bluuebunny/crossref_metadata_2025 huggingface dataset:
1304 Feasibility of Day-Case Laparoscopic Cholecystectomy in Paediatric Patients
Authors: Sabolic I , Khan M , Dada O , Soyombo O , Soccorso G
Published: August 2023

Aim

Standard approach for treatment of cholecystolithiasis is laparoscopic cholecystectomy (LC), however day-case laparoscopic cholecystectomy (DCLC) has not been established as standard procedure in paediatric population. This is to assess the feasibility and safety of DCLC in paediatric population focusing on post-operative outcomes as a measure of success and using a protocolised post-operative pain management approach.

Method

Data, which include demographics, surgeon (trainee/consultant), admission mode, length of stay, complications, and post-operative pain management as per hospital protocol were collected from the hospital database from 2016 to 2022. Patients who underwent DCLS were discharged within 23 hours. Telephone survey was conducted to investigate type and length of analgesia administered at home.

Results

31 patients underwent LC with a day-case rate of 77%. 63% were female. Mean age was 11 years (3 - 16). Obesity and haemolytic disorders were present in 29% and 8%, respectively. 96% were elective admissions. 20% had ASA I, 48% ASA II and 32% ASA III. Post-operatively, opioids with paracetamol/ibuprofen were administered in 96%, and in 80% as post-discharge analgesia. Post-discharge analgesia was administered 1 - 7 days, and 28% used oral opioid analgesia at home up to 3 days. Post-operative complications were present in 2 patients - 1 infected umbilical wound and 1 persistent dyspepsia. Six months readmission rate was 8% due to hypogastric pain treated conservatively. After a 3-month follow-up, all the patients were discharged.

Conclusions

LC can be performed safely as a day case procedure with excellent outcomes using a standardised post-operative and post-discharge pain management protocol.
235 Late Start Times Do Not Disproportionately Prolong Operating Times in Major Head and Neck Reconstruction
Authors: Stark D
Published: August 2023

Introduction

Operating start time delays are deemed as having a detrimental effect on theatre efficiency, subsequent delays, costs, and potentially outcomes. This study assessed the significance of delayed operating start times on major head and neck reconstruction cases and whether later starts led to disproportionately later finishes. Focus was placed on free osteocutaneous fibula flap reconstruction due to long operating times, difficult anaesthesia, frequently overrun and the perception of increased morning efficiency.

Method

Single centre identification of 26 patients using coding informatics that were diagnosed with an intra oral malignancy or osteoradionecrosis requiring reconstruction with a free osteocutaneous fibula flap. Data was manually retrieved between 2015 to 2020 from electronic patient records and statistical analysis was completed using Microsoft Excel.

Results

Total number of patients collated was 27, however 1 was excluded due to insufficient electronic logging of patient data. The total mean age was 64.8 (40-79), 50% were male (13) and 50% were female (13). The mean start time was 9:57, end time was 18:52 and duration was 10:50 (4:46 to 13:42).

For surgery start times before 10:00 a.m. the mean start time was 9:31, end time was 20:16 and duration was 10:46 (8:30 to 22:56). For surgery start times after 10:00 a.m. the mean start time was 10:22, end time was 19:25 and duration was 10:54 (10:01 to 00:51).

Conclusions

Delayed operating start times have minimal significance on theatre efficiency and don’t disproportionally prolong operating times in major head and neck reconstruction cases.
266 Malignant Melanoma: Highlighting Delays in the Pathway from Biopsy to WLE (Wide Local Excision) + SLNB (Sentinel Lymph Node Biopsy)
Authors: Davies M , Kyle D , Alrawi M
Published: August 2023

Aim

To highlight delays in the malignant melanoma (MM) pathway for patients undergoing a Wide Local Excision (WLE) and Sentinel Lymph Node Biopsy (SLNB). Aiming to evaluate if Trust standards are met, to provide a 31-day clock from time of clinic discussion for WLE and SLNB, to date of operation. In particular, comparing pre- (2019) and post-COVID (2022) waiting times.

Method

Retrospective data collection of patients with a MM diagnosis AJCC (American Joint Committee on Cancer) 1B-2C requiring WLE and SLNB, who were operated on between January-December 2019 and January-October 2022. All operations were performed at the Royal Victoria Infirmary, Newcastle. The following parameters were collected: AJCC grade; SLNB site and result; date of: initial biopsy, biopsy result, skin cancer multidisciplinary meeting (MDT), clinic discussion, and operation. Exclusion criteria: AJCC 1A and 3, incomplete original biopsy (i.e. initial 2-week wait clock had not stopped), incomplete documentation of clinic discussion date, extreme delays (3 patients >140 days, due to acute illness and initially declining operation).

Results

The average time from clinic discussion to operation was 35 days in 2019, compared to 53 days in 2022 (p-value <0.05). 56% (n = 79) of 2019 patients underwent their operation within the 31-day target, compared to 13% (n = 14) of 2022 patients, p<0.05. This statistically significant difference was irrespective of AJCC grade and SLNB site.

Conclusions

Statistically significant decrease in the percentage of patients meeting the 31-day target in 2022, compared to 2019. Delays were affected by an increase in number of MM referrals and limited capacity for operating.
313 Preoperative CT Imaging: A Tool to Predict Incisional Hernia Outcomes Following Abdominal Wall Reconstruction
Authors: Frommer M L , Faderani R , Pérusseau-Lambert A , Kanapathy M , Malhotra A , Khosh Zaban M , Floyd D , Butler P E M , Ghali S
Published: August 2023

Aim

Abdominal wall reconstruction (AWR) is a surgical technique used to manage recurrent incisional hernias, which cause significant morbidity and are difficult to treat. In this study, we sought to determine whether subcutaneous abdominal fat thickness (AFT) measured at the xiphoid process, umbilicus, and pubic tubercle using preoperative CT scans could predict postoperative outcomes in patients undergoing AWR.

Method

A retrospective cohort study was conducted on all patients who underwent AWR at our institution between 2009 and 2021 with a minimum follow-up of 12 months. Using preoperative CT scans, AFT was measured at the xiphoid process, umbilicus, and pubic tubercle, as well as the hernia dimensions. Demographic, operative, and surgical outcome data were also collected and analysed using statistical tests.

Results

The results showed that 9 out of 101 patients (8.9%) experienced hernia recurrence. Smoking was significantly associated with an increased risk of hernia recurrence (p<0.001) and had a predictive odds ratio (OR) of 18.27 (p = 0.041). Increased AFT at the xiphoid (p = 0.005), umbilicus (p<0.001), and pubic tubercle (p<0.001) were also associated with hernia recurrence and additionally with risk of infection. However, only AFT at the pubic tubercle reached significance in the multivariate logistic regression model predicting recurrence (OR = 1.10; p = 0.030) and infection (OR = 1.04; p = 0.021).

Conclusions

In conclusion, smoking and increased subcutaneous abdominal fat thickness at the pubic tubercle are significant risk factors for recurrence and infection in patients undergoing abdominal wall reconstruction, and preoperative optimisation should focus on reducing these factors.
404 Imaging for Plastic Surgery Trauma Referrals – Does It Reduce Unnecessary on the Day Patient Transfers?
Authors: Drury D
Published: August 2023

Aim

To determine whether requesting images for plastic surgery trauma referrals reduced the number of patients transferred to hospital for on the day assessment and management.

Method

Two data collection periods between 31/08/22 - 18/09/22 (round 1) and 24/10/22 – 17/11/22 (round 2) were undertaken. For round one on call plastic surgery SHOs were asked to keep track of all trauma referrals outside of their base hospital which they accepted for on the day review. Once the patient had been reviewed SHOs were asked whether they felt the patient required on the day management or if the patient could have been safely triaged to be seen the following day. During round two SHOs were additionally asked to request images from the referrer were able and to note whether this altered or confirmed their initial management plan.

Results

Round one: 15 patients were transferred for on the day review with 80% deemed as requiring on the day management whilst 20% did not. Round two: 13 patients were transferred for on the day review with 92% deemed as requiring on the day management whilst 8% did not. Images were sent for 9 patients, altered the initial decision in three cases and confirmed the initial management in 6.

Conclusions

Requesting images for plastic trauma referrals can reduce the number of patients unnecessarily seen on the day, reducing patient stress, and making better use of hospital resources.
516 The Livingston Nexobrid Pain Protocol - Further Experience in 80 Patients
Authors: Warwick A
Published: August 2023

Introduction

Our unit has employed Nexobrid in the debridement of burns. It is a painful process yet there is no formal analgesia protocol in the literature. The team in Livingston developed a successful bedside pain protocol which is fast acting, long lasting and has a quick recovery time. It is administered by the Acute Pain Team nurses and reduces the need for invasive techniques and specialist medical staff.

Method

A Fentanyl based Patient Controlled Analgesia (PCA) protocol with clinician administered boluses is used in this unit. Patients’ pain scores were documented throughout the procedure, as well as their perception of their worst pain and their overall satisfaction with the treatment. All patients undergoing enzymatic debridement outwith the ITU environment utilised this protocol.

Results

Eighty patients undergoing Nexobrid burns debridement were included in this study. The PCA ran for around 4 hours. Pain was most severe on removal of the enzyme however after bolus analgesia, the mean score at this point was 3/10. Patient satisfaction with the treatment was reported as “very satisfied” or “satisfied” in 95% of cases. No complications were reported.

Conclusions

Addressing the significant psychological element of the pain response was an important role of the Pain Nurses in preparing patients for the debridement process.

The analgesia protocol is safe, easy to administer and remains well tolerated, providing a high level of patient satisfaction and low rate of complications in the enzymatic debridement of burns. The role of the Pain Nurse in this protocol is important.
544 Effect of Tranexamic Acid on Microvascular Thrombosis in Autologous Free Tissue Transfer
Authors: Leow S H , Arnaout A , Ridha H
Published: August 2023

Aim

The use of Tranexamic Acid (TXA) has been shown to be effective in reducing haemorrhage and mortality in numerous surgical settings and has a wide range of proposed benefits linked to anti-inflammatory effects which promotes healing and reduces pain and discomfort. However, the surgical community has been reluctant to incorporate TXA use into mainstream practices in microvascular surgery due to possible risk of thromboembolic events. Hence, we aim to report our experience with the use of TXA in microsurgical reconstruction.

Method

We performed a retrospective single-centre cohort study including any patients who underwent autologous free flap tissue transfer at a district general hospital, from 1 January 2016 to 20 April 2022. The Chi-squared test was used to determine if there were any significant differences between the proportion of patients who developed any evidence of microvascular thrombosis, flap failure, or return to theatre. Univariate logistic regression was used to calculate odds ratio.

Results

The treatment group (N = 160) received TXA (1g intravenous) at the time of general anaesthetic induction as per the senior author’s routine practice, while the control group (N = 80) did not receive TXA at any point of the hospital admission, according to the normal practice of other surgeons. No differences were found between the proportion of patients who developed flap failure, venous congestion or were returned to theatre between the TXA and control group.

Conclusions

Our study shows that TXA administration did not increase microvascular thrombosis in free flap reconstructive surgery, contributing evidence that TXA is safe to use in microvascular surgery.
675 Are Postoperative Outcomes in Flap Operations Affected by Obesity?
Authors: Meenu A , Karanth V , Kumar N C S , Acharya A
Published: August 2023

Aim

To explore the outcomes of flap surgeries and how obesity affects them. To find if there is a correlation between CBC indices (also inflammatory markers) with flap survival.

Method

All flap surgeries on adults in the collaborating departments in an Indian tertiary care hospital from 2021-2022 excluding finger flaps were prospectively analyzed. Data of 90 patients including postoperative complications, preoperative Neutrophil-Lymphocyte Ratio (NLR) were recorded.BMI is calculated to classify patients based on Asia-Pacific guidelines where BMI>25 is obese, 23-24.9 is overweight, <18 is underweight.Chi square tests were used to assess association between obesity, NLR and early (within 7 days of surgery) &late (beyond 7 days) postoperative complications -flap loss, wound dehiscence, surgical site infection. Multiple regression model and ANOVA test were also done with these variables.

Results

There is significant association between patients’ obese or overweight habitus and postoperative surgical site complications. 38% early (p = 0.001) and 36% late (p = 0.044) complications happened in obese patients alone.

There is significant association between NLR and early postoperative complications (p = 0.002).60% with high NLR values had severe early postoperative complications, compared to 16.7% of patients with normal NLR and 21.1% with mildly raised NLR.

Obesity and high NLR [NLR 10-18 or moderate stress, NLR>18 or severe stress] independently have significant correlation (0.038 for obesity, 0.015 for NLR) with early postoperative complications.

Conclusions

Obesity combined with high preoperative NLR is a quick, inexpensive predictor of poor early postoperative flap survival.
1224 A Systematic Review Exploring the Mechanisms Behind Autologous Lipotransfer for Radiation-Induced Fibrosis
Authors: Pattani N , Sanghera J , Langridge B , Frommer M , Abu-Hanna J , Butler P
Published: August 2023

Aim

Radiation-induced fibrosis (RIF) is a recognised consequence of anti-cancer radiotherapy, especially after multiple and prolonged dosing regimens. There is no definitive treatment for late-stage RIF, although the use of autologous fat transfer (AFT) has shown promise. However, the exact mechanisms by which AFT improves RIF remain poorly understood. We aim to explore existing literature on the effects of AFT on both in-vitro and in-vivo RIF models, and to collate potential mechanisms of action.

Method

PubMed, Cochrane reviews and Scopus electronic databases from inception to January 2022 were searched. Our search strategy combined both free-text terms with Boolean operators, derived from synonyms of adipose tissue and RIF.

Results

The search strategy produced 2645 articles. Of these, 76 underwent full-text review for eligibility, yielding 26 for final analysis. Eight conducted in-vitro experiments utilising a co-culture model, whilst 21 conducted in-vivo experiments. AFT interventions included adipose-derived stem cells (ADSCs), stromal vascular function, whole fat and microfat. Notable findings include downregulation of fibroblast proliferation, collagen deposition, epithelial cell apoptosis, and proinflammatory processes. AFT suppressed hypoxia and pro-inflammatory interferon-γ signalling pathways, and ADSC-treated tissue stained strongly for anti-inflammatory M2 macrophages. Although largely proangiogenic initially, studies show varying effects on vascularisation. There is early evidence that ADSC subgroups may have different functional properties.

Conclusions

AFT functions through pro-angiogenic, anti-fibrotic, immunomodulatory, and extracellular matrix remodelling properties. By characterising these mechanisms, relevant drug targets can be identified and used to further improve clinical outcomes in RIF. Further research should focus on ADSC sub-populations and augmentation techniques such as cell-assisted lipotransfer.
1262 The Relationship Between Eye Dominance and Congenital Limb Absence: A Retrospective Study
Authors: Brown S , Lam W , Hooper G
Published: August 2023

Aim

Congenital limb absence, the absence of one or more limbs present at birth, is a rare but potentially debilitating condition. Previous research has suggested that there may be a relationship between eye dominance and the development of congenital limb absence, but this relationship has not been extensively studied. In the general population, 35-56% of left handers are left-eye dominant and 62-73% of right handers are right-eye dominant. The aim of this retrospective study is to explore the relationship between eye dominance and congenital limb absence.

Method

Medical records of individuals with congenital limb absence from between May 1995 and March 2002 were reviewed, and eye dominance was determined through the use of standardized eye dominance tests. A multivariable logistic regression was developed to determine the effect of limb deficiency laterality on eye-dominance.

Results

A total of 81 patients were eligible for inclusion in the study with a median age of 25 (IQR = 20). 54.3% (n = 44) of the patients were female. Laterality of limb absence was 27:54 (Left:Right). In our study group, 81.5% of left-hand dominant patients were left eye dominant. 83.3% of right-hand dominant patients were right eye dominant. Patients were more likely to be right eye dominant than left eye dominant (OR 22.39, 7.02-85.80, p<0.001).

Conclusions

This study suggests that there may be a potential link between eye dominance and the development of congenital limb absence. Further research is needed to fully understand this relationship and its potential implications for the prevention and management of congenital limb absence.
1276 The Impact of Low BMI on Patient Reported Satisfaction Following Deep Inferior Epigastric Perforators Flap Breast Reconstruction in a National Breast Cancer Centre in the Republic of Ireland
Authors: Dhannoon A , Sheahan C , Christodoulides N , Marino S , Martin-Smith J
Published: August 2023

Introduction

Low-BMI patients are candidates for both implant and free autologous tissue breast reconstruction. However, deep inferior epigastric perforators (DIEP) flaps are not a popular option among thin women. The objective of this study was to evaluate patient reported outcomes among this patient’s population.

Method

A retrospective chart review was conducted for all the DIEP-based reconstruction performed over a five-year period between June 2016 and June 2021. Inclusion criteria included patients with BMI < = 25. Data collection included patients’ demographics, timing of surgery, laterality, number of pedicles, irradiation, complications and adjustments thereafter. After Ethical approval, patients were contacted to assess post-operative satisfaction using the Breast-Q ®.

Results

During the study period, 169 DIEP flap-based reconstruction were performed, a total of 59 patients fell in the low BMI category. Twenty-seven patients had immediate reconstruction and only 2 patients had bi-pedicled flap. The Average age was 48.8 years and average was BMI 23.3. The majority of our patients were non-smoker (n = 57) and didn’t receive adjuvant radiation (n = 43). Only 32.6% (n = 15) had adjustment. The unilateral reconstruction patients made 93.0% (n = 14) of those requiring adjustment with 60% of them (n = 9) undergoing lipofilling. The total response rate to the Breast-Q survey was 79.6% (n = 47). Overall Breast-Q scores showed high satisfaction with breasts with high overall levels of psychological, sexual, and physical wellbeing.

Conclusions

DIEP flap-based reconstruction was demonstrated to be a safe and aesthetic reliable procedure in our cohort, yielding high level of psychological, sexual and physical wellbeing.
35 Enhanced Vetting of Urology Referrals in NHS Lanarkshire
Authors: Rutherford G , Tan L J , Amer T
Published: August 2023

Aim

There is an unmatched need for outpatient clinic appointments across all specialties in the NHS. We aimed to reduce unnecessary clinic appointments within the Lanarkshire Urology Department and thus allow timely access to outpatient appointments for newly referred patients with greater clinical need.

Method

Following a successful pilot in December 2018 all referrals to Lanarkshire Urology department underwent an enhanced vetting process by a consultant urologist with particular attention to:Detailed review of electronic records and imagingBooking of scans/ repeat blood tests prior to consultationsSignposting to more appropriate services such as the community continence clinic were indicatedWritten advice, with returned referrals giving clear guidance and evidence-based recommendations where appropriate

Subsequently 3 phases have been completed

Phase 1: June-December 2019.

Phase 2: June-December 2020.

Phase 3: January - November 2021

Results

Pilot and Phase 1

6.3% of referrals were clinically canceled with the referrer being sent case specific clinical advice. This increased to 9.5% in phase 1.

Phase 2:

There were 3012 outpatient urology referrals between June and December 2020.

762 patients were vetted as clinically canceled, an 87% increase from 2019, reducing the number of clinic appointments required by 25%.

Phase 3:

9634 patients were referred between January 2021 and November 2021, 15.8% (n = 1484) vetted as clinically canceled/ advised only. Furthermore, 548 patients were taken straight to test decreasing duplicate appointments.

Conclusions

We have recognized that vetting is a factor that, done well, can mitigate unmatched demand in outpatient services.
123 Optimising Pre-Operative Intravenous Fluids to Reduce the Incidence of Acute Kidney Injury in Hip Fracture Patients
Authors: Ng N , Smith T , Leow J M , Williams M
Published: August 2023

Aim

Acute kidney injury (AKI) in hip fracture patients is associated with increased morbidity, mortality, and hospital stay. Local policy recommends 500ml of Plasmalyte on admission to the Emergency Department (ED), followed by another 500ml at 100ml/hr. Subsequently, patients without AKI should receive maintenance fluids until post-operative oral fluid intake is adequate. IV fluid (IVF) prescriptions in line with local policy were defined as ‘adequate’.

Method

Three prospective audits were undertaken with interventional measures deployed between cycles. Data collected included blood results, IVF received, past medical history, and the pre/post-operative incidence of AKI. Interventions include an ED proforma used as an admission checklist and educating ward doctors with a narrated video and posters.

Results

None of the twelve patients in the first cycle received adequate IVF. The second and third cycles had twenty-seven and twenty-eight patients, respectively. Between these cycles, ED’s IVF prescription adherence improved from 37.0% (10/27) to 46.4% (13/28). On the wards, IVF prescription adherence significantly improved from 33.3% (9/27) to 78.5% (22/27). Pre-operative AKI was 3.7% (1/27) in the second cycle and 0% (0/28) in the third cycle. Post-operative AKI was 3.7% (1/27) in the second cycle and 7.1% (2/28) in the third cycle. None of the post-operative AKI patients received adequate IVF. The third cycle showed that the primary Plasmalyte and secondary Plasmalyte were prescribed appropriately in 57% and 50% of patients, respectively.

Conclusions

Our interventions successfully improved IVF prescriptions on the wards. However, adherence can be further improved to local policy to reduce the incidence of AKIs.
316 The Impact of a Surgical Same Day Emergency Care (SDEC) Unit
Authors: Lukaszewicz A , Linganathan S , Morris C , Strong P
Published: August 2023

Aim

SDEC units are part of the NHS long term plan. It marks a shift from assessment units to tailored emergency care hubs providing genuine dual assessment and treatment. Its aim is to provide optimal care for patients in a timely manner by the appropriate teams, enabling reduced time to emergent treatment, reduced pressure on other acute services and shorter inpatient stays. This is ever more pertinent in the modern, post-pandemic NHS with staffing and funding challenges combining with record numbers of expectant patients awaiting urgent operations. This QIP aims to investigate one such unit’s effectiveness.

Method

SDEC surgical admissions data was collected from the online system BIS or from the clinical notes between September 2021-2022. This was then graphed on excel and analysed.

Results

Pertinent findings include: 47% drop in ED surgical presentations. 66% surgical emergency attendances seen in SDEC (43% prior to SDEC). Decision to admit time reduced by 150 minutes. Median time from arrival to discharge reduced by 7 hours.

Conclusions

This SDEC unit has had a positive impact on ED workload and improving decision making & throughput of surgical patients. As well as supporting previous studies on SDEC benefits this model works for all surgical specialties. It is also objective and repeatable, allowing like-for-like comparison. Limitations include short study period, and lack of patient satisfaction assessment. It is also unclear which specific elements of SDEC model have had the beneficial effects.
342 Procedure Room Lists for Core Trainees
Authors: Burrows A , Singh R , Read J
Published: August 2023

Aim

To reduce the waiting list times for local anaesthetic (LA) “lumps and bumps” in our trust and simultaneously increase our junior surgical trainees’ logbook numbers and confidence; by piloting a trainee led procedure room list during covid recovery.

Method

Clinic letters for the 49 patients on the waiting list were vetted for appropriate cases by the firm core trainee (CT) and registrar. The CT liaised with supervising colleagues, admissions, and management to plan and complete ad hoc “procedure room” lists in free slots of the existing theatre timetable.

Results

From 08/09/22 to 01/12/22 (12 weeks), 27 procedures were completed by junior surgical trainees over seven sessions. The trust’s waiting list for benign local anaesthetic procedures decreased from 49 weeks to 1 week. Trainee logbook numbers for these procedures increased nearly 20-fold compared to similar 12-week periods earlier in training. Comparison in confidence levels of the trainees, as assessed by a questionnaire, increased markedly from the beginning to the end of the project, in suturing, diathermy, and excision of benign subcutaneous lesions. There were no complaints or adverse events.

Conclusions

This quality improvement project was led from inception to completion by surgical trainees and played a significant part in the trust’s COVID recovery. Trainee delivered “lumps and bumps” lists can be introduced safely within the envelope of existing resources and can lead to improved trainee operative numbers and confidence. We are working to create a formal pathway for these patients and embed this into the local core training curriculum.
347 General Surgery Ward Round Documentation: A Quality Improvement Project
Authors: Dyer M , Mazumdar E , Abdelkarim M E A , Morgan R
Published: August 2023

Aim

To improve the rate of inclusion, and quality, of important clinical details in the ward round documentation of General Surgery inpatients at a district general hospital.

Method

A 15-point ward round checklist was created, containing clinical details which were considered appropriate to be included in all wards round entries. An initial audit of 71 ward round entries was performed, assessing their compliance to this checklist.

Following this, a ward round proforma was created and put into use. One month later, 106 wards round entries were sampled for a repeat audit, 85 of them having used the ward round proforma (80.2% compliance). These 85 entries were then analysed for compliance against the checklist, and results compared to the first cycle.

Results

Use of the proforma demonstrated improvement in 11 out of 15 checklist components, with one component (a documented management plan) remaining at 100% compliance. The proforma achieved an 100% compliance of 3-point patient identification (+43.7%), with dramatic improvements in the documentation of NEWS score/observations (+22.5%), medication review (+26.7%), thromboprophylaxis review (+53.4%), examination findings (+45.3%) and escalation/DNACPR status (+37.7%).

The 3 components where performance declined were the name of the ward round lead (-8.5%), date (-2.4%) and time (-10.6%), most likely due to design of the proforma which has been rectified and will be reaudited to ensure improvement.

Conclusions

Using a ward round proforma greatly improves consideration and documentation of important clinical details on ward rounds. This has positive implications for patient safety and facilitates the subsequent ongoing care of the patient.
363 The Use of Printed Radiographs to Document Dental Extractions for Alveolar Bone Graft Patients
Authors: Gkorila A , Langford M , Bussell M , Fallico N
Published: August 2023

Aim

Recent cases of additional operations had to be offered prior to an alveolar bone graft (ABG) to complete dental extractions. Appropriate planning is important to avoid multiple GAs or the potential extraction of a wrong tooth. This quality improvement project was performed to assess and improve our practice.

Method

As a gold-standard, all dental extractions should be correctly identified and documented on printed orthopantograms (OPG) or upper standard occlusal (UOS) radiographs at the time of ABG planning. Documentation should include their timing (pre- vs intra-operative), a cross tooth marking on the radiograph, signed by two consultants, and filed with the consent form.

In the first audit cycle we completed retrospective data collection of the above parameters for all ABG clinic patients between June and August 2021. After discussion with the stakeholders and implementation of changes, prospective data was collected for the second cycle, from October to December 2021.

Results

The documentation of the date of the OPG and UOS improved from 26.6% (4/15) to 100% (11/11). For 1 of the patients in the 2nd cycle, no OPG was done, as the patient's dental development didn't justify it. For the preoperative extraction cases, the presence of printed OPG in file increased from 53.8% (7/13) to 100%, marking of teeth improved from 57.1% (4/7) to 83.3% (5/6), and filing of the consent forms remained stable around 70%.

Conclusions

Adherence to the gold-standard was improved in most aspects as a result of this quality improvement project. Further changes will be introduced to achieve 100% compliance rate.
378 Improving Opioid Stewardship in General Surgical Practice
Authors: Reid R , Vijayagopal K , Digne-Malcolm H , Khan J S , Butler R , Peters P , Htet W , Mohamed R , Ahmed M , Wilson J , Magee C
Published: August 2023

Aim

The last 30 years has demonstrated a steady increase in drug-related deaths, with opioids implicated in at least 2,219 deaths in 2021 in England and Wales1. Inpatient opioid prescribing in surgery has been demonstrated to correlate with long term use post-discharge2. We aim to improve opioid stewardship at our DGH to reduce ‘opioid-load’ in the community, thereby reducing likelihood of long-term post-operative use.

Method

Intervention included teaching for junior doctors, audit meeting presentation and posters designed collaboratively with acute pain team. Prospective data collected for 92 patients discharged from general surgery from October 2022 and compared to previous data pre-intervention from June 2020. Opioid prescriptions were converted to Milligrams of Morphine Equivalence (MMgEq) for analysis.

Results

Following intervention, max average 58.64 MMgEq/day compared to 85.88 MMgEq/day previously. Max PRN prescription now 49.77 MMgEq/day compared to 57.18 MMgEq/day. Increased involvement of acute pain team (15.9% to 20%) and improved use of multimodal analgesia (PCA - 3% to 13%, NSAIDS - 2% to 16.5%, rectus sheath blocks – 1% to 4.2%). Discharge prescribing also improved; only 57.6% discharged with opioids, 89% had documented plan for GP and 49% had specific duration.

Conclusions

Our results demonstrate marked improvement in surgical opioid prescribing. There is potential for further improvement including introduction of opioid misuse risk calculator and formalising opiate prescribing guidelines in surgery.
502 A Retrospective Review of Laparoscopic Colectomies Informed Consent Documentation, with a View of Standardisation Are Patients Properly Informed?
Authors: Laulloo S , Muhammad K , Abduljabbar M , Ahmed G , Perakath B
Published: August 2023

Introduction

Shared decision-making and consents are fundamental to good medical practice and are paramount to our surgical practice. A lack of clear recorded information given to patients about the surgical procedure, associated risks and potential complications can cause harm. Landmark cases such as Montgomery vs Lanarkshire Health Board, emphasized the importance of accurate and informative consent forms.

Aim

To improve the quality of our consent forms. To standardize our consent forms for laparoscopic colectomy resection surgeries performed at The Department of General Surgery at Wye Valley NHS Trust. To produce a model consent form to reduce future medicolegal issues related to poor documentation.

Method

We identified 22 common risks and complications associated with any laparoscopic colectomy surgery. Consent forms were analysed for documentation of: Demographics, risk factors, clear handwriting; Known relevant risk factors associated with the procedure; Benefits and any additional procedures required and Name & grade of healthcare professional.

Results

The most common complications mentioned across the consent forms were Anastomotic leak /Collection (94%), Wound infection, Bleeding, and DVT/PE (90%). Complications like post-op pain, post-op ileus, stoma complications, iatrogenic bladder/ureter injuries, and mortality were under-recorded. As a result, the quality of our consent forms and information provided to our patients is widely variable.

Conclusions

Proper completion of consent forms is crucial. Introducing a modified consent form with pre-filled risk factors/complications will allow for more accurate consent form completion ensuring relevant complications are discussed with patients.
573 Proforma for Referrals to the Paediatric Surgery Ward from General Practice (GP) Surgeries and Urgent Care Centres for Foundation Year One (FY1) Doctors
Authors: Kalu U A , Abu-Suleiman A , Edet G , Quinn C , Fleet M
Published: August 2023

Introduction

The foundation year one (FY 1) doctors hold a bleep and receive referrals from primary care centres especially from the General Practice (GP) surgeries and Urgent Care centres. For many FY 1 doctors, this job may be their first experience in the NHS in taking referrals and it could be quite challenging to take a good referral from primary care centres in the NHS. This was the basis to conduct this quality improvement project (QIP) to help the FY 1 doctors in taking good primary care referral documentation.

Aim

To develop a primary care centre referral proforma as a guide for the FY 1 doctors in taking referrals and to assess the junior doctors and other ward staff satisfaction in using the proforma.

Method

This QIP was registered and approved by the Continuous Quality Improvement Team of Hull University Teaching Hospital NHS Trust. This was a prospective study with designed proforma for FY 1 doctors to be used following primary care centres referral to the Paediatric Surgery ward.

Results

There were 38 primary care referrals between 16th October 2022 and 20th December 2022 with 30 referrals from the GP surgeries and 8 referrals from the Urgent Care centres. The overall satisfaction was excellent with the use of the designed proforma by the FY 1 doctors and other ward and we had 100% completion in filling in the designed proforma.

Conclusions

A well designed referral proforma could improve the confidence and quality of referral documentation from primary care centres by FY 1 doctors.
666 Improving Consent Form Completion Rate and Quality in Plastic Surgery
Authors: Zhao Z , Serle J , Kiakou M , Leong S , Armstrong A
Published: August 2023

Aim

The consent form is a medico-legal document which seeks to reflect the quality of the consenting process. We aim to audit and improve the quality and completion of surgical consent forms in a plastic surgery department in a major trauma centre.

Method

Retrospective review of Consent Form 1 for surgical procedures completed in May 2022. 3 aspects were audited: legibility, information sharing, and seeking consent. An educational poster was created as the intervention. The audit was repeated in October 2022. A survey was sent to obtain clinicians' experience to compare to the results.

Results

The first cycle audited 62 consent forms: 79% were completely legible with no abbreviations. 98% contained 3 patient identifiers. 83% had completely legible benefits and risks documented. 71% had the information of the consenting clinician clearly documented. 3.3% had documented if a carbon-copy was offered to the patient.

Post-intervention, 54 consent forms were audited. 100% were completely legible with no abbreviations. 100% contained 3 patient identifiers. 91% had completely legible benefits and risks documented. 93% had the information of the consenting clinician clearly documented. 39% had documented if a carbon-copy was offered to the patient.

10 clinicians responded to the survey: 70% described having little to no formal training in completing consent forms; 60% noted that they have learnt through observing others.

Conclusions

A simple intervention is enough to significantly improve the quality of documentation of consent forms. Greater education of how to correctly complete the consent form is important in the education of a surgeon.
765 Improving the Assessment of Patients Post-Angioplasty: A Quality Improvement Project in a District General Hospital
Authors: Shah S , Mohammed E
Published: August 2023

Aim

Complications post-angioplasty are rare and include haematomas, haemorrhage, and acute limb ischaemia. National guidelines recommend patients should be kept in an area where limb perfusion and complications can be assessed, but doesn’t detail what this encompasses. Others have suggested this could include examination of pulses, limb perfusion and an ankle brachial pressure index (ABPI). This QIP aimed to improve the examination of patients’ post-angioplasty and develop internal guidelines to support this.

Method

Data was collected retrospectively between 01/12/2021 – 18/03/2022 and 25/03/2022 – 31/07/2022 for patients undergoing inpatient angioplasties. Documentation was examined for evidence of assessment of the following domains: 1) Peripheral pulses, 2) Wound site, 3) Haemodynamic stability, 4) Limb perfusion, 5) ABPI, 6) Decision regarding anticoagulation, and 7) Same day assessment. A teaching session was delivered to doctors teaching them how to examine these patients, use a doppler and measure an ABPI. We re-audited and created guidelines which were displayed on the surgical wards.

Results

There was a notable improvement in the examination of peripheral pulses (33% to 100%), wound sites (47% to 93%), limb perfusion (40% to 93%), same day review (73% to 86%) and decisions regarding anticoagulation (60% to 71%). Haemodynamic stability and ABPI remained unchanged.

Conclusions

We show that teaching juniors how to examine patients’ post-angioplasty improves the assessment of these patients. This is important for early identification and treatment of complications. Though this was carried out in a small district general hospital, it also highlights the need for more detailed national guidance.
784 Advanced Nurse Practitioners Benefit Patient Care and Flow in an Elective Surgical Hub During Recovery From the COVID-19 Pandemic
Authors: Jang S , Phillips J , Jones T , Boulton R
Published: August 2023

Advanced nurse practitioners (ANPs) have an independent scope of practice in patient care. ANPs were introduced to an elective surgical hub during the COVID-19 pandemic in a similar capacity to senior house officers. We examined the impact of ANPs on patient care as viewed from healthcare professionals and patients, and in facilitating timely discharge to maintain flow.

We constructed two separate questionnaires, one for healthcare professionals (HCPs) and one for patients. We compared the time to completion of discharge summary, adjusted for patient volume, before and after ANPs were introduced to the ward to determine patient flow.

We received 27 responses from HCPs: 18 doctors, 7 nurses and 2 allied health professionals. Average score for overall impact on patient care was 9.2 out of 10. We received 9 responses from patients, of which 6 responded having never met ANPs during their care. Of the 3 responses, average score for overall impact on patient care was 5 out of 5. After ANPs were introduced, discharge summaries had an average completion time of 12:56, which was 6 minutes later than before their introduction (t-test, p = ns). We found that there were more admissions before the introduction of ANPs (25 before, 58 after), indicating a maintenance of flow despite increased workload.

ANPs in this elective surgical hub form an integral part of the team who can carry out the majority of ward-based tasks independently. Despite more than double patient volume, flow was maintained. Further work is needed to increase their recognition amongst patients.
888 Improving the Documentation of Skin Closure and the Plan for Its Removal for Trauma & Orthopaedic Patients
Authors: Peace C , Crone A , Hegarty P
Published: August 2023

Aim

Surgical patients require closure of wounds with skin clips or sutures. Removal at an appropriate time can prevent complications, namely infection. Our goal is to ensure clear documentation of closure type and plan for removal. The Royal College of Surgeons states that “details of closure technique” and “detailed post-operative care instructions” are required.

Method

Retrospective data collections were undertaken in January and September 2022 for trauma patients in Altnagelvin Hospital. Data was gathered from Operation Notes. The first collection included 30 patients, the second included 24 patients. Two main interventions were implemented. The first of these was presentation of the initial findings at a departmental audit meeting for the purpose of education. The second was to amend operative proformas to include different types of skin closure and its removal at a prescribed time in the post-op plan as “delete as appropriate” options.

Results

Following our interventions, the correct skin closure was documented in 100% of patients. Plan for removal of closure was documented in 84.6% overall between both written and typed notes. Typed operative notes had 100% plan for removal documentation compared with only 66.67% of written notes. In the first collection, only 55% of patients had adequate removal plans documented on typed notes so the amended operative notes being introduced have resulted in a clear improvement.

Conclusions

Accurate documentation is essential for patient safety and simple interventions can result in a drastic improvement in quality. Pre-typed operative notes were superior to written operative notes and should be used where available and appropriate.
908 Factors Affecting Last Minute Cancellation of Elective General Surgical Cases; Preliminary Findings of a QIP
Authors: Clarke E , Prabhakaran J , Suliman H , Singhal T
Published: August 2023

Introduction

Waiting lists for elective general surgeries have been growing steadily over the past few years, with short-notice cancellations affecting both cost and patient safety. There are currently nationwide incentives to cut referral-to-theatre delays and tackle the backlog of over 7 million patients (NHS backlog data analysis - British Medical Association 2022).

Aim

To identify common causes of short-notice cancellation of elective general surgery lists, and identify targets for intervention for minimisation.

Method

This audit was registered with the department. Prospectively collected elective general surgery lists between January and November 2022 were compiled and analysed. We coded the reason for cancellation from patient records.

For the patients found to be unfit on the day to come in (TCI), we reviewed PAC notes to see whether they had been deemed fit at PAC and how this had changed.

Data were coded and analysed on Microsoft Excel on secure Trust computers.

Results

Between 01/01/2022 and 06/11/2022, 508 (22%) of the scheduled 2300 cases were cancelled, with 235 (10.2%) within 48 hours of their scheduled start date.

Acute patient illness and patient unavailability were the most common causes of short notice cancellation of a case (n = 41), followed by time constraints (n = 33), patients not being medically optimised (n = 27) or no longer requiring surgery (n = 21, as well as administrative error (n = 14).

Conclusions

Targets for intervention following these preliminary audit results included improved patient literature at pre-assessment, clerical chart review in the lead up to the surgery to ensure all administrative tasks have been performed, and a clinical review immediately prior the TCI date to identify any intercurrent illness.
1004 Assessing Appropriateness of Referrals to the Trauma and Orthopaedic Department
Authors: Taiwo B , Menyah E , Garcia S
Published: August 2023

Background

The Trauma and Orthopaedic (T&O) on-call service receives referrals from the emergency department (ED), general practice (GP), urgent treatment centres (UTCs), and requests for inpatient reviews. The virtual fracture clinic (VFC) pathway allows ED and UTC clinicians to assess, discharge and refer when necessary. For VFC, the on-call Orthopaedic Consultant will review the case the next working day and make an appropriate plan. The VFC pathway consists of a traffic light system, in which clinicians can safely discharge with written advice (green), refer to the VFC (yellow) or refer to the on-call team (red).

Method

The aim was to assess how the VFC pathway was being utilised. All referrals to the T&O on-call team over 3 weeks were assessed retrospectively. The following referrals were excluded - Fractured Femur, Head Injury, Trauma Calls and Back Pain Pathway. The following data was collected - Patient details, diagnosis, referral source, the reason for referral, plan, double booking with VFC and appropriateness.

Results

191 referrals were analysed. Most referrals are from the ED (51%) and UTC (23%). 35% of referrals were deemed to be inappropriate. 38% of inappropriate referrals (25/66) should have been referred to VFC. A significant minority (7%) were referred to the on-call team and VFC.

Conclusions

Education and collaboration are required with ED and UTC to ensure the proper use of the VFC pathway. The recent integration of documentation systems will assist in ensuring all clinicians have access to relevant information. Documentation of trauma meeting outcomes should be standardised.