, operative diagnosis, operative findings, complications, extra procedure performed, tissue removed/added, details of closure, blood loss and antibiotic prophylaxis. After intervention documentation improved and percentages rose and reached almost 100%.

Conclusion

Proper documentation is of great importance as it carries both medical and legal implications. Three step intervention showed remarkable improvement in documenting of these operation notes according to standard RCS guidelines.
472 Accuracy of Documentation and Handover of Surgical Operation Details in Cardiac Surgery
Authors: Hara N , Volpi S , Yates M , Corredor C , Shipolini A
Published: November 2022

Introduction

GMC Good Medical Practice Guideline states that documentation must be clear, accurate and legible. Accurate documentation of operation notes ensures proper postoperative care and forms important legal documents. This audit aims to assess the accurateness and consistency of recorded operation names throughout patients’ hospital stay following cardiac surgery, as well as the effect of standardisation of operation names to improve the accuracy of documentation.

Method

Patients undergoing cardiac surgery at St. Bartholomew's Hospital from November 29 to December 10, 2021, had data prospectively collected from their electronic patient records, which were compared to the standardised operation name. After the first audit cycle, junior medical staff were educated on the standardisation of operation names. Electronic patient records were reviewed again for patients undergoing cardiac surgery from January 10 to January 20, 2022.

Results

Following intervention, there were significant improvements in the accuracy of documented operation details. Initially, 65% of operation notes were accurately documented, whereas 96% of operation notes were completed to the ideal standard post-intervention. There was a 37% increase in the number of accurate discharge summaries, while inaccuracies and missing operation names were reduced to 0% from the initial 12%.

Conclusions

Accurate documentation of operation details is expected by GMC standards. Poor documentation can hinder the quality-of-care patients receive postoperatively. We have shown variation in descriptions of standard operations and multiple inaccuracies throughout patients’ hospital stay. We suggest agreed standardisation of operation details and education of junior medical staff regarding accuracy of documentation to enhance compliance with the GMC standard.
489 Imaging of Acute Pancreatitis in a UK District General Hospital
Authors: Lee CH , Taneja J , Kotamarthi A , Nita G
Published: November 2022

Aim

Imaging should not be routinely used in the diagnosis of Acute Pancreatitis unless there is: diagnostic uncertainty; failure to responding to conservative management; severity confirmation needed. It is suggested that optimal timing for CT assessment should be at least 72 hours after the onset of symptoms. We aimed to benchmark our unit and assess the imaging of Acute Pancreatitis and compare this against the standards set up by the Royal College of Radiologists (RCR).

Method

Patients with a CT proven diagnosis of Acute pancreatitis were included with data retrospectively collated and analysed over a 5-month period in 2021.

Results

30 consecutive patients with CT confirmed Acute Pancreatitis were included (57% male, 43% female; mean age: 53 years). 50% had optimal timing of scans (72 hours after onset of symptoms), 67% of scans were deemed appropriate (diagnostic uncertainty, assessing severity). 40% of CT reports did not comment on all 3 prognostic factors (presence of pancreatic necrosis; free intraperitoneal fluid; extensive peripancreatic fat stranding). Only 27% of patients had an ultrasound of the gallbladder within 24 hours of Acute Pancreatitis diagnosis.

Conclusion

The findings of this snapshot study is in line with the existing literature. Our unit does not meet the targets set out by the RCR (95%). There remains a need to standardise the approach to imaging and we aim to aid this by disseminating the study findings to the relevant departments and increasing knowledge amongst the clinicians. Re-audit is planned in the coming months.
515 Operative Documentation Audit of General Surgery
Authors: Darbi E , Ong CT , Mroczek T
Published: November 2022

Introduction

Documentation is an important part of healthcare practitioners’ daily routine. The importance of documentation is well stress in the literature and by the GMC's good medical practice. Good documentation ensures patients receive the best possible clinical care. Recently, the Royal College of Surgeons (RCS) published guidance aiming to improve the reported poor quality of operative documentation.

Method

The RCS operative notes guidelines were used as the audit criteria. These guidelines consisted of 19 domains and the adherence of the general surgery department operative documentation to each of these domains was measured. A 100% adherence to the RCS guidance was set as the audit standard. Data was collected during a period of four weeks from a set of General Surgery patients under the care of a random range of consultant surgeons.

Results

Data from 50 general surgery patients between 13/10/21 and 04/11/2021 were analysed. 47% of the 19 documentation domains stated by the RCS had 100% adherence. In addition, only 4% of the 50 patients’ operative notes had 100% adherence to all the 19 domains specified by the RCS.

Conclusion

Current operative notes documentation in the general surgery department does not meet the standards of this audit. However, possible areas of improvement are identified to bring current practice closer to the RCS operative notes guidance.