bluuebunny/crossref_metadata_2025 huggingface dataset:
212 Outcomes Of 25-Gauge Pars Plana Vitrectomy Surgery in Primary Rhegmatogenous Retinal Detachment in Pakistan: A Multi-Center Study
Authors: Hussain S Z M , Awan M A , Siddiqui M A R
Published: October 2021

Aim

To evaluate the primary anatomical success and visual outcomes in patients with rhegmatogenous retinal detachment (RRD) undergoing 25-gauge pars plana vitrectomy (25g PPV) surgery in Pakistan.

Method

This is a five-year retrospective, interventional cohort study of 418 consecutive patients with RRD who underwent 25g PPV. Surgeries were performed by two experienced surgeons at tertiary care hospitals in Pakistan. Consecutive patients, who underwent 25 g PPV surgery as treatment for RRD between October 2013-October 2018 were included. We excluded patients who had a history of previous retinal surgery or who did not complete the 4-8 weeks primary outcome visit. Data was collected from the patient’s files by using a pro forma. SPSS version 23.0 (IBM SPSS Statistics, Armonk, NY) was used. A p-value of < 0.5 was considered significant.

Results

We identified 452 patients through coding system of hospitals who underwent 25g PPV surgery between October 2013-October 2018. Secondary retinal surgery and incomplete follow up cases were excluded. A total of 441 patients’ files were reviewed for the study, out of which 418 patients met the criteria for final analysis. Males were in a higher number 284 (67.9 %). The average age was 49±15.8. In our study, 186 (44.4%) patients were phakic at the time of presentation. At 2 months follow up, the primary anatomical success rate was 87.1 %.

Conclusions

Surgical outcomes of RRD with 25g PPV surgery in our study were similar to the outcomes reported in the developed world. We propose a prospective multicenter national study to prospectively evaluate the risk factors for RRD surgical failure in the Pakistani population.
246 FRActure Clinic Treatment: a sURvey of patient Experience (FRACTURE)
Authors: Javed O , Khan M , Foxall-Smith M , Hafez A , Mason W
Published: October 2021

Aim

BOAST guidelines on fracture clinics suggest a standard of care that all patients with significant injury should expect to receive in a Trauma & Orthopaedics outpatient setting in the United Kingdom.

Method

A prospective analysis of 358 patients presenting to fracture clinic at Gloucestershire Hospitals NHS Foundation Trust from September to November 2020. Patients completed an anonymous questionnaire based on BOAST guidelines.

Results

Most patients received a written management plan (82%), but only some received a leaflet (36%) and definite information about their procedure (47%). Most patients felt a leaflet (72%) and information about procedures (87%) would be useful. Patients were generally seen early or within 30 minutes of their appointment time (77%), but some waited more than 30 minutes (23%). Most patients found X-rays easily (91%) and rated staff (97%) and fracture clinic experience (93%) as very good or good. Comments included noting an efficient and friendly service, with suggestions on providing more information on waiting times and procedures to be performed.

Conclusions

Our study showed high patient satisfaction with fracture clinic and particularly positive feedback about staff. Areas of improvement include providing more leaflets and information about practical procedures. Following this audit, we will produce leaflets on common conditions and record videos on common procedures such as application of casts, splints and removal of k-wires or sutures, which can be accessed by patients prior to their appointment. The audit could be repeated at a regional or national level to help centres assess the level of care provided.
264 Does the Introduction of Ward Round Stickers Improve Surgical Ward Rounds?
Authors: Sharma V , Fitzpatrick E , Sharma D
Published: October 2021

Aim

With surgical teams in the NHS pushed to their limit under unprecedented demands, simple and effective ways for maintaining standards of patient care are necessitated. This quality improvement project aims to implement user-friendly and coherent ward round stickers as an adjunct to surgical ward rounds to deliver standardised care.

Method

Baseline performance was measured against The Royal College of Surgeons of Edinburgh Surgical Ward Round Toolkit. Five recorded items were studied including: bloods, venous thromboembolism(VTE) prophylaxis, regular medications, observations, and handover to nursing staff. The surgical team was informed of the audit but not over which dates it would be conducted. In the first cycle, data was collected over a 4-week period. Ward round stickers were then implemented, and a second cycle was completed 2 months later over another 4-week period.

Results

Baseline performance recorded from 74 ward round entries showed checking of bloods, VTE, regular medications, observations and handover ranged from 0% to 65%. After the introduction of ward round stickers, a second cycle was performed from 81 ward round entities. There was significant improvement from baseline with compliance in recording all five items > 85%.

Conclusions

This quality improvement project showed that the use of stickers as an adjunct to surgical ward round is a simple and effective way of evidencing good practice against recommended standards.
278 Duration of Prescription of Dexamethasone in COVID-19 Pneumonitis
Authors: Moen C
Published: October 2021

Aim

The RECOVERY trial showed the effectiveness of using 10 days of dexamethasone for patients hospitalised with Covid-19 disease who required oxygen or mechanical ventilation while an inpatient. This QIP sought to measure compliance with this recommendation.

Method

Live data was obtained using University Hospital Crosshouse’s electronic prescribing system (JAC). The audit was limited to patients on Ward 2D, which at time of writing was one of the hospitals COVID 19 wards. The first audit was performed on Friday 13/11/20 at 18:00. All dexamethasone prescriptions had the duration of the prescription assessed (at the time all patients were on oxygen therapy for COVID-19 infection). Patients with a course longer than 10 days with explicit documentation to continue past 10 days were counted as a correct prescription in this audit. For the second cycle results were shared with middle tier doctors working on Ward 2D 16/11/20. Notices were also left on all computers on the ward with the message “Please ensure your patient is only prescribed a total of 10 days of dexamethasone unless an extended course is clinically indicated”. A third cycle was carried out 01/12/20. Notices were left on all computers in the combined assessment unit with the same message as above.

Results

It found most patients were receiving more than the 10 days due to prescription errors (86%). Teaching on the COVID ward resulted in 83% of the prescriptions being correct. Teaching in the receiving unit of the hospital resulted in no change.

Conclusions

Prescriptions of dexamethasone for Covid-19 patients requiring oxygen on ward 2D were found to be longer than the advised 10 days shown to be effective in the Recovery trial. Teaching on the ward was found to be an effective method to decrease prolonged courses of dexamethasone.
310 Cost Savings Through Utilisation Of Procedural Clinics Over Operating Theatres for Skin Lesion Excisions
Authors: Page D
Published: October 2021

Aim

Skin lesion excisions make up a significant proportion of procedures performed by General Surgical teams. A large proportion are performed under local anaesthetic (LA) alone and are frequently performed in a main operating theatre (OT) but would be amenable to been performed in a minor procedures clinic (MPC) which could represent significant savings for excision of lesions in terms of money and better utilisation of OT. The purpose of this study is to evaluate the proportion of skin lesions currently excised under LA in OT that would be amenable to been performed in MPC and calculating the cost saving associated with this in terms of dollars and time in OT.

Method

A retrospective audit was performed of all skin lesion excised in OT at 2 regional hospitals in Queensland between October 2019 and October 2020. Data was recorded for the type of anaesthetic used, type of lesion excised and total time each patient spent in the OT. Cost per minute of both OT and MPC time were estimated using standard costs.

Results

A total of 229 patients had skin lesions excised in an OT in this period. Of these, 102 (44.5%) of them were excised under LA alone and used 4930 minutes of OT time. The dollar saving of performing these procedures in a MPC over OT is estimated to be $147,874.00 (approximately 71% less).

Conclusions

Utilising MPC over an OT for excision of skin lesions under LA represents a significant dollar cost saving and opportunity cost saving.
315 Chaperone Documentation in The Breast Clinic: A Closed Loop Audit
Authors: Maden C , Lee A , Kelly M l , Im Y R , Barkeji M
Published: October 2021

Aim

Intimate examinations are potentially uncomfortable and embarrassing. In addition to offering chaperones routinely, it is also important to clearly document the circumstances, with implications on patient dignity and safeguarding both patients and staff. We aimed to analyse the quality of chaperone documentation in the breast clinic before and after intervention.

Method

Audit standards (GMC and Chelsea & Westminster Trust guidelines): [1] Consent [2] Chaperone use/refusal, and [3] Chaperone role and identity should be clearly documented in the notes. We collected breast clinic data prospectively over one week, then re-audited after interventions including teaching sessions to the breast MDT, introduction of electronic (e)-notes (Cerner©), and creation of an instructional video demonstrating how to create an automatic template to easily document the aspects of chaperone use.

Results

110 patients’ notes were analysed in the first cycle, and 74 in the second. Documentation improved significantly between cycle 1 and 2 for: consent (0% vs. 38%, p < 0.0001), identity of chaperone (12% vs. 35%, p = 0.0003), and role of chaperone (8% vs. 23%, p = 0.0091). Documentation for chaperone use or refusal improved, but this was not significant (27% vs. 35%, p = 0.3305).

Conclusions

Documentation improved significantly for most standards, likely due to the template prompting the clinician. However, documentation remains suboptimal. Possible reasons include forgetfulness in a busy clinic, or shortage of staff available to chaperone. Future recommendations include creating a mandatory template on the e-notes for all breast clinic documentation including a section for chaperone use, role, and identity, and providing more staff such as HCAs for the clinic.
342 A Closed Loop Audit on The Quality of Documented Consent in Orthopaedic Procedures
Authors: Bakhiet A
Published: October 2021

Aim

A thorough discussion of associated risks is essential when obtaining informed consent for any surgery. The consent form serves as a permanent record of the conversation and can have implications as a legal document in court. The aim of this audit was to assess the quality of documentation on consent forms for Orthopaedic procedures.

Method

Prospective data was collected from consent forms for patients undergoing 6 prespecified procedures and compared to British Orthopaedic Association (BOA) guidelines for consent. We analysed how many of the risks had been documented on the form, and whether the incidence of these risk was emphasised. The data was then collated, analysed and presented at a local trauma meeting.

Templates for consent were printed and inserted into consent booklets on the ward to serve as a memory aid. Data was prospectively collected again to complete the audit cycle.

Results

Prior to the implementation of the consent templates, 8% of consent forms mentioned all possible complications, with 12% emphasising the incidence of the main risks. Post intervention, all significant risks were listed in 29% of forms, with 33% listing the risks in a logical order and emphasising their incidence.

Conclusions

The process of obtaining consent is a complex but crucial component of surgical practice, with the consent form serving as an important medicolegal document. This study shows that the use of pre-printed consent templates to aid memory can improve documentation and can be adapted and individualised accordingly for each patient.
398 Outcome of Laparoscopic Cholecystectomy in Patients Over 80 Years Old
Authors: Gumaa D , Hunt A , Karunaratne D , Shresta S , Al-Robaie B
Published: October 2021

Background

Gallstone disease is a common cause of morbidity in old patients. Conservative treatment is usually the first line of treatment due to concerns about the risk of surgery. In our study we are trying to assess the outcome of laparoscopic cholecystectomy in patients over 80 years old.

Method

Retrospective cohort study done in a large district general hospital where good number of laparoscopic cholecystectomy is done every year. Main outcome is Mortality, return to theatre and post op ITU admission. Data collected from patients records.

Results

74 patients in total were operated on. 14 operations were done as emergency (during the same inpatient admission). Indication for surgery varied between cholecystitis, pancreatitis and biliary colic. But the main indication in the emergency group was acute cholecystitis. 55 % of the patients had significant medical background with ASA 3. 30 days mortality was 0 in both emergency and elective groups. 2 patients required ITU admission post op, mainly for premorbid status, and both were in the emergency group. There was only one return to theatre in the emergency group for washout. 90% of the elective group patients were done as day case with no post op complications.

Conclusions

Laparoscopic cholecystectomy is safe operation to be done in the elderly population. ITU admission is mainly because of the patient’s co-morbidities so patients should be selected carefully and have proper pre op assessment.
408 The Swiss Cheese Effect: Following Lower Limb Emergency Admissions Through Hospital
Authors: Daga K , Sara X , Le Blevec L , Khalfaoui M , Charalambous N
Published: October 2021

Introduction

The Swiss cheese model analyses failure in a system: when holes align this creates ‘a trajectory of accident opportunity’. In healthcare this could translate to morbidity and/or mortality of patients. We investigated potential points of failure in treating lower limb injury patients through their hospital journey. Three points were investigated: (1) prescription of venous thrombo-embolism (VTE) prophylaxis, (2) operation note information and legibility (3) time delay in post-operative blood tests.

Method

A total of 105 patients of emergency lower limb surgical patients were identified retrospectively from two centres across the North West Region between the 31/07/20 and 21/11/20. Data was collected on (1) prescription of thrombo-prophylaxis, (2) information recorded, and legibility of operation notes as per RCSEng and (3) time delay in post-operative full blood count when compared to operation note recommendation.

Results

We found that between 10-55% of patients were prescribed anti-embolism stockings versus 100% given chemical anti-coagulation on day 1 of admission. Of a total of 23 data points, the mean number of points missing on operative notes was 4.90 (range: 2-10). A total of 82.5% handwritten operation notes were deemed legible. Post-operative full blood counts were ordered in 83.3% of patients, with the first order ranging between 1-5 days post operatively.

Conclusions

The cumulative effect of having these errors at all three points greatly increases the chance of morbidity/mortality of patients. Our experience demonstrates a failure to meet trust and Royal College of Surgeon’s guidelines. We aim to re-audit this nationally with our planned intervention.
499 A Retrospective Audit on Detection Rate of Clinically Significant Cancer Among MP-MRI Targeted Biopsy – A Single Centre Experience
Authors: Zuling E T , Murali-Krishnan S
Published: October 2021

Men with high serum prostate specific antigen (PSA) typically undergo standard transrectal ultrasound-guided prostate biopsy (TRUS-biopsy) during which 10 to 12 cores are obtained. TRUS-biopsy can cause side-effects including bleeding, pain, and infection. Multi-parametric MRI (MP-MRI) used as a triage test might allow men to avoid unnecessary TRUS-biopsy and improve diagnostic accuracy. According to the renowned PROMIS study, for clinically significant cancer, MP-MRI was more sensitive and less specific than TRUS-biopsy. In this study, we performed a single centre, retrospective audit on the detection rate of clinically significant cancer among MP-MRI targeted biopsy and compare it with the standard TRUS biopsy. Clinically significant cancer is defined as Gleason score ³ 4 +3 or a maximum cancer core length 6mm or longer. Besides, we also compare the rate of clinically significant cancer in MP-MRI targeted biopsy against the PROMIS study. Through this audit, we found that in 2019, there is a 54% (60 out of 112 patients) of clinically significant cancer in MP-MRI biopsy and 41% (26 out of 64 patients) of clinically significant cancer among standard TRUS biopsy. Comparing it with the PROMIS study in which clinically significant cancer was detected in 38% in the MP-MRI targeted biopsy group and 26% in the standard-biopsy group, the adjusted difference in our study (13%) is similar to PROMIS study which is 12%. In conclusion, our study reaffirms that MP-MRI targeted biopsy reduce over-diagnosis of clinically insignificant prostate cancer and improve detection of clinically significant cancer.
531 An Admission Proforma to Improve Clerking Documentation in the ENT Department During the Covid-19 Pandemic: A Full Cycle Audit
Authors: Brown G , Ashton C , Poulios A
Published: October 2021

Aim

Good Surgical Practice states that surgeons must ensure that accurate, comprehensive, legible and contemporaneous records are maintained for all their interactions with patients. It is therefore critical that the clerking document, as the initial record of an admission, meets this standard. During the Covid-19 pandemic, an emergency rota meant that cross-covering of ENT at junior level was increasingly required in our hospital. Understandably, these trainees were less familiar with admitting ENT patients and of departmental standards. Our aim was to evaluate the quality of clerking documentation in our department during this period and investigate whether a standardised admission proforma could improve this.

Method

Clerking documents for all patients admitted in April 2020 were checked for completion of venous thromboembolism (VTE) risk assessment and inclusion of ten key pieces of information as outlined by the Surgical Tool for Auditing Records score. As was standard at this time, all clerking documentation had been completed on blank hospital continuation paper. A departmental admission proforma was introduced before admissions in June 2020 were then assessed identically.

Results

Improvement was noted in all measured parameters with no adverse effects. There was particular improvement in documentation of referral source (28% to 97%), consultant in charge (35% to 90%), name/grade/bleep (25% to 94%) and VTE risk assessment (14% to 78%). Trainee response was positive.

Conclusions

A simple admission proforma can markedly improve the standard of clerking documentation and therefore increase patient safety during a turbulent time. We would encourage other departments to consider developing their own.
543 Improving the Management of Acute Ureteric Colic in A Multi-Centre District General Hospital: A Closed-Loop Audit
Authors: Desai C , Bruce A , Ehsanullah S A , Otite U , Ahmad S
Published: October 2021

Introduction

The British Association of Urological Surgeons (BAUS) released guidance in 2018 regarding the optimum management of acute ureteric colic: a condition which can present as a surgical emergency. Our aim was to review the current practice at our hospital in diagnosing and managing acute ureteric colic and ultimately, implement sustainable change to address any areas of limitations.

Method

The following data was retrospectively collected for of all patients admitted with acute ureteric colic: investigations performed, medications administered, details of surgical intervention and follow-up. 1st Cycle: March 2017 to February 2018. Intervention: Teaching sessions delivered to staff (including doctors and nurses) in the A&E and urology department. 2nd Cycle: January 2019 to December 2019.

Results

268 patients presented to A&E with ureteric colic – 18% increase from previous year. On admission: 60.4% of patients had serum calcium checked, 97.7% had a CT KUB performed within 24 hours and 67.2% were given NSAIDs; this is a 20.4%, 0.4% and 5.2% increase from the previous year, respectively. Only 31.3% of patients had an acute surgical intervention. The average wait time for clinic follow-up was reduced to 41 days following departmental education, but only 26.4% of patients were seen within the BAUS advised 4-week timeframe.

Conclusions

Re-audit showed distinct improvement in the management of acute ureteric colic. Thus, departmental education strategies have had a positive impact. It is recommended that the reservation of one daily elective theatre slot for an emergency operation and a computerised clinic booking system will further optimise our management in line with BAUS guidance.
603 VTE Prophylaxis Compliance on The Burns Unit
Authors: Sayed M A , Murray E , Soueid A
Published: October 2021

Aim

To assess if VTE risk assessments are correctly completed and implemented on the Burns Unit.

Method

2-week prospective analysis of all inpatients admitted to the adult Burns Unit. Data was collected from patient files and drug Kardexs. Variables including TBSA, date of injury, date of admission, date of VTE risk assessment score, correct prescription according to score and implementation were compiled in an excel spread sheet. Audited against Trust and NICE Guideline 89.

Results

The first cycle identified errors in risk assessment completion related to inaccurate BMI assessment and failure to identify the burn as a risk factor. The risk assessment was only re-assessed 71% of the time post operatively or following change in condition. An action plan included re-education of medical staff, reminder posters in theatre and re-designing the burns operation note to include a VTE re-assessment tick box. A re-audit showed an improvement in correct VTE scoring from 65% to 100% and VTE reassessment from 71% to 100%.

Conclusions

Following the first cycle, Wythenshawe Hospital Burns Unit has improved in compliance with the NICE and Trust Guidelines. The two most frequent errors identified on completion of the risk assessment form have not been seen in the second cycle following education of medical staff. All patients should continue to be prescribed the prophylaxis indicated, unless contraindicated. For those patients who cannot wear AES due to a burn to their lower legs, flowtrons and/or enoxaparin should be considered instead. For those patients who refuse treatment an incident form must be completed.
606 AUDIT: IV Fluid Prescribing in Surgical Patients
Authors: Shakir T , Mills E , Koomson A , Iqbal M
Published: October 2021

Aim

A recent change to electronic fluid prescribing has enabled us to evaluate our adherence to recommendations. NICE clinical guideline 174 states that patients should receive 25-30ml/kg/day water and 1mmol/kg/day of sodium, potassium, and chloride with regards to maintenance fluid therapy. We retrospectively audited our practice in surgical patients.

Method

Patients were selected from two surgical inpatient wards in a district general hospital utilising random sampling over a one-month period. Prescribed intravenous fluid (IV) therapy over a 24-hour period was collected; in addition to weight, presence of an acute kidney injury (AKI) and indication for IV replacement (maintenance versus resuscitation).

Results

50 patients were identified during the period. All of them were emergency presentations. Maintenance fluids were prescribed for 76% of patients. No patients had an AKI at time of data collection. The mean weight was 75kg. Overall, patients received a mean fluid volume of 2.3L/day. The mean concentration of electrolytes administered over a 24-hour period were: Sodium 297mmol, Potassium 13mmol, Chloride 237mmol. When adjusting for patient weight, this resulted in a net administration of: Sodium +221mmol, Potassium -62mmol, Chloride +162mmol.

Conclusions

Three quarters of surgical patients were administered maintenance fluids. The electrolyte contents of these fluids were inadequate. Patients received 295% excess Sodium, 216% excess Chloride, and 82% less than the recommended daily requirement of Potassium. We aim to introduce a protocol for maintenance fluid prescribing, in addition to teaching sessions, that would allow for adherence to guidelines and improve patient care.
636 Optimising Operative Capacity for Hand Trauma - An audit
Authors: Shahid S
Published: October 2021

Aim

Assess compliance with departmental and BSSH guidelines for hand trauma. Optimise operative capacity within the department. Promote minor ops experience among the junior doctors.

Method

Retrospective review of the overbooked patients seen in the Hand trauma Unit (HTU) in August 2020 using the eTrauma system and time to operation using the Lorenzo patient record system.

Results

Overall Local Compliance rates

Overall BSSH Compliance rates

Main area of non-compliance was waiting time for tendon operations, with a 30% breech rate (>5 days waiting time).

Conclusions

Interventions before re-audit: On call junior doctor to be based in HTU for the whole day- will allow for minor procedures (nail beds and skin lacerations) to be done at bedside. The above will free up capacity in the minor ops theatre for tendons.
668 Inguinal Hernia Repair: Are We Compliant with The Recommended Consent Process?
Authors: Barghash M , ElGhobashy T , Cheema N , Mansour M
Published: October 2021

Aim

Inguinal hernia repairs are one of the most commonly performed operative procedures in the UK. An adequate consent process gives the patient the autonomy in making decisions related to their care and treatment. In this project, we were auditing whether hernia patients have gone through a standardised consent process from time clinic presentation up to the day of surgery.

Method

This was a retrospective audit based on the Royal College of Surgeons’ (Good Surgical Practice) guidelines and trust local policy. We assessed 50 case notes for patients who had inguinal hernia repair between November 2019 and November 2020 in two of the busy district general hospitals in the UK.

Results

We found that our practice was fully compliant with documenting patient demographics, signatures, and the name of the procedure in the consent forms. Documented discussion prior to surgery was found only on79% of clinic letters. Poor compliance was noted in documenting some of the possible risks in the consent form including testicular atrophy (59%), injury to vas, vessels, and nerves (56%), wound complications (49%), chest infection (24%). Zero compliance was noted in documentation missed hernia and mortality as potential risks to the procedure.

Conclusions

A detailed documented discussion with the patient in relation to benefits, risks, and alternatives of surgery should take place on clinic presentation as well as on the day of surgery to ensure compliance with the consent process.
683 Minimum Data Set in Documentation of Operative Findings in Diagnostic Laparoscopy
Authors: Nakhuda S , Liyanage A , Satchidanand R
Published: October 2021

Aim

Legible, accurate and clear documentation of operative findings is an integral part of patient safety, with guidelines from the Royal College of Surgeons and General Medical Council having clear standards of operative note-keeping. However, a substantial variation in the quality and accuracy of these notes can still be observed in everyday practice. We recognised the significance of a minimum set of data in operative record keeping for diagnostic laparoscopies as a standard, to improve quality and uniformity.

Method

We retrospectively examined 50 diagnostic laparoscopies over 6 months and assessed their operative notes against the guidelines described above. We found that there was no clear uniformity in reporting, subjective descriptions used and a significant amount of under-reporting of operative findings. We developed a proforma as a substitute for the documentation of operative findings which was implemented in the second phase of the audit and the compliance was assessed over a 3-month period.

Results

We found that usage of the proforma was limited (9/22), however those notes using the proforma were compliant with the guidelines for operative note keeping, to a much higher degree than those without. All the operative findings were documented for 100% of those notes which used the proforma; for those using freehand notes, only the appendix was identified to the same standard, which is explained by all diagnostic laparoscopies proceeding to appendicectomies.

Conclusions

Using a proforma as standard record keeping can improve the quality and accuracy of operative notes and thereby help improve safety and quality of patient care.
704 An Audit of Marking of Cutaneous Lesions in A Two-Week Wait Skin Malignancy Service
Authors: Sutcliffe A , Chang C , Sugden P
Published: October 2021

Aim

Clinical photography enhances a medical record and facilitates communication with other professionals involved in care. It is utilised frequently in the management of skin malignancy. The essence of good photography lies in accurate identification of the cutaneous lesion in question. National guidelines and local policy advise the use of circumferential marking to delineate a lesion of interest, and an alphabetical system for marking of multiple lesions. We audited compliance to standards for medical illustrations of cutaneous lesions in the two-week wait skin cancer clinic at University Hospital North Durham.

Method

Prospective audit of patients attending the clinic over a 7-day period (07/09/20-15/09/20). Data was collated from electronic records on a number of variables.

Results

175 patients met inclusion criteria. The majority (n = 160, 89.9%) were referred for a single lesion, the rest for multiple lesions. Hospital clinical photography was obtained in 148 patients (83.2%). Marking was deemed inappropriate in 44.6% of those in which clinical photography was obtained. Of these 66 cases, 12 cases were multiple lesions marked without letters, 52 had an incorrect indicator for the lesion (such as arrows or dots, allowing more ambiguous interpretation), and 8 had no indicator at all. Incidentally, one patient was photographed with dressings covering the lesions.

Conclusions

Compliance with standards for demarcation of skin lesions for clinical photography was found to be poor. This permits the wrong identification of lesions in future treatment episodes and could potentially have a significant impact on care. We propose the introduction of a referral document illustrating correct marking guidelines.
722 Review of The Introduction of Pre-Biopsy MRI Scanning in The Diagnostic Pathway for Prostate Cancer
Authors: Soma A
Published: October 2021

Introduction

The diagnostic pathway for prostate cancer has changed recently with the introduction of a pre-biopsy MRI. This audit aims to identify whether this change helps the University Hospitals of Morecambe Bay NHS Foundation Trust meet the national standard of referral to treatment time of 62 days.

Method

This audit will follow the individual journeys of patients on the previous (05/2017 – 05/2018) and new pathway (08/2018 – 04/2019). In addition, they will be divided based on the treatment they chose – surgery or radiotherapy.

Results

Old pathway:

New pathway:

Conclusions

Comparing the new pathway to the previous, there is a reduced proportion meeting the RTT. One way to combat this is ensuring patients have their MRI scans, if suitable, prior to their first clinic, which shows to be the most effective way to meet the RTT.
764 Is Consent Valid in Common Orthopaedic Surgeries?
Authors: Byrne A , Galhoum M , Prasad R
Published: October 2021

Aim

Consent is at the heart of the doctor-patient relationship. Valid consent should be voluntary, informed and the patient must have the capacity to make the decision. It is the doctor’s responsibility to ensure the patient can make an informed decision. The aim of this audit is to assess the validity of consent within Salford Royal Foundation Trust Orthopaedic department.

Method

We retrospectively reviewed 225 consent forms for four common orthopaedic trauma procedures: 44 wrist ORIF, 48 ankle fixation, 71 hip hemiarthroplasty and 62 fixations with DHS. BOA-endorsed OrthoConsent and SRFT-produced leaflets were utilised as a standard for reported surgical risks and complications. Collated patient consents were compared against these standards. Exclusion criteria included consent four and polytrauma patients.

Results

96 forms were excluded leaving 129 consent forms. In all four procedures, 86%-100% had documented infection, nerve injury and bleeding. Compartment syndrome was not documented for any wrist ORIF patients. CRPS was recorded in only 57% of wrist and 31% of ankle ORIF patients. Wound healing complications was documented in 17% of ankle ORIF. In 71% of DHS and 64% of hemiarthroplasty patients, risk of death was not recorded.

Conclusions

Targets for achieving satisfactory consent form documentation were not met and showed significant variation amongst clinicians. It suggests that patients are not being fully informed of benefits and risks of surgery. Recommendations include the introduction of posters and encouraging printing off patient information leaflets and improving education on valid consent for rotational doctors.
768 Impact Of COVID-19 And BOAST Standards on Surgical Management of Upper Limb Injuries in A Large Teaching Hospital
Authors: Naylor T
Published: October 2021

Aim

During the first peak of the COVID-19 pandemic, the BOA recommended that upper limb surgery for trauma should be avoided if possible, or performed as day-case if unavoidable, to reduce the risk of COVID-19 related negative outcomes. This audit assessed compliance with recommendations and impact on proportion of injuries managed conservatively due to COVID-19 risks, inpatient stay duration, COVID-19 infections, and corrective surgical intervention rates.

Method

Data was collected for all referrals to orthopaedics for upper limb fractures/dislocations at a large NHS teaching hospital in the North West over a 10-week period from April 4th to June 12th. Follow up was performed to 6 months after date of injury. Care was audited against the “British Orthopaedic Association Standard in Trauma: Management of patient with urgent orthopaedic conditions and trauma during the coronavirus pandemic”.

Results

A total of 112 patients were referred. 76% of patients were discharged from Emergency Department, with surgery indicated in 48%. Of those, 11% (n = 6) were not operated on due to COVID-19 risks and 1 patient from this group (16.7%) has required secondary corrective surgery. Surgery was completed as day-case procedure in 50%. COVID-19 swabs were not taken in 46% of referrals, 50% had a negative test and 4% positive. No patients tested positive after discharge following treatment.

Conclusions

Few cases were managed conservatively based on COVID-19 risk, and only 1 patient has required secondary surgery. More upper limb injuries may be managed conservatively, as per BOAST standards, with day-case procedures better utilised as an alternative.
767 Are Full Length X-Ray Radiographs of The Femur Required in Neck of Femur Fractures with Co-Existing Malignancy?
Authors: Ghobrial M , Vaidya A , Thahir A , Krkovic M
Published: October 2021

Introduction

It is common practice that we obtain full-length femur x-ray radiographs in patients admitted with a neck of femur (NOF) and a history of co-existing malignancy. The aim of this retrospective study is to evaluate the type of malignancies associated with NOFs and whether obtaining a full-length femur X-rays changes the treatment plan.

Method

Of the 2416 patients screened, 18% had co-existing malignancy (n = 431). The most common age to sustain a NOF with co-existing malignancy was 81, while 66% of them were females and 34% were males. The most common type of fracture sustained was an intra-capsular NOF (60%, n = 256), followed by inter-trochanteric fractures (31%, n = 133) and then sub-trochanteric fractures (9%, n = 42).

Results

The one-year mortality was 29% (n = 125). One in four of these fractures were associated with a co-existing breast malignancy (25%, n = 107), followed by prostate cancer (13%, n = 55). Bladder, colorectal, skin SCC and lung cancer each contributed 6-7% (mean n = 29). Other cancers contributed to the rest of the 36%. Metastatic cancer to the skeletal system was noted in 7% of the patients(n = 30), resulting in a pathological fracture and 20% (n = 6) of these were contributed by a primary lung cancer. All in all, all of the 30 patients who had distant bone metastasis underwent the treatment they normally would undergo had the leg length femur X-rays not been done.

Conclusions

In our series of patients with NOF fracture and existing skeletal metastatic deposits, the leg-length femur X-rays did not add any value related to the way the fractures were managed.
860 Distal Radius Fracture Management in A DGH Do the Guidelines Fit?
Authors: Thumbadoo R , Patel B , Fennelly J , Kitaoka S , Adamu-Biu F , Chennagiri R
Published: October 2021

Aim

Distal radial fractures are common injuries within adults at a variety of ages. The best treatment option remains a debated subject. The BOAST guidelines aim to guide the initial management of these fractures in the emergency department we audited against these guidelines in a local district general hospital.

Method

A retrospective audit was performed of adult patients with distal radius fractures who attended in December 2019, at a local district General Hospital. Patients were identified by using the Orthopaedic Take lists. Notes were reviewed for patient demographics, quality of documentation of neurovascular status, documentation of fracture information, including further management.

Results

There were 16 cases identified, 87.5% were female with mean age of 63 with over 56 % in the over 65s category. Only 19% of cases had appropriately documented neurovascular status. 57% were lacking specific documentation of each nerve as per BOAST guidelines, as well as 57% had no documentation of radial pulse. With regards to reductions undertaken in ED only 44% were documented if reduction took place. Of the reductions that were documented 66% documented type of analgesia used. 17% used regional anaesthesia as preferred in BOAST guidelines.

Conclusions

Overall compliance with BOAST guidelines was poor. Several areas to improve were seen, for which the recent launch of a new in-house smartphone application is aimed to improve access to BOAST guidelines. There was great difficulty in achieving the BOAST guidance with regards to the use of regional anaesthesia, nationally most A&E departments reduce these fractures under a haematoma block.
1022 Equivalent Management for All Fragility Fractures Occurring in The Older Patient
Authors: Lenihan J , Waseem S , Rawal J , Hull P , Carrothers A , Chou D
Published: October 2021

Aim

Neck of femur fractures (NOFs) are painful and occur in a vulnerable group of our population. Complications occur if their pain is under treated. Optimal management in the United Kingdom is governed by Best Practice Tariff (BPT). This was extended in 2020 without supporting published evidence to include all femur fractures (ROFs).

We sought to compare PRPS for NOFs and ROFs throughout hospital admission.

Method

We performed a retrospective matched analysis of all isolated osteoporotic ROFs to NOFs at our centre between 2018-2019. We analysed electronic patient records for relevant data. Matching criteria included Age +/- 2 years; cognition; walking aids; ASA; and social residence. Primary outcome measure was patient-reported pain scores (PRPS) at set time points. Secondary outcome measures were peripheral nerve blocks (PNB); patient controlled analgesia (PCA); time to surgery; anaesthetic type; length of stay (LOS); weightbearing status and 30-day mortality. Data was statistically analysed.

Results

11 ROFs were matched to 104 NOFs. There was no statistical difference between the two groups for age, sex, nor cognition and no difference in time to surgery; anaesthetic type; LOS; nor 30-day mortality. ROFs were more painful at all time points although not statistically significant. ROFs were more likely to have traction; PCA both pre- and post-operatively and not to weight bear. NOFs were more likely to have a PNB.

Conclusions

ROFs are as painful if not more so than NOFs. Few ROFs receive PNB and require PCA. Better control of symptoms may improve outcomes. We support the extension of BPT.
1053 Comparing MRI Parameters in Quantifying Patellofemoral Instability
Authors: Nagi S , Hing C
Published: October 2021

Aim

Patellofemoral instability is where various stabilising factors of the patellofemoral joint undergo pathomorphological changes. It has an incidence rate of 5.8 per 100,000 in UK and has been associated with osteoarthritis[1]. Variations in the factors that stabilise the patellofemoral joint can be observed on MRI including measurements of the trochlea in relation to the patella, the femur and soft tissue changes. This study aims to compare different measures used to detect and quantify patellofemoral instability on MRIs and to look for any significant difference in their use both in isolation and together.

Method

109 MRI reports of 78 patients diagnosed with patellofemoral instability were reviewed and all quantitative and qualitative parameters reported were inputted in a data table. Quantitative elements known as the Dejour protocol included the trochlear sulcus angle, patellar tilt angle, tibial tuberosity-trochlear groove distance and the Insall-Salvati ratio. Qualitative factors involved facet changes, patellar position, and any damage to soft tissue.

Results

It was found that the Insall-Salvati ratio greater than 1.2 and the patellar tilt angle of greater than 11 degrees irregular ranges had the greatest incidence in the MRI reports found 77.1% and 87.6% respectively in MRIs that reported them.

Conclusions

There is a discrepancy between quantitative parameters in their correlation with patellofemoral instability for the MRI reports observed. [1]: Ye Q, Yu T, Wu Y, Ding X, Gong X. Patellar instability: the reliability of magnetic resonance imaging measurement parameters. BMC Musculoskeletal Disorders. 2019;20(1).
1188 Management of Prosthetic Joint Infections and Fracture Related Infections at A District General Hospital
Authors: Rajgor H , Ponniah G , Li M , Osman K , Moores T
Published: October 2021

Aim

The aim of our study was to determine if there was cohesion in management of orthopaedic infections between the surgical and microbiology team to ensure optimal patient outcome in accordance with BOA standards for management of Orthopaedic infections. Surgical sampling intraoperatively of orthopaedic infections was evaluated.

Method

We retrospectively reviewed 19 patients that had suspected PJI or fracture related infections between July 2019 to December 2019 at a District General Hospital. Patient information was collated from patient notes, fusion, bone infection database and MDT notes. Analyses were performed using R (R Foundation for Statistical computing, Vienna, Austria).

Results

19/19 patients had a preoperative antibiotic plan prior to index surgery. 0% of discharge summaries contained information for patients or primary care staff regarding management of a suspected orthopaedic infection. 100% of patients who were septic were reviewed by a consultant within 24hours of admission. 72% of patients that had operative intervention had 5 microbiology + 2 histology samples. 0% of patients had surgical recording of process of sampling. All patients were discussed at the newly formed Bone infection MDT with a microbiology consultant, radiologist, and allied health professionals.

Conclusions

For optimal management of orthopaedic infections an MDT approach is vital. Early microbiological input and appropriate surgical sampling and debridement are key to providing a diagnosis of deep infection. The newly created PJI pathway will aid future management of orthopaedic infections and standardise care.
1260 Comparison of the Intramedullary Nail and Dynamic Hip Screw in the Management of Subtrochanteric Femoral Fractures
Authors: Arshad Z , Thahir A , Rawal J , Hull P , Carrothers A , Krkovic M , Chou D T S
Published: October 2021

Aim

Subtrochanteric femoral fractures are said to occur in the 5cm of bone immediately distal to the lesser trochanter. This study aims to compare peri-operative outcome measures in patients with subtrochanteric fractures treated with either an IMN, or an alternative construct, the dynamic hip screw (DHS).

Method

A retrospective review of all subtrochanteric fractures presenting to our institution between October 2014 and May 2019 was performed. All patients were classified into two treatment groups, IMN or DHS. These groups were compared on outcome measures including radiation dose area product (DAP), length of hospital stay, estimated blood loss, mortality, and re-operation/complication rate.

Results

A total of 86 patients presented to our institution with a subtrochanteric femoral fracture during the study time period. Of these, 74 (86%) received an IMN and the remaining 12 (14%) received a DHS. The only comparative outcome measures showing a statistically significant difference between the two groups were radiation DAP and blood loss., both of which were significantly lower in the DHS group. All other comparative outcome measures failed to reach statistical significance.

Conclusions

Although current United Kingdom national guidelines advise all subtrochanteric femoral fractures should be treated with an IMN, the outcome measures used in this study suggest that the DHS, which also has a reduced implant cost compared to an IMN, may be the better option in some cases. There may not be one optimal implant for all subtrochanteric fractures. Recent biomechanical research suggests that the DHS is able to provide adequate fixation in more stable fracture subtypes, whereas an IMN may be required for unstable subtrochanteric fractures.