bluuebunny/crossref_metadata_2025 huggingface dataset:
163 Audit cycle on the formal introduction of a standardised orthopaedic trauma patients’ admission pro-forma: the first Italian experience
Authors: Pace V , Lanzetti R M , Caraffa A
Published: May 2021

An internationally recognised issue of general district hospitals is the accuracy and completeness of the admission documentation, particularly in a trauma setting. We built and formally introduced a Hospital Trust Wide admission pro-forma for orthopaedic trauma patients.

An Audit looking into the quality and completeness of the admission documentation for orthopaedic trauma patients was carried out at a single Hospital Trust in December 2017. This was followed by a second round Audit with formal implementation of our new clerking pro-forma.

Compliance was 94% overall. The documentation was incomplete in 7% of the cases. Delays of patients’ treatment caused by lack of documentation or written plan/instructions was recorded in only 3% of the cases. Satisfaction questionnaire: excellent 55%, good 42%, fair 7%, poor 1%.

The pro-forma provides all relevant information needed to fully assess orthopaedic trauma patients and plan the appropriate management. His utilisation facilitates completeness of documentation with a standardised approach. This is a unique work on the introduction of a standardised clerking pro-forma for the admission of orthopaedic trauma patients with excellent results in terms of compliance and improvement of patients’ care. Our study seems to be a quality improvement intervention with potentials of becoming a milestone for further improvements.
178 Suspected Cauda Equina Syndrome in a District General Hospital
Authors: Ellerton L , Benjamin-Laing H , Harrison W J
Published: May 2021

Introduction

Cauda Equina Syndrome (CES) is rare but when the diagnosis is delayed patient morbidity is significant. Recently, NICE Clinical Knowledge Summaries have updated their red flags on CES to be more explicit enabling earlier referral and diagnosis. A joint project between Orthopaedics and Radiology departments aimed to assess the current pathway of Cauda Equina Investigation at a District General Hospital.

Method

Data was collected from the local Radiology database for requests between July 2017 and August 2018. This included both direct requests to assess for CES and implied. Raw data revealed a potential of 600 patients, of which we have analysed 332 patients met the eligibility criteria.

Results

Only 58 patients had a documented complete bladder function assessment, of those 33% had incomplete or partial bladder emptying. Time to MRI scan ranged from 50mins – 23 hours & 52 mins. 47% had negative scans with CES or Cord compromise on MRI scan was demonstrated on 9%. 23 patients were transferred urgently to the receiving tertiary centre.

Conclusions

We found that nearly 90% of patients were being incompletely assessed and time to scan ranged significantly. We are producing a trust wide suspected CES pathway to improve patient assessment.
187 Improving Awareness of Managing Post-Operative Haemorrhage in Patients Undergoing Thyroid and Parathyroid Surgery: The SCOOP Protocol
Authors: Bhattacharya S , Jegadeeson J , Ramsingh J , Truran P
Published: May 2021

Introduction

Post-operative haemorrhage is a rare but potentially life-threatening complication of thyroid surgery and occurs in 1 in 100 patients. Our aim was to assess current levels of awareness of post-operative haemorrhage in the surgical department and to improve confidence in managing this.

Method

Questionnaires with a combination of clinical questions were distributed amongst nurses, foundation doctors, senior house officers and registrars in the surgical department.

Results

There was a clear gap in awareness in all grades. The British Association of Endocrine and Thyroid surgeons (BAETS) have guidance on the management of these patients and in particular the acronym SCOOP (Steristrips removed, Cut subcuticular sutures, Open skin wound, Open strap muscles, Pack wound). 18/24 of participants had not heard of the SCOOP protocol. Most nurses (6/12) all junior doctors (8/8) showed lack of confidence in managing patients with suspected bleeding.

Conclusions

An informative poster was created for relevant clinical areas as per the BAETS recommendation. These posters outlined the steps in the SCOOP acronymas well as the main clinical signs of haemorrhage. BAETS recommend that all first responders, including nursing staff, junior doctors and the crash team should be aware of the SCOOP protocol. Simulation training sessions are in progress for these members of staff.
193 An Audit of Compliance for NICE Guidance of Management of Displaced Intracapsular Neck of Femur Fractures
Authors: Sheen J , Higgins G
Published: May 2021

Introduction

The 2011 NICE guideline ‘CG124 Hip fracture: management’ covers the management of hip fractures in adults aged over 18. It was updated in 2017 to highlight the role of total hip replacement in intracapsular fracture management – Recommendations 1.6.2 and 1.6.3.

The aim of this audit was to assess, and improve, the compliance of Torbay Hospital’s management of intracapsular neck of femur fractures.

Method

The study was split over the three cycles, using data from the National Hip Fracture Database, followed by a review of patient notes. The first audit of 2017 data assessed the compliance of the department. A first change was then implemented to operation note documentation and 2018 data analysed. A further change was then implemented to operation notes and 2019-2020 data analysed.

Results

The 2017 audit showed a compliance of 67.7% against statement 1 and 41.1% against statement 2. After the initial change, the 2018 re-audit showed a slight improvement to 76.0% and 54.9%. After the second change was made, compliance subsequently rose to 100% and 100%.

Conclusions

The initial compliance with NICE guidance was poor. Following changes to the documentation on the operation note, compliance rose to 100%.
219 Documentation of Scrotal Examination in Male Children with Abdominal Pain
Authors: Da Costa K , Watson S , Perks H , Battersby C
Published: May 2021

Background

Abdominal pain is a common presentation in all age groups with 7-10% of emergency department admissions.

Method

This registered audit looks at male children (aged <16), admitted with abdominal pain during this period. Approximately 2,877 children under the age of sixteen were admitted, 1,582 males. This equates to 55% of children admitted within 3 months. Manual note analysis from ED records identified 53 males <16 years of age with abdominal pain for inspection of documentation.

Results

45% of inspected notes had documented genital and scrotal examination, none of which had a documented consent. In addition, 21% had a documented chaperone for the intimate examination. None of the cases had BOTH consent and presence of chaperone documented.

Conclusions

A common presentation in children lacks significant elements of documentation. This is noted in multiple specialties. Potentially overlooked aspects of examination can lead to missed or delayed identification of time sensitive diagnosis namely testicular torsion, with possible substantial legal, professional, and financial consequences.

To improve the quality of documentation, education at junior doctor level has been carried out, with further analysis to take place and with the view to incorporate the three elements of an intimate examination: consent, chaperone, and findings.
233 Concomitant Surgical Atrial Fibrillation Ablation Follow-Up Against Best-Practice Standards at A Tertiary Cardiac Surgery Centre in Brighton
Authors: Singh S , Hussain A , Kugan G , Lewis Michael
Published: May 2021

Introduction

Best-practice as per JCTVS 2006 meta-analysis recommends following patients who undergo concomitant surgical Atrial Fibrillation (AF) ablation at 3-months, 1, 2 and 3 years to ensure AF resolution. A dedicated nurse-led arrythmia clinic managed these patients at Royal Sussex County Hospital (RSCH), Brighton but was relinquished. Follow-up was incorporated into routine cardiothoracic/cardiology clinics. This audit compares current practice at RSCH against best-practice (JCTVS).

Method

Patients who underwent surgical AF ablation between 2016-2017 at RSCH notes were interrogated for demographic, clinical and outcome data. Survival, freedom from AF at 3-years and post-operative anticoagulation/rate-control medications at follow-up data were extracted.

Results

Sixty-two patients underwent surgical AF ablation; 21 were followed up locally at RSCH and included in the final analysis. 53% had post-surgical AF resolution. At 3-years, 48% were free from AF; all patients survived. Only 38% patients had 4 follow-up appointments as per best-practice standards. 62% and 66% continued anticoagulation and rate-control medications, respectively.

Conclusions

Best-practice standards were poorly met. Patients inappropriately followed-up could incur severe AF-related complications including longer hospital stay, treatment and poorer quality of life. A nurse-led arrhythmia clinic can prevent AF-related hospital admissions and sequalae by ensuring cost-effective review, optimal anticoagulation, and rate/rhythm control.
236 Novel Guidelines to Avoid Routine Blood Tests After Robotic Assisted Radical Prostatectomy (RARP)
Authors: Nathan A , Hanna N , Rashid A , Patel S , Phuah Y , Flora K , Sharma A , Cleaveland P , Kasivisvanatha V , William N , Mia S , Collin J , Sridha A , Kelka A , Sha N , Kell J , Briggs T , Shaw G , Sooriakumaran P , Rajan P , Lamb B , Nathan S
Published: May 2021

Introduction

Patients undergoing RARP commonly require routine post-operative blood tests. This practice dates from an era of open surgery, with increased blood loss and complications. We aim to improve specificity of blood test requests with novel guidelines.

Method

1039 consecutive RARP patients at two tertiary urology centres in the UK were audited. Novel guidelines constructed based on risk stratified evidence from the initial audit were used to prospectively audit 133 patients.

Results

16% had clinical concerns post-operatively. 1% and 4% had an intra- and post-operative complication. Intra- or post-operative clinical judgement flagged post-operative complications in 99.9%. 80% had routine blood tests with no clinical concerns. 6% had delayed discharge due to delayed processing of blood tests. 0.9% received a peri-operative transfusion.

Re-Audit Novel guidelines reduced the number of blood tests requested from 100% to 36%. Specificity in diagnosing a complication improved from 0% to 67%. Discharge delays reduced from 6% to 0% and no post-operative complications were missed (sensitivity 100%).

Conclusions

Routine blood tests, without an indication, did not flag any additional post-operative complications. Blood transfusion is rare for RARP. Novel guidelines to request post-operative blood tests will reduce costs and discharge delays whilst maintaining appropriate patient safety and care.
261 Using Technology to Improve Inpatient Surgical Lists
Authors: Gowda A , Chia Z , Fonseka T , Smith K , Williams S
Published: May 2021

Introduction

Every day in our surgical department; prior to our quality improvement project, Junior Doctors spent on average 3.26 clinical hours maintaining 5 surgical inpatient lists of different specialities with accessibility of lists rated as “neutral” based on a 5-point scale from difficult to easy. Our hospital previously had lists stored locally on designated computers causing recurrent difficulties in accessing and editing these lists.

Method

We used surveys sent to clinicians to collect data.

Cycle 1: Surgical Assessment Units list on Microsoft Teams

Cycle 2: Addition of surgical specialities and wards lists onto Microsoft Teams.

Cycle 3 (current): expand the use of Microsoft Teams to other specialities.

Results

Utilising technology led to a 25% reduction in time spent on maintaining inpatient lists, to 2.46 hours a day, and an improvement in the accessibility of lists to “easy”. Across a year, this saves over 220 hours clinician hours which can be used towards patient care and training. Furthermore, use of Microsoft Teams has improved communication and patient care, in the form of virtual regional Multi-Disciplinary Team meetings and research projects.

Conclusions

Microsoft Teams is currently free to all NHS organisations in England so there is potential for these efficiency savings to be replicated nationwide.
262 Analysis of the Factors Contributing to Unplanned Admissions of Surgical Day Cases
Authors: Al-Zubaidy R , Greaney C , Malik H , Awan F
Published: May 2021

Introduction

Day surgery has many benefits including a reduction in waiting lists, cancellations, hospital acquired infections and need for inpatient beds. It is also highly cost effective. The aim of this study is to identify which factors lead to the unanticipated admission of day cases, in order to adjust future patient selection, and retain efficiency

Method

A list of day cases that took place in 2017 was obtained from the HIPE department in St. Luke’s General Hospital. Day case patients who required admission were retrospectively analysed with the use of patient charts. Patient factors such as age, gender and co morbidities were recorded. The root cause of admission was identified, and the data collated.

Results

457-day cases took place during 2017. 35/457 patients were admitted postoperatively (admission rate of 7.8%). The majority of patients were admitted post cholecystectomy (22) and incisional hernia repair (8). Surgical factors were responsible for almost all admissions.

Conclusions

Surgical factors/complications are not always predictable, but a thorough review of a patient’s background history and imaging can lead to the identification of patients, who should be directed away from day surgery, minimising the need for unexpected admissions, and maximising the efficiency of the unit.
275 Feasibility and Patient Satisfaction of Intra-Detrusor Botulinum Toxin (Botox) Injections Under Local Anaesthetic (LA) In the Outpatient Setting
Authors: Tan Y C , Tien T , Ow N L , Chowdhury S l
Published: May 2021

Introduction

Intra-detrusor Botox injections for overactive bladder has shifted to being performed under local anaesthetic rather than general anaesthetic to improve cost and efficiency. However, it may cause the patient pain and discomfort. We aim to assess the feasibility of LA Botox injections in the outpatient setting and to evaluate patient satisfaction.

Method

Our first cycle assessed whether patients would consider intra-detrusor Botox injections under local anaesthetic in the outpatient setting. Our services were then restructured to run LA Botox clinics. Our second cycle then assessed the patient satisfaction of these clinics using the client satisfaction questionnaire (CSQ-8) template.

Results

The first cycle showed that 70% (14/20) of patients would consider having outpatient Botox injections under LA. A potential annual saving of £88,434 was estimated.

The second cycle showed a high patient satisfaction rate with an average CSQ-8 score of 30/32 in 16 patients who had Botox injections in the outpatient setting. 9 patients reported being “very satisfied” with our service and the remainder reported being “mostly satisfied”

Conclusions

LA Botox injections in the clinic setting has a high patient satisfaction rate and can provide considerable cost savings. Suitable patients should have LA intra-detrusor Botox injections in the outpatient setting where possible.
281 Evaluating a Diagnostic Algorithm for Adult Appendicitis – A Quality Improvement Project
Authors: Zucker B E , Loro F , Tyer A , Shabbir J , Finch-Jones M , Blencowe N
Published: May 2021

Introduction

Diagnosing appendicitis remains challenging, despite being the most common surgical emergency. We conducted a single-centre mixed method quality improvement project to assess the validity of a diagnostic algorithm for appendicitis and the diagnostic impact of increasing cross-sectional imaging during the Covid-19 pandemic.

Method

Adult histology reports and preoperative imaging data were retrospectively retrieved for patients operated on between 1/7/19-31/12/19 (‘baseline data’) and an appendicitis diagnostic algorithm was developed.

Imaging and risk stratification data were prospectively collected, as part of a national audit, between 20/03/30-23/6/20 for all adult appendicitis patients. This data was used to evaluate the efficacy of the proposed diagnostic algorithm.

Use of imaging and histological diagnoses was compared between datasets.

Results

194 patients were included across both time periods. The rate of cross-sectional imaging increased from 36.6% to 76% and the normal appendicectomy rate (NAR) decreased from 5.22% to 2.4%. Thirty-six percent of patients in the latter time period were not managed in accordance with the proposed algorithm. The proposed diagnostic algorithm may have prevented up to 87.5% of normal appendicectomies across both time periods.

Conclusions

Increasing cross-sectional imaging was associated with a decrease in the NAR. The use of the proposed diagnostic algorithm may have reduced the NAR further.
291 Pre-Operative Venepuncture: An Audit of The Trauma and Orthopaedic Department at The Royal Sussex County Hospital, Brighton
Authors: Harris H , Antonio T , Hagiga A , Crone D
Published: May 2021

Background

NICE recommends that patients undergoing intermediate or minor elective surgery do not need routine coagulation or transfusion blood testing unless they are ASA 3+ or taking anticoagulation mediation, where testing may be considered. Currently there is no guidance for trauma patients.

Method

We identified all patients that underwent intermediate or minor trauma and orthopaedic surgery within a three-month period from December 2019- February 2020 at the RSCH. We excluded major trauma patients, patients taking anticoagulants and patients with complex admission or past medical history. Computer records were used to identify pre-operative investigations and admission history.

Results

843 patients met our inclusion criteria. In total, 92 clotting studies and 200 transfusion samples were taken preoperatively. The majority of tests were for patients undergoing ankle 130/292 (45%) or Tibia/Fibula 54/292 (18%) procedures. This equates to approximately 1168 blood tests per year. Based on the lab cost of £15.97 for a transfusion sample and £18 for a coagulation sample, this is a cost of approximately £19,616 each year on blood testing that is not indicated.

Discussion

We hope that by presenting these results we will help reduce the unnecessary time and financial burden of routine venipuncture in departments undertaking intermediate and minor surgery.
299 Implementing A Formal Surgical Handover Tool for Junior Doctors – A QI Approach
Authors: Gill E , Quested S , Lim J , Mohsin M
Published: May 2021

Introduction

An informative medical handover facilitates safe patient care. It was recognized that insufficient clinical information at handover resulted in unsafe communication in the general surgical department at Pinderfields General Hospital (PGH). We aim to utilise the Royal College of Surgeons’ (RCS) and British Medical Association’s (BMA) guidelines to improve the existing handover system, facilitate an efficient and relevant handover, and furthermore improve patient safety.

Method

General surgical foundation doctors (FDs) (n = 15) at PGH were surveyed to establish their perspectives of existing handover documentation. Subsequently a handover tool was iteratively designed, using tests of change, combining RCS and BMA guidelines with FDs’ suggestions of patient information required for safe handover. At two time points, FDs in the department were re-surveyed to measure improvement.

Results

Prior to implementation of a formal document, only 20% of FDs reported sufficient patient identifiers of the handover. This improved to 67% post intervention. Pre-intervention, 0% perceived the handover as ‘Excellent’, 20% as ‘good’. Post-intervention, these improved to 34% and 60% respectively.

Conclusions

Over six months, we improved the FD’s handover document, resulting in positive feedback of perceived safety of surgical patient handovers. However, recognised time constraints have highlighted the need for more efficient handover documentation.
307 Improving Compliance with Standard of Care Guidelines for Suspected Cauda Equina Syndrome Across A District General Hospital Network
Authors: Richardson D , Greenway F , Mostofi A , Pereira E
Published: May 2021

Introduction

Cauda equina syndrome (CES) is a spinal emergency that cannot be reliably detected through clinical examination alone and as a result requires prompt MR imaging to provide a diagnosis. This audit examined compliance to standard of care following service improvements in line with the updated SBNS/BASS national guidelines for CES.

Method

A retrospective analysis of 200 patients referred to neurosurgery for suspected CES: 100 pre- and 100 post-service improvement SBNS guideline implementation.

The online neurosurgical database was reviewed, cases assessed for completeness of referral information (including appropriate exam and pre-referral MRI) with patient demographics, referring hospital and outcome also recorded.

Results

Prior to the SBNS guidelines only 19 patients received MRI prior to referral, 70% of all referrals were incomplete or contained erroneous clinical information. Post-service improvements there was a 68% increase of pre-referral MRI (32 cases), and an improvement in quality of clinical information with only 19% of referrals providing insufficient or unreliable information.

Conclusions

Through relatively simple changes to local policy, patient care flow and education of emergency department clinicians we have significantly improved pre-referral MRI rates as well as overall referral quality across the whole DGH network.
317 Why Are We Cancelling Theatre Cases at Ealing Hospital? What Can Be Done?
Authors: Rokkas S , Sethi B , Kim I
Published: May 2021

Introduction

Following a recent spate of on the day cancellation of elective operations being cancelled on the day of surgery, a need for a wider review was felt. Our aim was to identify the causes behind these cancellations.

Method

Retrospective data collection was performed to categorise patients according to the reason for cancellation. Analysis consisted of case presentations being prepared and presented to the surgical consultants.

Results

A total of 130 operations were cancelled on the day of surgery. 22 patients were cancelled due to the procedure not being required and 10 patients were cancelled due to insufficient pre-operative investigations.

Analysis of the 32 cases demonstrated that the majority of cancelled patients were seen and listed for surgery after clinical review by the registrar without involvement of the consultant.

Some cancellations occurred when the consultant responsible for listing the patient was different of the operating consultant.

Both factors lead to differences in opinion arising on the day of surgery.

Conclusions

Ensuring patients are only listed after discussion with the consultant would reduce cancellations arising from lack of experience and clinical misjudgment of the registrar. It would also ensure that cases added to the pooled operating lists are less subjective in their indication and readiness.
318 Management of Incidental Pancreatic Cysts –Are We Adhering to Guidelines?
Authors: Sharmin A , Ahmed R , Singhal T , Kumar M
Published: May 2021

Background

The majority of pancreatic cysts (PC) are incidentally diagnosed. Most NHS Trusts do not have pathways to manage them. We reviewed the management of incidental PC and adherence to guidelines.

Method

Data was collected across three hospitals in our Trust between January 2018-January 2019 when there were no guidelines. Reaudit was performed between July 2019-February 2020 following the introduction of trust guidelines that recommend all PC be discussed in MDT meetings.

Results

The first audit identified 79 patients and 28 in the second. 53% (42) and 64% (18) patients were referred to HPB/GI MDT during the two periods. There was an 11% increase in MDT referrals, however, 35.71% of patients were still not referred. During the initial audit, 62 % (23/37) of patients in the Non-MDT group had no surveillance scans, potentially missing high-risk patients and 38% of patients (14/37) still underwent surveillance scans from non-GI specialists which could be unnecessary. 44% of patients underwent surveillance following MDT in the second period as compared to 83% prior to guidelines (p = 0.002).

Conclusions

Robust guidelines for incidental PC identify high risk cysts that warrant future surveillance/treatment and avoid unnecessary scans releasing radiology capacity.MDT referral ensures malignant transformations are identified early and reduce morbidity and mortality.
322 Snapshot Re-Audit of Implant Checks in SWLEOC Theatres
Authors: Getachew F , Baryeh K
Published: May 2021

Introduction

Never events represent a huge cost burden to the NHS due to litigation. One such event occurred at a high-volume orthopaedic unit involving the wrong implant being inserted into a patient. An extensive investigation was undertaken which highlighted a combination of human error in the implant checking process and implant storage system. As a result, local guidance was developed to ensure a ‘prosthetic pause’ was performed prior to implant opening.

Method

An audit of implant checking practices was performed. The first cycle involved 14 cases observed over two weeks and the second involved 16 cases over five weeks. The checks were deemed compliant if the operating surgeon read aloud the implant details to the team, the scrub nurse did the same and both happened prior to implants being opened.

Results

The initial audit had 8 of 14 cases complying with local guidance. Following the addition of laminated copies of the guidance to all theatres, the guidance being re-distributed to staff and targeted education of the scrub team this improved to 13 of 16 cases.

Conclusions

Targeted interventions and the introduction of a ‘prosthetic pause’ resulted in an improvement in compliance with implant checks and reduces the risk of further never events.
365 Arrival to Decision: Improving Waiting Times in Surgical Ambulatory Care
Authors: Mahmood F , Patel P , Islam O
Published: May 2021

Introduction

An audit of the newly established Surgical Emergency Ambulatory Care Unit (SEAC) at Furness General Hospital found perceived patient waiting times were high. This Quality Improvement Project assessed the patient flow through the SEAC unit and aimed to improve the average time from arrival in the department to senior review by 10%.

Method

The Plan Do Study Act (PDSA) methodology for quality improvement was used, the time from arrival in the unit to senior decision was recorded for each patient seen over one-week data collection periods. Analysis of the data allowed for a patient process map to be created to visualise bottlenecks in patient flow. The findings were discussed with all team members and an agreed intervention was implemented and tested.

Results

Over three PDSA cycles, a significant improvement in the overall time from arrival to decision was achieved, from an average time of 193 minutes to 150 minutes. This was achieved by introducing a referral form, which altered how and when members of the multidisciplinary team communicated with each other.

Conclusions

Clear communication at the appropriate time between all members of the SEAC team significantly improved the average time from arrival to decision.
367 Improving Handover Documentation in Surgical Inpatients Using Weekend Handover Stickers
Authors: Boyle C , Chien S , McCallum A
Published: May 2021

Introduction

Transfer to the care to the oncoming team is the point at which inpatients are most vulnerable. Effective handover is vital to protect patient safety and clinical governance. The Royal College of Surgery (RCS) Safe Handover guidelines highlight relevant information required for comprehensive handover. This QI project aimed to determine if implementation of weekend handover stickers in surgical patients’ notes improved handover documentation.

Method

A retrospective records-based audit of patients admitted under general surgery over a 4-week period was performed. Standards were set using the RCS guidelines to determine if sufficient weekend handover was documented.

We designed weekend handover stickers to be inserted in notes based on guidelines. A re-audit cycle over a 4-week period was performed to determine if the intervention improved handover documentation.

Results

119 patients were in the initial audit. 125 patients were in the re-audit. Documented handover in the notes improved from 43.7% to 89.6% after intervention.

Documentation of the following clinical information also improved: clinical situation (43.7% to 92.0%); co-morbidities (14.3% to 89.6%); current issues (71.4% to 94.4%); weekend blood tests (32.8% to 92.0%); antibiotic therapy (21.8% to 92.0%).

Conclusions

Weekend handover stickers resulted in a significant improvement in handover documentation improving patient safety.
389 General Surgery Operative Cancellations Within Aberdeen Royal Infirmary 2019
Authors: McIntosh S , Jardine R , Ghazanfar M
Published: May 2021

Introduction

Operative cancellation rates can be up to 17.6%, resulting in delays to patient treatment and management. This audit was conducted to assess underlying reasons for operative cancellations with the aim to minimise cancellations in the future.

Method

A retrospective review of General surgery operative cancellations during 2019 at Aberdeen Royal Infirmary was undertaken. Data was obtained from Theatre Management.

Results

28548 operations were performed across all surgical specialities during 2019 with 2664 operations cancelled. Within General Surgery, 447 were cancelled (182 emergency (40.7%), 265 electives (59.3%)). The most common reason was lack of theatre time for elective cases and procedure no longer needed for emergency cases. For cancelled elective surgeries, there was a median time of 29 days before being operated.

Conclusions

We highlight that both elective and emergency operations are susceptible to cancellation. There are clear differences in the reason of cancellation between elective and emergency. Going forward, it is worth discussing booking emergency operations with the on-call consultant to ensure they are necessary. Regarding elective operation cancellations due to lack of theatre time it would be imperative to assess the exact cause of this as to minimise operative cancellations. We plan re-audit once a departmental discussion has been made.
398 Theatre Waste Management and the Impact of COVID-19
Authors: Luney C , Little C
Published: May 2021

Introduction

Audit of waste management in an elective orthopaedic complex was interrupted due Covid-19 pandemic. We investigated the impact of the enforced changes on theatre waste due to Covid-19.

Method

Over a 1week period data on waste bag availability and number of bags of each category of waste per surgical case in an elective theatre complex was collated; this was compared to waste generated during Covid-19 pandemic.

Results

Prior to Covid-19 only clinical waste bins were available in many non-dominant clinical areas providing evidence of inappropriate routine disposal of domestic/recyclable waste. Pre-Covid-19 a mean of 6waste bags were used per surgical case (3.7yellow clinical bags, 1.3black domestic bags, 0.4clear recycling bags), with Covid-19 changes to waste management practice the mean number of waste bags used per case increased to 11 (9 orange contaminated bags, 0.5black, 0.3clear bags).

Conclusions

Clinical waste management has a significant economic and environmental impact. Covid-19 has led to nearly all waste being deemed to be contaminated and so requiring incineration, with increased volumes of waste generated per case through widespread adoption of PPE. This has increased cost and reduced the ability to recycle non-contaminated waste.
399 A Re-Audit of Secondary Prevention Medications Following Coronary Artery Bypass Grafting: Are We Still Compliant with The Updated Guidelines?
Authors: Dey A , Sastry P
Published: May 2021

Introduction

In the years following myocardial revascularisation with bypass grafts, patients remain at risk for subsequent ischemia as a result of native coronary artery disease progression or development of graft occlusion. Therefore, secondary measures, primarily medical therapy, play an indispensable role in post-operative care. An audit conducted in 2014 identified reduced compliance to prescription of secondary prevention medications. This audit aims to re- evaluate the level of compliance to updated guidelines.

Method

A retrospective case-note review of 100 patients, who underwent CABG (Coronary Artery Bypass-Grafts), was conducted primarily focusing on prescription of secondary prevention drugs at discharge, indications, and contraindications.

Results

99% patients were discharged on anti-platelet agents. However, 12%, discharged on dual anti-platelet agents, did not have any indications for them. 97 % patients were discharged on beta-blocker. Of the 3 defaulters, one had contraindication to beta blockade. 96% patients were discharged on one or more lipid lowering agents and 74% were discharged on ACEi/ARBs. Of the 26% patients discharged without RAAS (Renin Angiotensin Aldosterone System) inhibitor, 9% had no clear indication for it whereas for 7%, it was contraindicated at discharge.

Conclusions

A generalised improvement in compliance rate is noted for secondary prevention medications prescription according to updated guidelines from the previous audit.
420 Accuracy of Documenting Complications When Consenting Patients for Laparoscopic Appendectomy
Authors: Karki B B
Published: May 2021

Background

Appropriately performed informed consent acts as a shield against false complaints or claims of malpractice against the doctors. Laparoscopic Appendectomy accounts for a significant portion of general surgical workload hence shows a difference in the patient consenting.

Method

A proforma was devised which included recognised complications of Laparoscopic Appendectomy and grade of the consenting medical professional. The proforma containing 10 standard complications was then cross-referenced with the consent forms of 38 patients and the documented risks in each form was noted.

Result

The result showed a wide variation in the documentation of complications based on the grades of the medical professional. Out of 38 consent forms, 32/38 ( 84.21 %) were completed by Junior Grade Doctors out of which 15/32 by FY2 and 17/32 by Core Surgical Trainees (CST) and 6/38 (15.78 %) by Specialist Registrars (SpR). Of the set standard 10 complications, FY2 documented an average of 4.2, CST documented 6.2 and SpR documented 8.16 complications.

Conclusions

The study showed a need of improvement in the documentation of complications especially among Junior Doctors. Procedure specific complication stickers was developed for a standardised list of complications which will act as a source of information for the patient and prompt doctors to discuss the risks.
422 Improving Theatre Capacity for Orthopaedic Trauma Cases
Authors: Karbowiak M , Kohls J
Published: May 2021

Introduction

Delay to surgery in orthopaedic trauma is associated with higher morbidity and mortality, as well as prolonged hospital stay. In this study we have looked at how replacing half-day sessions with all-day trauma lists at the Royal Surrey NHS Foundation Trust has affected theatre efficiency and waiting times for surgery.

Method

Details for all trauma cases (with patient demographics, injury, and surgery details) operated on in April 2019 and April 2020 were collected using hospital records.

Results

88 cases were identified in April 2019 - the average time from presentation to hospital to the operation was 3.82 days. In April 2020, there were 79 cases with average time to surgery of 1.26 days. There was a reduction in the number of ambulatory trauma, however, more femoral trauma was recorded in April 2020. The reduction in waiting time for surgery following the introduction of all-day lists was statistically significant with p value <0.05 across all subcategories except upper limb trauma.

Conclusions

The introduction of all-day trauma lists led to a statistically significant reduction in the time from patients presenting to hospital to surgery. In view of these findings, the department has now permanently introduced all-day lists on selected weekdays running alongside the elective sessions.
450 Retrospective Analysis of Surgical Clerk-Ins Within the Acute Receiving Unit: A Quality Improvement Project
Authors: Lee L , MacLeod A , Bradley A
Published: May 2021

Introduction

Accurate patient documentation at the ARU is vital to patient safety and ensuring smooth handovers to secondary care services. Because the nature of surgical treatment requires frequent patient handovers, and this increases the risk of miscommunication, we aimed to assess the quality of surgical clerk-ins and identify areas for improvement.

Method

Emergency admissions at the Dumfries Galloway Royal Infirmary were audited, looking at documentation quality under various clerk-in sections. Data was analysed before presentation to clinical governance.

Results

When 46 patient clerk-ins were examined, venous thromboembolism (VTE) prophylaxis plans were performed in only 24% of admissions - less than 1 in 4 patients.

Comparing out-of-hours and in-hours patient documentation, much higher omission rates were identified in the out-of-hours documentation: in systemic enquiry (42 vs 100%) and family history (31% vs 66%).

Conclusions

These results brought to attention the effect of hospital admission timing on patient documentation quality, and the lack of VTE prophylaxis planning. In surgery, these plans are key to minimising risk of avoidable thromboembolic complications.

A departmental meeting was convened to stress the importance of accurate and comprehensive clerk-ins to ARU doctors. Future audits could explore the factors influencing documentation quality for out-of-hours admissions, and ways to address these issues.
459 Implication of Changes in Management of Acute Pancreatitis During COVID-19 Pandemic
Authors: Ayoub N , Aboelkhair A , Mlotshwa M
Published: May 2021

Introduction

when COVID-19 pandemic stroked the country, the Royal College of Surgeons recommended cholecystectomy for gall stone pancreatitis could be delayed up to 12 weeks during Covid-19 pandemic. This may have exposed patients to recurrent gall stone morbidity and serious complications.

Method

Patients admitted with gall stone pancreatitis during Covid-19 period 12th March 2020 till 15th June 2020 to Western Sussex hospitals were analysed retrospectively for a period of 3 months post index submission. The endpoints were readmission rates and complication relating to gall stones.

Results

Conclusions

Delaying cholecystectomy for gallstone pancreatitis to 3 months is associated with significant readmission rates and serious complications. Cholecystectomy for gallstone pancreatitis should be categorised as 1B or 2 during Covid-19 period.
467 Impact of the Coronavirus Pandemic on Acute Surgical Patients’ Discharge Summaries
Authors: Ooi R , Stimson I B , Williams G
Published: May 2021

Background

The emergence of the Coronavirus pandemic has placed increased demands on the NHS workforce, especially in medical and intensive care units. The subsequent redistribution of surgical house officers to accommodate this in a single centre has possibly negatively impacted on the effective discharge notification of acute surgical patients.

Methods:

Discharge summaries of all patients discharged from a Surgical Assessment Unit were collected and analysed, to identify the date of completion and grade of responsible clinician. Data collection was carried out over three weeks before the initiation of lockdown measures and continued for a further three weeks during the peak of the Coronavirus pandemic with a three-week interventional period in between.

Results

In the initial audit, 36.2% of the 246 patients had delayed discharge summaries with an average of 7 days to complete. On re-evaluation, 45.3% of the 223 patients had delayed discharge summaries, with an average of 12 days to complete. A survey conducted post-re-audit identified that the most common reason for this was due to time constraints.

Conclusions

The reallocation of surgical staff has affected communication between primary and secondary care. Given the potential repercussions of these delays, healthcare systems should be made aware of this consequence, especially in preparation for any future resurgences.
473 Post-Tonsillectomy Advice: What Are UK Patients Being Told?
Authors: Gabrawi M , Haymes A , Davis J
Published: May 2021

Background

Tonsillectomy is one of the commonest surgical procedures performed in the UK, with just over 45,000 recorded in England in 2018-2019(1). Despite this there is wide variation in, and a lack of evidence for, the post-operative advice given to patients.

Method

Post-tonsillectomy patient advice sheets were obtained from 110 UK NHS Trusts and equivalent organisations. Their contents were analysed and compared with published literature on post-tonsillectomy management to determine whether the advice is evidence-based or not.

Results

Post-tonsillectomy dietary and fluid intake advice varied between hospitals; whilst many recommend eating and drinking a normal diet (88%), many recommended eating a ‘hard’ (26%) or ‘soft’ (8%) food diet. Literature written for adults was more likely to encourage adequate fluid intake than that for children (75% versus 25%). Non-evidence-based advice including avoiding fizzy drinks (21%), fruit juices (9%), and using chewing gum (51%), was frequently given. Reported post-operative risks and safety-netting also varied, with 71% advising urgent hospital attendance if any bleeding was experienced whilst 12% suggested that bleeding up to a spoonful was to be expected and should not necessarily be acted upon.

Conclusions

Much of the advice given appeared to be anecdotal and not based on, or contrary to, published evidence.
482 New Zealand Rural Hospital Junior Doctor General Surgery Guidelines for Emergency Department (ED): every little helps
Authors: Keren B , Voll J , Herewini A , Paranawidana R , Prasad J , Collins D
Published: May 2021

Introduction

Clinical guidelines are associated with improved patient outcomes. This is especially true for junior staff members with little clinical experience. We created Pocket Guidelines for the management of surgical patients in ED, aimed at house officers.

Method

Seventeen common surgical conditions were selected for guidelines. Information was collated on presentation, exam findings, differential diagnosis, laboratory tests, imaging, indications for referral, and timing. Evidence based guidelines were approved by General Surgical consultants in the department. The utility of our guidelines was assessed by surveying 20 junior doctors.

Results

16 out of 20 house officers responded to the survey, ranging from post graduate year (PGY) 1 to 4, majority of them (37.5%) being PGY1. 69% were female and 31% were male.

A 5- point Likert scale was utilised for answers. No house officers ‘strongly agreed’ with being confident in managing surgical conditions in ED. Over 80% strongly agreed with the need to have ED clinical guidelines for surgical patients. Over 90% of house officers, having studied the pocket guidelines, found these useful.

Conclusions

We implemented pocket guidelines for general surgery in a rural hospital ED to streamline surgical admissions. Guidelines were found to be beneficial by the majority of junior doctors.
494 Streamlining the Minor Operations Process - The Effect of Better Documentation
Authors: Schrire T , Estela C
Published: May 2021

Introduction

Plastic Surgery Minor Operations is a fast paced, rapid turnover operative environment. It is reliant on effective communication, accurate surgery, and time efficiency. It was noticed in our department that there was confusion regarding booking and operative intentions leading to delays in surgery and over-running lists. This was worsening patient experience and leading to delays in patient care.

Method

In response to the delays and confusion in booking, a new booking form was created, so all patients have a standardised booking containing the necessary information. This form was disseminated across all the booking clinics and formed a vital part of the pre-operative check in process.

Results

The audit was carried out at the time of introduction, and then re-audited a year later to see if the form has improved care for patients. Results showed that with the new booking form, people were not having to cancel or rearrange patients. Patient booking forms were sufficient, and a copy of the clinic letter no longer required for the operation to proceed or for clarity. It was noted that more senior advice was sought.

Conclusions

The new form has improved patient flow and quality of patient care, whilst streamlining the booking process.
496 The Use of Virtual Trauma Clinics (VTC) In the Assessment of Acute Hand Trauma; A Service Evaluation
Authors: Creasy H , Westley S , Shah R , Mistry R
Published: May 2021

As a UK tertiary referral centre for hand trauma the current COVID outbreak has led to the reconfiguration of trauma services. We evaluate the impact of our newly introduced VTC on our hand trauma service, comparing a cohort of patients who were managed pre-COVID, with our current revised pathway.

We carried out a service evaluation of all those patients processed by the VTC over 14 days in April 2020 (n = 184). We collected prospective data on timing of referral to assessment and surgery. This data was compared to a matched period in April 2019 (n = 162).

Post VTC there has been a significant reduction in time to clerking and time to surgery (p = < 0.001), with 98.1% being clerked within 1 day of referral. Post VTC 12.9% of patients were discharged directly from VTC, all other patients had definitive treatment in a single trip.

VTC has shown a clear benefit to patients with definitive management provided in a single trip in all cases. Whilst we have been able to clerk patients earlier any improvement in time to surgery depends on theatre staffing and availability, which differed in the two cohorts and certainly will as we move forward into normal services.
506 An Audit of Documentation in Orthopaedic Trauma Meetings
Authors: Jackson T , Chahal J
Published: May 2021

The aim of this audit cycle is to assess departmental compliance with the standards elucidated by the Academy of Medical Royal Colleges, and the British Orthopaedic Association with respect to patient record keeping in regard to trauma meeting documentation.

Specific criteria for the documentation of the information were devised from the audit standards. Over a one-week period in September 2019, patient notes from all Trauma and Orthopaedic the notes for all patients on the week’s take lists were inspected for trauma meeting documentation from the following morning.

A documentation proforma was then implemented and notes were then re-audited after 3 months of the intervention to assess its effect.

Most patients had trauma meeting documentation however it often lacked significant information such as the take consultant, injury, date/mechanism of the injury as well as correct contact details. After implementation of the proforma, there was an improvement to 70% or above for documentation of significant information in almost all established criteria.

Poor documentation often resulted in recurrent calls to the on-call team the following day to clarify diagnoses and plans which were often inadequate or unclear. This was improved through the introduction of a proforma to standardise the documentation present.