bluuebunny/crossref_metadata_2025 huggingface dataset:
274 Peri-Operative Communication with Next of Kin (NOK) for Patients Receiving Laparotomies: A Complete Audit Loop with an Educational intervention
Authors: Nwokedi E. , Butterworth J.W. , Lotca N. , Shakir A. , Islam R. , Oke T.
Published: February 2022

Aim

NICE Clinical Guidelines (CG138) specify the importance of involvement of family members and carers at key patient care junctures. Furthermore, published literature and our own experience reaffirm that ‘low-quality communication causes profound distress to families that can affect the quality of dying and bereavement'. There is little evidence on NOK’s experience for surgical patients, so we sought to assess whether NOK details were available and whether they had been contacted peri-operatively for patients receiving laparotomies.

Method

We performed a closed loop audit using NELA database to identify patients admitted for laparotomies between February 1st to July 31st, 2021. The initial data was collated, analysed, and presented during educational meetings with informal reminders for a week to implement changes. Thereafter, data was collected to complete the audit cycle on communication with NOK.

Results

A total of 70 patients were included. Prior to the implementation, 86% of patients undergoing laparotomies had NOK information documented in clinical records, with only 75% of telephone numbers reachable and 33% had documented evidence of contact within 48 hours post-operation. Post-implementation, 97% of patients had their NOK information in their clinical records, with 97% telephone numbers reachable and 41% had documented evidence of contact with 48hours.

Conclusions

The importance of clerical staff and clerking doctors establishing NOK’s details, documenting these within iCare/notes and establishing whether patient are happy with NOK being contacted for updates on patient management, could reduce distress and potentially improve the experiences of hospital admission, recovery and in some cases, bereavement.
277 Implementation of the ROSA Robot in a DGH
Authors: Easwaran A. , Jones R. , Easwaran P. , Kincaid R.
Published: February 2022

Introduction

The ROSA (Robotic Surgical Assistant) is designed to assist orthopaedic surgeons performing total knee arthroplasty (TKA). It is postulated that the real-time data provided by the ROSA robot aids the surgeon by providing objective values to bone resections and soft tissue balance, enabling better implant selection and positioning. This is thought to improve patient outcomes through reduced post-operative pain, reduced hospital stays and reduced revision rate. To date, the ROSA robot has solely been implemented in tertiary centres in the UK. This study investigates the implementation of the ROSA robot in a district general hospital (DGH) in a geographically isolated region of the UK.

Method

The ROSA robot was installed in St. Michael’s Hospital, Cornwall in July 2021. Prior to its clinical deployment, six surgeons undertook saw bone training. Following this, six ROSA-assisted TKAs were performed in six weeks between July and August 2021. Logistical challenges to implementation included difficulty in ROSA component delivery given geographical isolation, consultant training time dedicated to ROSA operation in the context of a busy DGH trauma rota and increased operative time during the learning curve.

Conclusions

Despite the challenges faced, we have demonstrated that ROSA can be implemented in a rural, geographically distanced DGH. Given the use of robotic assistance in other surgical specialties, this is an exciting prospect for elective knee surgery in the future.
278 The Paediatric Major Trauma Tertiary Survey: Are We Missing the Mark on Missed Injuries?
Authors: Bhojwani D. , Kapuge L. , Dewar G. , Bradshaw C.
Published: February 2022

The tertiary survey is an integral part of assessment in major trauma. This has been shown to reduce missed injuries resulting in better patient care and favourable medico-legal outcomes. A formal tertiary survey should be carried out for all paediatric major trauma patients.

The primary aim of this audit was to assess completion rates of the tertiary survey proforma for major trauma admissions under the paediatric surgery team at the Bristol Royal Hospital for Children. The secondary aim was to evaluate the adequacy of the current proforma and detect areas for improvement.

Paediatric surgery major trauma admissions were audited over a 7-month period and data was collected retrospectively from patient notes on Evolve (n = 20).

A formal tertiary survey was completed for 6 patients which equated to a completion rate of 30%. A total of 1 missed injury was identified (lip laceration) which required no further treatment. Head-to-toe examination was documented in all of the completed surveys but lacked detail. Documentation of gait was absent in 85% and a body map was not filled in for any of the patients.

The audit was presented at a departmental meeting to increase awareness about the tertiary survey and requirements for completion. An MDT of doctors, nurses and trauma co-ordinators was consulted to design a more thorough proforma which included specific sections for review of bloods and imaging.

Re-audit of the new proforma is ongoing and it is hoped that, in combination with educational initiatives, this will lead to increased identification of missed injuries.
279 Reconstruction as Part of Breast Care Service: Are We Doing It Right?
Authors: Ng H.Y. , Ng A.W.Ya. , Shaaban Mohamed
Published: February 2022

Aim

Breast cancer is the most common cancer in the United Kingdom. About one-third of our breast cancer patients underwent mastectomy. The Association of Breast Surgery (ABS) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) guidelines state that all patients who undergo mastectomy should be offered immediate breast reconstruction (IBR) and delayed breast reconstruction (DBR) unless contraindicated. This audit aimed to evaluate our service compliance to the guidelines and identify factors affecting the number of patients offered breast reconstruction (BR).

Method

Our audit evaluated all mastectomy cases (n = 137) done between March 2018 and February 2021. Patients with previous breast cancers were excluded. Data were collected from clinical notes and letters.

Results

20.4% and 32.1% of patients were offered IBR and DBR respectively. Only 14.7% of patients not offered IBR had contraindications recorded whereas the remaining had no discussions recorded. Of those not offered IBR, 57.8% were expected to have adjuvant radiotherapy. All male patients (n = 3) and those with American Society of Anesthesiologists (ASA) grade 4 (n = 5) were not offered any BR. The average age of patients not offered IBR was 63.9 whereas that of DBR was 66.7. The average estimated size of tumour of patients not offered IBR and DBR were 42.3mm and 45.7mm respectively. Only <10% of patients not offered BR were smokers.

Conclusions

There is room for improvement in terms of our service compliance. Breast care services should aim to provide all-inclusive care to patients. A consultation checklist can be used to ensure BR is discussed alongside mastectomy.
282 Audit for the Management of Acute Gallstone Disease
Authors: Garner J.
Published: February 2022

Aim

The aim of this audit was to investigate how patients referred by the Emergency Department (ED) with biliary disease were managed. Also, to identify a cohort of patients which could be safely discharged from ED with an outpatient US and follow up with the Surgical Assessment Unit.

Method

Data was collected from 23/11/20 to 11/12/20. The inclusion criteria were patients referred by ED with abdominal pain and a diagnosis of biliary disease. Data collected included blood results, US results and if they underwent a laparoscopic cholecystectomy (LC).

Results

There were 22 patients identified; 5 had biliary colic, 4 had cholangitis and 13 had cholecystitis.

The 5 patients with biliary colic had almost completely normal bloods on admission. While 16/17 patients with cholecystitis/cholangitis had elevated FBC, CRP or LFTs.

US was performed on 3 patients with biliary colic within 3 days of ED attendance. US was performed on 16/17 patients with cholecystitis/cholangitis, mainly within 2 days.

None of the patients with biliary colic received antibiotics and 2 had an inpatient LC. All patients with cholecystitis and cholangitis were admitted and treated with antibiotics. 1 patient with cholecystitis had a LC and 7 were on the waiting list.

Conclusions

This has shown that patients are being imaged with US efficiently and are treated appropriately with antibiotics. It has demonstrated that a blood test in ED is effective at differentiating between biliary colic and other diseases that require admission. However, improvements need to be made to increase access for patients to undergo timely LCs.
283 Creating an ERAS for Living Donors for Renal Transplant
Authors: Parfitt C. , Sutaria R.
Published: February 2022

Aim

To design and facilitate an enhanced recovery after surgery (ERAS) protocol for the Wessex Kidney Centre (WKC) for live donors for renal transplants. This audit focussed on the post-operative analgesia guidelines and average length of hospital stay post the ERAS protocol implementation.

Method

An enhanced recovery after surgery (ERAS) protocol was created for renal living donors. The protocol incorporated pre, peri and post-operative guidelines to optimise patient care. The protocol was based on a survey sent to all transplant units in the UK regarding their own pathways for live donors(13/23 units responded). The ERAS protocol was then trialled on all live donors throughout 2020 and into 2021 at WKC. For this audit, data was collected on length of stay, analgesia used post-operatively and the VAS scores recorded by patients to grade their pain levels.

Results

There were a total of 11 renal live donors from September 2020 to January 2021 during which data was collected on all donors. National average length of stay for live donors is 3.9 days. Post ERAS, the average length of stay at WKC is 2.1 days, reduced from an average of 6 days pre-protocol. There was a minimal change in VAS score at 6 hours post-operatively: 3.9 (pre-ERAS average 4.2). However, at 24 hours post-operatively, average VAS score was 2.6 (pre-ERAS average 3.7).

Conclusions

The introduction of a specific ERAS protocol for live donors for renal transplant notably improved the average post-operative pain scores and reduced the average length of stay to below the national average.
285 ‘Smart Phrase’ Ward Rounds: Do They Improve Documentation and Efficiency?
Authors: Kapriniotis K. , Loufopoulos I. , Kennedy Hutchinson C. , Geropoulos G. , Gresty H. , Pakzad M. , Greenwell T. , Ockrim J.
Published: February 2022

Aim

Accurate ward round documentation plays a crucial role in patient management. In the last two years, UCLH has introduced EPIC software. This gives opportunity to create templates for repetitive processes (‘smart phrases’). The aim of this project was to assess if the introduction of ‘smart phrase’ templates can improve the quality of ward round documentation.

Method

Following consultation, 5 fundamental domains were agreed to be included in the template, namely: Procedure and postoperative day, current clinical issues, physical examination, objective assessment (including vital signs, fluid balance/drains, blood tests, DVT prophylaxis, antibiotic status), and 24h treatment plan. A baseline audit was performed, then the new template was introduced. Two PDSA cycles were performed, for 3 weeks after introduction, and repeated two months later. Chi-square tests was used to assess statistical significance of change (p<0.05).

Results

A statistically significant improvement in documentation for all domains - apart from ‘current clinical issues’ and ‘24h planning', which were well documented to start - was observed after the introduction of smart phrases; with an average improvement of 34.8% (range 0–65.6%). The improvement was maintained at 2 months (improvement from baseline 35.1%, range 0–59%). A small decrement in documentation occurred between introduction and the 2-month PDSA assessments in some domains (mean change 0.7%, range -12.3 to 23%), although this was not statistically significant.

Conclusions

The introduction of smart phrases significantly improved ward round documentation of important parameters. Evolution of additional smart phrase is expected to further improve the accuracy leading to more efficient decisions and safer clinical practice.
287 A Sigma Six Approach to Improving Nephrostomy and Antegrade Stent Services After a Trust Merger – a Quality Improvement Project
Authors: Gami M. , McCafferty S.
Published: February 2022

Introduction

As hospitals merge into larger trusts there becomes a centralisation of some services. Urology relies on Interventional Radiology (IR) for Nephrostomy insertions and Anterograde stents in particular. Two lR lists run at Broomfield after centralisation. We aimed to innovate, through improving communication and appropriate prioritization of patients, to ensure patient safety and maximum utilisation of these lists.

Method

We used a sigma six, DMAIC approach. Data was collected over a 30-week period. Analysis was multifaceted, focused interviews with a thematic and stakeholder analysis. Value stream maps were created to assess waste, fishbone analysis to evaluate delayed cases, and a future state map was created, implemented, and controlled.

Results

Prior to the intervention, the average wait for IR was 3.66 (n = 74) days above the agreed standard of 3.5 days. Thematic analysis outlined lack of standardisation. Bottlenecks in the mapping process resulted from lack of communication. The fishbone analysis outlined organisational factors, such as rota publishing issues and task factors, such as lack of protocols and escalation clarity. The intervention was a standardised proforma, a new consultant to consultant communication channel, scan discussions at a registrar level and a point of escalation. Post intervention showed patient wait to be 1.22 day and staff satisfaction to increase 3-fold.

Conclusions

The DMAIC method proved for a comprehensive assessment of improvement. Patient waiting times can be reduced in hospitals with similar experience using such methods. Future Plan-Do-Study-Act can be used to continually improve once special cause variation has been eliminated – as it likely has in this case.
288 Do Frailty Assessments Improve Outcomes for Emergency Laparotomy Patients? A Quality Improvement Project
Authors: Bretherton K. , Charles-Rudwick M. , Velchuru V.
Published: February 2022

Aim

Our aim of the project is to increase completion rates of frailty assessments in emergency laparotomies to improve patient outcomes.

Method

This QI project focused on completion of the Rockwood Clinical Frailty Score (RCFS), Comprehensive Geriatric Assessment (CGA), Abbreviated Mental Test Score (AMTS), memory screening, place of residence and care level in patients over 65 years undergoing emergency laparotomies. Criteria was generated using British Geriatric Society recommendations and local hospital guidance.

A year was sampled pre-intervention with the criteria, time clerked and grade. Data was assessed for admission and mortality statistics, and re-admission rates. A presentation to surgical juniors relating to frailty, frailty assessments and guidelines was used as an intervention. The data was re-sampled to identify changes post-intervention.

Results

Fifty-four laparotomy patients were sampled. 28% had a completed RCFS, 15% had a CGA, 67% had a place of residence, 41% had level of care documented, 13% had a memory screen and 7% had an AMTS. The small sample size restricted data analysis, however, there was a general decrease in length of admission and time to medically fit with increased frailty score completion.

Post-intervention, completion of the RCFS, CGA, place of residence and care level increased. Completion of memory screening and AMTS decreased. Compliance increased in FY1s, SHOs and registrars.

Conclusions

The intervention had a positive impact: the average number of frailty criteria completed per patient increased by 39%, Foundation Year trainees now have frailty teaching, and the clerking booklet was reviewed. A re-audit is planned to ensure ongoing improvement.
290 ‘Save Blood' - Strategies to Reduce Inappropriate Routine Bloods Tests in a Surgical Department
Authors: McFadyen R. , Ewing A. , Jenks* S. , Deans C.
Published: February 2022

Aim

To quantify the number of inappropriate blood tests in our 72-bed Surgical Department and identify strategies that reduce the number of unnecessary electronic blood test requests. This should reduce patient harm, demands on staff time, laboratory processing burden and financial expenditure.

Method

Each audit involved logging all blood tests for every surgical inpatient over two consecutive days. Upon reviewing the clinical records, it was decided whether tests were clinically indicated or ‘inappropriate’.

Following a baseline audit, three interventions were sequentially introduced over a one-year period, and the department re-audited after each: (1) educational sessions with junior medical staff and creation of ordering guidelines, (2) poster presentations, and (3) policing of requests by middle-grade doctors and removal of electronic blood test ordering bundles.

Results

Across the baseline audit to interventions 1–3, numbers of patients with at least one inappropriate test were recorded as 45/73 (62%), 51/63 (81%), 41/57 (72%), and 27/32 (84%), accruing totals of 363, 289, 303, and 149 inappropriate tests respectively. This gave an overall reduction in the rate of inappropriate blood tests per patient per day from a baseline of 0.9, to 0.9 then 0.8 to 0.5 with successive interventions.

Conclusions

Despite the innovation of electronic ordering systems enabling close audit of test schedules, inappropriate tests remain common. Educational sessions for junior doctors, written guidelines, and poster presentations had little influence on this.

However, rationalising electronic order bundles and involving senior doctors in decision-making, almost halved the rate of inappropriate tests. These more effective strategies will be disseminated throughout our hospital.
291 Single Centre Retrospective Study of Outcomes of Neck of Femur Fractures
Authors: Gungadin P. , Ferns J. , Gupta S. , Sharpe K.
Published: February 2022

Aim

To assess operative decision-making for patients with neck of femur fractures.

Method

2-year retrospective analysis of 150 patients in a single centre looking at outcomes focusing on complication rates and mortality.

Results

Mortality stood at 6% at 1 month and 25% at 1 year compared to quoted literature (10% at 1 month and 30% at 1 year). Surgical complication rates varied between fracture pattern and operative choice. Notably, the use of cannulated screws in displaced intracapsular fractures had a very high rate of failure at 80% (4 out of 5) compared to 0% for dynamic hip screws (0 out of 5). In undisplaced intracapsular fractures, the failure rate of cannulated screws remains high at 15% (2 out of 13) which is in-keeping with current literature. Surgical complications of hemi-arthroplasty remain low with only 3 out of 73 patients having significant complications (intra-operative fracture, dislocation, and acetabular erosion).

Conclusions

Cannulated screw fixation should be carefully considered, especially in the setting of displaced intracapsular fractures. Hemi-arthroplasty or two-hole DHS may have superior results in the fracture pattern and indeed, in undisplaced fractures.
294 Implementation of Colorectal Robotic Assisted Surgical Programme During a Global Pandemic: Collaboration Between Territorial and National Waiting Times Centre
Authors: Hughes R. , Massie E. , Saldanha J. , Komolafe S. , Chapman R. , Kirk A. , Vella M. , Moug S. , MacArthur C. , Mackie H.
Published: February 2022

Introduction

Golden Jubilee National Hospital (GJNH) established a thoracic Robotic Assisted Surgical (RAS) programme in 2018. In March 2021, GJNH invested in a new elective colorectal service and in response to the Scottish Government robotic investment established a collaboration with a territorial health board to host their robot and start a RAS colorectal programme. We provide an overview of barriers and facilitators leading to establishing this new collaboration.

Method

An observational review of RAS training timeline. Demographics, surgical operations, and hospital length of stay were documented. Surgeons, perioperative team, management, and industry (Intuitive) were interviewed to provide insights into implementation and training.

Results

Boards approved RAS business case in April 2021, robot on-site with GJNH governance approval in May. First cohort of colorectal surgeons completed proctored training July 2021. To date, 17 RAS resections performed (mean age 64, 9 males: 8 female). Mean length of stay 4.65 days. No anastomotic leaks and no mortality reported. Interviews revealed key facilitators: advantage of having an established RAS perioperative team and building on pre-existing industry links; developing and strengthening collaborative working between different health boards and surgeons. Barriers included: education of all team members to ensure patient safety for new specialty; multisite collaborative working.

Conclusions

This work provides a template model for future RAS collaborations between different sites and health boards. Collaborative working in a green-hospital setting may improve equity of access for patients whilst future-proofing surgery against further waves of the pandemic.
297 Variations in Orthopaedic Trauma Presentation During COVID-19 Lockdown
Authors: Ahmad M. , Chaudhry M.N. , Shaikh A.A.
Published: February 2022

Introduction

In living memory there has never been a start to the year as 2020, due to Covid -19 Pandemic. Like every other surgical speciality, Orthopaedic trauma surgery faced significant challenges during this period in terms of numbers as well as variation in trauma patients’ presentation.

Aim

The purpose of our study is to analyse the numbers and variations in orthopaedic trauma and its presentations during the pandemic in comparison with 2018 and 2019.

Methods

The data for this audit was collected from orthopaedic register of Our lady of Lourdes Hospital, Ireland. Patients operated under orthopaedic trauma team in three months period (March, April & May) in 2018, 2019 and 2020 were selected for analysis and comparison.

Results

In 2020, total number of surgeries were 32% less than the average of previous 2 years. (373 in 2020 vs 543 in 2019 and 551 in 2018). Similarly, the paediatric trauma surgeries dropped by 32 % in this period. Significantly lower proportion of sport related injuries, RTAs, and assaults presented in 2020. Higher proportion of trauma resulting from simple slip, falls from height and trampoline was observed in this period compared to previous two years. Slightly higher proportion of tibial pilon, calcaneum and peri-prosthetic fractures was noted as compared to previous years.

Conclusions

Significant reduction in total number of trauma cases as well as high energy trauma (Road Traffic Accidents, Sports Trauma) was observed due to limited mobility in pandemic, whereas higher proportion of low energy fractures occurred during this period of restrictions.
302 Metastatic: Benign Lymph Node Ratio (LNR) and Lymph Node Yield (LNY) as Predictors of Survival in Resected Colorectal Cancer (CRC)
Authors: Issa M. , Ahmad S. , Vijayagopal K.A. , Freeborn S. , Omolokun O. , Griffine A. , Wilson J. , Magee C.
Published: February 2022

Background

Lymphadenectomy is central to tumor prognosis. 12 LNY during CRC resection is a standard of good oncological resection, but 30–50 percent of resections do not achieve this. LNR was suggested to be a more accurate predictive factor.

Aim

To examine the prognostic significance of LNY and LNR on survival in patients with non-metastatic CRC.

Method

A retrospective study on patients with CRC treated at a DGH from January 2015 to February 2017. Outcome measures were Disease-Free (DFS) and Overall Survival (OS).

Results

265 cases were identified. The mean age was (71.4±11.3) years with a median follow-up of 56 (range 0–72) months. Median LNY was 18 (range 0–66) nodes. 74.9% of the cases have> 12 LNY and only 25.1% of the cases have < 12 LN yielded in the specimen; however, 76.4% have LNR of 0-<0.25. Increasing LNR was associated with poorer OS and

DFS (p-value 0.0001). An LNR of (0.75–1) was associated with a very poor prognosis (p-value 0.0001); it showed 30 and 33 months less in median OS and DFS retrospectively than LNR

(0-<0.25). LNY did not show any statistically significant predictive factor in survival.

Multivariate analysis showed OS and DFS are affected (R2 = 27.3% and 26.1% retrospectively) mainly by LNR. It did not show statistical significance with the other variables, including TNM, LNY, and Dukes' stages.

Conclusions

Increasing LNR was a marker of poor survival; however, LNY was not a statistically significant predictive factor. LNR is better in predicting survival than TNM and Dukes' staging.
303 Mapping the Landscape of Surgical Registries in the United Kingdom
Authors: Moore C. , Avery K. , Young A. , Hinchliffe R. , Potter S.
Published: February 2022

Introduction

Well-designed surgical registries are essential for high-quality patient-centred evaluation of implantable devices and surgical procedures. The importance of registries was highlighted in the recent Cumberlege report that detailed important innovation failures such as the use of vaginal mesh. Many surgical registries exist, but it is currently unclear how different registries are funded; designed; what data are collected; how databases are hosted and if the data can be linked to other datasets. There is therefore a need to understand the characteristics of and variation in existing surgical registries to make recommendations for how these could be improved. The aim of this work is to identify existing surgical registries in the UK and describe and summarise their key characteristics to inform recommendations for how surgical registries may be improved.

Method

Existing surgical registries will be identified using multiple different sources, including society websites; search engine review; a targeted search of Medline and Embase databases and expert knowledge. Details of each registry will be extracted using a standardised data extraction proforma developed by the study team. Characteristics of identified registries will be summarised into a narrative review.

Results

Identification of registries is ongoing. Preliminary data extraction has highlighted marked heterogeneity in the design, content, and structure of existing surgical registries. Data extraction is ongoing, but results will be available for presentation at the ASIT meeting.

Conclusions

There is considerable heterogeneity in existing surgical registries. Further work is needed to establish the extent of this variation and identify areas that can be improved.
305 Effect of COVID 19 on Ward Notes Documentation Standards
Authors: Salik M. , Mir M.H. , Arafa M. , Sanjay P.
Published: February 2022

Aim

To assess the effect of COVID 19 on ward notes documentation standards

Method

100 ward notes entries (before COVID, during COVID Peak, and after COVID Peak, 100 each) were evaluated against set ward notes documentation standards derived from the GMC Good Medical Practice document. The results were analysed, and the three data sets were compared to assess any effect of the COVID 19 pandemic on ward notes documentation standards.

Results

Individually, clear handwriting and documenting signatures showed a slight decline, and a slight increase was seen in the use of unknown abbreviations during the COVID-19 Peak. However, documentations standards were maintained across other categories and even showed improvement in some standards. Overall compliance showed a small improvement rather than a decline during the COVID 19 Peak.

Conclusions

COVID 19 Pandemic has certainly had an effect on every aspect of life globally. The health sector came under significant pressure and saw unprecedented stressful working conditions during the peak of the pandemic. However, even under the unprecedented pressures of COVID 19, we were able to maintain remarkable documentation standards and even showed improvements across various standards.

It should be kept in mind that there are limitations to this Audit and further studies are needed to confirm these findings.
306 In the COVID Aftermath, Using an Innovative Collaborative Approach to Improve Wait Times for Skin Cancer Patients
Authors: Brennan C. , Stone M. , Pinder R. , Gowda A.
Published: February 2022

COVID-19 led to drastic reductions in non-urgent medical visits and cancer care. Surgical patient backlogs mean new strategies are required to decrease wait times and administrative costs whilst improving patient outcomes. We review the impact of combined speciality Plastic Surgery and Dermatology 2 week-wait (2ww) clinics on wait times and hospital attendances and associated cost implications when compared to the single speciality clinics.

Retrospective analysis comparing Plastic surgery (PS) and Dermatology (DM) 2ww clinics against combined Dermatology and Plastic surgery (DP) clinics across the same 3-month period in 2018 and 2019 at a single UK tertiary centre.

283 patients reviewed across the same 3-month period in 2018 and 2019 (PS n = 53, DM n = 158, PD n = 72). PD reviewed most patients per clinic (Averages: PD n = 18.0, PS n = 8.8, DM n = 12.1). Hospital attendance decreased from 1.84 to 1.51 visits. 42.9% of excisional biopsies were performed on the same day as initial assessment compared to 18.0% in PS/DM clinics. Referral to surgery time decreased from 67.7days to 50.4 days, and tertiary assessment to surgery from 49.5days to 36.9days. PD attracted tariffs of up to £29.78 more per patient.

Combined clinics see more patients and attract higher tariffs per patient, whilst reducing outpatient attendances and wait times to surgery. This has significant cost-saving implications whilst optimising cancer care.
307 Improved Compliance with Enhanced Recovery Protocol Medications for Elective Joint Replacements Using the E-Lective App
Authors: Dela Cruz N.J.M. , Gibbons C.
Published: February 2022

Aim

Enhanced recovery pathway(ERP) in elective joint replacements has been shown to reduce length of stay, reduce re-admission rates, and can improve early functional recovery. Local analgesia and VTE prophylaxis protocol in current use has been produced by members of the multidisciplinary team but awareness of it needs to be optimised.

Method

We performed a retrospective review of discharge summaries and prescriptions from April 1 to April 30, 2021, of all primary joint replacements at Chelsea and Westminster Hospital. These were assessed against the local ERP Protocols for elective arthroplasties. ‘E-Lective App’ - a peer to peer shared mobile application containing an offline repository of existing Enhanced Recovery medication protocols, ward directory and follow-up booking feature was presented to clinical staff at the clinical governance meeting. Prior to these, protocols were only accessed or shared through WhatsApp. Re-assessment was done a three months later for a period of one month’s July 1 to July 31, 2021.

Results

Prior to launching ‘E-Lective App,’ compliance with the ERP Discharge Medications protocol was 70.1%. At last review in July 2021 this had significantly improved to 96% on average (p<0.05). Readmission rate due to pain and swelling had decreased by 65%.

Conclusions

This quality improvement project highlights the need to innovate to improve compliance to current standards of prescribing medications as part of the Enhanced Recovery Protocol. ’E-lective app’ is a novel and effective guide on maximising ERP pathway for joint replacements.
309 Adherence to BSG Guidelines Regarding Definitive Management of Gallstone Pancreatitis at Epsom and St Helier Hospitals
Authors: Singh S. , Oladeji E.
Published: February 2022

Aim

To audit the definitive management of gallstone pancreatitis in terms of cholecystectomy and ERCP at St Helier Hospital and comparing with the standard British Society of Gastroenterology guidelines (BSG), between Nov 2019 to Nov 2020.

Method

It's a local audit and data was collected retrospectively. A total of 72 patients with gallstone pancreatitis in a year were identified.

Results

The total number of patients managed according to guidelines, i.e., within two weeks of diagnosis (Lap chole + ERCP) were 20 patients (27.78%). Timing of ERCP, when needed was adequate (7 out of 9). No intervention has been done yet in 43% of the patients. Declined/ unsuitable for any intervention/surgery (35%), Patient transferred to another trust (16%) and death of the patients are the most common causes of the no-intervention.

Conclusions

Gallstone pancreatitis patients will come under P2 as a priority which means these patients will get priority over biliary colic/symptomatic gallstones for the early date of surgery. Recommendations have been submitted for another theatre slot for emergency laparoscopic cholecystectomy.
310 Ethical Challenges Facing Autonomous Surgical Robots
Authors: Mughal H.
Published: February 2022

Aim

Despite delays, automation is expected across all fields, with notable interest in surgical robotics. With this comes many of the ethical and moral dilemmas the industry is expected to face in bringing autonomation, to surgical robots, into clinical practice.

Method

A review of the available literature published on automation, machine ethics and surgical robotics.

Results

One of the key issues at the heart of autonomous surgical robotics lies the responsibility in the event of complications. Does it lie at the hand of the robotics manufacturer, the clinician or clinical organisation or possibly the patient? A question that remains unanswered despite the relative expectation of autonomous robotics into clinical practice in the coming years.

Furthermore, how should a robot proceed in an emergency? An automated surgical robot, which lacks a moral framework, may be unable to deal with emergencies especially within the context of fluctuating local environment where the needs of patients are distinct and everchanging.

In addition to this, a political and ethical concern is the expected number of job losses of highly skilled professionals and the training need to adapt to changing work. Can these professionals be employed in a different capacity? Moreover, data concerns have been highlighted, how best to use patient data to improve the technologies whilst preventing misuse of sensitive information.

Conclusions

Based on current literature, greater work is needed to be done to address the ethical issues before implementation of autonomous surgical robotics.
312 Foreign Bodies in the Urinary Tract - Can We Learn Something from the Pandemic?
Authors: Pinnamaraju P. , Warner R. , Pai A.
Published: February 2022

Aim

We aim to quantify the morbidity and resource utilisation from patients presenting with foreign bodies in the urinary tract and analyse the effect of the coronavirus pandemic on the numbers. Often these patients have co-existing mental health issues, which necessitates coordinated multi-disciplinary care. It is important that patient care is assessed holistically, with assessment of whether changes in mental health care impact urological morbidity.

Method

We performed a 2-year, retrospective, single-institution study of patients requiring removal of foreign bodies from their urinary tract.

Results

There were 49 episodes of patients needing removal of foreign body; all were inpatients at the regional mental health hospital.8% of patient episodes presented with urinary sepsis. All patients had successful general anaesthetic, endoscopic removal of the foreign body from their urinary tract. There was significantly more episode’s pre-pandemic (38 episodes, mean 2.7 per month) than during the pandemic (11 episodes, mean 1.1 per month). During the pandemic, staffing levels within the mental health hospital have been increased to enable isolation procedures to be conducted when necessary. It was felt that the reduction in foreign body insertion episodes was a consequence of this. The resultant reduction in acute hospital admissions and procedures is estimated to have saved £400,256 per annum.

Conclusions

Patients presenting with a foreign body in the urinary tract utilize a considerable number of resources and are a source of morbidity. Urosepsis and retention are common sequelae. Reduced episodes during the pandemic have shown that increased staffing levels have a positive effect and could be cost-effective. It is imperative that this data is used to appropriately allocate resources to reduce patient morbidity.
313 Importance of Surgical Approach and Resection Status on Outcomes of Patients with Adrenocortical Carcinoma (ACC)
Authors: Wong W.Y.K. , Pitfield D. , Challis B. , Casey R. , Kosmoliaptsis V.
Published: February 2022

Aim

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with overall poor prognosis. We aimed to examine the relationship between tumour resection margins (R0/R1), surgical approach (laparoscopic vs. open) and clinical outcomes in our practice.

Method

We conducted a retrospective review of patients diagnosed with histology-proven ACC (01/2015–12/2020) who proceeded to surgery and were followed up at Addenbrooke’s hospital (n = 24). We examined overall and progression-free survival (PFS) censored at date of death or at last follow-up.

Results

Patients had a median(SD) age at presentation of 58.5(11.0), were female in 62.5%; median(SD) length of follow-up was 29(20.1) months. The tumour histology was oncocytic variant in 50% of cases. R0 resection was achieved in 16/23 cases and was associated with better PFS [median(SD): 28.5(19.3) months for R0 vs. 8(25.0) for R1] and overall survival [median(SD): 33(18.4) months for R0 vs. 29(22.6) for R1]. 15/16 and 1/7 patients with R0 and R1 resection respectively were alive at end of follow-up. R1 resection status and survival were associated with ENSAT stage (85.7% stage III-IV for R1 vs. 25.1% for R0) although tumour size was not significantly different. A greater proportion of R1 patients (57.1%) had laparoscopic surgery (3 of those had tumour size>6cm) than R0 patients (25%). Outcomes for oncocytic ACC tumours were not different.

Conclusions

R0 resection is of paramount importance for ACC outcomes. Careful pre-operative work-up of indeterminate adrenal lesions to raise suspicion for ACC and consideration of open surgery for large tumours may help improve outcomes.
314 Biodegradable Temporising Matrix (BTM) Use in a Traumatic Chest Wound: A Case Report
Authors: Carrington-Windo E. , Leong S. , Ibrahim N. , Hepburn T. , Pope-Jones S.
Published: February 2022

We describe the innovative use of biodegradable temporising matrix (BTM) in a large traumatic chest wound in a 23-year-old lady at the Welsh Centre for Burns and Plastic Surgery. The wound was sustained after the patient fell from a tractor into a large silage rake, resulting in injuries to her chest and limbs. Following meticulous debridement, the resulting full thickness skin defect measured 30x30 cm extending from the sternal notch to the upper abdomen, with bone, muscle, and breast tissue exposure. No donor sites for free flap reconstruction were available due to the limb injuries.

BTM is a recently developed synthetic dermal substitute and has been utilised to achieve soft tissue coverage in complex wounds i.e., post debridement in burns, traumatic injuries, and necrotising fasciitis. It was used in this case as it confers a number of advantages against skin graft alone such as reduced susceptibility to contracture and the ability to cover small areas of exposed bone. It also demonstrates reduced susceptibility to infection compared with other dermal substitutes.

To our knowledge, this is the first use of BTM to cover breast tissue. The central chest is a difficult anatomical region to reconstruct due to the importance of maintaining breast contour and avoiding wound contracture and deformity. The patient was closely followed up in dressing clinic and application of split skin autograft over the delaminated achieved an aesthetically excellent and functionally result, with breast contour maintained and full range of movement at the axilla.
319 G-Master: A Novel 3D Printed ACL Graft Preparation System That Improves Speed and Autonomy
Authors: Dela Cruz N.J.M. , Papavasiliou T. , Gibbons C.
Published: February 2022

Aim

One of the most commonly performed procedures in orthopaedics is anterior cruciate ligament reconstruction. Autograft hamstring tendons are mostly used. The preparation of a hamstring autograft varies on patient factors and clinician choices. The use of a bulky, and expensive metal platform is usually involved, or an assistant is tasked to hold the other end of the graft. We aim to produce a 3D-printed sterilisable preparation system (G-Master) that improves autonomy and speed of the surgeon preparing the ACL graft.

Method

A stereolithography file (.stl) of the device was designed on Blender program and then manufactured on a commercial Fusion Deposition Modelling Ender 5 3-dimensional (3D) printer using a polylactic acid variant. The 3D printed parts include an attachable platform, two pillars whereby the attached pillar is where the endobutton (SN) holding the autograft sits in tension. These were autoclaved at 121°C under 15 psi of steam pressure for 30 minutes before the operation. Approval for device use was subjected to a rigorous process as class I devices as per the UK government Medicines and Healthcare Products Regulatory Agency guidelines and was then successfully used in vivo.

Results

We found the bespoke device to be beneficial in reducing graft preparation time and overall cost while increasing the autonomy of the surgeon and efficiency of the knee operating theatre list.

Conclusions

This is, to our knowledge, the first ACL graft preparation system that was produced using rapid prototyping and 3D printing. Other applications of 3D printing in manufacturing orthopaedic surgical instruments should be explored.
321 Surgery Induction Guidebook – an Aid to a Successful Transition
Authors: Abbas M.K. , Gurung G. , Lim E. , Umar R. , Sharmadaal A. , Zehra S.
Published: February 2022

Aim

There is a 4–12% increase in mortality following the August change over in the National Health Service (NHS) UK. A well-structured induction programme is mandatory to improve both the competency and confidence of new junior doctors. This activity was designed to evaluate and improve the induction process in Pilgrim Hospital by introducing an induction guidebook. It aimed to provide a sustainable and reliable source of information to junior doctors.

Method

An initial survey in the department assessed the needs and identified the information required for the guidebook. An induction guidebook was designed and circulated during the changeover. A feedback survey was conducted after the six months of the initial Induction guidebook release, to know the usefulness of components of the induction guidebook and identify any gaps to improve the guidebook.

Results

A total of 15 participants completed the feedback survey. 47% (7) found the induction guidebook beneficial and 53.3 % (8) found it ‘slightly beneficial'. Similarly, only 1 participant (6.7%) rated the guidebook to be “of minor importance”, while 53% (8) rating it “very important” part of induction. The feedback for the contents of the book was also encouraging with suggestions.

Conclusions

The guidebook proved to be a valuable source in helping new doctors during times of transition to adjust to the local system and improve the induction process. It provided information about local guidelines, job overview, team structure, IT, useful contacts, and other relevant information. We recommend the departmental guidebook as a vital part of local departmental induction during the changeover.
322 Feasibility of Loupe Assisted Subinguinal Varicocelectomy in Treatment of Male Infertility
Authors: Kale S. , Rashid T. , Cardoza F.
Published: February 2022

Aim

To study the impact of loupe-assisted subinguinal varicocelectomy on semen quality, serum testosterone level, and spontaneous pregnancy rate.

Method

The data were prospectively collected for 102 infertile men with clinical varicocele. The preoperative values of semen analysis parameters and serum testosterone level were compared with postoperative values at 6 months. Spontaneous pregnancy was assessed at 6 months.

Results

The mean age of patients was 31.56 ± 4.31 years. Primary infertility was reported in 86 patients, while 16 had secondary infertility. Bilateral varicocele was seen in 79 patients while 23 had a unilateral varicocele. The total sperm concentration (x106/ml) before and after varicocelectomy was 12.82 ±3.91 and 20.06 ±2.13 respectively (p<0.0001). The total sperm motility (%) before and after varicocelectomy was 37.67 ±7.23 and 55.46 ±4.51 respectively (p<0.0001). The sperm morphology (Kruger/Strict morphology criteria, %) before and after varicocelectomy was 3.11 ±0.80 and 3.70 ±0.78 respectively (p<0.0001). The serum testosterone level (ng/dl) before and after varicocelectomy was 323.90 ±67.81 and 396.74 ±40.88 respectively (p<0.0001). The Spontaneous pregnancy rate in couples with primary and secondary infertility was 18.60% and 31.25% respectively. The difference in their rates was not significant (p = 0.251). The overall spontaneous pregnancy rate was 20.5 %.

Conclusions

Loupe-assisted sub-inguinal varicocelectomy is a safe and effective modality for treating infertile men, particularly when provision for microscopic surgery is unavailable. However, only large-size comparative studies or multi-centric trials can confirm this.
324 Improving Consenting Practices in a Breast Surgery Unit
Authors: Senn D. , Grover K.
Published: February 2022

Introduction

Gaining consent, defined as “the process of providing the information that enables the patient to make a decision to undergo a specific treatment,” is a key part of a patient’s journey when having an operation. Consent forms serve as a significant medico-legal document; it is therefore imperative that they are completed accurately. The aim of this audit was to assess the current consent practice in a breast surgery unit, to monitor compliance with RCS and GMC guidelines and local policy on consent.

Method

Consent forms for all patients undergoing an operation over a three-week period within the breast surgery unit were reviewed. Data collected included use of abbreviations, patient and surgeon details and adequacy of procedure-specific complications. Interventions were then made in an attempt to improve compliance with guidelines. A repeat audit over another three-week period was performed to assess for improvement.

Results

The first cycle identified issues including incomplete documentation and inadequate complications listed. Targeted teaching and procedure-specific complication stickers were introduced to improve consent accuracy. Data was collected three-months post-intervention to evaluate for sustained improvement in consenting practices. Correct documentation of essential items (patient and surgeon name) increased from 83% to 100% (p<0.05). Results revealed a statistically significant improvement in consent form accuracy. Use of abbreviations reduced from 14% to 3% and record of procedure-specific risks improved.

Conclusions

The interventions employed significantly improved consenting practice within our unit. The insight gained from this audit can be applied across other trusts to improve compliance with the consent process.