Acute Surgical Service Research Articles

WP3.14 - A Single Unit Service Review in Northern Ireland: The Ever-increasing Acute Surgical Take and the Need for Service Adaptation

Abstract Aims Referrals to the on-call general surgeons in the unit has increased significantly over the past year. Staff levels and hospital resources have not changed to reflect this increasing demand on the service. Our aim is to evaluate the increase in numbers and develop a strategic plan for resolution. Methods A database of referrals to the on-call surgical team was developed using the daily handover records. Two periods of data collection were undertaken, each lasting a duration of 30 days, taking place approximately one year apart. Patient demographics and clinical information was gathered using our electronic care record and electronic notes record. Data gathered included diagnosis, treatment, investigations, interventions, length of stay, suitability for ambulation and follow up. Results The total number of patients referred to the on-call team during cycle one was 233, compared with 405 in cycle two; this is a 74% increase in referrals. During the windows of data collection, 75% of patients with an unscheduled admission did not undergo any intervention and 80% were deemed suitable for ambulation. Conclusion Increasing demands on the NHS require a forward-thinking approach to how we provide an acute surgical service. This study demonstrates that a large proportion of patients are suitable for an ambulatory model of care and development of this service would be a valuable adjunct to the unit. To propose an ambulatory service providing urgent surgical assessment would be an asset to the Trust; potential outcomes would include improving the patient experience, reducing inpatient admissions and bed days, with the associated cost-saving.

O97: Long term outcomes after negative appendicectomy: does morbidity justify mandatory pre-operative confirmation of appendicitis prior to surgery?

Abstract Introduction Negative appendicectomy is sometimes described as a quality indicator of an acute surgical service. Previous studies have suggested that negative appendicectomy carries an unacceptably high risk of morbidity and advocate pre-operative imaging to confirm a diagnosis in all cases, despite the resource implications this policy carries. This study quantified long term morbidity after negative appendicectomy. Methods This retrospective cohort study identified all patients who underwent appendicectomy for suspected appendicitis from June 2010 to August 2015 at a single centre. Patients with a histologically normal appendix were identified and their notes were interrogated to record outcomes; median follow-up was 10.6 (range, 8 – 13) years. Complications after surgery were classified using the Clavien-Dindo system. Results 1914 patients had an appendicectomy. 181 patients (9.5%) had a negative appendicectomy. There were 40 re-admissions after surgery; half (20 patients) were within 30 days. The most common causes of re-admission were ongoing symptoms with no identifiable cause (15 patients, 37.5%) or post-operative pain (9 patients (22.5%). Overall post-operative complication rate was 11 patients (6.1%). Of these, 6 patients had Grade 1 or 2 complications, 5 patients (3%) had Grade 3 complications (return to theatre for infection, bleeding or hernia) and none had Grade 4 or 5 complications. There was no mortality. Conclusions There is low short- and long-term morbidity after negative appendicectomy which suggests that routine pre-operative imaging to confirm a diagnosis of appendicitis before surgery is unwarranted. The concerns around complications after negative appendicectomy appear unjustified and should not be a quality indicator.

Long term outcomes after negative appendicectomy: does morbidity justify mandatory pre-operative confirmation of appendicitis prior to surgery?

Abstract Aims Negative appendicectomy is sometimes described as a quality indicator of an acute surgical service. Previous studies have suggested that negative appendicectomy carries an unacceptably high risk of morbidity and advocate pre-operative imaging to confirm a diagnosis in all cases, despite the resource implications this policy carries. This study quantified long term morbidity after negative appendicectomy. Methods This retrospective cohort study identified all patients who underwent appendicectomy for suspected appendicitis from June 2010 to August 2015 at a single centre. Patients with a histologically normal appendix were identified and their notes were interrogated to record outcomes; median follow-up was 10.6 (range, 8 – 13) years. Complications after surgery were classified using the Clavien-Dindo system. Results 1914 patients had an appendicectomy. 181 patients (9.5%) had a negative appendicectomy. There were 40 re-admissions after surgery; half (20 patients) were within 30 days. The most common causes of re-admission were ongoing symptoms with no identifiable cause (15 patients, 37.5%) or post-operative pain (9 patients (22.5%). Overall post-operative complication rate was 11 patients (6.1%). Of these, 6 patients had Grade 1 or 2 complications, 5 patients (3%) had Grade 3 complications (return to theatre for infection, bleeding or hernia) and none had Grade 4 or 5 complications. There was no mortality. Conclusions There is low short and long-term morbidity after negative appendicectomy which suggests that routine pre-operative imaging to confirm a diagnosis of appendicitis before surgery is unwarranted. The concerns around complications after negative appendicectomy appear unjustified and should not be a quality indicator.

SP8.2 Management of Acute Surgical Abscesses (MAGIC): National prospective audit

Abstract Aim Subcutaneous abscesses are common, accounting for 2% of all emergency attendances. The aim of this project was to describe the management and outcomes associated with the management of subcutaneous abscesses in surgical practice. Method A national, prospective audit was undertaken. Adult patients presenting to an acute general surgical service with a subcutaneous (non-perianal) abscess between September and December 2022 were included. Data relating to their presentation, management, and outcomes were collected. Outcomes of interest included rates of recurrence, readmission, and complications within 60 days of treatment. A centre-level survey was administered to gather data on clinical resource use and sustainable practices. Results A total of 1247 patients were included across 55 centres. The most common abscess locations were pilonidal (18.8%), posterior thorax (14.5%), and buttock (11.7%). The majority (84.4%) were treated with incision and drainage and half (51.9%) of these also received antibiotics. Surgery was mostly performed with general (65.2%) or local (33.0%) anaesthesia. The rates of recurrence (5.7% vs. 6.7%) and readmission (14.0 vs. 10.3%) were broadly similar, respectively. A quarter (26.6%) of hospitals incorporated dedicated abscess management pathways. The majority of hospitals used single-use items for abscesses drained in ambulatory/ward areas (90.2%) but not in the operating room (13.7%). Conclusions Wide variation exists in the management of subcutaneous abscesses. These data, along with other preparatory work, may justify a trial of general and local anaesthesia in appropriately selected patients.

ThTP8.9 The SARS-CoV-2 first wave impact in the acute inflammatory surgical pathologies

Abstract Anecdotal evidence suggests that community infection control measures during the COVID-19 outbreak have modified the number and natural history of acute surgical inflammatory processes (ASIP-appendicitis, cholecystitis, diverticulitis and perianal abscesses) admissions. This study aims to evaluate the impact of the COVID-19 pandemic on the presentation and treatment ASIP and quantify the effect of COVID-19 infection on the outcomes of ASIP patients. This was a multicentre, comparative study, whereby ASIP cases from 2019, 2020 and 2021 (March 14th to May 2nd) were analyzed. Data regarding patient and disease characteristics as well as outcomes, were collected from sixteen centres in Madrid, and one in Seville (Spain). The number of patients treated for ASIP in 2019 was 822 compared to 521 in 2020 and 835 in 2021. This 1/3rd reduction occurs mainly in patients with mild cases, while the number of severe cases was similar. Surgical standards suffered a step back during the first wave: Lower laparoscopic approach and longer length of stay. We also found a more conservative approach to the patients this year, non-justified by clinical circumstances. Luckily these standards improved again in 2021. The positive COVID-19 status itself did not have a direct impact on mortality. Strikingly, none of the 33 surgically treated COVID positive patients during both years died postoperatively. This is an interesting finding which, if confirmed through future research with a larger sample size of COVID-19 positive patients, can expedite the recovery phase of acute surgical services.

The impact of partial and complete lockdown during the COVID-19 pandemic on acute surgical services: a retrospective cohort study

PurposeThe burden of the coronavirus disease of 2019 (COVID-19) pandemic on the healthcare sector has been overwhelming, leading to drastic changes in access to healthcare for the public. We aimed to establish the impact of implemented government partial and complete lockdown policies on the volume of surgical patient admissions at a tertiary referral center during the pandemic.MethodsA database was retrospectively created from records of patients admitted to the surgical ward through the emergency department. Three 6-week periods were examined: The complete lockdown period (CLP), which included a ban on the use of cars with the exception of health service providers and essential sector workers; A pre-COVID period (PCP) 1 year earlier (no lockdown); and a partial lockdown period (PLP) that involved a comprehensive curfew and implementing social distancing regulations and wear of personal protective equipment (e.g., masks) in public places.ResultsThe number of patients admitted to the surgery ward was significantly higher in the PCP cohort compared to the CLP and PLP cohorts (p = 0.009), with a 42.1% and 37% decline in patients’ admissions, respectively. Admission rates for patients with biliary pathologies and vascular thrombotic events increased. 30-day mortality rates did not differ significantly between the three periods (p = 0.378).ConclusionsWhile COVID-19 lockdown regulations had a significant impact on patient admission rates, surgical outcomes were not affected and the standards of care were maintained. Future protocols should strive to improve access to healthcare to avoid complications caused by delayed diagnosis and treatment.

EGS P06 Delays in Operating on General Surgery Patients Causes Increased Morbidity and Burden on the NHS

Abstract Background The number of patients waiting for an operation in the United Kingdom has never been higher, as of February 2022 over six million people were waiting for treatment. There is pressure nationally on trusts to implement strategies aimed at reducing the backlog of elective procedures. Long waiting lists can lead to a greater demand on acute surgical services as patients require treatment for their condition while they wait for their procedure. This study aims to determine the impact that long waiting lists have on patients, and how readmissions affect acute services in a busy tertiary General Surgical unit in England. Methods Snapshot data was captured on a single day in February 2022 using the trust patient records system combined with the General Surgical waiting list. Data was collected and analysed in a bespoke excel data management tool built by the trusts patient costings team. The tool allows detailed analysis of patients readmitted whilst on the waiting list, outcomes and total cost. It also allows the data set to be explored as a whole and detailed patient level analysis. Wait time for emergency procedures was also analysed by length of pre-op and post-op stay. Results A total of 2902 patients were awaiting a General Surgical procedure in February 2022, with an average wait of 34 weeks. 394 (14%) of these patients have attended acutely since being listed for elective surgery. The total cost implication of these reattendances is £563,766. Analysis of a single procedure, such as laparoscopic cholecystectomy revealed 183 patients waiting for a cholecystectomy. 20% of these presented acutely, of which 68% was directly related to the listed underlying pathology with 34 bed days lost. 261 patients were awaiting a hernia (inguinal, umbilical, incisional) repair. 20% of these patients presented acutely whilst on the waiting list, with 33 lost bed days. Acute attendances increase as the waiting time increases; 38% of patients waiting over 15 months attend acutely, increasing to 50% at 22 months. Data from emergency procedures showed that as inpatient length of stay (LOS) pre-operatively increased in number of days, the post-operative LOS increased proportionally. Pre-op LOS of 1–2, 2–3, 3–4, 4–5, ≥5 led to post-op LOS of 2.9, 2.9, 4.2, 5.9 and 8.7 respectively. Conclusions This study highlights that long waiting lists can lead to significant burden on acute General Surgical services as patients seek medical attention for the condition they are awaiting surgical management for, leading to costs of over half a million pounds. The problem becomes intensified by lost bed days due to these acute presentations, which can lead to cancelled elective procedures and pressure on acute surgical services. This results in emergency patients waiting longer in-hospital for an operation, who then have a longer post-operative LOS. Combined these findings suggest a higher morbidity for these patients. There is an urgent need for innovative strategies to reduce waiting lists, and increase theatre productivity. Data analysis tools like these allow trusts to nuance strategies to address these issues directly.

EGS P02 The long term impact of service re-organisation on outcomes for patients with complicated peptic ulcer disease

Abstract Background 20 years ago acute surgical services were re-organised in our region to deliver subspecialist care of upper-gastrointestinal emergencies. Improved outcomes were reported as a result. Currently the unit has 24-hour availability for interventional and diagnostic radiology, emergency endoscopy and a specialist oesophago-gastric consultant surgeon. The aims of this study are to determine if, a decade after a major service re-organisation, any further improvements have been achieved in short-term outcomes and to provide long-term survival figures for this group of patients. Methods All patients admitted during a 62-month period from January 2010-February 2015, corresponding in duration and exactly a decade later than the previous report following service re-organisation, were identified from a prospectively compiled database. Results 287 patients were admitted during the study period. 235 patients were admitted with ulcer perforation and 52 patients underwent surgery for bleeding. Perforation. 8 patients (8/235, 3.4%) received end of life care. 37 patients (37/235, 15.7%) had initial conservative management. 191 (191/235, 81.3%) patients underwent operation (includes 1 patient with failed conservative management). 18 patients (18/191, 9.4%) died post-operatively. No patients selected for conservative management died. Within 5 years following discharge a further 34 patients died. 50% (17/34) of these were due to cancer. Actual 5-year survival was 73.3% (165/225, 10 patients lost to follow up). Comparing with the period following subspecialisation, overall in-hospital mortality was 10.4% vs 11.1% (14/135 vs 26/235) p=0.84, in-hospital mortality following surgery 7.9% vs 9.4% (9/114 vs 18/191) p=0.65 and in-hospital mortality following conservative management 23.8% vs 0% (5/21 vs 0/36) p=0.005. Bleeding. In-hospital mortality was 25% (13/52). This was not significantly different from the rate reported following service reorganisation, 23.5% (12/51) vs 25% (13/52) p=0.86. Within 5 years following discharge a further 12 patients died. 58% (7/12) of these were due to cancer. Actual 5-year survival was 51.9% (27/52 patients alive). Conclusions This study demonstrates that no improvement in surgical outcome in patients with complicated peptic ulcer disease has been achieved despite the delivery of what may be considered an optimal service. A significant improvement in outcome in patients selected as suitable for conservative management has been seen. 5-year survival figures for patients admitted with either perforation or bleeding are poor with cancer the most common cause of death within 5 years following discharge.

Comparative Laparoscopic Cholecystectomy in Acute Cholecystitis in DHQ Abbottabad, KP-Pakistan

Background: Early laparoscopic cholecystectomy before 72 hours is ideal for the treatment of acute cholecystitis after 72 hours, acute or ongoing fibrosis presents careful issues. Aim: To compare the results of an acute cholecystitis blood pressure monitoring center and a specialist acute surgical service 72 hours after symptoms. Study design: Cross-sectional study. Place and duration of study: Department of General Surgery Benazir Bhutto Shaheed Hospital, (DHQ) Abbottabad from 1st October 2021 to 30th March 2022. Methodology: One hundred and eighty acute cholecystectomy patients who went through CEL were enrolled. Record was gathered which included postoperative confusions, length of medical clinic stay, and season of a medical procedure. To get comparable outcomes, subgroup examination of older patients was performed. Results: Eighty operations were performed within 72 hours of symptoms and 100 operations were performed after 72 hours, Patients who received early laparoscopic cholecystectomy for more than 72 hours had longer complication-free time” (125.4 vs. 116 minutes, P=0.035) and hospital stay (4.59 vs. 3.09 days, P=0.001). Postoperative sampling was higher in patients older than 75 years (P < 0.001). Conclusion: Acute cholecystitis patients going through CLE in a careful unit might accomplish improved results even following 72 hours of side effects. In a subset of older patients, extensive hemostasis ought to be performed. Keywords: Acute cholecystitis, early laparoscopic cholecystectomy (ELC)

SP3.2.2 Improving Acute Surgical Services and Establishing Same Day Emergency Care Clinic in a District General Hospital

Abstract Introduction Surgical Same Day Emergency Care (SDEC) clinic service is a new challenging trend nationwide. We would like to share our experience establishing SDEC in a DGH setting. Our clinic runs two sessions daily Monday to Friday with capacity of 16 patients. The patients presented for; clinical follow-up post-discharge, radiological imaging and blood tests. All referrals are triaged by specialist nurses, seen by doctors of different grades - core surgical trainees and specialty doctors and supervised by the Consultant on-call. Methods Prospective ongoing audit carried out in SDEC monitoring the number of patients reviewed, diagnosis, investigations and outcome. We audited the documentation on the hospital's electronic system. Results In October 2021, 62 patients were reviewed, 97% had decisions made same day and only 3% required admission to SAU, 50% were allocated to a named consultant, 69% had blood tests, 53.2% had radiological investigations, 25% of patients were discharged with plans to follow up in elective clinics, and 1 patient was booked for elective operation. Our recommendations to improve quality of service were to allocate a dedicated staff nurse and healthcare assistant for more efficient workflow. Improving documentation of outcomes and allocating patients to named consultant for follow up. Conclusion Our model demonstrated successful service to provide semi-urgent care to surgical patients. SDEC has the capacity for more patients and subsequently will offload pressure from the emergency services provided by A&E and surgical admissions unit. This also makes a significant impact for on-call team to allow more focus on treatment of acute emergencies.

Development and Validation of the Medical Emergency Team-Risk Prediction Model for Clinical Deterioration in Acute Hospital Patients, at Time of an Emergency Admission.

To develop and validate a prediction model to estimate the risk of Medical Emergency Team (MET) review, within 48 hours of an emergency admission, using information routinely available at the time of hospital admission. Development and validation of a multivariable risk model using prospectively collected data. Transparent Reporting of a multivariable model for Individual Prognosis Or Diagnosis recommendations were followed to develop and report the prediction model. A 560-bed teaching hospital, with a 22-bed ICU and 24-hour Emergency Department in Melbourne, Australia. A total of 45,170 emergency admissions of 30,064 adult patients (≥18 yr), with an inpatient length of stay greater than 24 hours, admitted under acute medical or surgical hospital services between 2015 and 2017. The outcome was MET review within 48 hours of emergency admission. Thirty candidate variables were selected from a routinely collected hospital dataset based on their availability to clinicians at the time of admission. The final model included nine variables: age; comorbid alcohol-related behavioral diagnosis; history of heart failure, chronic obstructive pulmonary disease (COPD), or renal disease; admitted from residential care; Charlson Comorbidity Index score 1 or 2, or 3+; at least one planned and one emergency admission in the last year; and admission diagnosis and one interaction (past history of COPD × admission diagnosis). The discrimination of the model was comparable in the training (C-statistics 0.82; 95% CI, 0.81-0.83) and the validation set (0.81; 0.80-0.83). Calibration was reasonable for training and validation sets. Using only nine predictor variables available to clinicians at the time of admission, the MET-risk model can predict the risk of MET review during the first 48 hours of an emergency admission. Model utility in improving patient outcomes requires further investigation.

Behavioural Changes in a Patient With Schizoaffective Disorder

Background:A 46-year-old man has a diagnosis of schizoaffective disorder complained of intermittent abdominal pain for many years. Due to this, he had been reviewed by the GP and he was prescribed medication to help with his intermittent abdominal pain.Case Report:Over the years the abdominal pain gradually worsened. He also has communication issues due to language barriers and was unsettled for most of his assessment.His past medical history includes a duodenal ulcer, infected swollen legs and recurrent urinary tract infections.He continued to have pyrexia despite being on regular paracetamol. Following his second episode of pyrexia, he was referred to the hospital for further investigation.This was found to be acute acalculus cholecystitis, with possible cholecystocolic fistula and pneumonia. He was managed conservatively with intravenous antibiotics and is awaiting cholecystectomy.Discussion:Behavioural change in people with mental illness need not necessarily be linked to their mental state as it can very well be the atypical manifestation of physical illnesses- some of which could be fatal. Prompt recognition and referral to acute medical or surgical services is essential. Staff need training in bias, diagnostic overshadowing and atypical presentations in those with mental illness which will help reduce rates of avoidable morbidity and premature mortality.In any case physical illnesses may not present typically. Acalculous cholecystitis is a rare type of gall bladder inflammation and the cause in Mr X's case is not clear. At times of COVID-19, with the anxieties around exposure to hospitals and infections, it is important to be aware of this and ensure that people with worrying physical symptoms are promptly referred whether or not it is considered to be related to COVID-19.ConclusionDue to the pandemic, we were cautious on the ward and community about COVID-19 and preventing catching and spreading the infection. During all this, patients change of behaviour shouldn't be alluded to deterioration of mental health and mental health professionals should also consider ruling out physical causes for the change of presentation.

Predictors of interhospital transfer delays in acute surgical patient deaths in Australia: a retrospective study.

Interhospital transfers in Australia facilitate access to acute surgical services, however transfer delays can occur. The aims of this study were to examine Australian mortality audit data on acute surgical patients who were transferred after presenting with a surgical emergency, and to identify modifiable predictors of transfer delay. Surgical admissions between 1 January 2001 and 18 August 2020 were retrospectively extracted from the Australian and New Zealand Audit of Surgical Mortality database. Relevant factors and themes of interest were collated. Results were presented as odds ratios (OR) and 95% confidence intervals (CI), with statistical significance defined as P <0.05. After exclusion, a final 8270 cases were analysed. Non-modifiable predictors identified were female gender (OR 1.34, 95% CI 1.05-1.70, P=0.0184), comorbidities (OR 1.50, 95% CI 1.40-161, P <0.0001) and major non-trauma non-vascular specialty (OR 1.54 to 7.77, depending on specialty, P < 0.05). Modifiable predictors were inadequate clinical assessment (OR 49.48, 95% CI 32.91-74.38, P <0.0001), poor communication (OR 6.62, 95% CI 3.70-11.85, P <0.0001) and multiple transfers (OR 6.30, OR 95% 4.31-9.21, P <0.0001). Age, lack of bed and after-hours transfer did not predict transfer delays. Metropolitan transfers was protective against transfer delays (OR 0.64, 95% CI 0.47-0.86, P=0.0035). In the view of the receiving surgeon or assessor, all transfer delays potentially contributed to patient deaths, and may have been preventable. Strategies directed at modifiable factors could minimize delays. Increased surgical services in non-metropolitan regions could reduce need for transfer. Prospective data is required to examine if the same predictors are observed in surgical patients who survive.

Triage admission protocol with a centralized quarantine unit for patients after acute care surgery during the COVID-19 pandemic: A tertiary center experience in Taiwan.

During the COVID-19 surge in Taiwan, the Far East Memorial Hospital established a system including a centralized quarantine unit and triage admission protocol to facilitate acute care surgical inpatient services, prevent nosocomial COVID-19 infection and maintain the efficiency and quality of health care service during the pandemics. This retrospective cohort study included patients undergoing acute care surgery. The triage admission protocol was based on rapid antigen tests, Liat® PCR and RT-PCT tests. Type of surgical procedure, patient characteristics, and efficacy indices of the centralized quarantine unit and emergency department (ED) were collected and analyzed before (Phase I: May 11 to July 2, 2021) and after (Phase II: July 3 to July 31, 2021) the system started. A total of 287 patients (105 in Phase I and 182 in Phase II) were enrolled. Nosocomial COVID-19 infection occur in 27 patients in phase I but zero in phase II. More patients received traumatological, orthopedic, and neurologic surgeries in phase II than in phase I. The patients' surgical risk classification, median total hospital stay, intensive care unit (ICU) stay, intraoperative blood loss, operation time, and the number of patients requiring postoperative ICU care were similar in both groups. The duration of ED stay and waiting time for acute care surgery were longer in Phase II (397 vs. 532 minutes, p < 0.0001). The duration of ED stay was positively correlated with the number of surgical patients visiting the ED (median = 66 patients, Spearman's ρ = 0.207) and the occupancy ratio in the centralized quarantine unit on that day (median = 90.63%, Spearman's ρ = 0.191). The triage admission protocol provided resilient quarantine needs and sustainable acute care surgical services during the COVID-19 pandemic. The efficiency was related to the number of medical staff dedicated to the centralized quarantine unit and number of surgical patients visited in ED.

Necrotizing Soft Tissue Infection of the Forearms in a Patient Using Intravenous Heroin: Case Report of Advanced Wound Management Improving Dressing Tolerance and Expediting Skin Graft

BACKGROUND: Necrotizing soft tissue infection (NSTI) is rare and characterized by rapid onset and spread of inflammation and necrosis. The infection starts within the fascia but can rapidly progress to include musculature, subcutaneous fat, and overlying skin. Its presentation is considered a surgical emergency. Persons who use intravenous or subcutaneous opioids are at higher risk of NSTIs. PURPOSE: The purpose of this case report is to describe the positive clinical outcome after consulting with wound specialists and using a dressing regimen to expedite more rapid wound healing, shortened time to skin graft, and improved pain tolerance in a patient with a history of intravenous and subcutaneous heroin use. CASE REPORT: The patient presented with an NSTI that required extensive debridement of the bilateral upper extremities. The acute surgical wound service was consulted. A dressing regimen consisting of hypochlorous acid–preserved wound cleansing, followed by carboxymethylcellulose fiber with 1.2% ionic silver covered by hydrocellular foam to promote a moist healing environment, was used to facilitate granulation. RESULTS: Healthy granulation tissue was noted 6 days after debridement. The improved rate of granulation and the patient’s tolerance to dressing changes secondary to decreased pain from these dressings significantly expedited the time to graft and wound healing. The patient underwent split-thickness skin grafting 10 days after debridement. There was 100% uptake of the grafts on postgraft day 8. CONCLUSION: The favorable clinical outcome suggests that early consultation with wound specialists and implementation of the dressing regimen were effective in this patient regarding improved pain control and healing. However, because the patient left against medical advice on hospital day 20, the clinical course could not be followed beyond the first few postoperative weeks.

P-EGS28 Management of obstructive jaundice secondary to gall stones in an ambulatory setting

Abstract Background Our data from Leeds shows a 30% increase in patient attendance to the Surgical Assesment Unit (SAU) across a 5 year period, putting unprecedented demands on the acute surgical service. A new Ambulatory Surgical Centre (ASC) was established for the advancement of ambulatory care pathways that would ensure that acute patients are seen promptly and kept safe with monitoring in an appropriate setting without needing admission to the hospital bed base. Gallstone related disease accounts for a third of patient attendance to the emergency surgical services. We present our experience with an ambulatory pathway to manage patients with obstructive jaundice caused by gall stones, and propose a protocol driven pathway. Methods The ASC operates an acute, consultant led clinic, with access to urgent blood tests and dedicated USS, CT and MRI imaging capacity, and offers a direct referral service from Primary Care Networks (PCNs) through the Primary Care Access Line (PCAL). Patients referred with clinical jaundice or RUQ/Epigastric pain are investigated for derangement in their liver function, and assessed for the presence and severity of Acute Cholangitis (AC), according to the 2018 Tokyo Guidelines. Patients without evidence of cholangitis, or with AC Grade I are planned for management in the ambulatory setting, including investigations, monitoring and endoscopic/surgical intervention. Outcome data was collected retrospectively from PCAL data source, spanning from Oct 2020 till July 2021. Results A total of 98 patients were referred to the acute surgical service during this period. Out of these, 47% had Grade II (n = 35) or Grade III (n = 17) AC. 48% were suitable for ambulatory management, with no evidence of AC(n = 5) or Grade I AC(n = 43). 20% patients were found to have a cause other than gall stone disease. 55% have undergone intervention (33 Laparoscopic cholecystectomies, 22 ERCP) while 12 are on the waiting list for surgery. Conclusions Our protocol offers a safe, comprehensive and timely pathway for the management of patients with gall stone related obstructed jaundice in an ambulatory setting. This has helped reduce the demand on hospital beds for surgical patients.

SP4.1.4 Stay at home, protect the NHS, Save lives? The impact of the COVID-19 pandemic on acute surgical services

AimsSeveral centres described a ‘lockdown effect’: a reduction in emergency surgical admissions during national lockdown (23/03/20-01/06/20). The extent and reproducibility of this is unclear. We evaluated the impact of the COVID-19 pandemic on emergency general surgical activity in a district general hospital.MethodsWe conducted a retrospective analysis of patients admitted under general surgery and urology between 01/01/2017-31/12/2020 using coding data. Unpaired t-tests were used to compare the total monthly admissions, admissions by diagnosis and monthly operations performed between the ‘first wave’ (April-May 2020) and ‘average’ (all months 2017-2019), and between the ‘second wave’ (November-December 2020) and average.ResultsOverall emergency admissions in 2020 were reduced compared to the mean 2017-2019 (4498 vs 5037). Monthly admissions were significantly reduced in the first wave compared to 2017-2019 (mean monthly admissions=284.5 vs 419.8; p < 0.001) with the greatest reduction in patients with non-specific abdominal pain (mean=58 vs 109; p = <0.001). A significant reduction in monthly admissions with pancreatitis (mean=8.0 vs 14.6; p = 0.010) and diverticulitis (mean=10.5 vs 18.8; p = 0.028) were also observed. This effect was less apparent during the second wave (mean total admissions=384.5 vs 419.8; p = 0.249). Monthly emergency operations were reduced in both the first wave compared to average (68 vs 101.9; p = 0.007) and the second wave (74.5 vs 101.9; p = 0.025).ConclusionsWe found strong evidence of a ‘lockdown effect’ in our centre during the first wave. The cause is unclear and likely to be multifactorial. Further research is needed to evaluate whether surgical patients came to harm as a result.

EP.FRI.472Building the ‘LIEGS’ way – Establishing an ambulatory Rapid Access Theatre Service for those patients with acute surgical pathology requiring operative management

AimLTHT is the largest acute surgical unit in the UK and has seen an annual 11% increase in attendances with often 90 patients assessed daily. 40% patients present with acute biliary pathology but despite this there has been no dedicated operating list for this cohort of patients. Rapid Access Theatre (RAT) lists were created to manage these patients. We report our early results.MethodIn October 2020 the trust appointed four EGS Consultants forming a dedicated acute general surgical service. Emphasis was placed on creating ambulatory pathways and those patients safe to be managed at home but requiring surgical intervention are placed on a day case RAT list. COVID-19 has restricted the broad use of this service for all emergency admissions but biliary pathology continues to be amenable to these pathways. Data was collected retrospectively using in-house coding and electronic patient database systems. Results34 day case laparoscopic cholecystectomies were performed in the first 10 weeks. Mean age was 44(17-67) with a male:female ratio of 1:1. Mean wait time from clinical review to theatre was 11(3-23) days. 1 patient required overnight admission but there were no readmissions and no reported complications at 30 days. ConclusionDespite isolation restrictions resulting from COVID-19, the service has allowed patients to be assessed and treated in a timely, safe fashion. The new service has resulted in significant reductions in bed stays and improved patient experiences. Financial savings have been clearly delineated and as such expansion of the model is underway.

EP.FRI.821 Operative Treatment of Abscesses – Optimising A Timely Route to Theatre

Abstract Aim 1st audit cycle to assess whether patients presenting to the acute surgical service had their abscesses incised and drained in a prompt and timely manner. To develop a pathway for improving efficiency Methods All general surgical patients admitted to the surgical admissions unit between 1st September and 31st October 2020 by reviewing clinical and operative notes. Only those patients that had abscesses drained under general anaesthesia. Other specialties abscesses were excluded. Guidelines from the American Society of Colon and Rectal surgeons for draining abscesses acutely were used. Data was collected on various parameters. Results A total of 62 patients had abscesses drained. The mean age of patients was 32 years. The average waiting time between decision to operate and surgery was 14 hours and 54 minutes. 19% of the patients were sent home after decision was made to operate and brought back in the morning. Conclusion This 1st audit cycle concludes long waiting times and unnecessary overnight stay. A re-audit will be carried out using the same parameters in March 2021. Implementing a dedicated general surgical abscess pathway for patients without significant co-morbidities will improve efficiency and patient satisfaction.

EP.WE.1Hybrid Surgical Hot Clinic (HSHC): evaluation of Surgical Hot Clinic services during COVID-19 lockdown

AimsSurgical Hot Clinic (SHC) is an acute emergency service for management provided on an outpatient basis in the United Kingdom. Following the start of global Novel Coronavirus (COVID-19) pandemic and as per the statement released by the Association of Surgeons of Great Britain and Ireland (ASGBI), we modified SHC service to mainly provide telephonic follow-up with an occasional face-to-face service.MethodsAfter developing a local pathway for SHC services during COVID-19 lockdown, a quality improvement audit was conducted from 30th March till 26th May 2020. Through this pathway, telephonic consultation carried out in most patients while for selective face-to-face consultation designated Medical Ambulatory area used. The analysis then performed using SPSS version 20 to assess the serviceability of modified hybrid SHC.ResultsAmong 149 patients, 54(36.2%) were male, and 95(63.8%) were female, referred during Coronavirus lockdown. Out of these 149, 87(58.3%) referred from Accident & Emergency (A&E), 2(1.3%) from GP, 9(6.04%) after scan through radiology department while 51(34.2%) after discharge from hospital. Out of those who have telephonic consultation (n = 98), 12 patients were called in for review with either blood tests or further clinical examination. In total, only 10 out of 149 patients required admission to the hospital, either for intervention or symptomatic treatment.ConclusionHybrid surgical hot clinic (HSHC) with both telephonic & face-to-face consultation, as per requirement, is flexible, effective and safe patient-focused acute surgical service during COVID-19 like a crisis.