bluuebunny/crossref_metadata_2025 huggingface dataset:
486 The Use of Ketamine Sedation for the Treatment of Nail Bed Repairs in the Paediatric Emergency Department
Authors: Bradley A , Faulkner J , Jatan A , Stewart C
Published: November 2022

Aim

To determine if ketamine sedation is a safe and cost-effective way of treating paediatric patients presenting with nail bed injuries to the emergency department.

Method

A retrospective cohort study was carried out over a nine-month period in children between ages 18 months and 16 years old, presenting to the paediatric emergency department (PED) at Chelsea and Westminster Hospital, London, with nail bed injuries requiring repair by the plastic surgery team. The primary outcome measures are complications at the time of sedation and at outpatient follow up including surgical site infection at seven days. A secondary outcome measure of parental satisfaction was collected at four months. A cost analysis comparison against procedures completed under general anaesthetic was also undertaken.

Results

During the 9-month period, 10 nail bed repairs were performed under ketamine sedation in the PED. There were no serious adverse events recorded. No cases required further procedures and there were no cases of surgical site infections at 7 days. Parents reported favourable outcomes, with an average overall satisfaction score of 9.4 (where 10 is complete satisfaction). At follow up, there was one recorded complication which was successfully treated, with all patients being discharged from follow up within 3 months.

Conclusion

This small study has shown ketamine procedural sedation in the paediatric population to be a safe and cost-effective method for the treatment of nail bed injuries in children presenting to PED. We believe that this management strategy, brought to the fore during the COVID-19 pandemic, should be considered as standard across all PEDs.
546 A Longitudinal Case History of Skin Cancer Presentations from One of the UK's Longest Surviving Renal Transplant Patients
Authors: Rela M , Sarginson J , Rickard R
Published: November 2022

Introduction

The immunosuppression required by solid-organ transplant patients not only increases their risk of severe infections but also pre-disposes them to post-transplant malignancy, with skin cancers being the most frequent type. We present a longitudinal history of skin cancers in a patient who received their kidney transplant as a child and has been on immunosuppression for 50 years.

Case Report

The patient developed renal failure at 12 years of age and received a living donor renal transplant in 1970. He developed his first skin cancer in 2004, 34 years later. To date he has had a total of 173 lesions excised of which 123 were a non-melanoma skin cancer (NMSC) (108 basal cell carcinomas (BCCs) and 15 squamous cell carcinomas (SCCs)). None of these lesions had any high-severity features such as poor differentiation or lymphovascular invasion. Numbers of BCCs have not varied, but numbers of SCCs, Bowen's disease and Actinic Keratoses have risen gradually over time.

Discussion

The patient developed his first skin cancer later than has typically been reported in transplant patients and has had a ratio of BCCs to SCCs more similar to the non-transplant population.

Conclusion

Whilst the patient has had a large number of NMSCs over time, a recognised association for those taking immunosuppressive medications, the types and nature of his lesions mirrored that of the non-transplant population, which could relate to the fact he received his transplant as a child.
706 Cleft Palate in Pierre Robin Sequence
Authors: El Hasnaoui C
Published: November 2022

Introduction

Pierre Robin's sequence PRS is a congenital malformative sequence with a retrognathism, a glossoptosis, and an upper respiratory obstruction with an associated cleft palate. This malformative association can be disabling for both the child and his parents, because of its aesthetic, functional, psychological, and social impacts.

Aim

To assess how the cleft palate repair in PRS patients can help in the management of the condition.

Method

We have investigated 14 patients with PRS presenting cleft palates, collected over a period of 5 years, from March 2014 to November 2019 in the pediatric surgical emergencies department (PSE) in Rabat Children's Hospital (HER).

Results

Nine of the 14 patients had a complete cleft palate. The average age of intervention was 23 months ranging from 13 months to 4 years. The study showed a slight female predominance (n = 8, 57%). Regarding the treatment, 3 patients were treated with the Bardach's technique, 3 had the Von Langenbeck's technique, 3 had the Push-back technique and one patient who suffered from a post-operative persisting velar division was treated by veloplasty 3rd generation. The hospital stay was around 24 hours, and the post-operative follow-up was uncomplicated for all our patients.

Conclusion

Although we had relatively high success with our approach, the complexity and lack of consensus regarding the management of Pierre Robin's sequence still requires the involvement of a multidisciplinary team. The main aim is to give the best cosmetic and functional results in order to reduce the suffering of the PRS children and families.
725 Paediatric Resuscitation Burns Maintenance Fluid Selection - a Retrospective Review of Cases and Adherence to NICE, LSEBN and EMSB Guidelines
Authors: Noton T , Al Omran Y , Williams A
Published: November 2022

Aim

Appropriate fluid management in major burn injuries is directly related to burn survival rates. Despite this fact, there are still controversies regarding the choice of replacement fluid given during the resuscitation and maintenance stages in the acute management of burns. The aims of this study are to compare current paediatric maintenance fluid prescriptions against current guidelines, and to assess whether there is of any adverse effects (i.e., electrolyte disturbance).

Method

Details of all paediatric burn's patients (aged 18 years or under) who were admitted to the paediatric burns ward during an 18-month-period were screened. Only those coded as having sustained 10% TBSA burns or greater were included in data analysis. Data was then sourced using Cerner electronic patient record software.

Results

A total of 17 patients were identified, all sustaining scald injuries with between 10% and 22% TBSA burns. Every patient was given 0.45% NaCl with 5% dextrose as maintenance fluid. All IV maintenance supplementation was ceased after 24hrs. Only 53% of patients had pre- and post-fluid bloods taken. Average drop in sodium amongst these patients was 2mmol, with largest drop (5mmol) in the patient with the largest burns % TBSA.

Conclusions

We found zero compliance with current NICE guidelines, which suggests an isotonic crystalloid (such as 0.9% NaCl with 5% dextrose) for maintenance, therefore guidance in line with this should be considered. Larger burns TBSA or prolonged IV fluids may amplify electrolyte imbalances. The importance of consistent electrolyte monitoring amongst this patient cohort is key and should be encouraged.
963 Paediatric Full-Thickness Burns Caused by Cyanoacrylate Nail Adhesive - a Case Series
Authors: Noton T , Leon-Villapalos J , Atkins J
Published: November 2022

Cyanoacrylate glue, often found in acrylic nail kits, reacts in an aggressive exothermic reaction with cotton fabric. These potentially dangerous adhesives are freely available and there remains little understanding about the consequences on contact with cotton.

We present two paediatric cases of thermal burns related to the use of cyanoacrylate glue, both seen after the application of acrylic false nails.

The first patient is a 14-year-old girl, who presented with a 0.25% TBSA full thickness burn to the left heel, after she spilt some of nail glue onto her sock. The burn wound was initially dressed in Flamazine, but later required a formal debridement and split thickness skin graft (SSG).

The second patient is a 11-year-old girl, who presented with a 0.1% TBSA full thickness burn to the dorsal right foot, after applying false nails and again spilling the glue onto her sock. Immediate first aid with cold water was used. This patient was first managed in a local hospital before being referred to the burn's unit due to worsening pain. The wound was dressed in Acticoat, due to a sloughy appearance, and then underwent formal debridement and SSG.

Cyanoacrylate burns are caused by a thermal reaction rather than chemical as most may believe. In both cases described, cotton is likely to have acted as a catalyst, which is consistent with published literature. Warnings on packaging to increase awareness of potential reactions should be mandatory, as well as childproof packaging to help deter the unsupervised use of such adhesives.
965 Removal of Polydactyly in Paediatric Patients with Ligaclips, 10 Year Retrospective Analysis Establishing a Complication Rate and Acceptance to Patients
Authors: Herron Jonathan , Mishra Vaibhav , Al-Badry Waleed , Milroy Catherine
Published: November 2022

Polydactyly is the most common congenital hand deformity. There remains no consensus opinion on the management of a type B post axial polydactyly leading to variations in approach. This study aimed to assess the complication rate and acceptance to patients.

A retrospective analysis of Polydactyly type B patients in a tertiary London hospital was performed over a 10-year period. All of these patients had undergone a clinic ligation of the accessory digit with ligaclips. Those with bony elements (type A patients) were operated on in theatre and were excluded. Parents were asked to rate the outcome on a linkert scale as very poor, poor, fair, good, outstanding and complications from the procedure were recorded.

339 procedures were performed with a 100% success rate in removal of the accessory digits. Reported complications were as follows: one clip fell off but made no difference to the outcome, and seven ‘nubbins’ remained on the limb (2.06%) of which none were painful. There were no other complications reported. All parents rated the success of the procedure as good (1%, n=3) or outstanding (99%, n=336).

Using a ligaclip as the preferred method of removal for Polydactyly type B patients gave a complication rate of 2.06% which was exclusively in the form of ‘nubbins’ and the results were acceptable to patients.
984 The Efficacy of Different Nerve Transfers to Restore Elbow Flexion in Adults Following Brachial Plexus Injury: A Systematic Review and Meta-Analysis
Authors: Lee CYV , Cochrane E , Chew M , Bains RD , Bourke G , Wade RG
Published: November 2022

Aim

There are numerous donors available for neurotisation of the musculocutaneous nerve, following traumatic brachial plexus injury (BPI). However, there is uncertainty over which method is most effective for restoring elbow flexion. We set out to summarise and compared different nerve transfers for restoring elbow flexion after traumatic BPI in adults.

Method

Medline, Embase, medRxiv and bioRxiv were systematically searched from inception to 12 th April 2021. Studies reporting outcomes of nerve transfers to restore elbow flexion in adults were included. BPIs were categorised as partial or pan plexus. The primary outcome was ≥M4 elbow flexion on the British Medical Research Council (BMRC) scale.

Results

We included 64 articles, describing 13 different nerve transfers. There were 1335 adults with 813 (61%) partial and 522 (39%) pan plexus injuries. 75% of patients with partial BPIs achieved ≥M4 (95% CI 69%-80%); double Oberlin or two intercostal nerves appeared to give recovery. For patients with pan plexus injuries, 45% achieved ≥M4 (95% CI 31%-60%) and each month delay from injury to reconstruction reduced the probability of achieving ≥M4 by 7% (95% CI 1%-12%) where intercostal, phrenic or spinal accessory nerves were used as donors.

Conclusions

The choice of donor nerve affects the chance of attaining BMRC ≥4 in upper trunk reconstruction. For patients with pan plexus injuries, delay to neurotisation appears to be detrimental to motor outcome. This information may help clinicians and patients reach shared decisions about the choice of donor nerve(s) and the timing of surgery.
44 Empowering Surgical Foundation Year 1s (F1s) in the Management of High-Risk Post-Op Patients
Authors: Hawkins T
Published: November 2022

Aim

To improve the confidence of a cohort of surgical F1s in the management of high-risk post-op patients. Patients due to have an emergency laparotomy can be risk stratified using the National Emergency Laparotomy Audit (NELA) score. This score gives a percentage risk of mortality within 30 days of the emergency-laparotomy. Patients with a NELA score >5% are classified as high-risk. A proportion of patients will go to the Surgical high dependency unit (SHDU) post-op. The primary doctor presence in the SHDU is a single surgical F1. This leads to the surgical F1s having exposure to the management of high-risk post-op patients1.

Method

Data was collected on every patient to have an emergency laparotomy in the emergency theatre of a tertiary hospital. Over the course of 15 weeks in 2020–21, 36% of post-emergency –laparotomy patients in a tertiary hospital with a NELA score of >10% went to the SHDU post-op.

Results

A combined teaching and simulation workshop on common post-op complications was delivered for a cohort of surgical F1s. The feedback from this showed that all attendees felt that they were now more confident in managing common post-op complications.

Conclusion

Surgical F1s are exposed to the management of high-risk post-op patients. Feedback has shown that a combined teaching and simulation workshop on common post-op complications can increase the F1s’ confidence in managing these conditions.

1. NELA - National Emergency Laparotomy Audit [Internet]. Nela.org.uk. 2021 [cited 26 October 2021]. Available from: https://www.nela.org.uk/
53 Optimising the Holter Monitoring Process: A Quality Improvement Project
Authors: Musai J , Xhabija N , Sula F , Taho E
Published: November 2022

Aim

This quality improvement project began when we observed a lot of unsuccessful 24h Holter readings in our Cardiology clinic. Our project aim was to decrease the number of failed tests by improving health literacy, designing information leaflets, and organizing teaching sessions for the staff.

Method

First, brainstorm sessions were held, and we audited the service for a month to assess the inefficiency problem. A total of 3 PDSA cycles were completed between June 2021 and October 2021. We implemented a laminated information sheet for adult outpatients needing a Holter monitor that was handed out to patients in the waiting area. In addition, scripted messages were also created to guide the health care assistants when scheduling cases and conducting follow-up phone calls. We then introduced a patient information leaflet for patients to take home. Teaching sessions were organised, and we designed a Holter box to contain all equipment.

Results

Initial audit revealed a failure rate of 13.5% and an average turnaround time of 56 minutes. The failure rate after the first PDSA cycle was 13.04% and turnaround time 47 minutes. Data showed a 65.2% patient compliance despite 100% staff compliance. The second PDSA showed a decrease in failed tests to 5.7%, but turnaround time was 1:07. Final results revealed that the failure rate dropped to 2.85% and turnaround time was satisfactory (41 minutes).

Conclusions

The use of effective information tools to promote health literacy can improve workflow efficiency and patients’ understanding of ambulatory tests positively impacting service and patients’ experience.
102 Postoperative Haemoglobin Monitoring in Neck of Femur Fracture Patients. Can a Simple Teaching Session Improve Patient Safety on the Orthopaedic Ward?
Authors: Luckwell R , Van Binsbergen B , Harrison J
Published: November 2022

Aim

Patients who suffer neck of femur fractures (NOF#) are typically frail and at risk of postoperative anaemia which can contribute to a high mortality in this demographic.

This QiP reviewed how well postoperative haemoglobin (Hb) was being monitored on a Orthopaedic unit and assessed the effectiveness of a teaching session to improve this.

A secondary measure was to compare day 1 and day 3 Hb to establish an evidence base for the timing of postoperative Hb monitoring.

Method

Two cycles (1st loop: 8/3/21–21/3/21, n = 21. 2nd loop:3/7/21–16/7/21, n=15) were performed either side of a teaching session.

Day 1 and day 3 post-op Hb were recorded.

Inclusion criteria were patients who fitted NOF# best practice tariffs.

Results

Pre-intervention saw 90% of patients have day 1 Hb and 52% have day 3 Hb taken, this increased to 93% and 67% post intervention.

81% of patients showed a Hb drop between day 1 and day 3 (mean = 11 g/dL), with 90% of day 1 bloods already below reference range.

Conclusions

We demonstrated that a teaching session highlighting the importance of Hb monitoring in this patient demographic can improve the monitoring of postoperative haemoglobin and thus improve patient safety.

Secondly, a Hb drop is possible from day 1 to day 3 and therefore a day 1 Hb should not be relied on.

Future work will aim to investigate the longer-term trend of postoperative Hb to establish when an outpatient Hb should be performed.
275 ENT and Plastic Surgery Senior House Officers/house Officers Access to Patient Clinic Letters - Closed Loop Audit
Authors: Lam CM , Yii NW
Published: November 2022

Aim

To evaluate whether senior house officers (SHOs) and house officers (HOs) on plastic surgery and ENT: 1. have received training to access healthcare records and 2. feel confident with accessing healthcare records when needed.

Method

Retrospective audit. Questionnaires were sent to ENT and plastic surgery SHOs and HOs. After the first cycle of audit, the induction that ENT and plastic surgery SHOs and HOs receive at the start of rotation was changed to incorporate training for accessing healthcare records and a second audit cycle was completed. The audit gold standard were local trust guidelines, and the target benchmark was 100%.

Results

First audit cycle showed 0% of SHOs and HOs on plastic surgery and ENT were trained to access healthcare records at induction and 25% felt confident with accessing healthcare records when needed after their induction. After the changes to induction were implemented, the second audit cycle showed that 80% of SHOs and HOs were trained to access healthcare at induction and 100% of SHOs and HOs felt confident with accessing healthcare records when needed after their induction.

Conclusions

Induction at the start of a rotation is essential for junior doctors to be equipped with the knowledge required to deliver their clinical duties effectively. It is important to listen to feedback and improve this induction process. Further cycles of audit are required to assess if this change has been sustainable.
292 Patient Experience of Urodynamics Within a Urology Unit at a District General Hospital
Authors: Hayes J , Bahn-Christensen L , Perkins J , Pullar B , Foley C
Published: November 2022

Aim

Urodynamic assessment is an invasive outpatient diagnostic modality that is performed in most urological centres. What is the patient experience of our service, in regard to levels of anxiety, embarrassment and overall satisfaction?

Method

Patients undergoing urodynamic investigation, between August and November 2021, were asked to complete a questionnaire, with a visual analogue scale (VAS), where 1 was ‘not at all’, 2 ‘a little’, 3 ‘moderate’, 4 ‘a lot’ and 5 ‘extremely’. Levels of anxiety (pre- and peri-procedure), embarrassment, pain and overall satisfaction were assessed. Basic patient demographic data were obtained, in addition to the type of lower urinary tract symptoms (LUTS) under investigation.

Results

Questionnaires from 26 patients were obtained. The majority were male (80.8%) with a myriad of symptoms: 30.8% storage, 23% voiding and 46.2% mixed LUTS. The mean overall satisfaction, via the VAS, was 4.35. Anxiety was 3.38 pre-procedure, and 2.23 peri-procedure. Both pain and embarrassment scores were 1.81 and 2.08 respectively. All patients received a urodynamics information leaflet prior to their appointment. Furthermore, all patients would have been willing to undergo the procedure again in the future, if necessary, and recommended the unit to a friend or colleague.

Conclusions

On review of our local urodynamics service overall patient satisfaction is excellent, with low levels of peri-procedural anxiety, pain and embarrassment. Prior to their appointment, patients are understandably anxious and additional adjuncts to mitigate this, such as an informative telephone call in advance or urodynamics information video, are currently being explored.
326 Is Patient Satisfaction Affected by Replacing Face-to-Face Appointments with Telephone Assessments for Balance Complaints?
Authors: Bastawrous D , Kaleva A , Singh P
Published: November 2022

Aim

It was found that 91% of surgeons conducted virtual consultations during COVID-19 pandemic. In March 2020, ENT UK recommended that telephone review should be the first approach for all outpatients who do not need urgent treatment. Dizziness diagnoses may be made primarily from the medical history, making telephone clinics suitable. This study aims are to determine the level of patient satisfaction with telephone consultations for balance complaints.

Method

The electronic patient records of ENT patients were reviewed retrospectively to identify all adult patients with first presentation of dizziness between October 2020 and May 2021.Patients were contacted by telephone and completed the short form patient satisfaction questionnaire (PQS-18). The statistical software SPSS was used for analysis.

Results

26 out of 37 patients contacted were reached successfully giving a response rate of 70%. There were 12 patients in the telephone consultation group and 14 patients in the face-to-face group. Average general satisfaction and satisfaction with technical quality were lower in the telephone consultation group (p-values of 0.012 and 0.007 respectively). Total average score was also lower in telephone consultation group with p-value of 0.028. 91% of patients who had initial assessment by telephone needed a follow up face to face consultation as opposed to only 14% in the face-to-face group.

Conclusion

Patients were less satisfied with primary assessment of balance complaints by telephone. Most of these patients required face-to-face follow up consultations.
354 Surgical Proforma Done by Surgical Doctors; Clinical Audit
Authors: Al-Ghazawi M , Toquero L , Li M , Pauk T
Published: November 2022

Aim

To improve the clerking performed by all surgical grades at our Trust and to prevent any implication might happen in case the clerking was insufficient such as medical errors, delay in treatment and poor quality of data for future research and audits.

Method

Two cycle audit in which the first cycle analysed one hundred fully randomized surgical entries for completeness of all aspects of history, examination & plan over two months in 2021. Then new surgical proforma was applied and used for all patients thereafter. Subsequently, second cycle performed later, and same randomization was applied.

Results

Whereas fully completed proformas compromised only 4% of all entries in first cycle, this percentage increased by more than six-fold to reach 26% in second one. Both history of present illness and physical exam showed the major improvement. Even though some sections such NEWS score and social history kept showing small, completed percentage, it was slightly higher than in the first cycle. 69% was the total improvement across all sections between two cycles.

Conclusion

New surgical proforma applied at our hospital improved the clerking done by surgical doctors and hence improved the care provided to patients in first place and served as a very rich environment to future research and Audits.
369 Do We Need to Standardise the Neurosurgery Post-Op Note: A QI Project
Authors: Al-Nusair L , Nouri P , Gikas N , Newall N , Tsang K
Published: November 2022

Aim

Accurate, informative, and consistent documentation in the postoperative period is an essential aspect enabling effective and safe communication between healthcare professionals. Limited documentation can increase the risk of errors and suboptimal care. The Royal College of Surgeons (RCS) identified 18 criteria for operation note documentation for ‘Good Surgical Practice’, enabling continuity of care. Currently, the structure and information documented in a tertiary neurosurgical department varied. The aim of this quality improvement project was to improve the documentation in the department using a proposed proforma.

Method

A proforma was identified using the RCS guidelines and distributed via email. Operation notes of all patients undergoing neurosurgical procedures were compared against RCS guidelines from November 1st – November 30th, 2020, pre-proforma introduction. Operation notes were then re-audited from July 1st – July 31st post-proforma introduction.

Results

66 operations were identified in the pre-proforma group, and 49 in the post-proforma group. Date, time, details of tissue alteration, operative findings, incision, prosthesis identification, antibiotic use and signature were well documented in both pre and post proforma introduction (>90%). In the reaudited group there was an improvement in documentation of anaesthetist (37 vs 24%), complications (78 vs 35%), extra procedures (18 vs 2%), blood loss (22 vs 12%), and a small decrease in the documentation of DVT prophylaxis (59 vs 53%).

Conclusions

A structured proforma is useful for enhancing communication in the post-operative period. We aim to create a standardised template in the trust's note-taking system to standardise the documentation process and provide further training on the importance of documentation.
392 The Role of MRI in the Management of Scaphoid Fractures: A Closed-Loop Audit by Dorset County Hospital, UK
Authors: Finch B , Andrew S , Crook T
Published: November 2022

Prompt and accurate diagnosis of scaphoid fractures are crucial in preventing complications such as non-union, avascular necrosis & early-onset arthritis. Research has shown that initial radiographs detect a fracture in 85–90% of cases, but it can be occult in up to 10–15%. In 2016 NICE recommended that MRI should be considered for first-line imaging in patients with suspected scaphoid fractures. Our aim is to determine whether the clinical practice at DCH is matched with the recommendations set by NICE, and whether the implementation of a ‘Scaphoid Management Protocol’ led to increased compliance.

Retrospective analysis of all patients with suspected scaphoid fracture presenting to ED between May – September 2017, with reaudit between December 2017 - February 2018 and June – October 2020. Those patients who had gone on to have further MRI imaging were then identified, and the average time taken to MRI requests to MRI being performed was evaluated.

Prior to the protocol, 16% of patients with normal X-ray but clinical signs weren't referred to further MRI imaging – this reduced to 1% in re-audit. The average recorded time to MRI from the requested date improved with each audit cycle, with 37.6, 19.9 & 11.4 days, respectively. However, a new finding found that 35% of patients presenting to ED with scaphoid injury were not referred further for Orthopaedic assessment to exclude scaphoid fracture.

Implementation of a ‘Scaphoid Management Protocol’ significantly improved compliance to NICE guidelines of MRI imaging resulting in earlier fracture diagnosis and improved prognosis, as well as improving time to MRI from the request date.
397 Improving the Quality of Consent Forms in Emergency Laparotomy
Authors: Probert S , Ballanamada Appaiah N , Khan L
Published: November 2022

Aim

To improve the quality and completion of consent forms for patients undergoing emergency laparotomy.

Methods

A standard for emergency laparotomy consent forms, guided by recommendations from the National Emergency Laparotomy Audit (NELA) was established. This standard was used to score consent forms. Our initial audit of 20 consent forms scored an average of 41.9%.

A template sticker, specific to emergency laparotomy, was created. This contains all of the information deemed important by our standard. The sticker allows the surgeon completing the consent process to simply tick off the individual components once discussed with the patient and apply it to the regular consent form. The stickers were introduced to all of those involved in consenting patients, and their use was strongly encouraged.

Results

Consent forms were collected and scored over the following 2-months. Of the 18 consent forms, 33% made use of the consent form sticker, with an average score of 65.2% (improvement of 23.3%). In analysing scores for both the pre- and post-intervention consent forms, we found a P value of < 0.0001.

Conclusions

The use of consent templates specific to surgical procedures improves the quality of consent forms and ensures that all possible complications are discussed with patients. The use of stickers for emergency laparotomy has improved the quality of our consent forms. With ongoing use, we aim to ensure that all patients undergoing this procedure are adequately consented. There remains room for continued improvement, and we believe ongoing exposure to these stickers will lead to an up-take in use.
419 District General Theatre Efficiency: What Is the Patient Experience?
Authors: Sambhwani S , Essak K , Rayan F , Krishnaiyan R , Khairandish H , Hirschowitz D
Published: November 2022

Aim

The NHS Institute for Innovations and Improvement (NIII) has determined that a £7 million saving can be achieved per trust by improving theatre efficiency. With an increasing influx of admissions and trauma, alongside increasing trends pertaining to the pandemic and winter pressures, it is vital to optimise our patients’ journey.

Method

The journey of transition from pre-theatre to recovery was mapped and retrospective data on a single weekday theatre trauma list was collected over a one month stretch using ORMIS and 77 patients were identified and analysed.

Results

The average case load was found to be 3.7 cases with lowest case load during the end of the week.

The average send time for a patient was documented to being 8:45 (range:8:15–9:934) with an average turnaround time being 65 minutes for the first case and 37 minutes for subsequent cases.

The average knife-to-skin time was found to be 10:00 for the first case (range:9:21–10:34). The median intercase time (time take from the patient leaving theatre to the next patient entering theatre) was found to be 47 minutes (range:15–49).

Conclusions

Causes for delays in theatre flow were largely multifactorial and this impacted the first patient the most leading to a knock-on effect on subsequent patients on the list. With the NIII attributing an efficiency cost of £24.77/minute, there is a lot to be gained by maximising theatre efficiency particularly with current limited resources. A joint surgical and anaesthetic quality improvement project focusing on the golden patient was introduced with a patient focused approach.
421 Improving Confidence with Difficult Catheterisations
Authors: Olukoya O , Ng A , Bekarma H
Published: November 2022

Aim

The use of catheters is common amongst inpatients with variable successful completion rates resulting in frequent calls to the on-call urology team for assistance. A common concern from the urology team is that there is inadequate equipment stocked in A&E or CAU across NHS Ayrshire & Arran. Additionally, it is felt anecdotally that most “difficult” catheters are in fact easily inserted by urologists via the use of a larger silicone catheter. The aim was therefore to improve confidence with difficult catheters and knowledge of when to refer to Urology; and to improve access to equipment required for a difficult catheter.

Method

A questionnaire using Likert scales was distributed to medical and nursing staff across both acute sites within the health board to establish baseline confidence and ease of finding equipment. An intervention in the form of a guide to difficult catheters was introduced with work started on a difficult catheters trolley. A follow up questionnaire using Likert scales was distributed to assess confidence. The subsequent data was then collated and analysed.

Results

1st Cycle: 30 responses; 36.70% confident/very confident. 2nd Cycle: 7 responses; 85.70% confident/very confident and know when to refer; Ease of finding equipment remains variable; 71.5% found the guide to be clear/very clear.

Conclusions

Despite the lower response rate in the second cycle, the guide has been effective in improving the confidence of staff with difficult catheters and their knowledge of when to refer. Ease of finding equipment remains variable, however, due to the relative delay in establishing the trolley.
432 Improving the Use of Acute ENT Clinic in a DGH During the COVID19 Pandemic
Authors: Bondje S , Bateman L , Stephens J
Published: November 2022

Aim

The SHO led acute ENT clinic is used to assess and treat a variety of ENT pathology. Following the COVID19 pandemic, the department has seen an increase in referrals for conditions that do not meet departmental guidelines. To meet demand, our clinics were always overbooked and over running as juniors sought help from seniors for more complex referrals.

Method

A quality improvement project was initially set to be performed over a few months; however, due to COVID, data was collected over a year from December 2019 to 2020. We looked specifically at number of patients referred, reason for referral, number of follow-up appointments, senior review required and how COVID affected the running of the clinics.

Results

Compared with the clinic's standard operating procedure, 77.2% of clinics were overbooked and 69.8% of patients had unsuitable referrals. This prompted changes such as increasing clinic capacity by introducing full day clinics and increasing senior support by moving to the outpatient department, then clinics were only overbooked 1% of the time. Other areas for improvement highlighted such as advice given to patients as well as referral to main ENT clinic.

Conclusion

It was clear that the capacity of the acute clinic did not meet demand, and this was needed to ensure patient safety and adhere to ENT UK guidance. We implemented a more stringent referral system to increase patient safety by ensuring patients with appropriate pathology are seen in this clinic or referred to other relevant clinics where they can be seen earlier by seniors.
433 Antibiotic Compliance in Paediatric Appendicectomies: A Two Cycle QIP in a Tertiary Centre
Authors: McLean E , Gupta T , Little J , Hallows R
Published: November 2022

Aim

Acute appendicitis is the most common surgical condition in children in the UK. We did a Quality Improvement Project to determine if our hospital's paediatric appendicitis antibiotic guidelines were being followed.

Method

Data was collected retrospectively for all patients admitted with acute appendicitis between 01/05/2021 and 14/09/2021 at a tertiary paediatric centre. The compliance to centre protocol for antibiotic administration was assessed, including cefuroxime dose per kilogram. Following educational intervention, a second cycle of prospective data collection was performed 29/09/2021 to 18/11/2021 to reassess compliance and close the loop.

Results

Initial data collection (n=34) showed protocol compliance at 57.6%; where compliance was correct dose, duration, and combination of antibiotics. Notably, we showed 4 patients developed collections despite being on triple antibiotic therapy. Of these 3 were on the lower dose 20mg/kg Cefuroxime regime despite intraoperative findings. Following a Departmental meeting, the protocol standard dose of Cefuroxime was changed to 50mg/kg (max 1.5 grams as per BNF) for all presentations of acute appendicitis. Results were then fed back to the team and changes implemented; including updating the previous flowchart posters found in A&E, theatres, and ward. Second round of data collection (n=12) showed 91.7% compliance with protocol. Of the patients in this time, none developed abdominal collections.

Conclusions

This quality improvement project shows significant improvements in outcomes of appendicectomy, as well as improvements in protocol compliance achieved with education and simple interventions. We have shown an increase in compliance
438 Packed Red Cell Transfusion in Acute Surgical Patients, Are We Over-Transfusing?
Authors: Bright H
Published: November 2022

Aim

To improve a general surgical department's adherence to NICE guidelines on transfusion of packed red cells for low haemoglobin by improving knowledge of relevant haemoglobin thresholds (70g/L or 80g/L in ACS or renal failure requiring chronic transfusion).

Method

All patients admitted to a large London teaching hospital under the general surgical team in a 4-month period (2020–2021) were audited using their electronic records. Audited data was units transfused; pre-transfusion haemoglobin, heart rate, and blood pressure; pertinent medical history; and location of transfusion (ward/theatre). 10 patients were excluded due to being transfused perioperative or because of haemodynamic instability (covered under different guidelines). 16 patients and a total of 31 units were included in the audit. The interventions were 1) distribution of a poster showing the NICE guideline, reasoning for the guideline, and baseline data; and 2) a teaching session for junior doctors (FY1 to registrar).

Results

The proportion of transfusions adhering to guidelines increased from 33% (6/18) at baseline to 60% (3/5) after intervention 1 and 100% (8/8) after intervention 2. The combined post-intervention score of 85% (11/13) was statistically significant compared to the baseline (p=0.013).

Conclusions

Acute surgical patients were frequently over-transfused with packed red cells; risking adverse reactions and increased re-bleeding. An education programme aimed at junior doctors was successful in significantly increasing adherence to national guidelines on transfusion and improving patient care. Simple educational methods are therefore effective at improving care by promoting evidence-based practice. Future auditing would aid in assessing the sustainability of this improvement.
465 Ensuring Optimal Timing of Gastrografin and Imaging in Patients with Adhesive Small Bowel Obstruction
Authors: Yiu A , Edirisooriya M , Balendran B , Wheatstone S
Published: November 2022

Aim

This Quality Improvement Project (QIP) aimed to optimise outcomes for patients with adhesive small bowel obstruction (aSBO) by standardising Gastrografin prescriptions and the timing of subsequent abdominal X-rays (AXRs).

Method

Baseline data on Gastrografin prescription and timing of AXR for patients with aSBO was collected retrospectively over a 1-year period. From this, we identified potential interventions to reduce variation in the management of aSBO. We implemented a Plan-Do-Study-Act (PDSA) Cycle over a 4-month period by creating a prescribing protocol for Gastrografin on the Trust's electronic prescribing system with input from key stakeholders including surgeons, pharmacists, radiologists, and radiographers. We measured Gastrografin prescription accuracy and timing of AXR post-Gastrografin.

Results

The initial data collection (n=89) showed Gastrografin was used in 63% of SBO episodes and prescribed correctly in 79% of cases. AXR was performed in 77% of cases, with a mean time of 9:02 hours post-Gastrografin administration. 42% of patients underwent surgery. After implementation of our PDSA cycle (n=20), Gastrografin was prescribed in 71% of cases, with 100% prescription accuracy. AXR was performed in 88% of cases, with a mean time of 7:47 hours post-Gastrografin. 10% of patients underwent surgery.

Conclusions

We have successfully achieved our aim of reducing variation in Gastrografin prescription for patients with aSBO by demonstrating an increase in prescription accuracy from 79% to 100%. We have also shown an improvement in the efficiency of post-Gastrografin imaging for patients with aSBO.
483 Surgical Virtual Clinic: A Safe and Effective Alternative to Acute Surgical Clinics for Semi-Urgent, Ambulatory Patients
Authors: Osunlusi O , Patel S , Ashok A , Stonelake S
Published: November 2022

Introduction

Many ‘Hot Clinics’ deal with ambulatory patients only requiring semi-urgent investigation and treatment, potentially avoiding hospital admission. These clinics often use the same staff and resources being utilised for acute surgical admission and treatment. We present data showing that “Virtual Clinics” (VC) are safe alternatives to this system, improving patient service and relieving a significant burden on the acute surgical units.

Method

78 patients who came through the established VC between 23/12/2020 and 19/01/2021 (4 weeks), were assessed for delays in scan date, call-backs, diagnosis, referral patterns, readmission rates and eventual outcomes for those who needed surgical interventions.

Results

83% of patients had their scans within the set-out time of 72 hours. 89.7% of scans were reported on the same day. Only 18% of the patients had a surgical diagnosis. 51% had no diagnosis at all and were discharged safely from the clinic. 16.7% were still symptomatic at the time of the VC with 3.8% of these having a surgical pathology. 22% were referred to other specialities. 2 patients were referred to MDT.

In total, 6 patients were re-admitted to the hospital (7.6%). 4 patients were listed for surgery following the VC.

Conclusions

The VC proves to be a safe and effective system for semi-urgent, ambulatory patients. Re-admission rates are low, justifying the discharge of these patients from the acute surgical assessment unit to a virtual follow up environment.
491 Improving the Return Rate of the 6 Week Post Procedure Forms at King's College Hospital Tongue Tie Clinic
Authors: Horseman L , Patel S
Published: November 2022

Aim

The aim of the audit was to assess, and improve, the return yield of feedback forms from parents using the King's College Hospital tongue-tie service. In a procedure that's primary objective is to improve the mother and baby experience of breast-feeding, it is vital that we are aware of maternal perceptions on any improvements that the procedure conveys.

Method

Baseline return yields were initially collected and assessed using clinic and feedback data from January 2020. A focus group was held with the tongue-tie MDT to ascertain current procedures for feedback collection. During this it was identified that parents were never reminded to return the feedback form. Change was instigated in December 2020 with “Envoy Patient Messenger”, a software employed to send a text reminder to parents 5 days before feedback forms were due. January 2021 was used as a comparable month to analyse the effectiveness of the change.

Results

In January 2020, 4 (6.15%) parent feedback forms were returned out of the 65 babies undergoing tongue-tie procedures. Following initiation of the text reminder service, in January 2021, 15 (33.3%) of parent feedback forms were returned out of a possible 45, giving a 5.41x increase in return yield.

Conclusions

This audit demonstrated that simple measures such a text reminder service significantly increased the return yield of parent feedback forms following tongue-tie procedure. Work is ongoing with Patient Outcomes team regarding the introduction of an online feedback form.
510 Improving Trauma & Orthopaedic Handover During a Pandemic: Keeping Patients Safe - A Closed Loop QIP
Authors: Tse S , Busby C , Bryson D
Published: November 2022

Aim

Lack of communication and incomplete handover leads to errors and patient harm. Staffing challenges caused by Covid-19 highlights the necessity for high-quality handover. Our aim was to assess the quality of T&O weekend ward handover and evaluate the implementation of a formal handover document to improve the process.

Method

Junior doctors completed a survey to measure the efficacy and safety of current handover. A formalised written handover document in line with RCS Safe Handover recommendations was created and included in the doctors’ inductions. Evaluation was after 5 weeks with post-intervention questionnaires and new doctor rotation feedback.

Results

Prior to introduction of the handover document, 78% stated they were unable to formally handover. 77% experienced incomplete or unclear handover when working on the weekend. Lack of a standard handover process was deemed ineffective and unsafe.

All respondents reported more efficient working with the new process. The perceived safety rating significantly increased from 2.33 out of 5 to 4.23 (p<0.0001). The new cohort of junior doctors rated the safety of handover to be 3.54, showing there is still scope for improvement in patient safety.

Conclusions

The use of standardized handover tools had a positive impact, improving the safety and quality of weekend handover. Workload was prioritized appropriately with improved transfer of information between teams. Covid-19 creates numerous challenges for safe clinical care. Working in unfamiliar environments and last-minute rota changes need to be mitigated by robust handover processes.
527 The Challenge to Improve Patient Education for Newly Inserted Urinary Catheters on Discharge from the Emergency Department
Authors: Tyler G , Mills H
Published: November 2022

Aim

To improve education in patients with new urinary catheters on discharge from the Emergency Department (ED), decreasing the incidence and healthcare burden of subsequent catheter-associated complications.

Method

Qualitative study design was employed to survey all Healthcare Professionals (HCPs) working in the ED and establish the quality and means of information currently provided. A novel trust-endorsed proforma with information leaflet was created with urology team input and uploaded to the ED website. Staff were updated via email, WhatsApp and verbally and re-surveyed after 6 months. Survey responses were evaluated with descriptive statistical analysis.

Results

The majority of HCPs in the department reported nearly always/often providing information verbally to patients, with similar findings on re-surveying. The most commonly discussed topic with patients remained: “Common complications and where to seek advice”. HCPs reported never/rarely offering written information (75%, 74% before and after respectively) and nearly all HCPs surveyed did not know where to find patient information resources (81%, 79% respectively).

Conclusions

Written information provision remained poor despite creation of a proforma with information leaflet. A high departmental turnover of HCPs, alongside varying seasonal Covid burden may have reduced the efficacy of interventions. The findings may also be as a result of HCPs still not knowing where to locate such resources.

‘Nudge theory’ through placing leaflets next to catheter supplies, combined with improved education of new staff rotating through the department at individual inductions and the introduction of checklists are changes that have been since actioned and due to be re-surveyed in February 2022.