bluuebunny/crossref_metadata_2025 huggingface dataset:
896 Can We Count on Serum Hyperbilirubinemia to Predict Acute Complicated Appendicitis?
Authors: Jaskani S , Al-Hamid Z , Chattopadhyay D
Published: October 2021

Aim

Acute appendicitis (AA) is usually a clinical diagnosis and surgical intervention is typically a preferred choice to avoid potentially lethal complications like perforation and purulent peritonitis. Intra-abdominal inflammation can lead to hepatic cholestasis due to cytokine release, which can reflect as rise in bilirubin alone or in combination with other liver enzymes. The aim of this study was to evaluate hyperbilirubinemia as a predictor of complicated acute appendicitis (CA).

Method

A retrospective analysis of all the patients who underwent surgery for AA in a district general hospital in the UK from Jan 2018 to April 2019. All the patients underwent admission blood tests including White cell count (WCC), C- reactive proteins (CRP), and liver function tests (LFTs). For data collection hospital medical record was used. Complicated appendicitis (CA) was defined as Gangrenous, or perforated appendix wall, abscess formation, or generalized peritonitis.

Results

In total 236 patients underwent appendectomy. On histology 25 patients (10.6%) had normal appendix (NA). Furthermore, 161 patients (68.2%) had uncomplicated appendicitis (UA) and 50 patients (21.2%) had complicated appendicitis (CA). Serum Bilirubin (SB) was found to be statistically significantly raised in patients with CA (p value=0.0001) when compared with NA group. Overall sensitivity of SB, CRP and WCC for AA was(15.17%, 79.90%, and 57.82% respectively) and specificity was(100%, 36.36% and 68% respectively).

Conclusions

SB had low sensitivity and high specificity as compared to CRP and WCC for AA. Raised serum bilirubin levels can be considered as one of the supportive markers of complicated appendicitis.
1442 Are Blood Group and Antibody Screening Necessary Before Emergency Laparoscopic Appendicectomy?
Authors: Bhambra T , Pannu A , Jalal Q , Shah N , Rajput I
Published: October 2021

Aim

The incidence of bleeding complications in laparoscopic surgery are low. At present, there are no national guidelines on pre-operative blood group and antibody screening (G&S) in patients undergoing emergency laparoscopic surgery. The aim of this study is to establish the incidence of intraoperative bleeding requiring transfusion during emergency laparoscopic appendicectomy. In turn, this will indicate the necessity of routine preoperative G&S.

Method

Retrospective data collection of all emergency laparoscopic appendicectomy procedures at a large tertiary hospital from January 2015 to January 2020 (5 years). Patients having routine or open procedures were excluded. The transfusion department records were used to identify any patients receiving a transfusion intraoperatively.

Results

1362 emergency laparoscopic appendicectomy procedures were performed during the 5-year period. 4/1362 (0.29%) patients received intraoperative transfusion of blood products. Of these, 3 patients had known haematological disorders. One patient was transfused for bleeding associated with intraoperative miscarriage.

Conclusions

No patients required transfusion for surgical haemorrhage. The small number of patients requiring transfusion were predictable because of pre-existing haematological disorders and clinical status. Our data is one of the largest series available and the results demonstrate that routine preoperative G&S is not justified. Instead, a selective approach would ensure high risk patients are appropriately screened. In event of vessel injury and major haemorrhage, O negative blood can be used. Furthermore, we estimate that elimination of a routine second G&S sample could have saved our institution approximately £2500 per year.
439 Managing Parathyroid Carcinoma in the Age of COVID 19
Authors: Greene K , Truran P , Bliss R , Ramsingh J
Published: October 2021

Aim

Parathyroid carcinoma is a rare malignancy accounting for 1% of cases of primary hyperparathyroidism. Pre-operative diagnosis is difficult because in the absence of metastatic disease, the presentation is similar to benign parathyroid disease. In patients with hyperparathyroidism and severe hypercalcaemia or a significantly raised parathyroid hormone (PTH) level clinicians should consider parathyroid carcinoma and expediting surgical management. During the current pandemic, a high index of suspicion should be maintained to ensure that care is not compromised. A review of the management of patients with suspected parathyroid carcinoma during the COVID-19 pandemic is presented.

Method

In our tertiary referral centre for Endocrine surgery, 4 presentations of parathyroid cancer were reviewed. Their investigations, surgical management and post-operative outcomes are described with a brief literature review of parathyroid cancer.

Results

Of the four cases of parathyroid carcinoma described, all presented with severe hypercalcaemia and significantly raised PTH levels. Pre-operative mean calcium was 3.36mmol/L and mean PTH was 80pmol/L (52-99.8). Patients were imaged with a combination of cross-sectional imaging and ultrasound. Two patients had evidence of distant disease at presentation. 1 patient was transferred as an inpatient to our centre and the other three patients were seen within 2 weeks of referral; the mean time from referral to surgery was 14days (1-23). Post-operatively, all patients achieved normocalcaemia, with PTH levels normal in all but one.

Conclusions

Despite limitations on face-to-face clinic consultations and reduced capacity for elective surgery during the COVID-19 pandemic, all patients were investigated and managed promptly to ensure superior outcomes.
619 Is the Subdivision of Thy3 Nodules Needed? An Audit Reviewing the Management of Thy3 Nodules, and the Associated Malignancy Rates
Authors: Davies B , Sajjanshetty M , Thomas Z
Published: October 2021

Introduction

Following the 2014 update to the BAETS thyroid nodule cytology guidance, the management of Thy3 lesions was modified by subdivision into Thy3a and Thy3f categories. Both lesions remain indeterminate but are proposed to have differing risks of malignancy when counselling patents: these risks have been called into question by subsequent data.

Aim

This Audit aimed to review the management of Thy3 (Thy3a and Thy3f) cytological diagnoses, within an NHS Trust, and compare this to the BAET Guidance 2014. Further, malignancy rates for Thy3a and Thy3f cytology were made over the calculated over the time period.

Method

A retrospective Audit looking at 118 patients with a Thy3 cytology identified between 2014 and 2019. Data separated into data pre-2015 and 2015 onwards.

Results

In 2014, 29% of Thy3a nodules were managed in line with 2014 BAETS guidance. This improved to 34% from 2015. Meanwhile, Thy3f diagnoses were managed mostly in favour of the BAETS guidelines – 83% in 2014 and 92% 2015 onwards. The malignancy rates found, amongst all 118 patients, were 17.2% and 14.8% for Thy3f and Thy3a nodules respectively.

Conclusions

At this institution, Thy3 cytological diagnoses, regardless of classification into Thy3a or Thy3f, were largely treated in the same way (by a diagnostic hemi-thyroidectomy). The management of the nodules may reflect a variety of factors, including how comfortable patients and surgeons are when handling uncertainty. With malignancy rates for both Thy3a and Thy3f nodules being much the same, it is not surprising that they are managed in a similar way.
1481 Is Imaging for the Evaluation of Anosmia Really Necessary?
Authors: Boztepe S , Balakumar R
Published: October 2021

Aim

Although it is rare for anosmia to be caused by olfactory lesions, it is commonplace for some form of imaging to be undertaken to investigate olfactory loss in patients. This study aimed to identify the pick-up rate of pathology in patients who had an isolated complaint of anosmia.

Method

We undertook a retrospective study over a 2-year period between 2018 to 2020 in a teaching hospital. The cases were identified using the hospital radiology database for patients referred for CT or MRI of their head or sinuses due to anosmia. Patients referred with symptoms other than olfactory loss were excluded.

Results

Out of the 132 scans undertaken in this period, 52 were included with 47 being MRI scans. There were 5 (10%) patients who had intracranial pathology identified and these were all on MRI scans. Only 2 (4%) cases had actual olfactory tract-related abnormalities. This included absent olfactory bulbs and a soft tissue lesion within the region of the olfactory apparatus.

Conclusions

This study suggests a 4% pick up rate of olfactory tract-related pathology which demonstrates some value when investigating anosmia. However, with the large number of scans that do not alter management and the ever-increasing burden on our health system, large scale studies are needed to develop an evidence-based risk stratification approach.
1282 Evaluation of the Basket in Catheter Technique for Transcystic Bile Duct Exploration and Suspected Ductal Stones
Authors: Nassar A , Qandeel H , Khan K , Ng H , Hasanat S , Ashour H
Published: October 2021

Aim

The ‘Basket-in-catheter’ (BIC) technique facilitates laparoscopic transcystic ductal exploration (LTCE) and increases its success rate, being easier and safer than inserting the basket alone. This study evaluates the benefits in confirmed and suspected ductal stones.

Method

Prospective preoperative, operative and postoperative data on consecutive single session ductal explorations was collected over 28 years and analysed. BIC became our default technique for the transcystic approach to confirmed or suspected bile duct stones.

Results

741 of 1225 (60.5%) attempted LTCE were performed using retrieval baskets without dilating the cystic duct (CD). BIC was used in 646 (87.2%). Of 386 (52.1%) patients undergoing successful stone retrieval 62.7% had clinical and radiological risk factors for ductal stones and 92.0% had positive intraoperative cholangiography. 355 (47.9%) patients had preoperative or operative risk factors for CBD stones and equivocal cholangiography in 25%. Basket trawling was negative and repeat cholangiography confirmed resolution of abnormalities. Choledochoscopy was utilised in 484/1225 (39.5%), either primarily or when blind trawling failed to extract stones. Retained stones occurred in 7 patients, six requiring ERCP. Bile leakage occurred in 6 patients. There were two open conversions, no biliary injuries and no mortality. Post-operative pancreatitis occurred in 7 and recurrent stones in 8 patients.

Conclusions

The BIC technique achieves successful LTCE without CD dilatation in 40%, reducing the need for choledochoscopy and choledochotomy. It facilitates safe and speedy CBD trawling when stones are suspected due to preoperative or operative risk factors or equivocal cholangiography and helps surgeons acquire and consolidate ductal exploration skills.
442 COVID-19 And the Oral Surgery/Orthodontic Interface: Has A Delay in Treatment Complicated the Position of Unerupted And Ectopic Teeth Planned for Surgical Removal or Exposure?
Authors: Devine R , Holden A , Felstead A
Published: October 2021

Aim

To evaluate whether there has been a change in clinical or radiographic position and the resultant occurrence of complications of unerupted and ectopic teeth due to delayed treatment during the COVID-19 pandemic

Method

Data was collected over a three-month period at the Royal United Hospital, Bath, Oral and Maxillofacial Surgery Department. This was via a questionnaire distributed to clinicians and prospectively completed for each surgical procedure planned for the removal or exposure of ectopic canines, premolars, and supernumerary teeth.

Results

A total of 20 surgical extractions or exposures were performed during the three-month period, with 33% (n = 6) having a marked difference between their expected and final position. Complications occurred in 66.6% (n = 4) of cases that demonstrated a discrepancy in location. These were an increased surgical time, increased removal of bone or a cancellation of intended treatment. This cancellation occurred as the tooth had erupted enough for non-surgical management. In cases where there was no discrepancy (n = 14), no complications were reported.

Conclusions

These findings suggest the delay in treatment caused by the COVID-19 pandemic has resulted in a clinically significant change in the position of ectopic teeth planned for surgical removal or exposure. Given these findings, it is crucial that clinicians be aware that radiographic investigations are diagnostic and recent. The threshold for repeat imaging in all cases which have been delayed should be low to avoid unexpected surgical complications arising from inaccuracy in tooth localisation.
1110 The Cost of Fixing a Fractured Mandible: A Waste Reduction Project
Authors: Mitchell F , Parmar J
Published: October 2021

Introduction

Fractured mandibles are a frequent injury seen in the hospital and are commonly caused by interpersonal violence and accidental injury. The need to reduce expenditure in the NHS and redirect funds to where it is most needed is an important topic in recent times. The cost of open reduction internal fixation (ORIF) of mandible fractures can vary by the choice of equipment and technique used. Therefore, this waste reduction project aimed to identify any variation in treatment and minimise this.

Method

A data collection exercise was performed of isolated mandibular fractures which required surgical intervention. Operation notes were examined from April 2018 to March 2019, with 99 cases found. Information was collected about the number and type of drill bits, plates and screws that were used in the surgery. The expected cost for plating different mandibular fractures including simple, comminuted and multiple fractures was calculated which was compared to the actual average cost by type of injury and operating surgeon.

Results

The most common injury seen was Parasymphysis fractures, with the average ORIF cost across all surgeons being £239.07. The expected cost to fix this fracture was calculated at £237.95, or £325.31 if intra-operative intermaxillary fixation is used. It was demonstrated that the cost across all injuries was within the expected range and therefore no improvement could be made.

Conclusions

By limiting the available equipment, stocking the most cost-effective options, and teaching surgeons standardised treatments we are able to reduce the cost and waste in the hospital.
22 Motivations, Barriers, And Social Media: A Qualitative Study of Uptake of Women into Neurosurgery
Authors: Bandyopadhyay S , Moudgil-Joshi J , Norton E , Haq M , Saunders K
Published: October 2021

Objective

To explore how social media could be utilised to influence an individual’s motivation to pursue a neurosurgical career, an emerging topic area. The focus of this study was on women interested in neurosurgery.

Background

Women are significantly under-represented in neurosurgery. 18% of all neurosurgeons – including 8% of consultants – are women. Most previous studies have used quantitative methods that are not best suited to gaining an in-depth understanding of the barriers that women face in pursuing a career in neurosurgery, or what would enable more women to go into the speciality.

Method

In this qualitative study, individual semi-structured interviews were conducted until data saturation was achieved. Participants were women pre-neurosurgical trainees. The interview data was examined through a thematic analysis involving open and axial coding.

Results

Thirty women participated in the study. Four overarching themes were identified: (1) mentorship, (2) testimony from other women doing neurosurgery, (3) social media as a means of increasing interest in neurosurgery as a career choice, and (4) real-life exposure to the speciality.

Conclusions

There is scope to further improve uptake of women into neurosurgical training in the UK. Motivations and barriers to women pursuing neurosurgery should be addressed openly through early experience, role models and mentorship. Social media can help facilitate these opportunities, disseminate information and inspiration, and has the potential to undo societal biases.
1120 Clinical Applications of Local Field Potentials in Deep Brain Stimulation
Authors: Khan K
Published: October 2021

Aim

Local field potentials (LFP) are gathered when deep brain stimulation (DBS) electrodes are inserted into subcortical structures; however, the clinical application of these findings are unclear.

Method

A literature search was conducted using PRISMA guidelines, 231 papers were analysed for the literature review.

Results

The lack of dopamine in Parkinson’s disease (PD), is thought to increase the sensitivity of the basal ganglia-thalamo-cortical network to rhythmic oscillatory inputs causing pathological oscillations. Beta band frequency oscillations have been strongly linked to bradykinesia and rigidity in Parkinson’s disease patients. Whereas gamma oscillations were found to be prokinetic and possibly related to normal physiology. There has been varying views on LFP findings and tremor pathology, recent research has suggested a link between the ratio of slow and fast oscillations increasing resulting in a tremor. Studies found contradicting results with pathological oscillations, reasons for the variation include the time of the LFP recordings and the placement of the electrodes. The use of LFP presents a promising new technology namely adaptive deep brain stimulation (aDBS). aDBS has not been tested long-term in human patients, the safety and effectiveness long-term is unknown.

Conclusions

aDBS provide an exciting new technology however, the current evidence base provides a proof-of- principle, there are still many issues which need to be addressed before this can become an established treatment. With technological advances aDBS could revolutionise PD treatment and if perfected could potentially abolish patient’s symptoms completely.
973 Why Are Curative Treatment Rates So Low for Stage I/II Oesophago-Gastric Cancer in The West of Scotland?
Authors: Khan K , Gall L , Forshaw M
Published: October 2021

Aim

Over the last decade, quality performance indicators (QPIs) have been used to drive improvements in cancer care in Scotland. QPI-11 targets curative treatment rates for oesophago-gastric (OG) cancer and this target has been consistently missed. This study aimed to investigate why patients with potentially curable Stage I and II OG cancer did not receive curative treatment in the West of Scotland.

Method

The West of Scotland MCN database was interrogated for patients with newly diagnosed stage I and II OG cancer between January 2018 and December 2019 to identify those patients who did not have curative treatment. Electronic records were then analysed.

Results

81 patients (mean age of 79.3 ± 8.9 years; 41 (50.6%) female) were identified. Median Scottish Index of Multiple Deprivation was 3 (IQR 1-7). There were 46 (56.8%) oesophageal cancers, 49 (60.5%) adenocarcinomas and 63 (77.8%) were Stage II cancers. Formal CPEX fitness was assessed in only 6 patients (7.4%). Reasons for curative treatment not being received were as follows: not clinically fit (n = 69 (85.2%)); patient declined curative treatment (n = 7 (8.6%)); disease progression (n = 3 (3.7%)) and identification of synchronous cancers (n = 2 (2.5%)). 61 patients (75.3%) are deceased at the time of analysis, with a median time from MDT discussion to death of 6 (IQR 2-11.5) months.

Conclusions

Lack of fitness for radical treatment is the predominant reason for Stage I and II OG cancer patients in the West of Scotland not being treated with curative intent. This may be related to the previously described “West of Scotland” effect on health comorbidities.
471 C-Reactive Protein Accurately Predicts Severity of Acute Pancreatitis in Children
Authors: Walker H , Melling J , Jones M , Melling C
Published: October 2021

Introduction

Predicting severity of acute pancreatitis enables optimization of care, reducing morbidity and length of stay. Modified adult scoring systems have not yet been able to adequately predict severity in children. This study supports the use of CRP in children as a superior biomarker of acute pancreatitis severity compared with the modified Glasgow Pancreas score.

Method

This was a retrospective study of children presenting with a first episode of acute pancreatitis from 2002 - 2020 in a single tertiary paediatric surgical centre. Serum markers including CRP at 48 hours of admission were analysed. Statistical analysis included Receiver Operating Curve (ROC) analysis for promising biomarkers, and these were compared to the modified Glasgow Pancreas Score. A severe episode was defined by development of local complications and/or organ support. An Area Under Curve (AUC) >0.90 was defined as an excellent predictor of severity.

Results

Data of 59 children were analysed, median age 13 years, 22 (37%) patients had a severe episode. ROC analysis demonstrated CRP as the best predictor of severity, giving an AUC of 0.92. Optimum cut off value for CRP was 107. 5mg/L (p < 0.0001), producing 91% sensitivity and 84% specificity. This was significantly superior to the modified Glasgow Pancreas score, which gave an AUC of 0.66 (p < 0.0424) producing 36% sensitivity and 100% specificity.

Conclusions

We have shown that a CRP >107.5 within 48 hours of admission can be used to predict severity of acute pancreatitis in children with greater accuracy than current scoring systems.
468 Free Flap Breast Reconstruction in the UK: Are We Meeting the Demand?
Authors: Begaj A , Marlborough F , Allison K P
Published: October 2021

The demand for free flap breast reconstruction appears to be increasing. This study aims to evaluate the capacity for microsurgical breast reconstruction across the UK and compare this to the apparent demand to inform future workforce planning.

A questionnaire was sent to all the plastic surgery units in the UK to establish whether they performed reconstructive breast surgery, the number of free flaps they performed a year and what issues they were encountering in meeting the demand.

The response rate was 92.8% of 56 units. Current workforce planning figures show that there are 161 Consultant Plastic Surgeons who perform free tissue breast reconstruction. Across the UK, the total number of extra breast reconstructive surgeons felt to be needed was 78. The mean number of free flaps per year per surgeon was 20 [11-37]. Responders suggested that they felt 20 [12-30] free flaps were a suitable number to maintain their skills. 66% of the responders reported issues impairing delivery of their free flap service with access to theatre (41%) and inability to meet the demand (18%) as 2 of the key reasons.

Our results show that there is a demand for microsurgical breast reconstruction that is not being fully met at present. The authors hope that this survey may add to the evidence base that plastic surgeons remain an integral part of the care of many breast cancer patients and will encourage trainees to consider it as a subspecialty of choice.
600 Bilateral Upper Limb Compartment Syndrome After Massive Postpartum Haemorrhage
Authors: Payne A , Elahi S
Published: October 2021

Case Summary

Upper limb compartment syndrome (ULCS) is an uncommon limb-threatening emergency occurring as a result of increased interstitial pressure within osteofascial compartments. The overwhelming majority of causes occur in one limb, with frequent causes including fractures, reperfusion injury and burns. We report the unusual case of bilateral upper limb CS in a previously well 35-year-old female secondary to massive resuscitation following postpartum haemorrhage. The patient received 7 litres of blood products and 4 litres of crystalloid over a period of 8 hours. One hour postoperatively both hands became painful and swollen. Symptoms worsened over the following hour: both forearms were tense to palpate with demonstrable pain on passive extension of bilateral wrists and digits of the left hand, and capillary refill to all digits was brisk. Creatinine kinase was measured at 4,600U/L and bilateral forearm and left-hand fasciotomies were performed. The presence of bulging muscles in both forearms and the left hand confirmed the diagnosis of compartment syndrome, and perfusion was restored to all digits after release of the compartments. The patient later underwent split thickness skin grafting to both forearms and left-hand fasciotomy wounds. After 5 weeks of hand therapy, she regained good function of both hands. Bilateral ULCS is extremely uncommon but has been reported secondary to massive resuscitation, particularly in trauma patients, and we suspect that this was the cause in our patient.
1099 Financial Implications of Implementing MSLT-II Trial Findings for Treatment of Cutaneous Malignant Melanoma Patients in A Tertiary Referral Centre in The United Kingdom
Authors: Misky A T , Sadr A H , Nikkhah D
Published: October 2021

Aim

Cutaneous malignant melanoma is a significant public health challenge in the United Kingdom. Since the new American Joint Committee on Cancer (AJCC) version 8 definition of melanoma staging, more melanoma patients are eligible for sentinel lymph node biopsies (SLNB). Prior to the MSLT-II trial, SLNB positive patients were treated as a distinct group within cutaneous melanoma patients and in most centres would routinely undergo lymph node clearance (LNC) of the regional lymph node basin to control disease. Given the above developments in melanoma care, we compared the cost of SLNB and monitoring to the cost of LNC for patients with melanoma.

Method

We retrospectively reviewed all SLNB positive patients undergoing LNC or surveillance in 2019. We measured the cost of all clinical encounters for both groups and performed a cost analysis.

Results

Our study shows that the mean cost per patient of axillary LNC is £4731.64 and groin LNC is £5381.78 against a cost of £2896.67 for SLNBs. Mean inpatient stay was 2.8 nights following LNC and 0.11 nights following SLNB. 50% of LNCs and 11% of SLNBs were associated with post-operative complications.

Conclusions

Our data shows that treating uncomplicated SLNB positive patients with surveillance rather than immediate LNC results in reduced morbidity, lower complication rate and shorter inpatient stay for the patients, as well as lower financial burden to the unit. This is reflected by the UK Consensus statement on melanoma, suggesting that LNC should not be routinely offered for positive SLNB without high-risk features.
1334 Improving Patient Flow Through the Hand Trauma Pathway
Authors: Rela M , Clough E , Chu H , Hughes J
Published: October 2021

Aim

A full-cycle audit was conducted at our plastic surgery unit, assessing adherence to hand trauma standards by the British Society for Surgery of the Hand. These stipulate that time from referral to clinic for open injuries and closed fractures should be within 24 hours and 72 hours respectively and time to theatre from date of injury (DOI) within 4 and 7 days, respectively.

Method

Data for the initial audit was collected from Nov 2019-Feb 2020 and for the re-audit from Aug-Dec 2020. Lists were generated of 50 patients with open injuries including flexor tendon, extensor tendon and nerve injuries and 50 hand fractures in both cycles. Data was collected on DOI, date of referral, clinic review and surgery.

Results

The initial audit results showed poor DOI documentation (open injuries 30%, fractures 54%). For open injuries, 44% met standards for clinical review within 24 hours and 94% for time to theatre. For fractures, 94% met the standard for time to clinic and 90% for time to theatre. The interventions included adding the standards to the clinic booking form and creating a mandatory DOI field on the referral system. The re-audit showed improvement of DOI documentation (open injuries 95%, fractures 100%) and the proportion of open injuries seen within 24 hours to 60%.

Conclusions

The interventions had a positive impact on our hand trauma pathway. Areas for improvement include reducing the number of patient visits to the service and encouraging early decision-making, particularly for patients reviewed in the emergency department.
182 Improving Handovers from A Neurosurgical High Dependency Unit to Ward Teams
Authors: Faderani R , Mohamed A , Stewart P
Published: October 2021

Introduction

A good handover is fundamental in providing continuity of care within a multidisciplinary team, allowing for safe and effective management of patients.

Method

Handovers between the neurosurgical high dependency unit and the ward team were prospectively evaluated as patients were stepped down over a 6-week period. The handover rate and consequences of poor handovers (missed investigations, referrals, or delayed discharges) were documented. After 6-weeks, handover proforma was introduced and the rates were recalculated.

Results

In the initial 6-week period, 36 patients were transferred, with only 2(5.6%) appropriately handed-over. Consequently, 9(26%) patients had delayed scans, 5(15%) missed referrals, and 24(71%) delayed discharges. In the 6-week period following the introduction of the proforma, a total of 28 patients were transferred, with 19(67.8%) documented handovers. Consequently, 1(3.5%) patient had a scan delay, 0 missed referrals and only 2(7%) patients had delayed discharges.

Conclusions

By raising awareness of handovers and introducing a proforma, we improved documented handovers by 62.3% whilst reducing the rate of missed investigations, referrals, and delayed discharges by over 90%. This project highlights how small, simple, and easy to enforce changes can lead to significant improvements in the quality of care provided to patients.
609 Referral for Temporal Artery Biopsy: A Closed-Loop Audit to Improve Quality of Referrals with A Standardised Proforma
Authors: Balai E , Barraclough J
Published: October 2021

Aim

Temporal artery biopsies are performed by the ENT department within our hospital, with referrals generally coming from the Rheumatology team. The motivation to audit practice came from concerns that patients were perhaps not fully aware when a referral had been made, that they may not have understood the logistical implications of this and that key pieces of information were frequently missing. We aimed to audit current practice to assess overall quality of referrals in line with GMC guidance.

Method

We retrospectively audited all referrals for a temporal artery biopsy procedure between July 2018 – March 2020. Assessed the quality of referrals by presence of information relating 15 data points taken from GMC guidelines, covering patient demographics, investigation results and operative factors. In collaboration with the Rheumatology team, we designed and introduced a standardised referral proforma. We re-audited the quality of referrals between June – November 2020.

Results

In the baseline audit of 34 referrals, 2 of the 15 data points were present in 100% of referrals, 5 were present in 50-90%, and 8 were present in < 50%. Two patients were found to be unaware a referral had been made for a biopsy. Upon re-audit after introduction of the standardised proforma; out of 9 referrals, 14 out of the 15 data points were included in 100% of referrals.

Conclusions

Following introduction of a standardised referral proforma we saw significant improvements in the overall quality of referrals for temporal artery biopsy. We plan to continue to prospectively audit the pathway to ensure these improvements are sustained.
684 The Standard of Emergency Operation Note Documentation at A District General Hospital Compared Against The Royal College of Surgeons of England (RCSEng) Standard
Authors: Zuberi S , Mushtaq Y , Patel K , Joseph J , Gurprashad R
Published: October 2021

Introduction

Meticulous operation note documentation is essential for seamless, safe continuity of care in postoperative surgical patients. This study evaluated the standard of emergency operation note documentation at a district general hospital, when compared to the Royal College of Surgeons of England (RCSEng) guidelines and assessed the impact of a new operation note proforma.

Method

A retrospective review of 50 emergency operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Initial findings were presented at a local clinical governance meeting and a new electronic operation note was introduced. A further 50 emergency operation notes using the new proforma were analysed between August 2020 and December 2020.

Results

RCSEng mentions 19 main points that all operation notes must include. A total of 100 operation notes were reviewed and each given a score out of 19. Intervention of the new proforma showed significant improvement to the average score (15.64 vs 17.94; p < 0.0001) when compared to RCSEng guidelines. In particular, there was significant improvement in the documentation of assistants involved in the procedure (58% vs 98%; p < 0.0001), estimated blood loss (2% vs 63%; p < 0.0001) and specific mention whether the operation was emergency or elective (20% vs 86%; p < 0.0001).

Conclusions

Implementation of the new proforma showed significant improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasises the need for surgeons to familiarise themselves with the current guidelines and highlights the importance of tailoring local operation note proformas to match this national standard closely.
699 Does Pre-Operative Imaging Improve Negative Appendicectomy Rate?
Authors: Dirie J , Merali N , Macias A. Maria S
Published: October 2021

Aim

Appendicectomy is one of the most commonly performed emergency operations. There is no set guideline for an acceptable negative appendectomy rate (NAR) in the UK. Based on previous studies, a NAR of 15-30% is typically accepted. We sought to define our local practice NAR in our initial audit, introduced an appendicitis pathway based on this initial data, and then re-audited to assess whether there had been an improvement in the NAR.

Method

All emergency appendicectomies carried out over a 1-year period from April 2018 – April 2019 were initially analysed. The subsequent audit analysed data from August 2020 - November 2020, after the pathway had been introduced. Histological analysis was used to determine positive or negative appendicectomy.

Results

A total of 207 patients had an appendicectomy over the initial 1-year time frame. In our re-audit, 38 patients had an appendicectomy. Demographics were similar in both groups. The NAR increased from 17% to 18%.

Conclusions

On first glance, the NAR does not seem to have improved. On a closer look, all patients over the age of 18 in our re-audit had a pre-operative CT, and there were no negative appendicectomies in these patients. The issue arises with younger patients, in whom justifying the radiation associated with a CT scan may be difficult. Although ultrasound does not carry the same radiation risk, previous audits at our trust have shown both its sensitivity and specificity for appendicitis is below 50%. We may have to explore alternative imaging modalities in the paediatric population or accept the higher NAR.
920 Improving the Management of Post-Operative Hypocalcaemia In Thyroid Surgery
Authors: Collins R , Lafford G , Ferris R , Turner J , Tassone P
Published: October 2021

Aim

Hypocalcaemia is a frequent, and potentially dangerous, complication of total thyroidectomy [1, 2] due to the removal of the parathyroid glands. This quality improvement (QI) project was undertaken in a large Ear, Nose and Throat department in the East of England over a year. The project improved postoperative guideline compliance by optimising the recognition and management of patients at risk of hypocalcaemia. This process focussed on improving parathyroid hormone (PTH) and calcium blood testing, appropriate prescribing and the monitoring and management of hypocalcaemia.

Method

A baseline audit was conducted to determine initial guideline compliance. The QI process subsequently involved the introduction of a new intraoperative PTH pathway and the amendment of trust guidelines. In addition, there was a focus on improving clinician awareness of guidelines, junior doctor education, communication between operating surgeons and junior doctors and the optimisation of patient handover.

Results

The measurement of PTH at four hours improved from 42.5% to 52.2%. The project saw a significant improvement in the monitoring of hypocalcaemia (from 22.2% to 83.3% for patients with an intermediate risk of hypocalcaemia) and in the prescribing of prophylactic calcium supplements from 7.5% to 43.5%.

Conclusions

By optimising postoperative care this QI project improved patient safety as well as impacting on the duration, and overall cost, of inpatient stay.
939 Two Is Not Always Better Than One: A Quality Improvement Project Assessing Efficiency and Financial Implications Associated with Using Two Different Electronic Systems in A Busy Orthopaedic Department
Authors: Kutuzov V , Shah H , Chaudhry R , Tan Y C , Nathwani D
Published: October 2021

Introduction

Ensuring correct documentation and safe handover is key to the running of a successful surgical department. At Imperial College Healthcare Trust, this process has been made easier through various electronic systems available to our Orthopaedic department: our in-house CERNER system and out-of-house system eTrauma, the latter of which is predominantly used. The aim of this project was to assess our efficiency in terms of time management between the two systems, as well as financial implications of saved time.

Method

Multiple members of the Orthopaedic team timed themselves when entering information regarding a referral or an admission into both systems. This allowed us to estimate the financial implications of moving away from eTrauma.

Results

An average referral took 165 seconds (n = 27) to input information onto eTrauma, versus 38 seconds (n = 25) for CERNER. Time taken to document an admission was 127 seconds (n = 33) and 26 seconds (n = 31) respectively. The current hourly wage for our junior members is £22.84 per hour or 38p per minute. Moving away from eTrauma to CERNER will save around £1.50 for every 2 referrals and 2.5 admissions, solely from documentation. This is excluding the other benefits of CERNER, such as quick access to relevant clinical information, pathology results and imaging.

Conclusions

Leaving eTrauma behind will reduce the time spent on documentation by orthopaedic junior doctors. This will result in increased efficiency and will lessen the financial burden on an already overstretched budget. Our formal data will contribute to decision making and future resource allocation in our local Trauma and Orthopaedic Department.
950 A Close Loop Audit to Assess Awareness Among Non-Consultant Hospital Doctors Re Use of Personal Protective Equipment
Authors: Amin K , Fahad Ullah M , Hannon E , Feaney G , Khan J
Published: October 2021

Introduction

Personal protective equipments (PPEs) are like war uniforms in the fight against Corona Pandemic. The limited supply of PPEs warrant their proper use not only to avoid shortage of supplies but also to prevent any infectious spread to healthcare workers. This study aimed at analyzing awareness among non-consultant hospital doctors re proper use of PPEs

Method

A questionnaire was devised using local available guidelines published by university Hospital Limerick. The study was done in 2 phases. In 1st phase 100 questionnaires were distributed to non-consultant hospital doctors(NCHDs). Results were analysed and after 1st phase and emails were sent with results and local guidelines and a zoom educational session was organized. In 2nd phase, questionnaire was redistributed in a week's time and results were re analysed to close the loop.

Results

200 NCHDs participated in the study,100 in each phase. Most common age group in two phases was 21-30 yrs. Awareness about PPEs use for Covid 19 increased significantly in 2nd phase across all domains (what is included in PPEs (100% from 91%), Sequence for putting on PPEs (52% to 88% p < 0.05), steps for FIT test (57% to 74% p = 0.247) and sequence for removing PPEs (47% to 81% p < 0.05).

Conclusions

Though PPEs donning and doffing sessions were organized by the hospital officially, Awareness about effective use of PPEs among NCHDs further improved after organizing a Zoom educational session and auditing.
978 Improving Satisfaction in Patients with Learning Disabilities
Authors: McConaghie G , Mistry J , Thakkar K , Wigley D , Lam G
Published: October 2021

Aim

Patients with learning disabilities (LD) are less satisfied because they do not fully understand their surgical management. Poor communication between doctors & LD patients leaves them unhappy & reluctant to seek further help. We aimed to improve satisfaction in 90% of patients.

Method

In one year in a midlands DGH 201 patients with an LD were admitted. Interviews were conducted which highlighted key problems. Multiple ideas were reviewed, and the simple but effective intervention was a brightly coloured prompt sheet with 4 questions placed in the patient notes: Have you explained:

A simple scale tracked the patient & carer satisfaction over 8 weeks as the prompt sheets were introduced to patient notes by the learning disability nurses.

Results

A 90% increase in patient satisfaction was not achieved but considerable positive feedback was. Moreover, the LD nurses witnessed an increased use of hospital passports among doctors as well as improved patient-doctor communication. A small target population restricts the rapid collection of large amounts of data. The patient satisfaction measure was qualitative, and a 10-point scale would have detailed smaller changes. Lack of carer continuity also made it difficult to collect consistent data.

Conclusions

The role of learning disability nurses is key to improving patient understanding and satisfaction, but they can be assisted by channelling and maintaining initiatives to raise awareness of the needs of these patients.
1245 Enhanced Recovery Program in Colorectal Surgery at Basildon And Thurrock University Hospital
Authors: Chetitah Salim , Seraj S , Robinson A , Adetoye S , Haque Samer
Published: October 2021

Introduction

Enhanced recovery program (ERP) is an integrated multidisciplinary approach that requires participation and commitment from different member of staff, and the patient. This is an evidence-based protocol designed to standardize medical care, improve outcomes, and lower care costs. The aim of this study is to observe how ERP protocol is followed in our institution, and to monitor different outcomes. Data was compared to NICE guideline.

Method

We reviewed all patients who underwent elective colorectal resection for cancer between June 2018 and May 2019. data was collected retrospectively from patient electronic case notes. We monitored compliance with ERP protocol (NICE), as well as outcomes

Results

114 patients were included in our study. We noted that just 35% of patients had intraoperative nasogastric tube. Antibiotics: 74.56%, Catheter 98.24%, PCA 79.82%, Spinal anaesthesia 52.63%, Drain 38.59%. In the post op period, patients were mobilized at 1.89 day (1.27) [mean (SD)], NGT removal: 1.81 day (2.31) Refeeding: 1.36 day (1.01). It has been proven that patients with inadequate perioperative analgesia are more prone to develop ileus, to have a prolonged hospital stay, and have an overall higher mortality (p0.001)

Conclusions

It seems that there is a room for improvement especially in analgesia and prophylactic antibiotics. Following ERP protocols improves overall outcomes.
1602 A Quality Improvement Project on The Management of Patients with Traumatic Head Injury Presenting to A District General Hospital
Authors: Muthusami A , Techaboonanake S , Desai N , Malik N , Reynolds M , Ahn K , De Carvalho L , Gawley M , Waraich N
Published: October 2021

Introduction

Traumatic Brain Injury (TBI) is associated with morbidity and mortality. All District General Hospitals (DGH) in West Midlands liaise with Neurosurgery centres for management of these patients through a referral system (NORSe). The aim of this study was to assess outcomes in TBI following the implementation of vital interventions.

Method

A retrospective data was collected between 1/1/2019 and 1/12/2020. We included all patients admitted with traumatic brain injury over the age of 16. We accessed the data from the hospital database, clinical notes, and NORSe. A re-audit was performed following implementations of recommendations (proforma and care of elderly input). Further data were collected prospectively.

Results

Our cohort included n1=61 patients (first cycle) and n2= 29 (second cycle). The demographic age and gender were comparable in both cycles. The median time for Neurosurgery advice was 229 minutes (IQR 60-690) in the first cycle as compared to 80 minutes (IQR 40-120, P < 0.05) and the main cause for delay was inadequate information transfer. The mortality rate was 24% (5 were attributed to sepsis), as compared to 14% in the second cycle. The median length of stay (LOS) was 4 days (IQR 3-13.5) in the first cycle, which translates to a cost of £26,815 per quarter. In comparison, LOS was 3 days (IQR 2-4), which translates to the cost of bed occupancy of £12,771 and saving of £14,043 per quarter, in the second cycle.

Conclusions

The introduction of simple interventions in a DGH can help to significantly improve patient outcomes in those admitted with Traumatic brain injury.
1651 Improving Surgical Admission Clerking in A Major Trauma Centre – The Role of a Standardised Clerking Proforma
Authors: Arnaouti M , Foxall-Smith M , Mittapalli D
Published: October 2021

Introduction

High quality medical records are integral to Good Medical Practice in the UK, for provision of good patient care. This study assesses the effectiveness of a structured Surgical Assessment Proforma in improving documentation, within the Surgical Assessment Unit (SAU) of a major trauma centre.

Method

A four-phase prospective study was undertaken – using PDSA methodology. This included: initial clinician survey and proforma development, audit, re-audit post-implementation, and final user survey. Evaluation and proforma design utilised standards from the RCS(Eng) and the PRSB. Notes of all patients admitted to the SAU, over two separate one-week periods, were assessed for completeness of documentation. Statistical analysis employed T-Test, with a P value of < 0.05 considered significant. The study was considered service evaluation, and therefore exempt from ethical approval.

Results

Pre-Proforma Survey

100% of respondents felt a proforma would be beneficial. 77% believed key elements of clerking were missed within the previous system.

Cycle 1 (n = 62)

Of note, assessment categories lacking information were: Responsible Consultant, Medication History, Allergy Status and Differential Diagnosis.

Cycle 2 (n = 119)

Of 45 assessment criteria: 38 improved (23 significantly (P < 0.05)), 2 showed no change, 5 were reduced (2 significantly (P < 0.05)). Documentation rates in nine categories improved by over 50%.

Post-Proforma Survey

73% of doctors and 86% of allied health professionals (AHPs) agreed documentation improved with proforma use. 66% of clinicians agreed proformas reduced omission of essential information and provided safe clerking guidance for doctors. 100% of AHPs agreed the proforma improved handover.

Conclusions

In a major trauma centre SAU, standardised proforma use improves completeness of clerking.