bluuebunny/crossref_metadata_2025 huggingface dataset:
782 A Rare Complication in A Post-Operative Bariatric Patient: COVID-19 Induced Mesenteric Venous Thrombosis
Authors: Winstanley J , Goodfellow M
Published: May 2021

Introduction

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has provided enormous challenges in the delivery of surgical care. In addition to respiratory tract infections, coronavirus disease 2019 (COVID-19) is associated with both arterial and venous thrombotic complications.

Case Details:

We present a case of acute superior mesenteric venous (SMV) thrombosis in a 36-year-old female patient who underwent Roux-en-Y gastric bypass three years previously. Her presentation with acute abdominal pain occurred 6 days after a positive nasopharyngeal swab. An admission CT scan demonstrated an abrupt cut off in the proximal SMV with resultant small bowel oedema. Subsequent thrombophilia screening and mutation testing for myeloproliferative neoplasms were all negative. She had also previously carried three pregnancies to term without any thrombotic complications. Hence, the high suspicion of acute COVID-19 induced mesenteric thrombosis.

Conclusions

In patients who have previously undergone Rouy-en-Y gastric bypass and lost significant weight, acute abdominal pain normally raises a high suspicion of internal hernia. However, as the pandemic progresses surgeons need to be mindful of COVID-19 induced mesenteric thrombosis as a differential diagnosis during the workup of acute abdominal pain. This was well demonstrated on a CT scan with intravenous contrast.
937 Is the Dog Still Man's Best Friend?
Authors: Ashraf S , Waseem M
Published: May 2021

Introduction

It is colloquially known that dogs are man’s best friend. However, animal attacks cause a large number of injuries and deaths worldwide, with 70% of injuries being caused by pets. This study highlights the impact of dog related injuries.

Method

Data was collected retrospectively over 1 year in a small district general hospital. The search term “dog” was used to find patients who had attended A&E or fracture clinic. This data was analysed for patient demographics, injury type and severity, management, and cost to the NHS.

Results

The majority (77%) of patients were female and elderly, with the modal age group being 70-79. Of the 38% of patients requiring admission, average length of stay was 6.7 days. Fractures made up the majority of injuries (56%) and 17% of patients required operative management. A further 2% suffered from post-operative complications. The average cost to the NHS was £1,695 per patient.

Conclusions

Dog related injuries disproportionately affected women and the elderly, with a large portion requiring operative management. Some patients developed further complications. As well as health burden there was also a financial burden associated with these injuries. These health and financial detriments are not often considered when deciding on pet ownership.
1001 Intra-Articular Distal Radius Fracture Surgical Intervention Threshold Origins and Development
Authors: Esworthy G , Johnson N , Dias J , Divall P
Published: May 2021

Background

Treatment of intra-articular distal radius fractures is guided by the displacement of the articular fragments. Symptomatic post-traumatic arthritis is expected to occur if step displacement is > 2mm; this value is often used as an indication for surgery if closed reduction is not possible.

Method

A systematic review was performed to establish the origin and adaptations of the threshold, with papers screened and relevant citations reviewed. Orthopaedic textbooks were reviewed to ensure no earlier mention of the threshold was present.

Results

Knirk and Jupiter, 1986, are the first to quantify a threshold, with all their patients developing arthritis with >2mm displacement. Some papers have discussed using 1mm, although 2mm is most widely reported. Current guidance from the British Society for Surgery of the Hand supports 2mm. Although this paper is still widely cited, the authors published a re-examination of the data showing methodological flaws which is not as widely reported. They claim their conclusions are still relevant today; however, the radiological arthritis does not correlate with the clinical presentation.

Conclusions

Knirk and Jupiter originated the threshold value of 2mm. The lack of correlation between the radiological and clinical presentations warrants further investigation. The principle of treatment remains restoration of normal anatomical position.
6 Improving Patient Flow in a Multi-Specialty Assessment Area by Introducing Referral Pathways for Orthopaedics and Plastic Surgery during the COVID-19 Pandemic
Authors: Gordon G , Fadulelmola A , Scott S
Published: May 2021

Introduction

The COVID-19 pandemic has seen fundamental organisational changes to emergency departments internationally. Specialties throughout the hospital setting have been asked to change their working practice, often with the aim of adapting to new processes in emergency departments. Early in the pandemic, the orthopaedic team at one district general hospital were required to provide 24/7 onsite cover in a multi-specialty area. Confusion over the referral pathways of two specialties (orthopaedics and plastic surgery) led to increase waiting times, constrained patient flow and poor patient and staff satisfaction.

Method

This quality improvement project occurred over three cycles of data collection and intervention over a two-month period. A novel referral pathway was developed and implemented after discussion with consultants in orthopaedics, plastics, and emergency medicine. Interventions included staff teaching, clarifying of roles at morning meetings and the deployment of posters.

Results

In cycle 1, 39% of orthopaedic referrals were inappropriately referred. By cycle 3, 0% of orthopaedic patients were inappropriately referred. Average time in department for patients referred to orthopaedics improved from 124 minutes to 88 minutes. Staff reported increased satisfaction, with appreciation for the clarification on referral criteria.

Conclusions

This QUIP demonstrates how simple interventions during times of crisis can solve complex organisational issues.
56 Antibiotic Prescribing for Open Fractures - A Quality Improvement Project to Enhance BOAST 4 Attainment
Authors: Imsirovic A , Walton T J , Drake P J H , Guryel E
Published: May 2021

Introduction

Open fractures are associated with increased infection rates and the evidence shows timely administration of prophylactic antibiotics within one hour of injury improves the outcomes.

Method

A multi-cycle audit was carried out retrospectively for patients presenting to Brighton and Sussex University Hospitals NHS Trust (BSUH) with an open limb fracture in 2018-2020. Targeted teaching was carried out for orthopaedic trainees, prompt posters created and alterations to the trauma clerking proforma were implemented.

Results

In first cycle, 48 (92.3%) out of total 52 patients were prescribed antibiotics prior to definitive surgical management, with a mean time to administration of 271 minutes. Of these, 41 (78.8%) received prescriptions according to BSUH guidelines. The use of STAT ‘once-only’ prescriptions was found to significantly reduce the mean time to administration for 154 minutes. In second cycle, all of 29 patients (100%) were prescribed antibiotics prior to definitive surgical management, with a reduced mean time to administration (233 minutes). Of these, 26 (89.7%) received prescriptions according to BSUH guidelines, and a significantly greater proportion received initial STAT prescriptions (51.7% vs. 15.4%).

Conclusions

This quality improvement project has demonstrated the successful implementation of targeted changes to improve the attainment of BOAST 4 guidelines.
64 The Impact of Inadequate Pain Control Following Chest Trauma on The Incidence of Hospital Acquired Pneumonia and Hospital Admission Length
Authors: Butterworth W , Ong O T , Magar O , Bird J , Scannell R
Published: May 2021

Introduction

The National Audit Office (2010) report estimated there was 20,000 cases of major trauma per year in England; of which 5,400 died and many others sustaining permanent disability. Blunt chest wall injuries are associated with high levels of morbidity and mortality, and we aimed to investigate the impact of poor pain control in patient outcomes.

Method

Compliance with trust guidelines was assessed via a retrospective audit of all chest trauma patients between October 2019-20.

Results

28 chest trauma patients identified (M:F 15:13) with ages ranging from 47-94 yrs old (average age 73). Chest trauma was associated with high levels of morbidity (32%) and mortality (7%). 39% patients were found to have inadequate pain control. Only 17% patients eligible for regional anaesthetic blocks were performed within 24hrs. 33% patients developed hospital acquired pneumonias (HAP), of which 44% had received inadequate pain control. Average admission length of patients with a HAP was 15 days compared to 5 days without. 85% patients experienced either delayed or no assessment by specialist teams (i.e., physiotherapy, pain team).

Conclusions

Chest trauma patients often receive inadequate pain control and delayed specialist team input resulting in increased frequency of HAPs, admission length and morbidity/mortality.
101 Use of Blood Cultures to Detect Bacteraemia in Surgical Patients: A Prospective, Closed Loop Quality Improvement Project
Authors: Osborne C
Published: May 2021

Introduction

Sepsis is a complex, life-threatening condition, posing a significant burden to both NHS resources and society in general. Bacteraemia is a common presentation in surgical pathology and requires prompt investigation and treatment. Blood cultures remain the gold standard for detecting bacteraemia and providing targeted antibiotic therapy. We aimed to improve the overall use of blood cultures in pyrexial surgical patients.

Method

A three-loop, prospective quality improvement project was performed. Patients identified as being pyrexial were reviewed to determine when it was recorded and whether blood cultures were taken. Following a departmental presentation, two further audit cycles were performed at two months and seven months post-intervention to determine long-term response.

Result

A total of 56 patients were included over the three audit cycles. Blood culture adherence improved from 58.7% at baseline to 65% at 7 months. Most notably, out-of-hours compliance improved from 44.4% to 66.6%. 2-month compliance was 85%, however, this comprised of only 7 patients.

Conclusions

Early recognition and management of sepsis remains a key area of improvement. Whilst overall and out-of-hour blood culture compliance improved, continued education is needed to further increase this.
108 Developing A Non-Biopsy Protocol for The Female Cohort 25-29 Years with Clinically Typical Fibroadenoma Conforming to Maxwell Criteria on Ultrasound – Our Peninsular Experience in Wirral
Authors: Arif T , Vinayagam R
Published: May 2021

Introduction

The aim of this study was to introduce a non –biopsy protocol in our department for benign breast lump referrals confirmed as typical U2/3 fibroadenoma on imaging. Current UK guidance is not to biopsy sonographically typical fibroadenoma in women under 25 years. We have studied our population extending the radiological Maxwell criteria reflecting benign outcomes in 25-29 years cohort.

Method

Retrospectively data was collected of all women between 25-29 years of age undergoing core biopsies for ultrasound confirmed fibroadenoma between 2014 and 2019 over a period of five years. The number of cancers picked up was compared with the number of referrals and the discordance between radiological diagnosis of fibroadenoma and histopathological confirmation of malignancy was recorded.

Results

A total of 1707 referrals were made across five years. n = 175 image guided core biopsies were carried out for U2, U3, U4 lesions appearing as fibroadenoma on ultrasound. Out of these (n = 175), all lesions coded U2/3 (n = 165) based on Maxwell criteria on ultrasound were negative for cancer. U4 lesions on ultrasound were confirmed as cancers mimicking fibroadenoma(n = 10).

Conclusions

This retrospective audit of 1707 patients provides sound evidence for non-biopsy of typical fibroadenoma in 25–29 years cohort sonographic features meet strict criteria.
184 30% Reduction in Time to Admission for Trauma Cases; An Integrated Multidisciplinary Model of Care Pathway in a Major Tertiary Hospital
Authors: Cheung Y , Carmody O , Synnott K
Published: May 2021

Introduction

Blue Book Guidelines recommend admitting hip fracture patients to an orthopaedic ward within 4 hours of presentation. BOAST guidelines advise early multidisciplinary team management. Since 2018, our Institution has utilised an integrated, multidisciplinary model for referrals of trauma patients in the Emergency Department. We hypothesised that this significantly reduces time to admission.

Method

We retrospectively reviewed data on all trauma cases admitted over a two-month period in 2017 and 2019 (before and after development of our Integrated Pathway). Our Integrated Pathway is facilitated by a mobile application which is accessed by all ED and Orthopaedic medical staff, including Consultants, allowing instantaneous communication.

Results

Sixty-six trauma patients were admitted to our Institution between December 2017 and January 2018. Average time taken from triage in ED to admission by the Orthopaedic team was 7hrs 10mins. Sixty-three patients were admitted over the same period in December 2019 and January 2020. Average time taken from triage in ED to admission by the Orthopaedic team was 4hrs 59mins.

Conclusions

Our Integrated Multidisciplinary mobile application system resulted in a 30.5% decrease in time to admission, which is a significant improvement. We would recommend the introduction of similar systems in other hospitals as part of their Model of Care Pathway.
238 Colorectal Cancer Surveillance In IBD: An Audit of a Large NHS Healthcare Trust
Authors: Claxton H , Johnson C
Published: May 2021

Aim: To investigate compliance with endoscopic screening guidelines for patients with Inflammatory bowel disease (IBD) in a large English Foundation Trust.

Method

A database of pathology specimens coded with a diagnosis of IBD since 2012, was cross-referenced with trust-wide colorectal cancer database.

NICE guidelines (2011) provided audit standard: Low risk require 5 yearly, moderate risk 3 yearly, and high-risk yearly colonoscopies. A randomised sample of IBD patients (n = 50) and all patients with both IBD and colorectal cancer (n = 4) were compared to this standard.

Results

Compliance to the audit standard within the population (n = 54) was only 50%, and only 25% within sub-group with both IBD and Colorectal cancer (n = 4).

Conclusions

Only 4 cases of colorectal cancer within our IBD population were on record since 2012, suggesting incomplete patient identification, perhaps due to unreliable coding.

The importance of optimising cancer screening programmes has only increased following the burden of the COVID-19 pandemic. Compliance within the audit population (n = 54) was only 50%, these findings promote a review of the screening process within the trust and advocate further complementary audits of additional NHS healthcare trusts.
248 Improving Handovers from A Neurosurgical High Dependency Unit to Ward Teams
Authors: Faderani R , Mohamed A , Stewart P
Published: May 2021

Introduction

A good handover is fundamental in providing continuity of care within a multidisciplinary team, allowing for safe and effective management of patients.

Method

Handovers between the neurosurgical high dependency unit and the ward team were prospectively evaluated as patients were stepped down over a 6-week period. The handover rate and consequences of poor handovers (missed investigations, referrals, or delayed discharges) were documented. After 6-weeks, handover proforma was introduced and the rates were recalculated.

Results

In the initial 6-week period, 36 patients were transferred, with only 2(5.6%) appropriately handed-over. Consequently, 9(26%) patients had delayed scans, 5(15%) missed referrals, and 24(71%) delayed discharges. In the 6-week period following the introduction of the proforma, a total of 28 patients were transferred, with 19(67.8%) documented handovers. Consequently, 1(3.5%) patient had a scan delay, 0 missed referrals and only 2(7%) patients had delayed discharges.

Conclusions

By raising awareness of handovers and introducing a proforma, we improved documented handovers by 62.3% whilst reducing the rate of missed investigations, referrals, and delayed discharges by over 90%. This project highlights how small, simple, and easy to enforce changes can lead to significant improvements in the quality of care provided to patients.
256 Antimicrobial Stewardship in Skin Cancer Surgery. Assessing Best Practice in Reducing Significant Post-Operative Complications
Authors: Walker K , Keward A , Botha E , Knepil G
Published: May 2021

Introduction

Antibiotic prescription is variable and with the growing frequency of antibiotic resistance, responsible use of antibiotics is necessary in keeping with Public Health England (PHE) Antimicrobial Stewardship guidelines. An audit was conducted to assess current practice of prophylactic antibiotics prescription in Skin Cancer Surgery in the department of Oral & Maxillofacial surgery.

Method

A retrospective case note review of patients who had undergone reconstructive surgery following skin cancer excision, recorded use of systemic and topical antibiotics and infective outcomes. Inclusion criteria were patients that had undergone surgical excision and reconstruction of skin cancer, followed by a wound assessment in an outpatient’s clinic with the outcome measure of infection defined by PHE Surgical Site Infection guidelines. A standard of 5% infection rate which is recognised by the British Association of Dermatologists was used.

Results

There was a 2% significant post op infection rate in patients with topical antibiotics used and 4.5% where neither systemic nor topical antibiotics were used. Immunocompromised patients had no increased incidence in significant post op infections occurring in either group.

Conclusions

The standard was met illustrating the low infection rate following reconstruction of Skin Cancer defects with or without prophylactic antibiotics and support a more discerning approach to antimicrobial prescribing.
321 Role of Antibiotics in Acute uncomplicated diverticulitis, A Systematic Review and Meta-Analysis
Authors: Tahir A A , Ali K M , Khan A U , Kamal S , Hussain A , Khan A U
Published: May 2021

Introduction

Diverticular disease is a common health problem with a wide clinical spectrum. About 75% of the patients would have uncomplicated diverticulitis. Cornerstones of treatment are antibiotics, analgesia, and dietary advice. Recent evidence has shown that its treatment is controversial, questioning the use of antibiotics. Aim is to assess the role of antibiotics in the treatment of acute uncomplicated diverticulitis.

Method

This is a systematic review and Meta-analysis. Literature review of the available studies was conducted using search engines like Pubmed, Medline, Embase, Google Scholar, and Cochrane databases. Statistical analysis was conducted using RevMan5.4.

Results

Out of 1754 records 1324 were duplicates, 430 studies were screened. 395 were further excluded.35 full text articles were assessed and in the final review 10 studies were included. PRISMA guidelines were used. Pooled OR for recurrence = 0.92 (95% CI = 0.74 to 1.13). Pooled OR for Hospital stay= -0.66 (95% CI= -1.12 to -0.21). Pooled OR for complications = 1.06 (95% CI = 0.69 to 1.64). Pooled OR for treatment failure= 1.24 (95% CI = 0.90-1.69).

Conclusions

We conclude that from the available evidence antibiotics have no role in reducing recurrence, complications, treatment failure, and duration of hospital stay in acute uncomplicated diverticulitis.
342 Rib Fracture Scoring at The Royal Sussex County Hospital, A Major Trauma Centre
Authors: Harris H , Mitha Z , White D , Davies W
Published: May 2021

Introduction

In April 2017, The Royal Sussex County Hospital introduced rib fracture scoring to help guide the management of rib fractures.

Rib fracture score = (number of fractures x number of sides) + age score1

In this study, we audit our adherence to the scoring system and compare our management of chest trauma before and after its implementation.

Method

All admissions with rib fractures between 1/10/2016- 28/02/2017 (N = 35) and 1/10/2019- 31/01/2020 (N = 41) were recorded. Electronic and written notes were used to retrospectively record multidisciplinary care involvement, analgesics, chest infection and death.

Results

The pre-intervention cohort had an average age of 55.1 years and rib score of 8.8. The post intervention cohort had an average age of 67.2 years and score of 11.3. Following implementation, 45% of patients had a rib score recorded. Post-intervention, anaesthetic involvement increased by 34.5% and 15.4% more patients received a regional block. Inpatient nights fell from 11.2 to 10.1, mortality rate from 7% to 4% but the incidence of chest infection remained similar.

Conclusions

The implementation of a rib fracture scoring system has led to greater multidisciplinary care and higher levels of pain management. A larger study is required to assess patient outcome given the change in sample population over time.
356 Reducing Long Term Opioid Prescribing Post Thoracic Surgery
Authors: Allen N , Gregg A , McGuigan J
Published: May 2021

Introduction

Patients are routinely started on strong opioid analgesia after surgery with most receiving a prescription for these to continue discharge. We examine the analgesia prescribed in our unit, comparing to ERAS principles from EACTS. We aimed to reduce the total equivalent dose of morphine prescribed on discharge by implementing ERAS principles.

Method

We undertook a retrospective analysis of the analgesia prescribing for patients post open and VATS procedure noting the total dose opioids (using the equivalent dose of morphine). We examined how many patients were still being prescribed opioids analgesia long term, defined as 6 weeks post procedure. We implemented ERAS principles, changing to morphine rather than oxycodone, using short-acting preparations and increasing use of opioid sparing analgesia including NSAIDs.

Results

20% of patients started on strong opioids post procedure were still being prescribed these 6 weeks later. We used ERAS principles to reduce the equivalent dose of morphine dispensed on discharge by a third.

Conclusions

We identified a significant issue with long term opioid prescribing and initiated measures which have resulted in positive change. Our next cycle will measure the outcome of our changes on long-term prescribing implement a multi-disciplinary approach to try reducing the burden of long-term opioid prescribing further.
372 Short- And Long-Term Outcome of Pneumonectomy for Lung Cancer: 20 Years’ Experience of a Single Centre
Authors: Amran R , Hussain A , Din A C , Cowen M , Chaudhry M , Loubani M , Tentzeris V , Qadri S S
Published: May 2021

Introduction

Surgery is the most important therapeutic modality for the treatment of primary lung cancer. Studies normally reported as 30-days or 90-days post-operative mortality or 5-years survival. However, survival for ≥10-years is rarely mentioned.

Method

Retrospective data collection from a tertiary centre database was implemented which include patients who underwent pneumonectomy from January 1998 until November 2019. The data was analysed for short and long-term outcomes including their respective Thoracoscore.

Results

268 patients who had pneumonectomy were selected, in majority for lung cancer. 79.1% were male with mean age is 63. Overall operative mortality in this cohort was 4.9% while reported national mortality for pneumonectomy for lung cancer is 7%. No 30-days post-operative mortality in the last 5 years. The 5,10- and 15-years survival rate for patients are 36.9%, 23.9% and 20.3% respectively. This showed significant increase in the survival rate for 5- and 10-years post-pneumonectomy in comparison to previous study. Long-term survival was better in female with age <70 years. The overall survival rate >15 years is 0.4%.

Conclusions

This study shows that our operative mortality for pneumonectomy is significantly lower (30% less) than national mortality. This confirms that pneumonectomy is still an effective modality in the treatment of lung cancer.
397 Impact of COVID-19 on Theatre Utility
Authors: Luney C , Little C
Published: May 2021

Introduction

Covid-19 has significantly impacted the environment in which surgeons operate. Level-2 PPE is worn in our orthopaedic theatres, with increased time taken for simple tasks due to claustrophobia, excessive heat, and difficulties in communication due to masks, including donning and doffing. We sought to determine the impact of Covid-19 on theatre utility.

Method

8week period during Covid-19 was reviewed for semi-elective orthopaedic surgery. Pre-Covid-19 case controls for age, procedure and ASA were identified. Electronic database was used to determine total time in theatre complex, time taken for anaesthesia, total procedure time, and time taken for patient to leave the theatre.

Results

27patients undergoing semi-elective surgery during Covid-19 pandemic and 27-matched controls from before pandemic were identified. No statistically significant difference in procedural or anaesthetic time. Significant difference in time interval between cases (14minutes pre-Covid-19 v 58minutes during Covid-19; p < 0.05). Mean theatre start times are 51minutes later during Covid-19.

Conclusions

Procedural times of surgery have not significantly increased, however the time between cases has increased; resulting in a decrease in overall theatre complex utility and direct impact on future costing.
474 Increasing the Availability of Operation Notes at Hand Surgery Follow-Up Through the Use of Electronic Operation Notes
Authors: Macneal P , Brar S , Dassanayake S , Jones K , Ghareib A , Moledina J
Published: May 2021

Introduction

The availability of operation notes is crucial to provide high-quality post-operative care. This clinical audit evaluates the availability of operation notes at post-operative follow-up, in a Tertiary Hand Unit, before and after implementation of electronic operation notes.

Method

This was a prospective audit analysing the availability of operation notes at the first post-operative hand surgery appointment. The initial data collection was over a 6-week period (July – August 2019). Following this, a standardised electronic operation note template was created in line with BSSH Hand Trauma Guidelines and RCS Good Surgical Practice. Six months later, a re-audit was conducted over a 4-week period (March 2020).

Results

The initial audit included 104 adult patients, with operation notes available for 64% (n = 67) of patients, and 94% (n = 63) of those were in paper format. Following implementation of electronic operation notes, the re-audit included 53 adult patients. For these patients, 96% (n = 51) of their operation notes were available, and 96% (n = 49) of the operation notes were electronic.

Conclusions

These findings demonstrate that electronic operation notes greatly increased the availability of operation notes at follow-up This innovation has significant implications for upholding well-coordinated continuity of care for patients undergoing surgery.
481 Improving the Quality of Pelvic Radiographs - Making A Difference One Picture at A Time
Authors: Saleem S , Parikh S , Parratt T
Published: May 2021

Inadequate pelvic radiographs can lead to missed pathology, necessitate repeat imaging, and subsequently compromise patient safety. The audit conducted aimed to assess and improve the quality of pelvic radiographs at our Trust against local and international guidelines.

Retrospective analysis of pelvic radiographs over a one-month period using PACS at Colchester General Hospital was conducted. All pelvic radiographs were assessed according to International Guidelines (EUR 16250EN). Postoperative radiographs were measured against local guidelines. The results were then presented in the departmental meeting and a re-audit was performed in June 2020.

A total of 190 pelvic radiographs were collected in September 2019. From the 23 postoperative radiographs, 9 did not include distal end of prosthesis. During the re-audit in June 2020 the same number of pelvic images were collected. Data showed that only 2 out of 29 postoperative images did not include the distal end of the prosthesis.

The audit demonstrated need for improvement at our Trust. This was carried out through a presentation in the departmental meeting, highlighting areas that needed improvement. The re-audited results from June 2020 have shown an improvement in the quality of pelvic radiographs and have had direct implications in clinical outcomes.
485 Optimisation of The Evening Surgical Handover Process in A Large Tertiary Surgical Department - A Quality Improvement Project
Authors: Brennan P , Holroyd D
Published: May 2021

Introduction

The aim of the project was to improve the quality and effectiveness of the evening surgical handover in a large tertiary surgical department, incorporating up to 150 patients.

Method

Audit standards were derived from GMC and RCSEng guidelines. An initial audit of the evening handover was conducted over a period of two weeks. Following this, a standard operating protocol (SOP) was introduced, with re-audit 4-weeks following implementation.

Results

The initial audit identified an inconsistent format and significant variability. Few handovers commenced with all team members present (11%) and were uninterrupted (33%). A laminated handover SOP checklist was produced and a new proforma was introduced to document tasks or reviews required overnight. A mandatory evening surgical HDU round was invoked and a “watchers” system was introduced to identify patients at highest risk of deterioration.

Re-audit demonstrated significant improvements in all domains to > 85%. ICU referrals overnight decreased from 6% to 2%. Further improvements measures were implemented in the form of a dynamic virtual handover document.

Conclusions

A structured SOP improved the consistency of the handover process. A night review of all HDU patients reduced the rate of ICU referrals. Implementation of virtual handover processes may be required in the COVID-era.
499 Upper GI Surgical Clinic Referrals, Can We Improve Patient Experience?
Authors: Abouelazayem M , Belchita R , Wan A
Published: May 2021

Introduction

With increasing pressure on NHS to deal with long waiting lists, solutions to reduce waiting times are imperative. In the era of the COVID-19 pandemic, we need to reshape the way we look into Outpatient clinic appointments.

Aim

To review all clinic referrals to UGI surgical clinic and highlight any potential pathways that can improve waiting times and patient experience.

Method

Patients referred to UGI clinic over 2 months were collected from Iclip, EPR and EDM. Post-discharge appointments and DNA’s were excluded. Data collected included time from referral to clinic, type of referral, symptoms, investigations, potential pathway, first clinic outcome, and appropriateness of referral.

Results

Total of 147 referrals analyzed. Time from referral to clinic appointment is 51 days. GP referrals represented 73% while the rest from consultant colleagues. The most common symptoms were biliary colic and GORD. OGD and PH manometry were the most common investigations requested. The most common first outcome was pre investigate and clinic follow up. Two potential pathways identified are Biliary colic and GORD pathway. 90% of referrals were appropriate.

Conclusions

Biliary colic pathway and GORD pathway are 2 potential pathways that can cut off waiting times for clinic appointments and improve patient experience in outpatient clinics.
524 Anaesthetic Use and Packing in Subcutaneous Abscess Management: A Retrospective Before and After Analysis Within A Two-Cycle Audit
Authors: Elkadi H , Dodd E , Bolton W , Poulton T , Burke J , Jayne D
Published: May 2021

Introduction

In the United Kingdom, there are no widely used guidelines within the management of subcutaneous abscesses by incision and drainage (I&D) to direct the use of local anaesthesia (LA) vs genal anaesthesia (GA); or the use of wound packing vs no packing.

Method

Two cohorts of patients undergoing I&D procedures were retrospectively identified from attendance records over a 3.5-month period. The first cohort was between 16th October 2018 to 31st January 2019. The second cohort of patients was during the COVID-19 pandemic following the introduction of new RCS guidance (intervention) between 29th March 2020 and 15th June 2020.

Results

Seventy-one patients before and 63 after the intervention were included. There were significantly more procedures performed under LA after the introduction of the intervention (n = 52; 82.5%) vs before (n = 4; 5.6%) p < 0.0001. The incidence of wound packing decreased after the intervention (n = 43; 68.3% vs n = 62; 87.3%) p = 0.00452.

Conclusions

The results demonstrate that during the pandemic, change in practice resulted in more subcutaneous abscesses being treated with LA. The majority of abscesses were packed in both cohorts although the incidence declined after the intervention. Future research should explore the patient satisfaction regarding pain management and the abscess recurrence rate.
546 Patient Opinions on Care Received in Virtual Clinics Compared to A Face-To-Face Clinic Appointments in General Surgery During The COVID-19 Pandemic. A Retrospective Patient Feedback Study
Authors: Fanning S , Palmer H , Sturrock B , Hussain A , Carney C , Jaunoo S
Published: May 2021

Introduction

Virtual clinics were implemented during COVID-19 to reduce patient contact. We identified the need to seek feedback from patients relating to their perceptions on care received at a virtual clinic compared to a face-to-face clinics.

Method

Patients who attended a virtual clinic in General Surgery were selected at random from a database of 627 patients. They were called and asked to complete a google survey which was sent via email. A shorter survey was also conducted over the phone for patients who did not have an email address.

Results

79.6% (n = 43) of patients felt their care did not suffer because of non-face-to-face contact. 63% (n = 34) reported that their symptoms were fully assessed during the virtual clinic. 77.8% (n = 42) did not feel rushed by the virtual clinic, 92.6% (n = 50) answered that they had the opportunity to ask questions. 68.5% (n = 35) answered their care did not suffer by not being examined. 72.2% (n = 39) felt that the outcome of the clinic was not changed because of non face-to-face contact.

Conclusions

Patient feedback on the care received in the virtual clinic was positive. This may suggest that virtual clinics could be utilised in outpatients care with good reception from patients.
553 Quality Improvement: The Implementation of Routine Tertiary Trauma Survey in all Trauma Patients Aged Over 60 Years in a Busy District General Hospital
Authors: Hughes C , Berry A
Published: May 2021

Introduction

Missed injury (MI) in trauma-patients is a widely reported phenomenon, with rates varying from 1.9-39%. Methods exist to reduce the incidence of MI’s such as the tertiary-trauma-survey (TTS). Robust primary and secondary surveys should indeed identify all injuries and facilitate management. However, for trauma patients, there remains an unwanted prevalence of MI. We hypothesized the addition of TTS may reduce the incidence of MI in a District General Hospital (DGH) and reduce associated morbidity and mortality; in particular in those aged >60.

Method

Patient notes for 18 consecutive trauma admissions in those >60 years were audited for admission demographics, timing and outcome of primary, secondary, and tertiary surveys, and occult injury. The TTS bundle was subsequently implemented in all trauma inpatients >60.

Results

In the primary round, 11% (n = 2) had evidence of TTS within 36hr of admission, reflective of exceeding the TARN criterion. TTS is now being utilised and we expect to see >98% compliance.

Conclusions

TTS is now incorporated as routine patient care for all trauma admissions >60. Compliance will be re-audited; aiming to reduce the opportunity for missed injury morbidity.
577 Risk Factors Analysis for Contralateral Neck of Femur Fracture in Elderly Population
Authors: Gurusinghe S , Weerasinghe K , Navaratnam D , Gophinath G , Castejon Morales G , Joachim T
Published: May 2021

Introduction

Neck of femur fracture (NOFF) carries significant morbidity, mortality, and cost implication to the health system. Subsequent contralateral fracture(SCNOFF) further decreases patient performance and increases healthcare burden. The aim of this study was to identify and evaluate potential risk factors and effects of SCNOFF.

Method

Retrospectively analysed NOFF database from 2012 to 2019 was. Inclusion criteria were patients over 60 years with low energy fractures. Polytrauma, pathological and atypical fractures were excluded.

Results

There were 114 patients (4.18%) with contralateral hip fractures out of 2727 total NOFF patients. Mean age was 82 years old for the first hip fracture and 85 years for the second. Average time interval between fractures was 36 months.

During the two admissions, mean decline in Abbreviated Mental Test Score(AMTS) was 0.4, deterioration of Clinical Fragility Score and Charlson Morbidity Index were from 4.5 to 5.9 (P < 0.0001), and from 5.4 to 6.1 respectively. Mobility was dropped by one level. institutional residency was increased from 23 to 46 (P > 0.0014).

Conclusions

There is a drastic decline in clinical frailty, mobility status and increase residential dependency following a subsequent fracture. Our findings demonstrate the importance of emphasizing preventive measures to reduce the incidence of SCNOFF.
600 The Use of a Wide-Awake Local Anaesthesia No Tourniquet (WALANT) Technique in Foot and Ankle Procedures - A Randomised Control Trial
Authors: Borg T M , Tahir M , Heidari N
Published: May 2021

Introduction

Wide awake local anaesthesia no tourniquet (WALANT) is a widely used technique in upper limb procedures that has gained increasing popularity during the coronavirus pandemic. The benefit of WALANT for foot and ankle surgeries is less clear, especially in patients with multiple comorbities. The primary aim of this study was to compare post-operative pain levels in patients undergoing ankle fracture fixation. Secondary objectives included comparison of intra-operative patient experiences, clinical outcomes, and patient satisfaction 1-year post-procedure.

Method

129 patients presenting with ankle fractures were enrolled in a multicenter randomised control trial from February 2016 to January 2020. Patients with medial malleolar, lateral malleolar, bimalleolar or trimalleolar fractures received either WALANT (62 patients) or spinal anaesthesia (67 patients). A 5ml solution of 0.9% saline and 2% lidocaine with 1: 100,000 adrenaline was used for WALANT.

Results

Compared to patients who received spinal anaesthesia, those in the WALANT group experienced less post-operative discomfort and were more satisfied 1-year post-procedure (p-value = 0.003). Surgical outcomes were similar for both groups. Cost analysis revealed that WALANT is significantly more economical.

Conclusions

WALANT is an effective and safe anaesthetic for foot and ankle procedures. Without use of a tourniquet, it reduces post-operative pain and so, eases patient recovery.
627 Improving the Timing of Abdominal Ultrasonography for Women Presenting with Suspected Appendicitis: A Closed-Loop Audit
Authors: Bastola D , Swafe L , Oke T
Published: May 2021

Introduction

Right iliac fossa (RIF) pain in women is a common presentation to accident and emergency (A&E). Abdominal ultrasonography (A-US) is particularly helpful due to the ability to detect various pathologies. The aim of this audit was to reduce delays in performing A-US.

Method

The timing of A-US taking place following referral to general surgeons by emergency doctors was analysed. The data was retrospectively collected between April 2018-April 2010 in two hospitals from the same trust. Posters of the results were put up in the surgical department to highlight the importance of obtaining A-US early on. A re-audit was consequently carried out collecting data between July 2019 - April 2020.

Results

69 females were included in the first audit cycle and 39 in the re-audit. The average time from referral to A-US taking place was 14 hours and 15 minutes in the first audit and 4 hours and 37 minutes in the re-audit.

Conclusions

The A-US findings with correlated histology highlights that A-US plays a role in improving diagnostic accuracy. The results from the re-audit revealed a shorter average time taken for A-US to be performed following referral. There is scope for the development of a pathway allowing emergency doctors to request A-US.
634 Review of Nephroureteric Surgical Service in a District Urological Center
Authors: Chin Y F , Chakravarti A
Published: May 2021

Background

New Cross hospital has been offering radical/partial nephrectomy, nephro-ureterectomy for cancer patients and simple nephrectomy for non-functioning kidney with availability of robotic system facilities since 2016.

Methodology

Retrospective analysis of data collected prospectively between January 2019 and September 2019. All patients underwent nephrectomy/nephroureterectomy and their demographic, comorbidities and surgical outcomes data analysed.

Results

7 underwent lap robotic nephroureterectomy, 27 underwent laparoscopic radical nephrectomy, 4 underwent laparoscopic simple nephrectomy, compared to total of 13 combined cases in 2018. FtM ratio- 1:1.92(13:25). Mean cohort age 64. Mean cohort BMI is 28.3. Mean pre-op HB is 132.9. Average op time for nephroureterectomy is 247 minutes, nephrectomy is 108.2 minutes. Average blood lost is 70mls, no patient of the cohort required any blood transfusion. 1 case sustained splenic laceration had surgical repair, 1 case was abandoned due to extensive bowel involvement. No cases required conversion from laparoscopic to open procedure. Post operatively, 1 patient developed VT, 1 patient had subcut haematoma, Average increase in serum creatinine is 42, and average Hb drop is 10.7. Average admission period were 3.7 days.

Conclusions

Our urological centre manage to perform more laparoscopic nephroureteric procedures as compare to previous year without much decline in terms of patient surgical outcome.
645 An EGS-Led Service for Acute Appendicitis Enhances Surgical Training Whilst Improving Outcomes for Patients: Results of A 6-Month Audit
Authors: Issa M , Sommereux L A , Osuji J , Meredith R , Muhammed M H , Guy R
Published: May 2021

Introduction

Appendicitis is common &treatment by appendectomy is usually undertaken. Variations in diagnostics &imaging are accompanied by high negative appendectomy rates (NAR) of around 20%. This study evaluated the outcomes of appendectomy in a dedicated Surgical Emergency Unit.

Method

All patients undergoing emergency appendectomy between 1stSept 2019&29thFeb 2020 were identified. Demographics, clinical findings, pre-operative investigations, intra-operative findings &post-operative outcomes were recorded.

Results

There were 192 patients (102 [53.1%] female;90 [46.9%] male). Median age was 36 years(range 8-80)with 25 below 14.Some 58.3% underwent imaging (ultrasound 33.5%; CT 32.5%).

Laparoscopic appendectomy (LA) was performed in 84.4% of cases with 11.4% open; conversion from laparoscopic to open was only 4.2%. Some 56% paediatric patients had open appendectomy & 44% laparoscopic with no conversions. Trainees were the sole or first operators in 63% of cases.

NAR was just 5.7%. Some 21(10.9%) patients were readmitted within 30 days of which 8 had a collection; all were treated conservatively.

Conclusions

Accurate clinical diagnosis & selective use of imaging in a dedicated EGS unit optimizes outcomes for appendectomy with low NAR & low complication rates. Appendectomy is effectively undertaken by trainees. LA is safely performed in children.
683 A Quality Improvement Project (QIP) To Increase Compliance with Peri-Operative Antibiotic Guidelines in Colorectal Surgery (CS)
Authors: Carter H , Wood C
Published: May 2021

Introduction

In CS, the correct use of antibiotics is important in order to reduce the risk of surgical site and intra-abdominal infections, whilst balancing risks from overuse of antibiotics. The Commissioning for Quality and Improvement (CQUIN) of 2019/20 identified that antibiotic prophylaxis guideline compliance could be enhanced in CS. This QIP aimed to improve local CS antibiotic prophylaxis and extension guideline compliance.

Method

In December 2019, an educational session was held to highlight the details of the local guideline and prescribing discrepancies. A3 posters of the guideline were created for accessible reference in operating theatres. Perioperative antibiotic prescription data from all colorectal elective cases in January 2020 were extracted and analysed using descriptive methods.

Results

Out of 93 cases in the sample, 70 (75.3%) were compliant with the prophylaxis guideline. However, metronidazole was commonly used in perianal surgery, which is not recommended. 13 cases required extension of the antibiotic course, of which seven were compliant (53.8%). The main issues included: use of agents and course durations which were not indicated; and a lack of antibiotic switch after a pause in therapy.

Conclusions

To further improve compliance with antibiotic guidelines, targeting historic practice, increasing awareness, and making systemic change is required for the next cycle.
684 Use of Overnight Pulse Oximetry and STBUR Questionnaire for Paediatric OSA In A District General Setting
Authors: Rogers A , Fraser L , Geary T
Published: May 2021

Introduction

Overnight pulse oximetry (OPO) is often used to support the diagnosis of obstructive sleep apnoea (OSA) and stratify risk of peri-operative breathing difficulties in children undergoing adenotonsillectomy for OSA. Our objective was to audit our indications for OPO and the impact on subsequent ENT management. We sought to assess the correlation of STBUR (Snoring, Troubled-breathing, Unrefreshed Questionnaire) score with OPO values in these patients.

Method

Retrospective review of 32 OPO reports over a 7-month period. Data collected included age, weight, indication, mean spO2, number of dips >4%, outcome and STBUR score.

Results

The commonest indication (19) for OPO was to assess severity of OSA in children <3 or those with significant comorbidity to determine best setting for surgery; 50% were ultimately managed in a tertiary centre. 10 children underwent OPO due to diagnostic uncertainty but significant parental concern; all studies normal and parents reassured. STBUR score correlated poorly with number of dips >4% (R = 0.0109) and mean nadir >4% (R = 0.0031) Weight poorly recorded (19%).

Conclusions

Referrals were generally appropriate and influenced management in all cases. STBUR scores insufficiently sensitive to stratify severity of OSA. New protocol developed.