bluuebunny/crossref_metadata_2025 huggingface dataset:
512 Trauma Meetings in the Time of COVID
Authors: Hasan R , Dhir R
Published: May 2021

Trauma & Orthopaedics (T&O) has taken a backseat during COVID-19. As the focus has shifted to care of COVID patients, other specialties have adjusted their daily working. At our local hospital, the dedicated Orthopaedic ward was absorbed into the Intensive Care department, necessitating migration to a smaller, shared working space. This project looked at ways of increasing clinical efficiency, patient safety and education within the T&O department.

Members of the T&O department at The Princess Alexandra Hospital were invited to attend daily trauma meetings virtually via Microsoft Teams. In addition, the impact of moving to a larger, dedicated meeting space was assessed. Pre- and post-intervention questionnaires were delivered to assess response.

Post-intervention questionnaires revealed a significant improvement in the perception of ability to see XRs (p < 0.001), quality of handover (p = 0.018), ability to discuss and formulate management plans (p = 0.002), social distancing (p < 0.001), location (p = 0.002) and trauma meetings overall (p < 0.000). The educational value of trauma meetings did not improve as anticipated, however.

Virtual Trauma Meetings are a useful adjunct, allowing clinicians safely contribute to clinical care. In addition, the location of daily trauma meetings is an important factor to consider, both for the safety of patients and for the safety of clinicians.
515 How Has ‘Montgomery’ Changed the Way We Document Risks on Consent Forms for Deceased Donor Kidney Transplantation? A Single-Centre Audit and Re-Audit
Authors: Hussein A M , Callaghan C J
Published: May 2021

Introduction

The 2015 Montgomery case changed the remit of risk discussions required during the consent process. This audit reviewed single kidney transplant (SKT) consent forms to establish which risks are documented, and whether this legal case affected discussions. Following the audit, we introduced a pre-printed consent form and closed the audit loop by assessing its uptake.

Method

Trust paper consent forms for all patients aged 50+ who received a deceased donor SKT in our centre in 2014 (n = 58; pre-Montgomery) and 2017 (n = 70; post-Montgomery) were reviewed to see if 20 perceived ‘gold standard’ risks were documented. A pre-printed procedure-specific consent form including all gold standard risks was then introduced in July 2019. A re-audit reviewed the case-notes of every alternate recipient aged 50+ of a deceased donor SKT from 01/08/19 to 29/02/20 to check if the pre-printed form was used.

Results

Overall, 53% of the 20 ‘gold standard’ risks were documented in 2014 versus 59% in 2017 (p = 0.55). There was a 91% uptake of the pre-printed consent form.

Discussion

This audit established the importance of using a pre-printed consent form to standardise risk discussions We propose that pre-printed procedure-specific forms should be encouraged throughout the NHS to support ‘Montgomery-appropriate’ consent discussions.
522 Audit of Acute Lower Gastrointestinal Bleed Management in a District General Hospital
Authors: Mallick S , Salem R , Payne A
Published: May 2021

Introduction

Acute Lower Gastrointestinal Bleed (ALGIB) is a common emergency surgical referral. This project aims to audit current practice at a district general hospital against new British Society of Gastroenterology guidelines, which gives recommendations regarding assessment (Oakland score), investigation and management.

Method

A retrospective study was undertaken over one year (2019) of patients presenting to A&E or referred via GP with ALGIB. Patients were identified through the coding department. An online proforma was used for data collection, which was analysed with SPSS.

Results

76 appropriate patients identified. Median length of hospital stay was 1 day. 10 patients (13.2%) scored ≤8 (probability of safe discharge 95%), 19 (11.8%) patients scored ≤9 (probability of safe discharge 93%) and 57 patients (75%) scored ≥10. 19 patients discharged the same day, of which 3 (15.8%) scored ≤8 and 8 (42.1%) scored ≤9. 23 patients admitted overnight, of which 5 (21.7%) scored ≤8 and 6 (26.1%) scored ≤9. Of 66 patients classified as ‘major’, 41 (62.1%) did not have a colonoscopy.

Conclusions

Introduction of a scoring mechanism and disseminating guidelines will enable GPs and A&E doctors to safely discharge ALGIB patients with appropriate outpatient investigations and reduce surgical admissions. There is currently poor compliance with inpatient investigations.
538 Patient Satisfaction from ENT Phone Consultations During COVID-19
Authors: Zammit M , Siau R , Williams C , Hussein A
Published: May 2021

Introduction

Telephone consultations (TCs) have rapidly increased in the outpatient setting due to the coronavirus pandemic. We have implemented a quality improvement project to improve patient satisfaction of TCs in our unit.

Method

This was a prospective complete-cycle project, with online patient satisfaction questionnaires sent following TCs in ENT clinics. This consisted of 28 questions including the Medical Interview Satisfaction Scale (MISS-21).

Based on results and a current literature review, a two-pronged intervention was designed, comprising of staff education and application of a model structured TC framework. A follow-up survey was subsequently undertaken.

Results

100 patient questionnaires were collected (April & June 2020). Significant improvements in MISS-21 scores were seen over the two surveys (p = 0.026). An average MISS-21 score of 114.6 (range 49 – 147) was seen in the first survey, with a mean score of 128.5 (range 79 – 142) seen in the second (maximum score of 147). There was a significantly increased preference for TC over FTF appointments over the two surveys (p = 0.021).

Conclusions

We have shown significant improvements in patient satisfaction and an increased TC preference through use of a structured consultation model. Its potential benefits in infection control and impact on outpatient workload may see TCs persist in the post-coronavirus era.
540 Point of Care Testing for Tetanus Immunity: A Systematic Review
Authors: Low R , Young K , Verani L , Cotton D T , Welman T , Moore L , Horwitz M D
Published: May 2021

Introduction

All patients presenting to emergency departments (EDs) with traumatic injuries require tetanus immunity assessments. Inaccurate tetanus vaccination history based on patient recall incurs unnecessary costs on the NHS. Point-of-care immunochromatographic tests (Tetanus Quick Sticks [TQS]) quickly identify tetanus immunity status. We aim to evaluate the diagnostic accuracy and cost-efficacy of TQS to assess their relevance in emergency care.

Method

The systematic review followed PRISMA guidelines. A retrospective search of MEDLINE, Embase, Global Health, HMIC and The Cochrane Library was conducted. Studies were eligible if sensitivity, specificity, or cost-efficacy of TQS were reported. At least two authors independently analysed the data from each study.

Results

12 studies were suitable for inclusion (n = 1,662,865 participants): one retrospective and 11 prospective observational cohort studies. Eight studies assessed diagnostic accuracy with the median sensitivity at 86% (55-100) and the median specificity at 97.5% (1-100). All six studies investigating cost-efficacy reported greater savings when using TQS instead of using vaccination history, due to a decrease in unnecessary tetanus vaccine and immunoglobulin administration.

Conclusions

TQS is a safe diagnostic tool, especially when used by trained operators. TQS widely reduces costs in comparison to traditional vaccination history. We recommend the use of TQS in Emergency Departments throughout the NHS.
541 Investigation of Suspected Prostate Cancer In UK; Evaluation of Local Practice and Feasibility of Moving Towards MRI As First Line Investigation – Re-Audit Following Change of Radiology Staffing
Authors: Lee S , Luk A , Kailash Y , Chaplin B
Published: May 2021

Introduction

NICE recommends MRI as first-line investigation for suspected clinically localised prostate cancer (PCa); previous local audit findings suggest this to be safe and feasible to implement. Recent retirement of radiology staffing however had resulted in MRIs being reported by teleconsultation radiology service. There were concerns on whether this may lead to more missed significant PCa. We performed a re-audit on our prostate MRI and biopsy to assess if this is indeed the case.

Method

All patients with suspected PCa who have had prostate MRI and biopsy simultaneously from April-August 2019 were retrospectively analysed.

Results

222 men were included. 36% of patients with negative MRI had positive biopsies; within this group 25% had significant disease (Gleason grade group ≥2). Compared with our previous audit, specificity for significant PCa has increased (from 34% to 46%), but with a reduced negative predictive value (from 97% to 91%).

Conclusions

If we are to implement MRI as first-line triage for potential subsequent biopsy, it would result in more men not going for a biopsy (from 18% to 25%), a reduction in diagnosis of non-significant PCa (from 21% to 36%), but at an expense of increase in missed significant PCa (from 3% to 9%).
565 Outcome of Enhanced Recovery Programme in Lower Limb Arthroplasties
Authors: Gurusinghe Suranga , Weerasinghe Konara , Aghazawi Laith , Shashidhara Singapura , Rambani Rohit
Published: May 2021

Background

Enhanced Recovery Programme(ERP) is structured process of patient education, appropriate analgesia and early mobilisation. ERP was introduced to address, demand for surgical beds and cancellation of orthopaedic procedures. Objectives of this study were to evaluate efficacy and safety of ERP.

Method

This was prospective study, over three months. Included, all lower limb arthroplasty patients eligible for ERP(all primary arthroplasty patient with lower anaesthetic risk). Pre-medication, intra-operative local anaesthetics infiltration, same day post-operative radiograph, combinations of analgesics, early mobilisation, and discharge back to the usual place of abode.

Results

201 patients, mean age was 71 years (42-87), 22 ASA (American Society of Anaesthesia) 1, 147 ASA 2 and 23 ASA 3 patients. Performed 121 total knee replacements and 80 total hip replacements. Average duration of weight bearing was1.04 days. Mean date of discharge was 1.37days (0-5). 8 patients were re-admitted (0.039%), they were, one with surgical site infection, another one for manipulation, 5 patients, suspected deep vein thrombosis (DVT) (all were excluded DVT). There was no failed discharge.

Conclusions

ERP is very safe and effective way of increasing performance of hip and knee arthroplasties by optimising availability of ring-fencing surgical beds and reducing the hospital stay.
593 The Utility of Routine Operative Swab Culture in Uncomplicated Peri-Anal Abscesses
Authors: Khajuria A
Published: May 2021

Introduction

Despite perianal abscess being a common presentation, certain aspects of its management remain controversial, especially the routine use of intra-operative swab cultures.

Method

A retrospective review of patients that underwent incision and drainage procedures for a perianal abscess over a six-month period was undertaken.

Results

Over 6 months, 50 patients were identified. The male to female ratio was 3:1 and median ASA score was 1. Only 6/50 patients presented with recurrent abscess and 1 patient had history of inflammatory bowel disease. On the basis of operative findings, 39 patients (78%) had uncomplicated abscess (not associated with cellulitis, sinus or fistula); swab cultures were performed in 26 (67%) of these patients. All patients were discharged on the same day; microbiology reports did not impact the treatment and no patients were followed up in clinic post-operatively or presented with recurrence. The number of unnecessary microbiology swabs undertaken in this cohort equates to approximately 52 unnecessary swabs a year. The cost of one swab is £10.10p, which means £520 could potentially be saved annually.

Conclusions

Routine intra-operative swab cultures do not impact management decisions, add to unnecessary costs and therefore should not be undertaken in uncomplicated or first presentation of peri-anal abscesses.
610 Virtual Burns Care in The Era Of COVID-19: A Regional Burns Unit’s Experience
Authors: Hayes J , Clements J , McGarry K , Rashid A
Published: May 2021

Introduction

In response to the COVID-19 pandemic a virtual burns service was established in Northern Ireland to reduce face-to-face consultations to only complex burns or those necessitating hospital admission to the regional unit.

Method

A combination of telephone calls, emails, photography, and Microsoft Teams software was utilised to facilitate a virtual review service. Our initial adoption of the system was audited during April and May 2020. Through Plan-Do-Study-Act (PDSA) methodology an electronic tertiary-referral proforma was established prior to closure of the audit cycle in July 2020.

Results

From the start of lockdown a significant reduction in face-to-face consultations was observed. Given the increasing use of virtual telephone consultation only 19.5% of the unit's total referrals (April, May, and July) were either reviewed face-to-face in dressing clinic or admitted. A target of 100% data point entry (including demographic, clinical, and initial management) for patients entering the virtual service was set. Following implementation of the e-Referral pathway an improvement in both the detail and completeness (95%) of patient referral information was achieved.

Conclusions

Our experience demonstrates that virtual burns care can be safely and rapidly adapted in response to evolving need. The potential role of virtual care post-COVID, in selected patients, is an exciting one.
631 The Time to Therapeutic Serum Levels of Vancomycin in Orthopaedic Patients
Authors: Rankin C , Robinson P , McCann C , Cockburn A , Palenzuela E
Published: May 2021

Introduction

Vancomycin is a commonly used antibiotic in the treatment of deep-seated infections. However, the current dosing calculator utilized in NHS Lothian may not adequately achieve therapeutic vancomycin serum concentrations (VSC), of 15-20mg/L, in a timely manner. We aimed to reaudit the length of time for vancomycin to reach therapeutic levels in orthopaedic patients using the new Lothian calculator. A previous audit loop looked at the current calculator in 2018.

Method

Inclusion criteria orthopaedic patients who were treated with vancomycin at the Royal Infirmary Edinburgh, data collection to finish mid-September. The duration to reach the therapeutic SVC, initial trough SVC and serial levels were recorded. A life-table analysis will be used to examine the data.

Results

First audit had Twenty-three patients. The mean initial trough VSC was 12.7mg/L. The mean duration to therapeutic VSC was 5.2 (± 1.3) days. Statistics not completed for second cycle, but initial data shows improvement in time to VSC.

Conclusions

A delay in reaching therapeutic concentrations was observed in a significant proportion of patients using the current calculator. A more rapid achievement of therapeutic levels is required to maximize the period of antibiotic delivery and subsequently improve patient outcomes. The new calculator pilot will hopefully show that improvement.
633 Surveillance for Head and Neck Cancer Recurrences: Is There Scope for A Tailored Approach?
Authors: Alvi M , Eagles E , Hamilton D
Published: May 2021

Introduction

Detection of cancer recurrence after treatment of head and neck cancer (HaNC) is vital. Current guidelines stipulate that following primary treatment HaNC patients are followed up for five years with a total of 18-24 appointments. This forms a bulk of the HaNC surgeon’s workload. Asymptomatic recurrences are rare. Patients educated regarding worrying symptoms may institute their own follow up. Such open appointment systems may be as effective at detecting recurrences

Method

At a moderate volume HaNC centre we reviewed 98 patients that had completed their five year follow up. We investigated cancer recurrences and whether these were symptomatic or asymptomatic at time of detection. We analysed each recurrence regarding the time since primary treatment.

Results

23 patients had HaNC recurrences. These recurrences were symptomatic in 17 patients and asymptomatic in 6 patients. Five of the six patients from the asymptomatic group had recurrences within two years of primary treatment. The final patient was of a high-risk histological subtype.

Conclusions

Asymptomatic cancer recurrences are uncommon especially after two years of regular follow up. After two years the frequency of appointments may be tailored on a patient-by-patient basis. Patients educated regarding symptoms of cancer recurrences may institute their own follow up.
639 ENT Telephone Follow Up in The Era of Covid-19: A Retrospective Qualitative Analysis Utilising Semi structured focus groups
Authors: Keates N , Mclaren O , Perkins C , Finnie C , Williams R
Published: May 2021

Introduction

Covid-19 and social distancing has triggered a seismic shift in clinical work especially during the first part of lockdown. This work looks to evaluate the experience and opinions of key stakeholders who took part in the process and use this to improve follow up in the future.

Method

3 Focus groups following the same semi structured format discussed key considerations in follow up in general, telephone follow up, key aspects in its delivery and how this could benefit the service provided to patients. The focus groups involved Juniors (registrar level doctors), Consultants and support staff (clinical and non-clinical).

Results

Several themes and subthemes were identified. Key points were that patients were universally in favour of telephone consultations; they find them convenient and enjoy not attending the hospital. All clinicians agreed that although Covid-19 lead us to review New patients via telephone this increased workload as they needed to attend later for an examination and felt it did not provide safe care.

Conclusions

There is certainly an increasing role for telephone follow ups in the wake of Covid-19 which can benefit ongoing patient care and aid in managing the departments follow up capacity. Further work is needed to review this.
678 An Audit of TRUS Biopsy Sepsis Within A District General Hospital Setting
Authors: Tezcan E
Published: May 2021

Introduction

Transrectal ultrasound (TRUS) biopsy is the standard investigation of suspected prostate cancer within the United Kingdom. TRUS biopsy has significant risks of associated complications, the most serious being sepsis. An audit was designed to evaluate the rate of sepsis following TRUS biopsy within a district general hospital setting.

Method

All men who underwent TRUS biopsy over a four-month period between October 2019 and January 2020 were retrospectively reviewed. Standard rate of sepsis for benchmarking was identified as 0.8% as quoted in the European Association of Urology (EAU) prostate cancer guidelines.

Results

88 men underwent TRUS biopsy between October and January. Three cases of TRUS biopsy sepsis requiring hospital admission were identified. The rate of sepsis determined was 3.4%. The average length of stay for the cases was 4.7 days. Oral co-trimoxazole was used as the empirical antibiotic prophylaxis pre-procedure in all.

Conclusions

The rate of sepsis was higher than the figure quoted in EAU guidelines. Routine local audit for TRUS sepsis is necessary to maintain standards and efficacy of prophylaxis, as well as the accurate counselling of patients on the expected risks of the procedure. Consideration should be given to targeted antibiotic prophylaxis based on pre-biopsy rectal swabs.
680 A Virtual Stone Clinic Using an Electronic Database Streamlines the Patient Pathway
Authors: Lee R X N , Heng T C R , Raju J A , Bodiwala D , Scriven S D
Published: May 2021

Introduction

We have set up an electronic database to record patients requiring follow-up, which is reviewed in a virtual stone clinic (VSC). A consultant led VSC is held weekly to review the database and follow-up patients virtually.

Method

Analysis of patients added over a 15-month period was performed. Outcomes included spontaneous stone passage rates, intervention rates and time from initial imaging to VSC outcomes.

Results

615 patients with a median age of 48 years were analysed. Emergency referrals to urology accounted for 85.9% of data. VSC review occurred a median of 5 days after initial imaging. Majority of stones were lower ureteric (64.6%), 28.1% upper ureteric and 7.2% renal stones. Follow up data was available for 557 patients (90.6%). 73.6% of patients passed stones spontaneously.

Median time from investigation to imaging was 21 days. 372 patients were discharged following VSC review. 111 patients were listed for surgical intervention. Median time to intervention was 21 days for ESWL, 62 days for ureteroscopy and 202 days for PCNL.

Conclusions

VSC leads to shorter waiting times for follow-up imaging and interventions in patients with renal stone disease. This is especially evident in the current Covid-19 pandemic, resulting in higher quality of care.
691 Audit of Drug Chart Completion in General Surgery
Authors: Uddin A , Hadjittofi C , Lovett B
Published: May 2021

Introduction

The accuracy of drug charts is crucial for good clinical practice. The General Medical Council states, doctors must keep clear, accurate and legible records, also applying to prescriptions. This audit quantified the accuracy of drug chart completion in a General Surgery Department within a District General Hospital.

Method

Single-centre retrospective assessment of drug charts in November 2019, assigning binary outcomes to each domain: “100% complete” (all details such as drug name, dose, unit, route, frequency, indication, duration, signatures) vs. “incomplete”. After analysis (Microsoft Excel/IBM SPSS v.24), results were circulated locally, followed by re-audit during June-August 2020.

Results

Comparison of audit (n = 22) vs. re-audit (n = 25) drug charts across 17 domains demonstrated higher completion rates for 7 domains: Alerts/allergies (4/22:18% vs. 18/25:72%; p < 0.001), signatures (2/22:9% vs. 17/25:68%; p < 0.001), venous thromboembolism risk assessment (5/22:24% vs. 24/25:96%; p < 0.001), antithrombotic (0/21 vs. 9/25:36%; p = 0.002), regular (1/22:5% vs. 10/25:40%; p = 0.04), as-required (0/21 vs. 5/22:23%; p = 0.020) medication and intravenous fluids (1/16:6% vs. 20/21:95%; p < 0.001). Performance in 10 domains was not significantly different (p ≥ 0.05).

Conclusions

Standard documents like drug charts may appear accurate at first glance. However, when assessed with strict criteria, performance is suboptimal. Simple, cost-effective educational interventions can significantly improve accuracy, with positive implications for patient safety.
695 Analgesic Ladder Compliance by Junior Doctors on Surgical Wards
Authors: Emanuel O , Mahdi S , Bondje S , Tjokarfa J , Dhunna J , Sivarajah V , Jose P
Published: May 2021

Introduction

Analgesia makes up an integral part of the management of the surgical patient. The World Health Organisation “analgesic ladder” details the escalation of analgesics from paracetamol through to opiates. Over the past decade, opiate prescriptions in the UK have increased by 22% to 40.5 million a year.

Method

Drug charts were reviewed on the surgical wards prior to presentation of the trust guidelines to surgical juniors. Inclusion criteria was non-cancerous adults who were not on chronic pain medications and had no known allergy or contraindication to NSAIDs. F1/2s were also surveyed on their knowledge of the trust guidelines

Results

Compliance improved in weak opioids (10.6%) and oramorph (19.1%) but fell in NSAIDs (-2.9%). Paracetamol was prescribed appropriately in 100%. 78% of doctors admitted to not having read the trust guidelines and 89% to not following them despite 100% being aware of the concept of the analgesic ladder.

Conclusions

We saw a tangible improvement in opiate prescribing by surgical juniors. However, the overall compliance to the analgesic ladder is still relatively poor given the doctors are all aware of the concept of the analgesic ladder, suggesting appropriate analgesic prescribing does not rank as highly in importance as it should.
708 Examining the Management of Acute Lower GI Bleeds in Order to Improve Policies and Reflect Safe and Updated Guidance
Authors: Han L , White H , Bosch K , Nair M
Published: May 2021

Introduction

Acute lower gastrointestinal bleeding (LGIB) tends to occur in elderly patients with complex comorbidities. At North Middlesex University Hospital (NMUH), LGIB patients are primarily managed by the surgical department. We amended local policies by integrating aspects of new guidelines published by the British Society of Gastroenterology (BSG).

Method

Handover documentation between November 2019 and January 2020 established patients admitted with LGIB (n = 45). Further data regarding the management of these patients was collated from clinical software and compared to standards set from BSG guidelines.

Results

We found NMUH to be efficient in ruling out upper GI bleeds via 24-hour OGDs and had low surgical intervention rates (0.02%). 40% of patients were transfused with an admission haemoglobin above suggested NICE thresholds, accounting for cardiovascular comorbidities. 56% of patients were discharged without a documented anticoagulation plan. Over 50% of patients did not have BSG recommended inpatient investigations.

Conclusions

Updated Trust guidelines aim to uphold areas that NMUH were shown to excel in, while reiterating NICE transfusion thresholds and include guidance regarding anticoagulant and antiplatelet medications. The Oakland score and shock index have been integrated into local protocols and will aid clinicians in making safe decisions in the management of LGIB patients.
714 Venous Thromboembolism Risk Re-Assessment Within 24 and 72 Hours After Admission (Closed-Loop Audit)
Authors: Aung M
Published: May 2021

Introduction

NICE and Poole Hospital guideline state venous thromboprophylaxis (VTE) risk assessment must be done on admission and at consultant review (within 24hr and 72hr after admission)

Changing from paper to electronic patient records(EPR) system omits some mandatory protocols.

Although VTE risk assessment on admission remains mandatory on EPR, records of re-assessment within 24 and 72hr becomes optional.

Method

100 random patients admitted to the orthopaedic department, before and after implementation of change.

Results

The initial data indicates 0% of recording for re-assessment after admission.

This action led to incorrect dosage and duration of chemical VTE prophylaxis in 20% of the patients.

After presenting the data to stakeholders, an instruction of entering VTE re-assessment on EPR was done by a teaching session and by putting up posters.

A discussion with the IT department resulted in setting up a dropdown-box for VTE re-assessment on EPR.

Re-audit shows a slight improvement in the recording from 0% to 3% for within 24hr and 22% for within 72hr.

Feedbacks indicates an insufficient time, a lack of senior staff member involvement and established workplace culture.

Conclusions

Despite some improvement, more junior and senior staff engagement, including cultural changes, are needed to achieve the national standard.
721 Imaging for Suspected Bowel Obstruction in Pennine Acute Trust (PAT): A Comparison with the National Audit of Small Bowel Obstruction’s (NASBO) recommendations
Authors: Foster K , Shah J , Bandyopadhyay S , Waugh C , Fawzy S , Morris L , Mansour M
Published: May 2021

Background

NASBO recommends Computed Topography (CT) over plain abdominal X-ray (AXR) for the investigation of bowel obstruction (BO). AXR is routinely used within PAT for investigation of BO which may be exposing patients to unnecessary radiation and adding unnecessary cost to the service.

Method

A retrospective audit collected data on patients with CT confirmed BO between July 2019 and February 2020. This looked at the percentage of patients who had both CT and AXR to investigate BO. The cost of these AXRs and the percentage of these AXRs that were normal were also calculated.

Results

A search identified 141 patients with CT proven BO. 81/141(57.4%) patients had both AXR and CT as a part of their initial investigations. Of those patients 26/81(32.1%) had no AXR features suggestive of BO. Only 12/81(14.8%) of those patients had serial AXRs following initial imaging. The cost for one AXR is £34.15 which means £2766.15 was spent on potentially unnecessary AXRs within this period.

Conclusions

PAT is performing potentially unnecessary AXRs which is exposing patients to unnecessary radiation and costing the trust. Plain AXRs do not rule out BO. We have recommended an investigation flowchart to PAT A&E departments to reduce unnecessary AXRs being performed.
741 Manipulation and Reduction of Paediatric Forearm Fractures in The Emergency Department Using Intranasal Diamorphine and Entonox
Authors: Kapoor S , Valand A , Dartnell J
Published: May 2021

Background

Paediatric forearm fractures are commonly encountered in Trauma and Orthopaedics. Currently most forearm fractures are manipulated in theatre the following day, increasing resource burden and delays in management. The aim of this project was to introduce guidelines to reduce fractures in the Emergency Department (ED) using intranasal Diamorphine and Entonox.

Method

197 cases were identified over a 6-month period in 2018 and 2019. 74 distal radial fractures and 123 mid shaft forearm fractures were analysed. Fractures with an intact periosteal hinge or a Salter Harris type 2 were reduced in ED. The pre manipulation and post manipulation radiographs were compared with particular attention to the post reduction angles.

Results

67% of fractures were reduced in the correct setting. A number of fractures reduced in ED required re-manipulation or internal fixation. Overall, there was a 56% reduction in patients undergoing general anaesthetic. There was a reduction in the mean length of stay from 36 hours to 3.5 hours.

Conclusions

Intranasal Diamorphine and Entonox offer a safe method for managing paediatric forearm fractures in ED. Implementation of this method facilitates early access to treatment and early patient discharge. Manipulation in ED offers significant financial savings and reduces demands on the Trauma Theatres.
753 Sesamoid Alignment After MIS Chevron Osteotomy and Its Role to Prevent Hallux Valgus Recurrence
Authors: Edres K A , Abdelghafour K , Felstead A , Adam C , Palmer S
Published: May 2021

Introduction

Incomplete correction of the sesamoid position after corrective osteotomy is a risk factor for recurrence of the hallux valgus deformity. This study was done to report the results of sesamoid alignment after chevron osteotomy.

Method

92 patients (111 feet) had minimally invasive (MIS) distal chevron osteotomy and release of fibular sesamoid ligaments done, sesamoid position was assessed in the weight-bearing views of the foot, tibial sesamoid position in relation to the mechanical axis of the first metatarsal was classified as grades 0-3 where the normal position was graded (0) and the most lateral sublaxation was graded (3). There were 2 groups; the reduced (grade 0-1) & the dislocated (grade 2,3) groups. Preoperative and post-operative radiographs were compared. Postoperative images were done 6-8 weeks post-operatively to ensure osteotomy healing.

Results

Sesamoids alignment was corrected following the MIS chevron osteotomy; 84 feet (75.7%) were from the dislocated group and 27 feet (24.3%) were from the reduced group pre-operatively improved to 102 feet (91.9%) reduced and only 9 feet (8.1%) dislocated following the procedure with P-value < 0.00001. To ensure inter-observer reliability, images were assessed by 2 observers with Cohen’s Kappa coefficient 0.477.

Conclusions

MIS chevron osteotomy can produce significant improvement of sesamoid position which is crucial to prevent recurrence of hallux valgus.
769 Analysing the Change – Outcomes and Benefits of Clinic-Based Removal of Renal Transplant Stents Using A Disposable Cystoscope
Authors: Chowdary P , Shetty S , Whittaker C , Prasad M , Mohamed I , Khurram M
Published: May 2021

Introduction

Literature is chock-full of data regarding the “when” of ureteric stent removal after renal transplantation. We have attempted to address the “who”, “where” and “how” components.

Method

The Isiris disposable scope was used to remove renal allograft stents from 383 patients in the Transplant Clinic from June 2018 to April 2020. An advanced nurse practitioner was trained in the procedure. The learning curve, incidence of complications, benefits and cost implications were studied, and compared with the cohort having stent removal with a traditional flexible cystoscope in theatres.

Results

There were 14 failures necessitating theatre removal. The transplant-to-stent-removal interval was significantly lower in the clinic cohort with a mean of 38.80 days (95%CI 37.26–40.34) to 46.55 days in theatres (95%CI 43.47–49.62). 11 patients had urgent bedside stent removal. The service was delivered independently by the nurse for 5.3% of the patients in June 2018 and progressed to over 80% by April 2019. Estimated net gain was £919/patient.

Conclusions

Moving transplant ureteric stent removals from a resource intensive all-day process in theatres to a one-stop event in the clinic is a safe and economical model that can streamline flow in patient pathway and inculcate new skills in other members of the multidisciplinary team.
772 Quality Improvement Project – Establishment of The Breast Pain Clinic at Torbay Hospital
Authors: Aribo E O A , Adeboye T
Published: May 2021

Introduction

Breast pain alone should not be imaged. The common misconception that breast pain alone is a symptom of malignancy and the subsequent impact on the Triple Assessment Clinic (TAC), lead to the development of the Breast Pain Clinic (BPC), a holistic service to educate patients and reduce unnecessary imaging.

Method

Retrospective data was collected of TAC attendees between September-December 2018, noting patients presenting solely with breast pain (BPP); number of BPP imaged; and those with positive results.

Prospective data collection of those attending the TAC and BPC were collected between September-December 2019.

Results

Retrospectively 17% (151/888) of TAC attendees were BPP, 23.8% (36/151) were imaged and 97.2% (35/36) had normal/benign changes.

Following BPC creation 7% (67/940) of TAC attendees were BPP, 31.3% (21/67) were imaged all with no positive results. 1% (3/94) of BPC attendees were BPP, all with normal/benign imaging.

96% of questionnaire respondents felt more confident managing breast pain.

Conclusions

The development of a BPC was successful in educating patients and reducing anxiety.

It also reduced the proportion of patients presenting to the TAC with pain and the proportion of patients imaged.

With further education of community practitioners on referral adherence, this service could benefit breast services nationwide.
791 Using Audit Data to Inform and Guide COVID-19 Recovery: A Case for the Re-Introduction of Immediate Breast Cancer Reconstructions
Authors: Hobbs N , Touqan N , Williams K
Published: May 2021

Introduction

During the COVID-19 pandemic, operations performed in NHS hospitals were restricted. Breast cancer surgery remained vital, however, to reduce theatre capacity pressures and re-admission rates the procedures available were rationalised to keep the risk of complications low. Immediate breast reconstruction was stopped.

COVID-19 recovery meant careful reintroduction of complex surgeries, with competing interests from different surgical specialities for theatre capacity within the Trust. The psychological effects of breast cancer are significant. Therefore, it was important to advocate for our patients and ensure the reintroduction of this service.

Method

To strengthen our case, a retrospective audit of all immediate breast reconstruction outcomes was performed for cases during the 12 months preceding COVID-19.

Results

64 patients underwent immediate implant and Acellular Dermal Matrix (ADM) breast reconstruction. Five (7.8%) patients returned to theatre. One (1.5%) returned during their initial in-patient stay due to haematoma. Four patients (6.3%) returned between 3 and 12 weeks following their original surgery date. Infection rates were higher in smokers or those with a BMI >35.

Conclusions

These results were presented to management and the reconstruction services were re-introduced in our Trust with stringent inclusion criteria. We can therefore offer our patients an improved service that considers both physical and psychological health.
844 The Frequency of Formal Audiological Assessment in Patients with Diagnosed Vestibular Schwannomas – A Single Centre audit
Authors: Khan D Z , Posa M , Buttimore J , Bance M , Helmy A
Published: May 2021

Introduction

Patients with vestibular schwannomas (VS) must have formal audiology during their workup, according to multiple national guidelines (including NICE).

Method

This retrospective study sought to audit the percentage of VS cases undergoing formal audiometry at a tertiary neurosurgical centre. An illustrative sample was selected randomly from local databases (2006-2019). Data collected included audiometry types (speech discrimination [SD], pure tone audiometry [PTA]), management pathway (surgery, radiotherapy or conservative) and symptom profile.

Results

200 cases were assessed, 7 were excluded (private patients, patients referred but not formally seen). Of the 193 cases included, 186 (96.4%) had ≥1 Pure Tone assessment [PTA], with 135 (70%) also tested on Speech Discrimination [SD]. The surgical cohort had the highest audiometry rates at 38/38, followed by 116/121 (96%) for surveillance and 32/34 (94%) for radiotherapy subgroups. Reasons for no audiology were: profound hearing loss at presentation (2/7), audiometry at local centres (4/7) and patient compliance (1/7).

Conclusions

Our service is highly compliant (96.4%), consistent across management categories. The rate of SD (70%), a functional measure of hearing impairment, can be improved. Monitoring surgical outcomes via formal audiometry should be standard, particularly surgical approaches that preserve hearing are chosen. Follow-up audiometry regimes can be standardized for those on surveillance pathways.
861 Evaluation of Understanding and Utilisation of Low Potassium Diets in Urology Wards. A Quality Improvement Project
Authors: Swamad M , Quraishi M , Buyungo J , Stephenson-Allen A
Published: May 2021

Introduction

Dietary restrictions are implemented upon renal inpatients considering their predisposition to electrolyte abnormalities from renal failure. A similar affiliation in urology wards is assumed due to similar patient profiles. Minimal awareness exists for low potassium alternatives on the catering menu. We aimed to review the understanding and utilisation of low potassium diets amongst healthcare professionals in our urological wards.

Method

Thirty staff members on our urological wards comprising of doctors, nurses and healthcare assistants were surveyed.

Results

Fifty seven percent were unaware of low potassium diet availability on the ward. None of the patients were offered or remained on a low potassium diet. During the cross-sectional review across 3 days, 25(45%) and 7 patients were identified to have renal failure and hyperkalaemia respectively. Three patients warranted renal replacement therapy.

Conclusions

Our study highlights the lack of awareness and underutilisation of low potassium diets on urology wards. An educational programme is being conducted with the guidance of dieticians and caterers. Ward guidelines will be established in patients with high risk of electrolyte imbalances. Low potassium diets will be emphasised on the catering menu. A subsequent evaluation will be performed to review the improvement in our understanding and utilisation enactments.
880 Improving the Acute Knee Injury Pathway – A Regional Quality Improvement Project in the Oxford University Hospitals
Authors: Kim D , Neal-Smith G , Wood A
Published: May 2021

Introduction

There are many patients being referred from A&E to orthopaedic trauma clinics in OUH for suspected ligament or meniscal damage, without convincing evidence of injury. This has led to demand for providing point of care ultrasound and streamlining of the referral process.

Method

We conducted an audit of all A&E presentations at the OUH receiving a knee XR across 3 months and tracked their investigative and referral progress.

Results:

Conclusions

Only 30% (57/182) patients referred to the Trauma clinic were deemed to have a serious ligament or meniscal injury. It is difficult to assess the extent of knee injury without specialist diagnostic equipment, which includes MRI or point of care ultrasound. This project has resulted in new trial protocols exploring the use of these technologies to improve this pathway.
883 Modified Framework for The Management of Acute Gallstone Disease During The COVID-19 Pandemic
Authors: White A , Brewer J , Efthimiou E , Khwaja H , Bonanomi G
Published: May 2021

Introduction

On 12/03/2020 WHO declared SARS-CoV-2 a global pandemic. PHE and RCS advised non-operative management wherever possible, changing management of acute gallstone disease from early laparoscopic cholecystectomy to conservative treatment and frequent percutaneous drainage. Planning, prioritisation, and implementation of “COVID-Safe” pathways presented multi-factorial challenges throughout the NHS.

Method

Prospective data of patients admitted with acute gallstone pathology was collected at Chelsea & Westminster Hospital (23/03/2020-16/08/2020), and prioritised using Tokyo, FSSA and RCS Guidance. A restructured “Gallbladder-pathway” was implemented comprising trust-wide referral proforma, weekly clinical planning MDT meetings and dedicated theatre lists.

Results

Sixty-eight patients were prioritized as either “Urgent” (25), “Expedited” (12) or “Elective” (31); comprising gallstone pancreatitis (11), acute cholecystitis (53), obstructive jaundice (12) and biliary colic (8). 12 patients required cholecystostomies.

During the “Peak” (23/3/20-02/06/2020) no cholecystectomies were performed, 10 in “Recovery” (02/06/20-06/07/20) in NCEPOD theatre, 21 in “Resolution” (06/07/20-18/08/20) since implementation of the “Gallbladder-Pathway”. Eleven patients (16%) re-presented while awaiting definitive treatment, none critically ill. The highest number of re-presentations was in “Urgent” patients (36%) and those with cholecystostomy (45%).

Conclusions

Early adoption of a modified “Gallbladder-pathway” during the pandemic allowed accurate case stratification, efficient resource allocation and safe care. Our model enabled prompt service recovery and a framework to navigate future disruption.
885 Telephone Consultations During the Covid-19 Pandemic; from the Perspective of One Oral and Maxillofacial Unit
Authors: Chaudhry H , Abiola J
Published: May 2021

Introduction

The Covid-19 pandemic has had a global impact on healthcare. As a result, changes have been made to healthcare provision. In the UK, the focus was changed to urgent and emergency treatment only, and therefore a shift from face-to-face consultations to video and telephone consultations was implemented. Our aim was to look at the telephone consultations in our oral and maxillofacial (OMF) department to identify their effectiveness.

Method

A search was carried out using the electronic patient record for patients booked for consultations in the OMF clinics from the 23rd of March to the 1st of May 2020. Trauma clinics and ad-hoc clinics were excluded.

Results

21 clinic codes were found as suitable for inclusion. 185 consultations were booked during the 6-week period. Of these, 165 were via telephone and 20 face-to-face. A total of 75 consultations resulted in discharge and 110 required further follow up or further investigation. Of the 75 patients discharged, 73 of these were via telephone. The main reason for discharge was delivery of benign biopsy results.

Conclusions

Covid-19 will have long term impacts on healthcare provision. If implemented correctly, virtual consultations carry the potential in making healthcare more accessible.
887 A Quality Improvement Project: Implementation of a New Epistaxis Pathway
Authors: Vasanthan R , Massoumi A , Forde M , Corbridge O , Sood S
Published: May 2021

Introduction

Epistaxis is one of the most common ENT conditions leading to unplanned hospital admission. This closed loop quality improvement project looked at epistaxis admissions, and whether patients could be safely managed on an ambulatory basis with unilateral intranasal packing, through the implementation of a new epistaxis pathway.

Method

Two prospective cycles at a District General Hospital. First cycle: three-month period (October-December 2018); recorded all patients admitted with epistaxis and the percentage with intranasal packing; criteria for discharge with unilateral intranasal packing created (including normal observations, normal clotting/haemoglobin, only on aspirin, safe home environment). Second cycle (after implementation of new pathway): two months (December 2019 and January 2020); recorded all patients admitted with epistaxis or discharged with unilateral intranasal packing; patient feedback obtained.

Results

First cycle: 31 epistaxis admissions; 12 patients met discharge criteria; average length of stay was 1.4 days. Second cycle: 22 epistaxis admissions; 4 admissions were avoided; 2 admissions were unnecessary according to new pathway; no patient-reported issues with pack at home.

Conclusions

Successful creation and initial implementation of pathway with no adverse outcomes. Approximately £1380 of savings through avoided admissions. Pathway expanded and successfully used during COVID-19 to include patients on anticoagulation as suitable for discharge with intranasal packing.
902 Too Hot to Handle? Acute Cholecystitis (‘Hot Gallbladder’) Management and Compliance with NICE Guidelines in A District General Hospital
Authors: Karim S , Tjoakarfa J , Bondje S , Jokinen T , Adegbola S , Vachlos G , Tewari S , Gupta V
Published: May 2021

Introduction

Current NICE guidelines recommend that patients with acute cholecystitis should be offered laparoscopic cholecystectomy within 1 week of diagnosis. However, the recommendation is often not met within our trust. We aim to investigate our compliance with these guidelines while outlining the complications and cost effects associated with delayed operation.

Method

A retrospective study identifying emergency patients presenting with image proven uncomplicated acute cholecystitis was performed. Hospital coding and finance departments were used to obtain this information.

Results

166 patients were identified within a 3-month period. Of which, 85 patients were diagnosed with acute uncomplicated cholecystitis and fulfilled the inclusion criteria. On average, patients waited 108 days for their cholecystectomies (range 14-281). No patients received a cholecystectomy within 1 week of diagnosis. 33 patients re-presented to hospital at least once and the total number of repeated admissions was 51. The average length of stay during readmissions was 6 days (range 1-27). The total cost incurred for those readmissions was £117,118.

Conclusion

Delayed cholecystectomies for acute cholecystitis increase the likelihood of repeated hospital admissions and place significant strain on resources. Furthermore, it is associated with increased risk of complications. We recommend introducing a weekly ‘hot gallbladder list’ within our trust dedicated for acute cholecystitis.