bluuebunny/crossref_metadata_2025 huggingface dataset:
530 Communication Not Technology: How an Electronic Patient Referral Process Affects Patient Care in Acute General Surgery
Authors: Magnisio S , Howitt A , Lockwood SL
Published: November 2022

Introduction

The Royal College of Surgeons (RCS) high-risk general surgical patient guidelines recommend that a patient who needs emergency surgical assessment must be seen within 30 minutes in the case of a life-threatening emergency, and within 60 minutes for a routine emergency referral. The aim of this audit was to assess the efficiency of a new electronic referral system in expediting surgical assessment compared with direct referrals to the surgical oncall team.

Method

The study assessed the referral process and time to surgical review over two weeks. We included patients assessed in SAU and excluded patients reviewed in the emergency department (ED). Referrals were received from ED, general practitioners (GP) or surgical outpatient clinics.

Results

A total of 214 patients were included, 54% (116) referred from ED, 32% (69) from GP, 12% (26) from outpatients’ clinic, 1% (3) self -presenting. The median waiting time was 108 minutes. Direct referrals had a median waiting time of 84 minutes (RR 0–347). Patients allocated to the electronic transfer list waited a median of 120 minutes (RR 6–720).

Conclusion

All patients waited longer for review than recommended by RCS guidelines. The electronic transfer system failed to expedite surgical review and may have contributed to delays in some cases. Communication between colleagues, not technology, is imperative to ensure timely assessment of the acute surgical patient.
575 Are More Patients Being Harmed Than Treated with VTE Prophylaxis in Plastic Surgery? A Single-Centre Cycled Audit Reviewing Prescribing Practices
Authors: Kazzazi F , McKean A , Magill H , Noton T , Mitchell C , Jatan A
Published: November 2022

Aim

Venous thromboembolism prophylaxis (VTEP) was introduced following research showing that it was successful at preventing thrombotic complications in surgery patients. However, recent evidence demonstrates that patients in this cohort had subclinical venous thromboembolic disease and the benefit of VTEP was over-estimated. The Number Needed to Harm (NNH) is 26–67 while the Number Needed to Treat (NNT) is 147. This retrospective analysis attempted to identify if incorrect prescriptions in patients undergoing plastic surgery was possibly causing greater harm in a single plastic surgery centre.

Method

A retrospective analysis of the notes of all admissions in 1 month was conducted. VTEP forms and prescriptions were reviewed and compared against recommendations from the National Institute for Health and Care Excellence as well as local policy. A teaching session was delivered to explain to the department issues with prescriptions, then another 1 month of notes were analysed.

Results

Conclusion

There was an over-prescription of VTEP in plastic surgery patients in our cohort leading to a potential greater number of harmed than treated patients. This may require an attitude change towards VTEP to reduce patient harm.
652 Quality of Ultrasound Report in Patients with Biliary Symptoms in the Context of Surgical Diseases
Authors: Hakeem A , Chedid Y , Mateescu D , Chattopadhyay D
Published: November 2022

Aim

The diagnosis of surgical pathology in patients presenting with biliary symptoms is highly reliant on a good quality ultrasound report, our aim was to identify if there are any deficiencies in reports of ultrasound which are important diagnostic parameters of upper GI abnormalities.

Method

Patients presenting to Bedford hospital with biliary symptoms who require an ultrasound of biliary diseases were included, 8 parameters from the guidelines of Society and College of Radiographers were taken and analysed, means of missing data was calculated, CBD diameter was considered as a significant parameter. Quality of report for CBD was further scrutinized with patients who required 2nd investigations like MRCP and CTAP using crosstabs.

Results

A total of 278 patients were included in the study, 97.9% were due to gallstone diseases and 2.1% were for post-cholecystectomy. 89.7% had mentioned the normality of CBD while only 21.1% mentioned the actual value of CBD. 93% reports mentioned flow of portal vein, 7% did not mention portal vein flow. Interestingly 2.1% of ultrasounds were for post cholecystectomy but during scans, 4.6% of patients had absent gallbladder. 98 (34.5%) patients had one or more secondary investigations. 22.9% of normally reported CBD on ultrasound had positive CBD findings on MRCP.

Conclusions

This audit demonstrates the importance of a good quality ultrasound report. A good quality ultrasound can aid in clinical diagnosis and guidance of further investigations. Important factors to consider are the value of CBD Diameter, portal vein flow and quality of biliary stone/sludge.
661 A Closed Loop Audit Assessing Adherence to IR(ME)R 2017 Guidelines in Reporting Intra-Operative Ionising Radiation Images in Trauma and Orthopaedic Operation Notes
Authors: Rottenburg H , Kopec C , Reed J , Ashworth M
Published: November 2022

Aim

To determine whether operation notes adhere to IR(ME)R guidelines when reporting intra-operative ionising radiation images.

Method

Trauma and Orthopaedic operation notes were selected using a random number generator. These were assessed for a clear record of ionising radiation usage, and a clear description of and/or diagnostic implications of the imaging. An operation note template was created to encourage mandatory reporting of images taken intra-operatively. The operation notes were assessed again, and data collected.

Results

In total 90 operation notes were assessed. Before implementation of the image reporting template, 87% showed clear use of ionising radiation, and 60% a clear description or diagnostic implications of images. After implementation of the template, 73% of reporters used it. Of those that used it, 100% showed clear use of ionising radiation and 100% a clear description or diagnostic implications of images. Of those not using the template, 62.5% showed clear use of ionising radiation and 50% a clear description or diagnostic implications of images.

Conclusions

IR(ME)R 2017 guidelines require a documented clinical evaluation recorded for each exposure to ionising radiation, and exposures not clinically evaluated are not justified. Ionising radiation carries a small but compound risk of cancer, and therefore all radiation should be clinically justifiable. This study shows that the introduction of a template to operation reporting systems increased the reporting of intra-operative images to 100%. One limitation is that the template can be easily bypassed, enabling the reporter to skip the image reporting section and not document their evaluation.
732 Re-Audit: Surgical Handover Documentation
Authors: Koroma P , Shehrazi SR , Shetty VD
Published: November 2022

Aim

Surgical handover aims to convey accurate, appropriate & concise clinical information that is correct and up to date. It is essential in providing continuity of care, ensuring patient safety, and avoiding clinical errors. This process should be led by the Consultant on call. In this audit we aimed to compare our handover documentation practice against guidelines formulated by RCS England.

Method

Surgical Handover sheets from September 2020 and March 2021 were used for data collection. A total of 66 & 41 new patients were included in the initial and re audit respectively. Essential and desirable criteria guidelines by RCS England were used to compare our documentation. Essential criteria documentation should be 100% as per RCS guidelines.

Results

Initial audit showed room for improvement in documentation of both essential & desirable criteria.

A new handover template was introduced, we displayed posters and sent email reminders of the RCS guidelines.

Re audit showed significant improvement in essential criteria: date of admission 47% to 60%, responsible consultant 0 to 100%, current diagnosis 83% to 100% and investigations 84% to 100%. In desirable criteria: Past medical documentation improved from 42 to 62%, management plans from 96 to 100% and COVID status from 52 to 79%, VTE was documented in 58% of patients.

Conclusions

Surgical Handover documentation improved after implementation of changes. Busy ward rounds, multiple clinicians leading rounds, frequent relocation of patients and patients in non-surgical wards can make the process complex.
742 Quality of Operative Notes for Renal Transplant Surgery - Is Our Documentation Satisfactory?
Authors: Gupta S , Mahesh S , Koimtzis G , Chalklin C , Ilham MA , Elker D , Stephens MR , Khalid U
Published: November 2022

Introduction

Operation notes are essential in providing details of the procedure undertaken. The Royal College of Surgeons (RCS) Good Surgical Practice (GSP) guidelines recommend a checklist of 18 documentation items. Although these guidelines are useful, their broad and non-specific nature provides limitations to fields like transplantation, where additional information is needed. Ghoneima et al recommended transplant specific GSP checklist of 32 criteria for operation notes in transplantation. Our aim is to evaluate renal transplantation operation notes against these criteria.

Method

A retrospective audit of renal transplant operation notes was undertaken within Cardiff Transplant Unit between October 2020–2021. Notes were reviewed against new transplant specific GSP checklist.

Results

A total of 85 renal transplants were performed by 8 Consultant Surgeons. Sixty-two (73%) operation notes were hand-written and 23 (27%) electronically typed. Eleven standards had documentation compliance of >95% (e.g., date, surgeons’ names, recipient blood vessels, incision, allograft vascular anatomy, perfusion timings, closure, signature, etc).

Some important transplant-specific information (e.g., primary renal disease, details of current renal replacement therapy, reperfusion characteristics, donor details (e.g., age, comorbidities), HLA mismatch, prosthesis (ureteric stent) details) were poorly documented (0–27% documentation compliance). Antibiotic and DVT prophylaxis documentation was also very poor (1–30%). Post-operative instructions did not record target blood pressure (0%) and postoperative potassium and ultrasound scan instructions were recorded in 65% of notes.

Discussion

Clear documentation is important for good surgical practice. This study highlights the need for a transplant-specific operation notes template, to not only improve the documentation but to standardize the key information recorded for every transplant performed.
762 Completed Cycle Audit on Treatment Escalation Planning Documentation in ENT In-Patients
Authors: Ho R , Shakeel M
Published: November 2022

Aim

Treatment Escalation Planning (TEP) helps ensure treatment foals of patients are developed understood and respected. Treatment Escalation documentation is a communication tool that provides staff immediate and accessible guidance in times of crises. A standardised form was created to improve and standardise TEP documentation in ENT in-patients. This audit aimed to review form completion rates. A further cycle was done to assess whether interventions improved practice.

Method

A retrospective audit of TEP form completion rates and quality of documentation. Paediatric patients and patients from elective surgery discharged on the same day were excluded. Data tabulated included age, co-morbidities, reason for admission, type of admission (emergency/ elective), DNACPR documentation (community and in-hospital), TEP form completion.

Results

The median age for patients included in the study was 73.5 years old. 83% were emergency admissions. Patients were multi-morbid (Malignancy, cardio and cerebro vascular disease, COPD etc.) In the first cycle 23% had in hospital DNACPR forms, 0% had community DNACPR and 0% had TEP forms completed. Intervention included staff education and physical reminders on handover documentation. Second cycle showed improvement, 40% of TEP forms were completed however 1 patient had community DNACPR in place but no in-hospital DNACPR.

Conclusions

Our intervention showed improvement in treatment escalation plan documentation. This audit also picked up a problem i.e., community DNACPR not converted to inpatient DNACPR whilst patient is an inpatient. Next steps include further intervention to improve completion rates and further audit to ensure longlasting improvement.
765 Preoperative Coagulation Screening Audit in General Surgery
Authors: Yomi-Orungbe E , Fazili N
Published: November 2022

Aim

Routine preoperative coagulation screening is considered standard practice to predict peri-operative bleeding. However, according to British Society of Haematology, indiscriminate coagulation screening is not recommended as it may to inappropriate delay of surgery, lead to further unnecessary tests and is also associated with significant costs. Instead, they recommend detailed bleeding history, including family history and use of medications. This audit was to evaluate the current practice and improve.

Method

A retrospective audit of 148 post-operative patients, randomly selected in Northwick Park Hospital admitted under the General Surgery between 01.04.2021 to 14.05.2021 at the initial audit and between 20.09.2021 to 07.10.2021 at the re-audit.

Results

The initial audit was done over a 6-week period with 98 cases selected. 19% of them had appropriate requests with 81% of the tests done being inappropriate. There was significant improvement by the re-audit with appropriate requests increasing to 56% and inappropriate tests dropping at 44%. The criteria for appropriate were a) Not requested as no significant medical history. b) Requested as clinically indicated. With each coagulation screening costing an average of £29.42, an overall estimate of £2971.42 was expended in inappropriate requests

Conclusion

All patients had relevant blood requests and PMH were documented but many inappropriate requests were made. It was recommended that instead of indiscriminate coagulation testing, a thorough history was advised to determine appropriate testing. There was a marked improvement at the re-audit with more appropriate requests being made.

Recommendations

Further meetings with the Anaesthesiologists to ensure a joint effort in achieving the target goal
769 Introduction of Electronic Proforma Improves Compliance of Operation Notes with the Royal College of Surgeons Guidelines: Results of a Closed Loop Audit
Authors: Oladeji E , Singh S , Katsos K , Kumapley L
Published: November 2022

Aim

Operative notes (op notes) are vital and confidential data. They serve as a fundamental means of communicating operative findings and procedure details and provide information on post-operative patient care. Their accuracy or otherwise have clinical, academic, and medico-legal implications.

This closed loop audit assessed the compliance of local general surgery operative notes with the guidance provided by the Royal College of Surgeons (RCS).

Method

Retrospective review of the general surgery operation notes completed locally to assess their various characteristics. 98 op notes were assessed for adherence to guidelines, followed by introduction of an Electronic Proforma (EP) and re-audit of 102 op notes 6 months after implementation of the EP.

Results

The overall compliance from the initial audit was below 80%. 7 parameters were identified with low compliance, their adherence ranged between 5% and 77%. The re-audit demonstrated increased adherence following implementation of the EP. There was improved compliance with the guidelines and documentation was generally found to be more accurate. Overall compliance was above 98%.

Conclusions

We achieved a sustainable change in the quality of op notes through the use of electronic op note template. This was made possible by collaborating with the IT department – this also underscores the importance of interdepartmental collaboration to effect changes.
798 Emergency Department Acute Urinary Retention Pathway Audit
Authors: Collis J , Pain TM
Published: November 2022

Aim

Method

Retrospective review of notes of patients coded as presenting with urinary retention in the ED between 01/02/2021 – 30/04/2021. Data collected from the hospital electronic patient system.

Results

Total 147 patients coded for presenting to the ED with urinary retention. 64 patients removed as not applicable. 83 patients audited: 61 male and 22 female. 61 male patients analysed.

A DRE was performed in 18% of those presenting with AUR. The residual volume was documented in 64%. Tamsulosin was started in 36%, not started in 36% and 16% were already on. Laxatives were started in 8%, not started in 69% and 16% were already on.

TWOC was successful in 43%, unsuccessful in 21% and not applicable in 26% (E.g., Listed for TURP).

A successful TWOC was achieved in 75% on both Tamsulosin and laxatives, 68% on Tamsulosin alone and 56% on neither.

Conclusion

A DRE is not being regularly performed on initial presentation to the ED. Residual volumes are being more regularly recorded. The combination of Tamsulosin and laxatives provided the highest success rate for TWOC whilst not providing any medication provided the lowest. There is scope to increase adherence to the ED AUR pathway which may improve the rates of successful TWOC's and guide future management.
823 Compliance with TED Stocking Usage in Surgical Patients in ELHT Surgical Wards
Authors: Abdel Jalil O , Yasin M , Lim S , Abdelrahim A
Published: November 2022

Introduction

Anti-embolic stocking (AES) is elastic stocking specifically designed to reduce the risk of VTE events. Multiple studies proved the effectiveness of AES in reducing the risk of DVT in hospitalized patients undergoing surgerical procedures.

Aim

Our Audit aimed to examine our doctors' compliance in prescribing AES, as well as the nursing staff's compliance in distributing the stockings to patients. We also aimed at investigating if any discrepancies are present between the different surgical wards in our hospital, or between weekdays and weekends.

Method

Data were collected by bedside observation of patients to see if they are wearing the stockings as well as inspecting the prescription charts.

The data collection occurred over 2 weeks with a random day picked on a weekday and on a weekend each week. Each surgical ward was reported separately to compare the results.

After presenting the results, a poster was distributed to educate doctors and nursing staff about the importance and true contraindications of AES. In addition, a sticker indicating the AES was added to the patient's board to check. A re-audit was done after one month.

Results

Initially, average in compliance with wearing the stocking was 50–70%, while the prescription rate was 44–84%. No major changes were noted between wards and between different days of the week. After the changes, slight improvement in the compliance was noted but not in prescription.

Conclusion

Educating staff and doctors about the importance of AES is essential for compliance, in addition to the need for repeated audits to check sustainability of changes.
830 Audit of Readmissions Within 30 Days of Total Knee Replacement (TKR)
Authors: Basha A , Chaudry A , El-Tawil S
Published: November 2022

Background

Total knee replacement (TKR) is a very successful operation but like all surgery carries risks. Patients can be readmitted, but not all necessarily linked to post-operative complications. National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man: 17th annual report, 2020, Prosthetic infection after total knee replacement is (TKR) of average 0.92%.

Aim

To identify causes of readmission after TKR & their frequency, within 30 days of surgery.

Method

Data spanning 2 years (Apr 2018- Apr 2020) were analysed. Patients’ details were retrieved for those with at least one readmission within 30 days of TKR and details include:

Results

Conclusion
842 An audit to assess adherence to the Tongue Reduction Integrated Care Pathway for Beckwith Wiedemann Syndrome
Authors: Howard T , Gabuniya N , Kerr S , Cornejo P
Published: November 2022

Aim

Beckwith-Wiedemann Syndrome (BWS) is a congenital overgrowth syndrome that occurs in approximately 1 in 15,000 births. A cardinal is macroglossia which can lead to sleep apnoea, difficulties feeding, speech, drooling and malalignment of teeth/jaw. Some children require tongue reduction surgery and are managed with a specific protocol to ensure the correct analgesia, fluid regime and commencement of oral feeds are delivered post-operatively. The aim of the audit was to improve adherence and awareness of the protocol to improve the patient journey.

Method

Initial audit cycle between 22/01/21 – 03/02/21 in the form of anonymous staff survey. Following initial results staff underwent two separate teaching sessions and posters were applied in key wards and staff areas. Repeat audit was completed between 01/07/2021 – 01/08/2021.

Results

Initial audit results demonstrated 44% (11/25) of ward staff were unaware of the Tongue Reduction Integrated Care Pathway and 56% (14/25) did not know which condition this protocol and surgical procedure was related to. Following both sets of interventions there was an improvement to 77.8% (14/18) of staff being aware of the protocol and 88.9% (16/18) of staff members knew which syndrome was associated with this pathology. Additionally, in the re-audit we demonstrated that 100% of participants were aware of the analgesia protocol. Correct rationale for fluid regime was demonstrated in 56% vs 24% demonstrating there is still room for improvement in this domain.

Conclusion

We have demonstrated that through teaching and the implementation of a poster we have improved the awareness of the Tongue Reduction Protocol.
843 Improving Antibiotic Prophylaxis Prescribing in Arthroplasty Surgery Following Neck of Femur Fracture (NOF#): A Clinical Audit Revealing Multi-Factorial Influences on Prescribing Accuracy
Authors: Ayathamattam J , Ansari A
Published: November 2022

Introduction

Post-op infection is a serious complication in surgery, particularly in arthroplasty. NICE guidelines advise antibiotic prophylaxis for all arthroplasty procedures to avoid this. This audit aimed to assess our concordance with our local guidelines and achieve improvements where we were deficient.

Method

Electronic prescribing records were analysed for 60 patients who underwent arthroplasty following NOF# across St. Richard's and Worthing Hospitals between 4/3/19 – 17/6/19. We presented these initial findings at our local orthopaedic clinical governance meeting to educate team members. We then collected a second cycle of data between 1/11/20 – 16/12/20.

Results

Patients receiving some form of antibiotic prophylaxis improved from 90% to 100%. Patients receiving the appropriate prophylaxis as per local guidelines increased from 78% to 83%. However, more patients were given incomplete prophylaxis in the second cycle: 5% of patients were on concurrent antibiotics for chest infection and were not given full prophylaxis, 5% of patients were under-dosed on gentamicin and 3% of patients were not given the full 24 hours’ worth of flucloxacillin. No patients developed joint infections post-op after following up for 6 months.

Conclusions

Although all patients were given prophylaxis in the second cycle, patients not receiving the full recommended course of antibiotics represents an avoidable risk in developing post-op infection. We identified that communication between orthopaedic surgeons, anaesthetists and orthogeriatric ward team members and awareness of prescribing responsibility were implicated in accurate prescribing of prophylactic antibiotics. We aim to address these with further education and amendments to performas and then re-audit to look for further improvements.
845 Assessing How Effectively Ankle Fractures Are Managed in Accordance with the BOAST Guidelines at a Major Trauma Centre
Authors: Jobson J , Saad A , Fernandes R , Jaly I , Burahee A
Published: November 2022

Aim

Ankle fractures constitute approximately 10.2% of all bony injuries. Due to pressures exerted by the COVID-19 pandemic, a series of modifications have evolved within subspecialty fracture management. The aim of our study was to evaluate our adaptations to the COVID-19 pandemic and assess our management of ankle fractures according to the BOAST guidelines.

Method

We performed a retrospective review of 30 skeletally mature patients with a closed ankle fracture presenting to a major tertiary centre. Our inclusion criteria comprised of the ‘BOAST guidelines for ankle fracture management’ published in 2016.

Results

Of the 30 patients within our cohort, 40% (n= 12) had stable ankle fractures, whereas 60% (n= 18) were unstable (based on the weber classification and evidence of syndesmotic instability). 63% (n= 10) had fracture manipulations prior to surgery. 50% (n= 5) had a documented re-examination of neurovascular status. All patients had a post reduction image. 88% (n= 16) with unstable fractures underwent operative fixation. 6 patients underwent external fixation prior to definitive management. The average time from injury to definitive fixation was 12 days with a range from 0–22 days. Only 8 patients had clear documentation of intraoperative syndesmotic stability.

Conclusions

The BOAST guidelines outline a range of standards that should be utilised when treating ankle fracture patients. We intend to use our study to educate healthcare professionals on the importance of accurate documentation and encourage shorter operative waiting times to improve standard of care and patient outcomes.
891 Improvement in VTE Prophylaxis and Hospital Admission Time for Colorectal Cancer Patients Following the Introduction of an Enhanced Recover After Surgery (ERAS) Nurse
Authors: Zhu XM , Cribb E , Smith J , Ashton G , Pawa N
Published: November 2022

Aim

Patients undergoing abdominopelvic surgery at high risk of developing VTE and NICE guidelines mandate a 28-day course of post-operative pharmacological prophylaxis for these patients. We completed a closed loop re-audit to examine the local trust adherence to national guidelines.

Method

A closed loop re-audit was performed to check for appropriate VTE prescription. 62 patients undergoing elective surgery for colorectal cancer were identified from May 2017 to April 2018. An ERAS nurse was appointed following the initial audit and subsequent data was collected on a cohort of 80 eligible patients from April 2021 to October 2021.

Results

Previous compliance against national guidance set by NICE was 32% for patients screened from May 2017 to April 2018. There was a significant improvement to a 74% compliance rate following the introduction of an ERAS nurse. The appointment of the ERAS nurses also resulted in a reduction in postoperative hospital stay of 1.2 days.

Conclusions

A significant improvement in appropriate VTE prophylaxis was provided to patients following the introduction of a dedicated ERAS nurse. In addition, patients had a mean reduction in hospital stay length.

Several points for future investigation based on findings: identification of cause behind missed prescriptions, patient education on self-administration of LMWH on discharge when applicable, and whether any VTE related complications occurred in either cohort.
899 A Closed Loop Audit of Imaging Rate in Suspected Complicated Acute Diverticulitis
Authors: Rayner A , Adepoju O , Wong G , Mobasheri M
Published: November 2022

Aim

Diverticular disease is commonly encountered in western populations, with complicated acute diverticulitis potentially leading to significant morbidity and mortality. The National Institute for Health and Care Excellence (NICE) recommend imaging these patients within 24-hours of admission, which is essential to confirm diagnosis and guide further management. We aimed to audit the imaging rate in suspected complicated acute diverticulitis within our department and identify ways to improve this.

Method

Data were collected from all patients admitted from January to June 2021 with suspected complicated acute diverticulitis as defined by NICE. Patients with normal inflammatory markers were excluded. Electronic records were reviewed for evidence of imaging performed within 24-hours of hospital admission and the imaging rate was compared with the previous audit cycle.

Results

96 patients were admitted with suspected complicated acute diverticulitis. 83 patients had raised inflammatory markers. 76 (91.6%) of these had contrast computer tomography (CT) scans performed within 24-hours of admission. Of the 7 (8.4%) patients who did not undergo imaging within 24-hours, 3 had recent imaging suggestive of diverticular disease or diverticulitis, 2 were treated with antibiotics, 1 patient refused, and 1 had CT within 48-hours due to delays waiting for dialysis.

Conclusions

We have shown continued good compliance with NICE guidelines, though the imaging rate has declined slightly compared with the previous audit cycle (94.3%). In order to maintain and improve these standards, we will offer educational sessions within our department to underline the importance of timely imaging in this patient group and continue to audit our performance.
903 Improving Documentation of Tourniquet Use in a Trauma Unit in Line with New BOAST Guidelines
Authors: Fitzpatrick N , Arneill M , Wilson L
Published: November 2022

Aim

Local tissue damage is a significant potential consequence of intraoperative pneumatic tourniquet use, via pressure-related damage or chemical injury. The British Orthopaedic Association released a guideline relating to the safe intraoperative tourniquet use in October 2021, dictating standards for documentation in operative records. Initial audit suggested that only 15% of the required information was documented. With updated operative record paperwork and electronic templates, we aimed to improve adherence to updated BOAST guidance.

Method

Following analysis of 14 days' worth of trauma operation records, results of local documentation of tourniquet use were presented at a departmental audit meeting. With departmental permission, changes were made to the operation notes template, to include tickboxes relating to the use of tourniquets, skin condition pre/post-operatively, method of isolation, method of exsanguination, and the pressure of tourniquet and duration of use in line with new guidelines. Additionally, a new, time-efficient template was designed for those using electronic records. Results were re-audited over a 14-day period following dissemination of the relevant templates.

Results

Initial results suggested that only 15% of required data surrounding tourniquet use was being documented, with none recording information relating to skin condition pre/post-operatively, method of isolation or exsanguination. Following aforementioned interventions led to an improvement in documentation from 15% compliance to 64% compliance.

Conclusions

Further efforts are required in order to further improve documentation of tourniquet use, particularly when in electronic format, initial re-audit results are encouraging for improved adherence to new BOAST guidance in a local trauma unit.
912 Do You Really Know What “Nil by Mouth” Means?
Authors: Lingam G , Oxley C
Published: November 2022

Aim

To assess if patients are receiving their regular pre-operative medications in according with local and national guidance and to assess if patients are being appropriately fasted pre-operatively.

Method

A prospective study performed across a 2-week period, assessing if every patient booked on the emergency theatre list was receiving the correct medications pre-operatively and if they were fasted for the appropriate length of time. This involved assessment of the patient's notes and drug chart, as well as clarification of any unknowns with the patient.

Results

65 patients met the inclusion criteria for the study; of which 28 (43%) had their regular medication prescribed. Of those, 61% did not receive their medications according to national and local guidance (medications were inappropriately held in the majority of cases). The omission of administering medication during the “nil by mouth” phase included the lack of critical medication in 3 cases: a potentially life-threatening error. Regarding fasting of the patient, it was found that the average time without drink was 14 hours 25 minutes, with the average time without food being even greater at 24 hours 12 minutes.

Conclusions

Patients are not receiving medications in the pre-operative fasting stage appropriately, this was mainly due to the incorrect assumption that “nil by mouth” is equivalent to no oral medications.

In addition to this, the study found that patients are being kept without food or drink for far too long prior to surgery and hence reducing the quality of their pre-operative status both clinically and biochemically.
944 Re Audit: Maintenance Iv Fluids Prescribing
Authors: Sehrazi SAR , Koroma P , Shetty VD
Published: November 2022

Aim

Many hospital admissions require intravenous (IV) fluid therapy to prevent or correct fluid status and/or electrolyte disturbances. Within our trust the recommended IV maintenance fluid is 0.18% Saline in Glucose 4%. This Re audit aimed to assess the knowledge and improve understanding of junior clinicians for IV maintenance fluid prescribing at Royal Preston Hospital by comparing our current practice to Trust guidelines/NICE guidelines

Method

A multiple choice knowledge questionnaire was used evaluate the knowledge of foundation doctors, core trainee's and advanced care practitioners (n=21). The trusts electronic system was used to review patients prescribed maintenance fluid. (n=50). 1st audit was conducted in October 2020 followed by re audit in April 2021.

Results

In 1st cycle only 16% of the patients had the recommended maintenance fluid prescribed. We displayed posters and sent email reminders of the trust IV fluid prescribing guidelines. Junior's knowledge of the IV fluid prescribing guidelines improved regarding: recommended maintenance fluid (52% to 80%), Daily fluid requirement in ml/kg/day (66% to 70%) and Recommended monitoring (52% to 100%). This ultimately led to the prescribing of 0.18% Saline in Glucose 4% in 38% of patients. Plasma-Lyte remained the most commonly fluid prescribed in both audit cycles (42% vs 50%).

Conclusion

Changes implemented after 1st cycle led to improvement is prescribing fluid of choice but there is still room for improvement. Juniors report consultant lead decisions influencing their prescribing and the availability of fluids on the wards.
978 Evaluation of the Quality of Our Consent Forms Used for Ureteroscopy and Nephroureteroscopy - Is It Time to Go Digital?
Authors: Rafi AU , Briesh M , Nadeem M
Published: November 2022

Aim

Consent documentation for surgical procedures must be precise and clear in order to achieve excellence in clinical practice. In this audit, we aim to compare our consent forms against BAUS information leaflets on ureteroscopy and stone procedure and assess the documentation of all serious and frequently occurring complications as mentioned on BAUS leaflet.

Method

We retrospectively reviewed the consent forms of 60 patients who underwent elective ureteroscopy between August 2020 - April 2021 to assess the quality of documentation as well as legibility of handwriting.

Results

As a total of 60 consent forms were reviewed. 35 males and 25 females contributed to the study with 59 being the median age. There were over 10 risks being commonly missed. Some of the important risks such as stone recurrence 95%, catheterisation 92%, major damage to ureter wall 86%, pain 71% and residual stone 61% were missed. The documentation also outlines other risks; ureteric stricture 53%, aesthetic risk 67%, failure to access ureter 51% and stent symptoms 47%. Minor damage to the wall of ureter 41%, alongside need of another surgery were recorded as other commonly neglected risks. However, only 7% of the consent forms did not mention bleeding and just 2% of the forms failed to include stent insertion as a common effect of procedure. Only 17% consent for did not have eligible handwriting, although this is subjective.

Conclusions

Documentation on consent forms for ureteroscopy lacks accuracy and missed important information. We propose use of digital consent form to assess compliance and quality of consent documentation.
983 Temporal Artery Biopsy - Bringing About a Much-Needed Change
Authors: Krishnakumar N , Barnes R
Published: November 2022

Aim

Looking into the process for sending a referral for a Temporal Artery Biopsy (TAB) and the causes of delays for the procedure at a local DGH.

Method

A retrospective review of all the TAB referrals sent and the time from referral to date of procedure over the past year done from11/2020 to 11/2021 was done. Specifically noticed points included urgency, side, time till date of procedure.

Results

Out of the 47 procedures done, 36% of the referrals were sent and about 64% were sent as urgent all of which were sent as emails to secretaries. The average time from referral to date of procedure was about 16 days, however urgent inpatient referrals with severe active symptoms were done by the 6th or 7th day from referral. About 7% of the referrals did not even include site required and 10% did not specify date since use of steroids. About 10% of the patients found to have not understood the procedure completely and its necessity which also contributed to delays.

Conclusions

This study found that a significant proportion of the TAB referrals were incomplete, that there was a need to re-review the entire patient information thus ending up in delays.

A consensus to create a new referral system specifically for TAB which includes all the relevant data for the surgeon and a new patient leaflet including a consent form which has been discussed and is in the stage of implementation for streamlining the process, improving patient experience, and causing positive impact on overall department functioning.
997 Audit Examining the Treatment of Patients Who Developed Post Operative Complications Following Appendicectomy
Authors: Garner J , Butler J , Evans T , Ferguson H
Published: November 2022

Aim

To identify trends in management of patients with post operative complications following appendicectomy in a district general hospital.

Method

The coding department identified patients who were admitted with appendicitis in the previous year and those who developed post operative complications. Data was gathered retrospectively from these patients using their online records.

Results

Coding identified 270 patients that were admitted between 22/10/20–29/10/21 with appendicitis. 19 patients had post operative complications. 9 had intra-abdominal collections, 5 had wound infections/collections, 3 had an ileus.

15/19 patients with complications underwent imaging, 8 had CT scans and 7 had US scans. Patients waited a mean of 0.4 days between presentation and imaging. Patients waited a mean of 2.2 and median of 0 days between imaging and appendicectomy.

12 patients had complicated appendicitis, 6 had simple appendicitis and 1 had a normal appendix. 16 patients had antibiotics pre and post operatively, 3 did not. The mean length of stay was 5.6 days for patients with complications, compared to a mean length of stay of 3.9 days for all patients with appendicitis.

Conclusions

Early identification and management of appendicitis reduces morbidity, and our centre appears to have lower than average complication rates. The patients who did develop complications, were generally imaged and operated on efficiently

An area of improvement is ensuring all patients undergoing appendicectomies are given at least one preoperative dose of antibiotics and up to 3–5 days post operatively if complicated as per WSES guidelines. We aim to re-audit this after an education drive within our department.
1007 Audit of Time to Surgery for Decompressive Craniectomy in Ischaemic Middle Cerebral Artery Stroke
Authors: Soh WY
Published: November 2022

Aim

Early decompressive craniectomy (DC) in patients with ischaemic middle cerebral artery (MCA) stroke is closely related to post-surgical outcomes in terms of mortality, morbidity, and functionality.

This audit compares the time to surgery for ischaemic MCA stroke patients in Hospital Sultanah Aminah Johor Bahru (HSAJB), Malaysia, with the recommended 48-hour timeframe by National Institute for Health and Care Excellence.

Method

This audit included ischaemic MCA stroke patients who underwent DC in HSAJB from 2017 to 2019. Time of symptoms onset to surgery was obtained retrospectively from Neurosurgery Department patient records. Data was analysed and compared with functional outcomes within 18 months post-surgery, where Modified Rankin Scale (mRS) of 0–3 represents favourable outcomes while mRS 4–6 shows severe disability or mortality.

Ethics approval was not required.

Results

16 out of 38 patients who met the inclusion criteria had clear documentation of time to surgery (n=16). 75% of the patients (n=12) underwent DC within 48 hours. Of these patients, only 25% (n=3) achieved mRS 0–3 post-surgery. Nevertheless, DC within 48 hours demonstrated relatively positive functional outcomes compared to DC after 48 hours, where no patients (n=0) achieved mRS 0–3.

Conclusion

Majority of ischaemic MCA stroke patients in HSAJB underwent DC within the recommended 48-hour timeframe. Despite the low probability of achieving good functional outcomes post-surgery, DC within 48 hours showed better chance of survival with less severe disability.

It is recommended to aim for DC within 48 hours in all ischaemic MCA stroke patients for better functional outcomes.
1038 Improving Adherence to Antibiotic Guidelines for the Treatment of Acute Cholecystitis: A Completed Audit Cycle
Authors: Doherty R , Stoll S , Sedighi T , Davidson C , Modi H
Published: November 2022

Aim

Acute cholecystitis (AC) accounts for up to one third of emergency surgical admissions. The initial management of AC includes fluid resuscitation and appropriate antibiotic therapy. The aim of this study is to audit compliance with local microbiology guidelines for the treatment of AC and to develop interventions that improve compliance rates.

Method

All patients admitted from September to December 2020 with radiologically confirmed AC were included in an initial prospective audit (n=39 patients). Antibiotic prescriptions, patient demographics, presence of fever (>38°C), inflammatory markers and liver function tests were recorded. The results were disseminated, educational material produced, and antibiotic “champions” appointed to improve adherence to antibiotic guidelines. A prospective re-audit was conducted from May to June 2021 to establish the effectiveness of the interventions (n=49 patients). Compliance rates before and after the interventions were compared using a Chi-squared test. Binomial logistic regression was carried out to establish whether any patient demographic or clinical parameters were independent predictors of prescribing behaviour.

Results

Compliance to antibiotic guidelines for AC significantly improved following the interventions (12.8% vs 57.1%; p<0.001). Age, gender, temperature, inflammatory markers, and liver function tests were comparable in both groups and were not found to be independent predictors of non-compliant antibiotic prescription.

Conclusions

Adherence to antibiotic guidelines for AC can be improved with educational interventions and the appointment of individuals responsible for ensuring correct prescribing behaviour. Interestingly, patient demographics, signs of sepsis or liver function did not influence prescribing behaviour, suggesting that divergence from antibiotic guidelines may be due to ingrained prescribing dogma.
1047 Regional Audit: Valid and Informed Consent for Lower Limb Arthroplasty in Orthopaedic Surgery: Are We Doing Enough?
Authors: Sohail Z , Mills R , Adebayo O , Mamarelis G , Acquaah F , Subhash S , Liew I
Published: November 2022

Aim

To investigate regionally the validity of the patient consent process for lower limb arthroplasty, compared to set data standards, with a view to investigating whether the consent process could be improved, and if so, how?

Method

Regional data from 8 hospital trusts (50 data sets collected from each hospital) across England was collected retrospectively from May 1st, 2021, (25 THR, 25 TKR), collated and collectively analysed against agreed, pre-determined set criterion.

Data standards included ascertaining whether alternatives to surgery were offered and exploring the likely benefits and risks.

Capacity to consent for procedure-specific surgery was measured as patients’ ability to understand, weigh up, retain, and communicate their decisions regarding surgery.

Hospitals regional data was collectively analysed.

Results

Capacity was only successfully fulfilled and documented regionally in 11.6% of hip and 13.9% of knee replacement surgeries, despite Consent Form 1 having been filled out in 94.8% and 88.5% of cases respectively, which were procedure specific in only 74.0% and 72.1% of cases.

Conclusions

Significant improvement can clearly be made to an area of already such high clinical negligence claims.

We propose a novel solution involving the digitalisation of the consent process, including multimedia surgical videos to better inform patients and reliably assist in establishing the validity of a patient's consent.

The implications of this are limited not only to Orthopaedic surgery but could have far-reaching consequences across all surgical (and indeed medical) specialties, where obtaining valid and informed consent for procedures remains integral to quality patient care.
753 Outcomes of Bariatric Surgery in Patients with Inflammatory Bowel Disease and the Development of De-Novo IBD Following Bariatric Surgery: A Systematic Review
Authors: Mian A , Khan S
Published: November 2022

Aim

A large proportion of patients with inflammatory bowel disease are obese. Outcomes of bariatric surgery in patients with IBD and on IBD disease course itself is not clear. Furthermore, there is some evidence that bariatric surgery can precipitate the development of De-novo IBD. Thus, the aim of this systematic review was to search the literature to summarise the evidence surrounding these questions.

Method

A comprehensive literature review was conducted based on the preferred reporting items for systematic reviews and meta-analysis guidelines (PRISMA). PUBMED, and MEDLINE databases was searched using Ovid for keywords and MeSH terms including “gastric bypass”, “sleeve gastrectomy”, “Roux-en-Y”, “Duodenal switch”, “RYGB”, “bariatric surgery” and “inflammatory bowel disease”, “IBD”, “Crohn's disease”,“Ulcerative colitis”, “UC”. Prospective and retrospective studies published up to March 2021 were included in this systematic review.

Results

22 studies met the inclusion criteria. Studies revealed that bariatric surgery is safe for patients with IBD and leads to comparable outcomes to patients without IBD. Some studies showed that patients with IBD remained in hospital for slightly longer periods of times than non IBD patients with a modest increase in the number of complications. Furthermore, studies suggest bariatric surgery may lead to the development of de-novo IBD in a selection of patients.

Conclusion

Bariatric surgery is effective for patents with IBD reporting significant weight loss at both the 6 and 12-month time points. Further studies are needed to more accurately determine if bariatric surgery can predispose to the development of De-Novo IBD in a select group of patients.