Audit Cycle Research Articles

Reducing Surgical Site Infections in Neurosurgery During the Intra-operative Phase: An Audit of National Institute for Health and Care Excellence (NICE) Guideline Adherence at a Major Trauma Centre.

Surgical site infections (SSIs) pose significant risks to patient safety and healthcare systems globally despite preventive measures. This study audits compliance with the National Institute for Health and Care Excellence (NICE) guidelines for SSI prevention during the intra-operative phase in the Neurosurgery Department at Salford Royal National Health Service (NHS) Foundation Trust. Conducted in two audit cycles from October 2022 to October 2023, the study assessed adherence to 19 key parameters aimed at minimising SSIs. Significant improvements were observed in various areas, including antibiotic prophylaxis information (from 44% to 90%) and bodywash compliance (from 14% to 80%). Compliance with skin preparation protocols also showed marked progress, with antiseptic application time improving from 12% to 80%. However, areas such as double gloving (increased from 36% to 44%) and the use of antimicrobial sutures (from 2% to 30%) indicate opportunities for further enhancement. The findings underscore the effectiveness of targeted interventions and the importance of continuous education and evaluation of surgical practices to reduce SSIs, ultimately improving patient outcomes and alleviating financial burdens on the NHS. Future audits are recommended to ensure sustained compliance and quality of care in Neurosurgery.

EGS SO09 - Documentation Of Mortality While Consenting For Major Emergency Operation In General Surgery : Are We Informing Patients Or Just Impressing NELA? A Three-Cycle Clinical Audit

Abstract Background Approximately 30,000 to 50,000 emergency laparotomies are performed annually in the United Kingdom (UK), with an in-hospital mortality rate of 9.2%. The UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report from 2011 recommends that the risk of mortality should be explicitly discussed with patients and clearly documented on consent forms and in medical records. The purpose of our audit was to assess the frequency of documenting the risk of mortality in consent forms and to evaluate the reporting of corresponding discussions in the medical records of patients undergoing major emergency general surgical operations. Method Patients were identified from our National Emergency Laparotomy Audit (NELA) database, and data was collected retrospectively from our online medical records. We included procedures from NELA performed on patients aged 16 and older who had the capacity to give consent. The first audit cycle took place from April to June 2021, the second from March to May 2022, and the third from March to May 2023. The results of the first cycle revealed gaps in documentation, leading to the implementation of periodic reminders for surgeons during meetings and the use of posters to reinforce best practices. Results The 1st cycle included 40 cases, with 93% documented mortality in NELA, 40% in consent forms, and 35% documented discussion about mortality in medical notes. The 2nd cycle reviewed 38 cases, showing 92% documented mortality in NELA, 71% in the consent forms, and 42% of documented discussion about mortality in the medical notes. The 3rd cycle assessed 32 cases, with 90% documented mortality in NELA, 92% in consent forms, and 51% in the medical notes. The improvement in documentation of the risk of death in the consent forms was statistically significant across all three cycles (p < 0.0001). Conclusion The three audit cycles demonstrated that implementing periodic reminders and posters for surgeons significantly improved the documentation of mortality risk. Documentation rates in consent forms increased from 40% in the first cycle to 92% by the third cycle, and in medical notes from 35% to 51%. These interventions effectively enhanced compliance with best practices. However, continuous effort is essential to maintain this improved practice. Regular monitoring, ongoing education, and reinforcement strategies should be employed to ensure that the documentation standards remain high and continue to improve patient care and safety.

HPB SO25 - The impact of chest physiotherapy on post-operative recovery from open liver surgery: A quality improvement project

Abstract Background The incidence of postoperative pulmonary complications (PPCs) after open liver surgery is high. Risk factors include age, body mass index, ex- or current smoker, and chronic lung disease. Early postoperative chest physiotherapy (CP), an essential part of any enhanced recovery protocol (ERP), can reduce PPCs, length of stay and healthcare costs. This study evaluated the uptake of CP after open liver surgery and resultant outcomes, following a quality improvement (QI) intervention. Method The project design involved two audit cycles: cycle 1 (C1) and cycle 2 (C2), each of five months duration, of consecutive patients undergoing open liver surgery, before and after a QI intervention (intensive preoperative patient education, poster campaign, increased engagement with physiotherapists regarding the importance of timely CP. Patients undergoing laparoscopic resections were excluded. Outcome measures included whether patients received postoperative CP at all, if so on which post-operative day (POD), for what duration, patient location, incidence of PPCs, and the length of postoperative stay. Statistical analysis was performed using (r 4-4.1) software, using the Chi-squared or Fisher’s Exact test. Results Despite more smokers/ex-smokers in C1(24%) versus C2(8%,p=0.04), only 18/50(36%) C1 patients received CP on POD1, versus 20/36(57%) in C2(p=0.07). Sixteen(32%) C1 patients received no postoperative CP, versus 7(19%) in C2(p=0.19). There were non-significant decreases in PPCs in C2(8%), versus C1(20%)(p=0.13). Three of four patients developing pneumonia in C1, and both those in C2, had no POD1 CP. Wards with higher physiotherapist:patient ratios had more POD1 CP: in C1 12/19(63%)[6/31(20%), p=0.001], and C2 14/15(93%)[6/20(30%) p=0.0001]. Median hospital stay was unchanged (4 days). Conclusion This QI project shows that even with an established enhanced recovery programme, the provision of postoperative chest physiotherapy is not universal. However, it can be improved with an education programme for both healthcare workers and patients.

BN SO11 - Optimising Day Case Laparoscopic Cholecystectomy: A GIRFT-Based Audit and Efficiency Analysis

Abstract Background Laparoscopic cholecystectomy (LC) is the gold standard for managing symptomatic gallstone disease and is commonly performed as a day surgery procedure due to its safety and efficiency. Despite its established benefits, recent analyses at our local hospital revealed a decline in the day case rate for elective LC, falling below the national median as highlighted by the Get It Right First Time (GIRFT) data. Method We analysed patient data for elective LC performed between 1st October 2023 and 29th February 2024. The data included patient demographics, length of stay, and reasons for unplanned admissions. Procedures from the hot and emergency lists were excluded from the analysis. To enhance the day case rate, a business case was developed to extend recovery staffing levels and coverage hours in the DSU from 6pm to 9pm. Additionally, we requested the coding team to distinguish elective cases from hot list cases for more accurate future analyses. The impact of these changes will be evaluated in a subsequent audit cycle. Results During the observed period, 86 elective LC cases were performed, with a day case rate of 64% (55/86), exceeding the national median of 60%. The discrepancy with the GIRFT analysis was due to the inclusion of hot list cases in their data. The primary reasons for unplanned admissions included monitoring observations (46%), late afternoon extubations (29%), and intra-operative concerns (18%). The median length of stay for unsuccessful day cases was 1 day. Cost analysis estimated the unplanned admission costs at over £12,000 for LC alone during the observed period, based on the NHS National Tariff 2024/25. Conclusion This audit demonstrated that our day case rate for elective LC surpasses the national median. By identifying key factors leading to unplanned admissions, we implemented targeted interventions, such as extending recovery area hours. These measures aim to further improve the day case rate, enhance patient care, and achieve significant cost savings.

OGC SO12 - Extended Venous Thromboembolism Prophylaxis in Postoperative Oesophagogastric Cancer Patients: A Completed Audit

Abstract Background Venous thromboembolism (VTE) is a life-threatening complication for cancer patients undergoing oesophagogastric surgery. The NICE recommends extending pharmacological VTE prophylaxis to 28 days for patients undergoing major abdominal cancer surgery. While the effectiveness of in-hospital VTE prophylaxis is well-documented, the optimal duration for postoperative VTE prophylaxis remains a subject of debate. This study aims to evaluate the prescribing compliance, effectiveness, and safety of extending VTE prophylaxis to 28 days following hospital discharge (HD), a policy adopted trust-wide since 2014. Method This is an 11-year retrospective study from July 2012-2022, followed by a complete audit cycle conducted between January 2023-2024. The study included all patients who underwent cardio-esophagectomy or gastrectomy for oesophagogastric cancers. Exclusion criteria comprised patients who died during the index admission, those who underwent benign oesophagogastric surgery or local excision of gastrointestinal stromal tumours (GIST), and patients with peripherally inserted central catheter (PICC) line-associated VTE. The primary outcome measured was the prescribing compliance of 28-day VTE prophylaxis post-hospital discharge. Secondary endpoints included the incidence of VTE and bleeding complications necessitating hospital readmission within 28 days of discharge. Results Our study included 582 patients, showing that post-2014, 423 out of 490 patients (86.3%) were discharged with 28-day VTE prophylaxis, compared to 13 out of 92 patients (14.1%) pre-2014, indicating a significant improvement (p<0.05). Only one patient (0.17%) developed VTE more than 28 days post-discharge, and no readmissions due to bleeding complications. In the subsequent audit, 63 out of 68 patients (92.6%) received the prophylaxis, further increasing prescribing compliance. Comparing the two periods, compliance improved from 86.3% to 92.6%, though not statistically significant (p=0.145). Overall, VTE incidence was minimised from 0.17% to 0%, with no readmissions due to bleeding complications. Conclusion Routine extended VTE prophylaxis for 28 days post-hospital discharge should be recommended for cancer patients undergoing oesophagogastric surgery. This practice has significantly improved prescribing compliance rates, reduced post-hospital discharge VTE incidence, and demonstrated safety, with no hospital readmissions due to bleeding complications.

학교자체평가와 학교자율 종합감사의 연계 방안 탐색

School evaluations are implemented to enhance the accountability of school’s teaching and learning while school audits are implemented to enhance the legitimacy of school administration and educational activities. So discussions are being raised about the possibility of linking 'school self-evaluation' and 'comprehensive school self-assessment'. This study aimed to inquire the possibility of linking school self-assessment and school autonomous comprehensive audit and to identify perceptions of its effectiveness. Regarding the possibility of linking both sides, considering conducting the school autonomous comprehensive audit and school self-evaluation simultaneously and writing a single result report, or conducting a school autonomous comprehensive audit after writing the school self-evaluation result report were recommended. It can have the effect of reducing faculty and staff workload, improving efficiency, and eliminating backlog in the audit cycle.

From ‘strong recommendation’ to practice: A pre-test post-test study examining adherence to stroke guidelines for fever, hyperglycaemia, and swallowing (FeSS) management post-stroke

BackgroundThe Quality in Acute Stroke Care (QASC) Trial demonstrated that assistance to implement protocols to manage Fever, hyperglycaemia (Sugar) and Swallowing (FeSS) post-stroke reduced death and disability. In 2017, a ‘Strong Recommendation’ for use of FeSS Protocols was included in the Australian Clinical Guidelines for Stroke Management. We aimed to: i) compare adherence to FeSS Protocols pre- and post-guideline inclusion; ii) determine if adherence varied with prior participation in a treatment arm of a FeSS Intervention study, or receiving treatment in a stroke unit; and compare findings with our previous studies. MethodsPre-test post-test study using Australian acute stroke service audit data comparing 2015/2017 (pre-guideline) versus 2019/2021 (post-guideline) adherence. Primary outcome was adherence to all six FeSS indicators (composite), with mixed-effects logistic regression adjusting for age, sex, stroke type and severity (ability to walk on admission), stroke unit care, hospital prior participation in a FeSS Intervention study, and correlation of outcomes within hospital. Additional analysis examined interaction effects. ResultsOverall, 112 hospitals contributed data to ≥1 one Audit cycle for both periods (pre=7011, post=7195 cases); 42 hospitals had participated in any treatment arm of a FeSS Intervention study. Adherence to FeSS Protocols post-guideline increased (pre: composite measure 35% vs post: composite measure 40 %, aOR:1.2 95 %CI: 1.2, 1.3). Prior participation in a FeSS Intervention study (aOR:1.6, 95 %CI: 1.2, 2.0) and stroke unit care (aOR 2.3, 95 %CI: 2.0, 2.5) were independently associated with greater adherence to FeSS Protocols. There was no change in adherence over time based on prior participation in a FeSS Intervention study (p = 0.93 interaction), or stroke unit care (p = 0.07 interaction). ConclusionsThere is evidence of improved adherence to FeSS Protocols following a ‘strong recommendation’ for their use in the Australian stroke guidelines. Change in adherence was similar independent of hospital prior participation in a FeSS Intervention study, or stroke unit care. However, maintenance of higher pre-guideline adherence for hospitals prior participation in a FeSS Intervention study suggests that research participation can facilitate greater guideline adherence; and confirms superior care received in stroke units. Nevertheless, less than half of Australian patients are being cared for according to the FeSS Protocols, providing impetus for additional strategies to increase uptake.

Assessing Hemodialysis Catheter Insertion Practices Against CDC Guidelines: A Closed-Loop Audit at a Tertiary Hospital in Egypt.

Background Following evidence-based guidelines during hemodialysis catheter insertion procedures is key to lowering catheter-related bloodstream infections (CRBSI) and other complications. Our aim was to examine all aspects relevant to the insertion of hemodialysis catheters in the dialysis unit at Alexandria Main University Hospital,Alexandria, Egypt, in order to identify practices that could be contributing to high complication rates. Methods We used the CDC's Guidelines for the Prevention of Intravascular Catheter-Related Infections to define the criteria relevant to hemodialysis catheter insertion procedures. These criteria were made into a form to be used as the primary auditing tool. The form was then used to record catheterization procedures in the dialysis unit from March 2024 to July 2024. Eighty patients scheduled for hemodialysis catheter insertion were randomlyselected, 40 in the initial cycle of the audit, and 40 in the re-audit cycle. Percentage adherence to each criterion was then calculated for each audit cycle and compared. Results Overall, adherence to the criteria assessed showed significant improvements, with mean compliance increasing from 69% in the initial cycle to 90% in the second cycle. In addition, the rate of mechanical complications recorded decreased. Conclusion Our study emphasized the effectiveness of using closed-loop clinical audits to ensure continuous improvement of care delivered during hemodialysis catheter insertion procedures.

Integration of Agile Technologies in Internal Audit

The study is devoted to the processes of integration of Agile technologies in internal audits. It was determined that Agile is a method and a way of thinking simultaneously, which ensures timeliness of receiving information, quick response to risks, and acceleration of audit cycles, thanks to which the effect of value creation is achieved for both top management and stakeholders. The analysis of statistical studies of the implementation of Agile technologies allowed the authors to conclude that the Agile approach is increasingly used in enterprises to achieve planned results, and to single out key changes in the concepts of internal audit, which became possible thanks to the implementation of the Agile approach. It is noted that there is no single path for transitioning to the use of Agile methodology for all organisations. In addition, such a transition can cause difficulties associated with rethinking the audit process. That is why the authors attempted to unify the work cycles of the internal Agile audit.

Evaluation and Improvement of the Quality of Surgical Operative Notes in the Department of General Surgery at Dongola Teaching Hospital, Sudan.

Background Surgical operative notes are essential for patient care and legal documentation. However, inconsistencies in the quality of these notes at Dongola Teaching Hospital, Sudan, highlighted the need for improvement. In line with guidelines from the Royal College of Surgeons of England (RCSEng), this study aimed to enhance the documentation practices in the hospital by implementing a standardized format. Methods A retrospective audit was conducted over three months at the General Surgery Department of Dongola Training Hospital. In the first audit cycle, 81 surgical notes were assessed, revealing significant deficiencies in adherence to RCSEng standards. An intervention was introduced, including a standardized template, training for surgeons, and widespread dissemination of the new format. A second audit cycle followed to assess improvements. Results In the first audit cycle, adherence to documentation standards was 50.3%, with missing or incomplete information in key areas. After the intervention, adherence improved to 71.9%. Notable improvements included documentation of extra procedures (18% to 100%), prosthesis details (0% to 100%), and antibiotic prophylaxis (71% to 97%). However, a slight decline was observed in postoperative care instructions, dropping from 100% to 90%. Conclusion The introduction of a standardized template and training significantly improved the quality of surgical documentation. Continuous efforts are necessary to maintain these improvements, particularly in areas where adherence remains suboptimal, such as postoperative care instructions.

Standards-based audit to improve quality of maternal and newborn care-A stepped-wedge cluster randomised trial in Malawi.

Audit is a quality improvement approach used in maternal and newborn health. Our objective was to introduce the practice of standards-based audit at healthcare facility level, and to examine if this would improve quality of care assessed by compliance with standards developed and agreed with healthcare providers. Our focus was on emergency obstetric and newborn care (EmONC). A multidimensional incomplete stepped-wedge cluster randomised trial with 8 steps was conducted in 44 healthcare facilities in Malawi. A total of 25 standards of care were developed. At each healthcare facility one (health centres) or two (hospitals) standards were audited per cycle with two consecutive audit cycles conducted. Each cycle consisted of five steps: (i) select standard to be audited, (ii) measure compliance with standard (measurement 1), (iii) review findings and identify what changes are required to increase compliance (iv) implement changes, (v) re-measure compliance (measurement 2). Each compliance measurement assessed 25 women. Multilevel mixed effects logistic regression models were used to analyse data for all standards. The crude overall compliance rate rose from 45% in the control phase (measurement 1) to 63% in the intervention phase (measurement 2) (from 51.6% to70.6% at Basic and from 34.5% to 50.8% at Comprehensive EmONC healthcare facilities. When adjusted for standard, facility type, month, and healthcare facility by month, the adjusted OR (95% CI) was 2.80 (1.65, 4.76). Actions taken to improve compliance with standards included improving staff performance of clinical duties and general conduct through re-orientation and staff meetings as well as improved supervision, and, ensuring basic equipment and consumables were available on site (thermometers, rapid diagnostic tests, partograph). The introduction of standards-based audit helped healthcare providers identify problems with service provision, which when addressed, resulted in a measurable and significant improvement in quality of care. ISRCTN registration number: 59931298.

Parkinson’s Disease (PD) Management in a Tertiary Irish Hospital

Abstract Background There is no Irish platform for operationalizing services for People with Parkinson’s and associated disorders (PwP). The UK-wide Parkinson’s clinical audit was developed in 2009, to address concerns about the quality of care provided to PwP. Our aim was to use the UK Parkinson’s Audit cycles to drive quality improvement in our service, providing the first Irish data on quality of care for PwP. Methods The audit’s service descriptor was completed in June 2022. A sample of PwP attending Movement-Disorder clinics completed patient reported experience measure questionnaires between May - July 2022. We retrospectively collected patient data using the audit tool, which was submitted electronically. This was directly compared to our service audit data from 2019. Results In 2019, we included 30 patients in our audit – average age 67yrs, 57% male, 100% Caucasian, average duration PD 7yrs. In 2022, we included 40 patients of similar demographics. The data collected showed our services had improved or remained stable across all domains from 2019 to 2022 including medication documentation, advanced care planning, multi-disciplinary team input, non-motor, activities of daily living and bone health assessments. The service user experience remained unchanged. In 2019, our service fell in the lowest quartile of standards amongst the cohort of services audited. We improved to the top half of services audited in 2022. This was achieved by mentoring from exemplar UK services, generating a proforma to standardize assessments in outpatients, providing information to clinicians regarding local services and engaging with patients in an annual ‘Have Your Say’ day. Conclusion Our data demonstrates that repeated national audit cycles, with the patient voice at the centre, are crucial in driving quality improvement across services for PwP. As the only Irish participant in the Parkinson’s UK Audit, it's clear a National Irish Audit would be the first step in optimizing care for PwP nationally.

DNAR: All or Nothing: Impact of Education Sessions Re-Audit in a Model 3 Hospital

Abstract Background Do Not Attempt Resuscitation (DNAR) orders are implemented to obviate inappropriate Cardio-Pulmonary Resuscitation (CPR) in patients with low chances of survival post-CPR. However, ambiguity regarding ceilings of care for patients with a DNAR order can arise. This re-audit aimed to review DNAR and ceilings of care documentation according to national HSE guidelines after education sessions, comparing results with the pre-education audit in a Model 3 Hospital. Methods A point-prevalence chart review of thirty-one adult medical inpatients with a DNAR order was conducted after two education sessions were held for Non-Consultant Hospital Doctors (NCHDs) and Consultants. Results Of all thirty-one charts, 35% documented DNAR status in the medical notes, with 32% documenting the reasoning for DNAR status, both of which were unchanged from the first audit cycle. There was an increase in documentation of patient discussion (61% versus 45%) and reasons if this was excluded (66% versus 41%). There was no change in documentation of patient relatives’ discussion (48%) but there was an increase in the reasons if this was excluded (25% versus 18%). There was an overall increase in ceilings of care documentation for ICU admission (three-fold increase), intubation (two-fold increase), inotropic support, and comfort measures, but rates of documentation were still less than 15%. This elucidates the efficacy of education sessions in improving DNAR documentation adherence. Recent studies have highlighted uncertainty among NCHDs regarding treatment escalation in acutely unwell patients in the absence of adequately filled DNAR orders and clear documentation of ceilings of care. Therefore, we posit the introduction of a Ceilings of Care document, akin to the United Kingdom’s Medical Advance Plan. Conclusion Accurate recording of DNAR status and ceilings of care is essential for quality care and treatment escalation. While simple education strategies have proven beneficial in enhancing compliance, additional efforts are needed to enhance ceilings of care documentation.

Development and Implementation of a Venous Thromboembolism Prophylaxis Protocol in the Rehabilitation Setting – A Completed Audit Cycle

Abstract Background 63% of all Venous Thromboembolic disease (VTE) is hospital-acquired, and 70% of hospital-acquired VTE is potentially preventable with appropriate prophylaxis. NICE recommends a VTE risk assessment for all patients admitted to acute hospitals within 24 hours. Validated risk assessment models for acute hospitals enhance provision of thromboprophylaxis, but no such protocols exist for the rehabilitation setting. The aims of this audit were to determine if VTE risk assessments are occurring on admission and during acute illness in rehabilitation wards, to assess the proportion of rehabilitation inpatients receiving VTE prophylaxis, and to develop and pilot a VTE Prophylaxis Protocol. Methods An initial audit was carried out on three rehabilitation wards in May/June 2023. A VTE Prophylaxis Protocol was developed based on the HSE VTE Prevention Program template, incorporated into the admission booklet on 3 pilot wards in February 2024, and practice re-audited in April 2024. Results Pre-intervention, 41 patient records were assessed. 0 patients (0%) had a documented VTE risk assessment on admission, 23(56%) had therapeutic anticoagulation continued, and 3(7%) commenced appropriate VTE prophylaxis on admission. 8 eligible at-risk patients did not receive prophylaxis. Post intervention, all patients (n=25) on the three pilot wards were re-audited. 10 patients (40%) had a documented VTE Risk assessment within 24 hours of admission, 9(36%) had therapeutic anticoagulation continued, and 5(20%) received appropriate VTE prophylaxis on admission (2 without a documented risk assessment). 3 at-risk patients did not receive prophylaxis (1 with a completed risk assessment), and 1 risk-assessed patient inappropriately received prophylaxis. Conclusion Implementation of a VTE Prophylaxis Protocol improved VTE risk assessment in rehabilitation. This small sample however did not demonstrate an association between prophylaxis prescription and use of the protocol. Further education and feedback is required to increase use of the protocol as part of this ongoing quality improvement project.

Retrospective Review of Falls in Medical Inpatients Following Introduction of a Falls Proforma at Wexford General Hospital

Abstract Background Inpatient falls are the largest category of preventable inpatient adverse events in hospitals coming at both great financial and safety cost to a healthcare system. Approximately 30% of inpatient falls result in injury, 4-6% resulting in serious injury with older patients have the highest risk of falling and injury. The aim of this retrospective audit cycle was to improve standards of falls assessments performed by junior doctors. Methods We initially conducted a retrospective review of 7 medical inpatient falls in July 2023. Standards were compared against NICE Guidelines on Assessment and Prevention of Falls in older people 2013 and NICE guidelines on Assessment and early management of head injury 2023. 15 key elements were analysed: doctor identifier, date and time, history of fall, confusion, pain, loss of consciousness, amnesia, seizure, vomiting, medication review, hip fracture, wrist fracture, skull fracture, Glasgow Coma Scale and neurological deficit. One point was given for each of the 15 key elements noted in the falls review. Following introduction of a falls proforma, we re-audited 18 falls in February 2024 to analyse differences in scores. Results Prior to proforma introduction, 7 falls reviewed had an average score of 3 points. 4 falls were reviewed by SHOs, 1 each by an SpR and Intern and 1 NCHD review was unidentifiable. Mean age was 72. Following proforma introduction, 18 falls in 13 patients were analysed. 2 patients did not have a falls review, 15 were reviewed by SHOs, 1 by an Intern. Average age was 81. Proforma was used in 7 cases with an average score of 12.7, and no proforma was used in 11 cases with an average score of 5. Conclusion These findings demonstrate improved quality of falls reviews using proformas in line with guidelines compared to those without. More education is needed to incorporate proformas into standard practice.

WP4.6 - Reducing Unnecessary Transfusion of Blood Products – A Quality Improvement Project in a General Surgical Department in a District General Hospital

Abstract Aims To audit adherence of transfusion of blood products against NICE guideline thresholds. To reduce unnecessary blood transfusions following departmental teaching sessions and installation of posters on surgical wards. Methods We retrospectively audited all patients receiving packed red cells transfusions consecutively across two consecutive four-month periods in a general surgery department. Departmental teaching sessions were held after the first audit cycle, supplemented by installation of posters including NICE guideline thresholds on surgical wards. The medical notes for each patient were assessed for pre-transfusion haemoglobin, indication for transfusion, and whether each transfusion was prescribed according to NICE guidelines. Results A total of 112 units of packed red blood cells in 42 patients and 133 units in 43 patients were transfused, respectively, before and after intervention. 45 units (40.2%) were prescribed according to NICE guidelines on first audit, improving to 67 units (50.4%) following intervention. 23 units of blood (20.5% of total) were transfused back-to-back inappropriately on first audit, reducing to 6 units (4.51% of total) after intervention. There were 2 self-limiting transfusion-related reactions (1.79%) on first audit, both in patients transfused above guidance thresholds, and no reactions following intervention. At a raw cost of approximately £135 per unit of donated blood, savings of £1830 were made over a four-month period (£5493pa), not including nursing and administration costs Conclusions Through simple local interventions and stricter adherence to transfusion thresholds, we reduced inappropriate above-threshold blood product transfusions in our hospital. This corresponded to a reduction in unnecessary blood-transfusion reactions and significant hospital savings.

ThP5.14 - Assessing Adherence and Cost Implications of NICE Guidelines for Intravenous compared to Oral paracetamol use after Resuming Oral Diet Following Liver and Pancreas Resections

Abstract Aim For post-operative pain management NICE recommends not to offer intravenous paracetamol unless the person cannot take oral medicine [NG180] 1.6.6. Despite this recommendation, many patients continue to receive intravenous paracetamol whilst on oral diet. This audit aims to assess the adherence and cost implications of NICE guidelines for switching from IV to oral paracetamol once oral diet resumes following liver and pancreas resections. Method Data for 176 patients undergoing major liver or pancreas resections at the Royal Free Hospital London (January 2022 to October 2023) was collected retrospectively. This included the number of IV and oral paracetamol doses, resumption of oral diet post-operatively, and the total number of IV paracetamol doses whilst oral diet resumed. Costings for IV and oral paracetamol were established, and the total cost was calculated per patient. After a departmental presentation, the audit cycle was completed. Result The analysis of the initial dataset disclosed that 69% of patients were administered IV paracetamol while on an oral diet, incurring a cost of £9412/100 patients, in contrast to £18.5 for oral paracetamol. Following the intervention, there was a noteworthy enhancement in adherence to guidelines, reducing the average days of IV paracetamol administration after resuming oral diet from 4.08 days pre-intervention to 2.06 days post-intervention. Conclusion This improved adherence showed almost 50% cost reduction compared to first audit. In addition to this we can also expect early patient mobilization, enhanced recovery, and prompt discharges. This audit provides valuable insight into optimizing postoperative pain management strategies and resource utilization.

EP359 - Introduction of a pathway to improve post operative nutrition for patients undergoing a Whipple procedure - a closed loop audit

Abstract Aim Adequate nutrition in the post operative phase is an essential part of recovery following pancreaticoduodenectomy. A pathway was introduced in the regional hepatobiliary unit to standardise post operative nutrition for this patient group. Methods Three audit cycles were completed by retrospective data collection following each intervention. The first cycle was completed between March and May 2023 (n=9). The nutrition pathway was then updated so patients were on the same oral pathway regardless of whether they received parenteral nutrition or not. The second cycle was completed from May-June 2023 (n=8) and a third cycle was completed from August-October 2023 (n=7) after an education session with surgical trainees by a registered dietitian. Results Day 1 of the pathway and prescribing of CREON and supplements were consistently done well. Improvements were seen in adherence to the pathway at day 2 (22%/75%/57%) and day 3 (11%/63%/43%) post op, median number of days to establishing soft diet (from 8 to 5), median day to stopping parenteral nutrition (from 9 to 6) and median length of stay reduced from 15 to 10 days. Conclusion Adhering to a post operative nutritional pathway for patients following pancreaticoduodenectomy establishes patients on oral nutrition earlier, allowing for earlier stopping of parenteral nutrition (and thus removal of central venous access) and facilitating earlier discharge from hospital. Future work will involve re-audit with a larger cohort and incorporating education on the pathway into the biannual induction to the unit for trainees.

FP8.10 - Sustainability in Hand Surgery

Abstract Aims Carpal tunnel release surgery (CTR) is a widely performed procedure in the NHS with significant contributions to waste and carbon emissions within surgery. 36,704 CTRs were preformed from 2022-2023 with an average carbon footprint of 12.0 kg CO2e. The aim of this quality improvement project is to reduce the carbon footprint of CTR through a lean and green model, and examine the rates of infection with this model compared to standard practice. Methods Retrospective data was collected for CTRs performed at the Royal Cornwall Hospital between 31/05/2022 and 01/02/2023 for the first audit cycle using standard set up and equipment. The primary outcome was rates of infection post-CTR. The lean and green model included reducing the number of instruments in the handset (36 items to 14 items), use of a smaller drape, and no gown for the procedure. The second cycle will be examining rates of infection following this intervention. Results Out of 100 patients in the first cycle, 1 patient was treated with antibiotics via a General Practitioner telephone consultation. These eco-changes were well received by staff members, with significant waste reduction this far (over 50 gowns and 25 aperture drapes). Data collection for the second cycle is currently underway. Conclusions CTR surgery is a commonly performed procedure with significant contributions to waste and carbon footprint within surgery. Through simple and low-cost changes to current practice we can promote sustainability in surgery and have a lasting positive impact on the environment.

WP7.4 - A closed loop audit assessing adherence to NELA frailty guidelines in over 75’s undergoing Emergency Laparotomy

Abstract Background and Aims The National Emergency Laparotomy Audit (NELA) 2023 recommend patients over 65 should have clinical frailty score (CFS) recorded, and, if frail or aged 80 or over, should have Care of the Elderly (COE) input. Due to the multi-morbid nature of frailty this population carry additional surgical and post-operative risk. This audit reviewed use of these recommendations at a large District General Hospital (DGH). Methods We performed a closed loop audit on all patients aged 75 and older who had an emergency laparotomy between September 2020 to December 2023. We collected data from their admissions, including CFS and if COE reviews had occurred. The data was analysed. Interventions included presentation at clinical governance, discussion with the COE consultant and a poster was developed for the surgical assessment unit. The data was again retrospectively collected to complete the audit cycle. Results A total of 94 patients were included. The initial audit found 0 patients had CFS recorded and 16% had COE review. The reaudit found significant improvement, with 92% of patients having CFS recorded and 46% having had COE review. Conclusion The second cycle audit has shown significant improvement at the DGH in recording CFS and organising COE reviews for patients over 75 having an emergency laparotomy. However, there remains scope for improvement. Suggested improvements include: a referral pathway to prompt COE reviews and the creation of the “general surgery geriatrician” similar to the ortho-geriatrician role. Organising COE reviews could improve patient outcomes and provide more holistic care.