Audit Cycle Research Articles

644 Improving VTE Prophylaxis in Spinal Patients – a Closed Loop Audit

Abstract Aim Venous thromboembolism (VTE) prophylaxis is one of the key components of safe patient care and can be particularly challenging when it concerns spinal admissions to the orthopaedic trauma ward. The first cycle of our closed loop audit aimed to assess the safety of VTE prescribing in spinal admissions at a district general hospital. The current cycle aims to evaluate guideline compliance following our interventions. Method Quality of VTE prophylaxis prescribing was measured against NICE (NG89) recommendations as well as local guidelines. Patients were identified based on prospectively maintained admission lists. The initial audit cycle was presented locally, and the following measures were introduced in order to improve prescribing: staff teaching sessions, nomination of a VTE guardian, inclusion of VTE plans in op-notes, publication of a dedicated spinal guideline and addition of a spinal section into the trust principal VTE guideline. The current audit cycle identified 22 spinal admissions. Results Out of the 22 patients, only one (4%) received inadequate VTE prophylaxis which is a significant improvement compared to the initial data (8 cases - 18%). Minor prescribing concerns were noted in three cases (14%) versus 15 cases (34%) in the first cycle. Overall, the re-audit proved that following departmental interventions the majority of patients received appropriate VTE prophylaxis with no prescribing or documentation errors (82% in the current cycle vs 48% initially). Conclusions We have demonstrated that significant improvement in VTE prophylaxis prescribing can be achieved by the means of educating staff and introducing simple and cost-effective measures.

252 Plastic Surgery Venous Thromboprophylaxis for Abdominal and Thigh Based Free Flap Breast Reconstruction Surgery

Abstract Aim Correct Venous Thromboprophylaxis (VTE) assessment and prescription is at basis of patient safety when considering patient hospital admission. Current local Guy's and St Thomas Hospital guidelines are in keeping with National Institute for Health and Care Excellence (NICE) guidelines recommending all patients to be assessed and prescribed VTE prophylaxis within 24 hours of admission. There are no specific local or national guidelines however that would recommend VTE prophylaxis specific to free flap breast reconstruction surgery. We assessed therefore adherence to VTE prophylaxis guidelines for patients undergoing abdominal and thigh based free flap breast reconstruction surgery. Patient outcomes were reviewed and VTE prophylaxis proforma was recommended. Method Patients who underwent abdominal or thigh based free flap breast reconstruction surgery between October 2017 and February 2019 were identified. Data was collected retrospectively and analysed via SPSS Statistics (IBM, USA). Results 51 patients were included in the first audit cycle; 50 patients in the re-audit. Overall improvement and 100% of patients received LMWH on admission. The timings of correct prescription versus actual administration of LMWH decreased however from 71% to 49%. Conclusion There is good adherence to assessment and administration of VTE prophylaxis across the patients. Unfortunately, the prescription of VTE prophylaxis itself is mostly incorrect. It is therefore with gratitude to the ward staff VTE is administered correctly. Further improvements in the communication therefore between theatre, ward and surgical staff and implementation of VTE prophylaxis proforma need to be considered.

899 A Closed Loop Audit of Imaging Rate in Suspected Complicated Acute Diverticulitis

Abstract Aim Diverticular disease is commonly encountered in western populations, with complicated acute diverticulitis potentially leading to significant morbidity and mortality. The National Institute for Health and Care Excellence (NICE) recommend imaging these patients within 24-hours of admission, which is essential to confirm diagnosis and guide further management. We aimed to audit the imaging rate in suspected complicated acute diverticulitis within our department and identify ways to improve this. Method Data were collected from all patients admitted from January to June 2021 with suspected complicated acute diverticulitis as defined by NICE. Patients with normal inflammatory markers were excluded. Electronic records were reviewed for evidence of imaging performed within 24-hours of hospital admission and the imaging rate was compared with the previous audit cycle. Results 96 patients were admitted with suspected complicated acute diverticulitis. 83 patients had raised inflammatory markers. 76 (91.6%) of these had contrast computer tomography (CT) scans performed within 24-hours of admission. Of the 7 (8.4%) patients who did not undergo imaging within 24-hours, 3 had recent imaging suggestive of diverticular disease or diverticulitis, 2 were treated with antibiotics, 1 patient refused, and 1 had CT within 48-hours due to delays waiting for dialysis. Conclusions We have shown continued good compliance with NICE guidelines, though the imaging rate has declined slightly compared with the previous audit cycle (94.3%). In order to maintain and improve these standards, we will offer educational sessions within our department to underline the importance of timely imaging in this patient group and continue to audit our performance.

1038 Improving Adherence to Antibiotic Guidelines for the Treatment of Acute Cholecystitis: A Completed Audit Cycle

Abstract Aim Acute cholecystitis (AC) accounts for up to one third of emergency surgical admissions. The initial management of AC includes fluid resuscitation and appropriate antibiotic therapy. The aim of this study is to audit compliance with local microbiology guidelines for the treatment of AC and to develop interventions that improve compliance rates. Method All patients admitted from September to December 2020 with radiologically confirmed AC were included in an initial prospective audit (n=39 patients). Antibiotic prescriptions, patient demographics, presence of fever (>38°C), inflammatory markers and liver function tests were recorded. The results were disseminated, educational material produced, and antibiotic “champions” appointed to improve adherence to antibiotic guidelines. A prospective re-audit was conducted from May to June 2021 to establish the effectiveness of the interventions (n=49 patients). Compliance rates before and after the interventions were compared using a Chi-squared test. Binomial logistic regression was carried out to establish whether any patient demographic or clinical parameters were independent predictors of prescribing behaviour. Results Compliance to antibiotic guidelines for AC significantly improved following the interventions (12.8% vs 57.1%; p<0.001). Age, gender, temperature, inflammatory markers, and liver function tests were comparable in both groups and were not found to be independent predictors of non-compliant antibiotic prescription. Conclusions Adherence to antibiotic guidelines for AC can be improved with educational interventions and the appointment of individuals responsible for ensuring correct prescribing behaviour. Interestingly, patient demographics, signs of sepsis or liver function did not influence prescribing behaviour, suggesting that divergence from antibiotic guidelines may be due to ingrained prescribing dogma.

1012 A Close Loop Audit of Acute Food Bolus Obstruction at a District General Hospital

Abstract Aim The British Society of Gastroenterology (BSG) recommends biopsies from two different regions in the oesophagus. A close loop audit was undertaken to assess performance at a district general hospital, against these guidelines and following newly agreed trust guidelines after the first audit cycle of a follow up OGD within 6 weeks of the presentation. Method Data was collected of patients admitted with a food bolus over the first cycle (March2019 to February 2021) and the second cycle (1/10/21 to 14/10/21). Exclusion criteria were age of less than 18 and sharp food bolus. Results 69 patients were identified. Average age was 60 years. There were 67% male patients and 33% female. 20% of patients underwent a follow up OGD in the first cycle and 45%underwent a follow up OGD within six weeks. 7% had two regions biopsy in the first cycle and21% in the second cycle. Average OGD follow up time was 92 days in the first cycle and 59days in the second cycle. Commonest findings on histology results were eosinophilic oesophagitis and Barrett's oesophagus (22% each), GORD (15%) and carcinoma (7%). Discussion Food bolus obstruction indicates the presence of pathology of the oesophagus and should be investigated as so, even despite spontaneous recovery from the acute event. Number of patients undergoing OGD within six weeks and a two regions biopsy improved through this audit by implementing the new trust guidelines.

842 An audit to assess adherence to the Tongue Reduction Integrated Care Pathway for Beckwith Wiedemann Syndrome

Abstract Aim Beckwith-Wiedemann Syndrome (BWS) is a congenital overgrowth syndrome that occurs in approximately 1 in 15,000 births. A cardinal is macroglossia which can lead to sleep apnoea, difficulties feeding, speech, drooling and malalignment of teeth/jaw. Some children require tongue reduction surgery and are managed with a specific protocol to ensure the correct analgesia, fluid regime and commencement of oral feeds are delivered post-operatively. The aim of the audit was to improve adherence and awareness of the protocol to improve the patient journey. Method Initial audit cycle between 22/01/21 – 03/02/21 in the form of anonymous staff survey. Following initial results staff underwent two separate teaching sessions and posters were applied in key wards and staff areas. Repeat audit was completed between 01/07/2021 – 01/08/2021. Results Initial audit results demonstrated 44% (11/25) of ward staff were unaware of the Tongue Reduction Integrated Care Pathway and 56% (14/25) did not know which condition this protocol and surgical procedure was related to. Following both sets of interventions there was an improvement to 77.8% (14/18) of staff being aware of the protocol and 88.9% (16/18) of staff members knew which syndrome was associated with this pathology. Additionally, in the re-audit we demonstrated that 100% of participants were aware of the analgesia protocol. Correct rationale for fluid regime was demonstrated in 56% vs 24% demonstrating there is still room for improvement in this domain. Conclusion We have demonstrated that through teaching and the implementation of a poster we have improved the awareness of the Tongue Reduction Protocol.

695 Improving Consent Forms for Laparoscopic Cholecystectomy; a Visual Consent Form Toolkit

Abstract Aim Laparoscopic cholecystectomy is a common elective operation with significant complication risks. GMC guidance on consent emphasises informed consent, and failure to warn patients of significant complications can lead to medico-legal implications. We aimed to assess the quality of risk documentation for laparoscopic cholecystectomies performed at our trust. In particular, we aimed to assess improvement since previous cycles after circulation of our boutique ‘Visual Consent Form Toolkit’, an easily accessible resource for risks associated with common procedures. Method Consent forms for 49 elective laparoscopic cholecystectomies performed at a busy district general hospital between September and November 2021 were retrospectively analysed. Risk documentation was audited against a standard of 15 common complications associated with laparoscopic cholecystectomy. Results There was significant improvement across the board. Risks previously documented at 100% remained at this level (infection & bleeding). Those previously well-documented showed further improvement (CBD injury, bile leak, damage to local structures, open conversion & VTE). Of those not previously well-documented (the rest), all except two (diarrhoea & pancreatitis) showed improvement. In particular anaesthetic risks, which was emphasised in our toolkit, saw the largest improvement. Conclusions Risk documentation on consent forms has overall considerably improved with the circulation of our ‘Visual Consent Form Toolkit’. More risks now fully or partially meet the expected standard. From those risks not meeting the expected standard despite numerous audit cycles, we understand that surgeons do not feel these risks should be documented in all situations for all patients, and therefore that an expected standard does not necessarily apply for these risks.

205 A Closed Loop Audit of CT Hip Scanning at Our District General Hospital

Abstract Aim This audit aimed to determine whether there was a delay beyond 36 hours in theatre cases due to delayed neck of femur fracture diagnoses for non ambulatory patients with no diagnostic abnormality identified on plain film. We examined the indications for CT scans to ensure a full examination had been documented and a trial of mobilisation had been attempted. Method CT hip scan requests audited retrospectively against whether they delayed surgery, if the scan was discussed with the T&O team, hot reporting prior to the scan request and if there was a full examination with documented weightbearing status. Data was compared with NICE guidelines on hip fracture management (CG214) and expected compliance was 95%. Following the initial audit cycle, teaching was given at A&E induction on the referral process and pathway and subsequently re-audited. Results Documented full examination improved from 85 to 93%. Weightbearing status was documented in 33% initially and 76% following the re-audit. There was a 44% improvement in the number of patients who had scans hot reported prior to CT scan occurring. In 95% of patients CT scan did not delay surgery beyond 36 hours. Conclusion CT scan delays did not lead to a delay in the 95% of patients going to theatre. However, with normal plain films it is crucial to have a documented attempt to weight bear prior to the CT request being made. Hot reporting of hip radiographs can be useful prior to requesting CT scans though reporting times and clinical workload can limit this factor.

762 Completed Cycle Audit on Treatment Escalation Planning Documentation in ENT In-Patients

Abstract Aim Treatment Escalation Planning (TEP) helps ensure treatment foals of patients are developed understood and respected. Treatment Escalation documentation is a communication tool that provides staff immediate and accessible guidance in times of crises. A standardised form was created to improve and standardise TEP documentation in ENT in-patients. This audit aimed to review form completion rates. A further cycle was done to assess whether interventions improved practice. Method A retrospective audit of TEP form completion rates and quality of documentation. Paediatric patients and patients from elective surgery discharged on the same day were excluded. Data tabulated included age, co-morbidities, reason for admission, type of admission (emergency/ elective), DNACPR documentation (community and in-hospital), TEP form completion. Results The median age for patients included in the study was 73.5 years old. 83% were emergency admissions. Patients were multi-morbid (Malignancy, cardio and cerebro vascular disease, COPD etc.) In the first cycle 23% had in hospital DNACPR forms, 0% had community DNACPR and 0% had TEP forms completed. Intervention included staff education and physical reminders on handover documentation. Second cycle showed improvement, 40% of TEP forms were completed however 1 patient had community DNACPR in place but no in-hospital DNACPR. Conclusions Our intervention showed improvement in treatment escalation plan documentation. This audit also picked up a problem i.e., community DNACPR not converted to inpatient DNACPR whilst patient is an inpatient. Next steps include further intervention to improve completion rates and further audit to ensure longlasting improvement.

354 Surgical Proforma Done by Surgical Doctors; Clinical Audit

Abstract Aim To improve the clerking performed by all surgical grades at our Trust and to prevent any implication might happen in case the clerking was insufficient such as medical errors, delay in treatment and poor quality of data for future research and audits. Method Two cycle audit in which the first cycle analysed one hundred fully randomized surgical entries for completeness of all aspects of history, examination & plan over two months in 2021. Then new surgical proforma was applied and used for all patients thereafter. Subsequently, second cycle performed later, and same randomization was applied. Results Whereas fully completed proformas compromised only 4% of all entries in first cycle, this percentage increased by more than six-fold to reach 26% in second one. Both history of present illness and physical exam showed the major improvement. Even though some sections such NEWS score and social history kept showing small, completed percentage, it was slightly higher than in the first cycle. 69% was the total improvement across all sections between two cycles. Conclusion New surgical proforma applied at our hospital improved the clerking done by surgical doctors and hence improved the care provided to patients in first place and served as a very rich environment to future research and Audits.

Vitamin B12 supplementation post-gastrectomy: a service closed-loop audit at St. James's Hospital, Dublin.

BackgroundVitamin B12 (VB12) deficiency is a well-described complication post-gastrectomy. It is caused by the loss of parietal cell mass leading to megaloblastic anaemia. This closed-loop audit assesses patient understanding of and adherence with VB12 supplementation guidelines post-gastrectomy.MethodsA closed-loop audit cycle was performed. After the first cycle, an educational intervention was actioned prior to re-audit. One hundred twenty-five patients who underwent gastrectomy between 2010 and 2020 were available for study (86 total gastrectomies (TG), 39 subtotal gastrectomies (STG)). Twenty-nine patients who had not been adherent with VB12 supplementation/surveillance were eligible for re-audit.Results91.9% (79/86) of TG patients reported adherence in regular parenteral VB12 supplementation. Adherence was significantly lower for STG for checking (and/or replacing) their VB12, with only 53.8% (21/39) checking their VB12 levels. 67/125 (53.6%) of the patients stated that they knew it was important to supplement B12 post-gastrectomy. 37.8% (43/113) of participants could explain why this was important, and 14.4% (18/125) had any knowledge of the complications of VB12 deficiency. Following re-audit, 5/8 (57.5%) of TG patients who had not been adherent with VB12 supplementation in the first cycle were now adherent with VB12 supplementation following our educational intervention. 7/17 (41.2%) of the STG group had received VB12 or made arrangements to receive supplemental VB12 if it was indicated.ConclusionThis study demonstrates good adherence in those undergoing TG. Patient understanding correlates with adherence, suggesting that patient education and knowledge reinforcement may be key to adherence with VB12 supplementation. A simple educational intervention can improve adherence with VB12 supplementation in patients undergoing gastrectomy.

EP-95 Full Cycle Audit on Prescription and Cost Effective Analysis of Metronidazole in Acute Surgical Unit

Abstract Aims Oral Metronidazole has very high bioavailability, similar to that of intravenous(IV) metronidazole. Prescribing oral Metronidazole has many advantages such as saving drug preparation time, reducing risk of line infection and also being more cost effective. We aim to study the incidence of prescription or oral Metronidazole and its cost impact in or acute surgical unit. Methods Retrospective analysis on the prescription and cost effectiveness of Metronidazole usage in acute surgical setting. Inclusion criteria for this study was acute surgical patients with viable oral route and who were prescribed oral or IV Metronidazole. Cost assessment was carried out using British National Formulary (BNF). Education and awareness campaigns were held to encourage the prescription of oral Metronidazole. A second cycle audit was done to measure outcome of education. Results First audit done in 2020 found only 12.5% of patients were prescribed oral instead of IV Metronidazole. This has improved to 61% during second cycle audit done in 6 months time after the awareness campaigns. Prescribing oral instead of IV Metronidazole would save approximately £64.77 per dose resulting in reducing total cost by £971.55 per standard course of 5 days treatment. Conclusion There is clear improvement in the rate of prescribing of oral Metronidazole following equation campaigns. Further improvement can be achieved through continued education of various members of surgical team which will ultimately result in reduced costs, lessen drug preparation time for nursing staff and lower risk of line infection for patients.

TU5.4 ‘Learning lessons, inspiring change and driving improvements’ - A review of morbidity and mortality meetings in General and Vascular surgery

Abstract Aim According to RCS/ASGBI guidance all surgeons should regularly attend Morbidity and Mortality meetings (M&Ms), as they are a key activity for reviewing the performance the team and ensuring quality of care. We aimed to review General and Vascular Surgery M&Ms at our site – are they in keeping with guidelines and can improvements be made? Methods A retrospective review of General and Vascular Surgery M&Ms was performed. Presentations were assessed against 12 key performance indicators (KPIs) as recommended by RCS/ASGBI. Following audit Cycle 1, a standardized M&M presentation proforma and an M&M outcome form were introduced, with subsequent second and third audit cycles completed. Results In comparison to Cycle 1, overall improvements were seen in 9/12 KPIs in both General and Vascular Surgery M&Ms. 100% compliance was demonstrated in both General and Vascular Surgery M&Ms in 7 KPIs. Improvements can still be made in the completion of Clavien-Dindo scoring, NCEPOD classification, as well as M&M outcome forms. Literature review discussions were not included in any General Surgery M&Ms in either cycle and in only 14% of Vascular Surgery cases. Conclusion Significant improvement in RCS/ASGBI compliance was demonstrated with the introduction of an M&M presentation proforma. Emphasis and encouragement should still be placed on the importance of literature reviews to promote learning, although we appreciate time limitations can have an impact on this. By improving the quality of M&Ms, surgical teams can learn lessons, inspire change and drive improvements.

EP-88 Plastic Surgery Venous Thromboprophylaxis for abdominal and thigh based free flap breast reconstruction surgery

Abstract Aims Correct Venous Thromboprophylaxis (VTE) assessment and prescription is at basis of patient safety when considering patient hospital admission. Current local Guy's and St Thomas Hospital guidelines are in keeping with National Institute for Health and Care Excellence (NICE) guidelines recommending all patients to be assessed and prescribed VTE prophylaxis within 24 hours of admission. There are no specific local or national guidelines however that would recommend VTE prophylaxis specific to free flap breast reconstruction surgery. We assessed therefore adherence to VTE prophylaxis guidelines for patients undergoing abdominal and thigh based free flap breast reconstruction surgery. Patient outcomes were reviewed and VTE prophylaxis proforma was recommended. Methods Patients who underwent abdominal or thigh based free flap breast reconstruction surgery between October 2017 and February 2019 were identified. Data was collected retrospectively and analysed via SPSS Statistics (IBM, USA). Results 51 patients were included in the first audit cycle; 50 patients in the re-audit. Overall improvement and 100% of patients received LMWH on admission. The timings of correct prescription versus actual administration of LMWH decreased however from 71% to 49%. Discussion There is good adherence to assessment and administration of VTE prophylaxis across the patients. Unfortunately the prescription of VTE prophylaxis itself is mostly incorrect. It is therefore with gratitude to the ward staff VTE is administered correctly. Further improvements in the communication therefore between theatre, ward and surgical staff and implementation of VTE prophylaxis proforma need to be considered.

WE5.13 Improving Pre-operative Risk Score Assessment In Patients Undergoing Emergency Laparotomy

Abstract Aim This audit was conducted with the aim to assess the compliance of recording of risk (P-POSSUM) scores in patients undergoing emergency laparotomy, with the objectives being to establish how many patients required ITU/HDU admission, documentation of P-POSSUM in patients requiring post-operative critical care admission and, pre operative P-POSSUM documentation in elderly patients aged >70 years. Methods Data of all emergency laparotomies at a DGH were obtained from electronic theatre records. The first cycle was from 14/02/2021 to 07/03/2021. The results were presented in the Divisional Audit meeting. Following this, audit cycle was completed with data from 20/06/2021 to 15/08/2021. Patient notes and theatre booking forms were reviewed to assess if P-POSSUM score was recorded and analyzed with Microsoft Excel. Results Twenty- three emergency laparotomies were performed between 14th February 2021 and 7th March 2021. Of these, P-POSSUM scores were recorded in 21.7% (5 of 23 patients). During the second cycle, 50 patients underwent emergency laparotomy. Following the presentation of our audit the compliance to recording P-POSSUM increased to 64% (32 of 50 patients). Of those patients requiring critical care admissions, there was a significant increase in the pre-operative recording of risk scores from 13.33% (2 of 15 patients) to 51.61% (16 to 31 patients). Conclusion Our compliance with documentation of risk score pre operatively in patients undergoing emergency laparotomy has improved over time. However, there remains a room for improvement. We recommend encouragement to record P Possum Scores compulsorily as standard prior to Laparotomies and to standardize the location of recording scores.

EP-505 Audit assessing compliance with General Medical Council (GMC) guidelines at Whittington Hospital Colorectal Department (NHS Trust)

Abstract Introduction The General Medical Council (GMC) released new guidelines titled ‘Decision making and consent’, which came into effect on the 9th of November 2020. It contains guidelines and standards for consenting patients for elective procedures and the documentation of said consent. Within the Colorectal Department of the Whittington Hospital, an audit was conducted to determine how closely the guidelines are being followed and whether that is reflected in the documentation. Methodology We evaluated 57 outpatient letters in the first cycle and 36 in the second. Our intervention was a poster of the guidelines in all clinic rooms for all consenting doctors to see prior to talking to patients. The four criteria were: Results Conclusion We see slight improvement during the second cycle. Still, the numbers are not satisfactory. A third audit cycle will be conducted once another round of interventions is implemented.

EP-373 Appropriate requesting of tumor marker, CEA, at a district hospital in Ireland: An audit cycle to improve practice

Abstract Aims Tumor markers play an important role in oncology and the appropriate requesting of tumor marker tests are facilitated by national and international guidelines, inappropriate use increases both the laboratory workload and overall cost of management. Our aim was to assess our practice against the ACBI (Association of Clinical Biochemists in Ireland) guidelines for carcinoembryonic antigen (CEA) and conduct teaching sessions to improve practice. Methods 1st cycle: All carcinoembryonic antigen (CEA) tests ordered in the hospital between the 1st to 31st of October 2020 were obtained through the HSE Online Lab Web Inquiry System, files were then reviewed for indications. Results from the initial audit were presented to the department and two separate teaching sessions were conducted to educate on the guidelines. 2nd cycle: All CEA test ordered from 1st January to 28th February 2021 were obtained, re-audited and results were compared. Results 76% of the tests ordered by General Surgery in the second cycle were appropriately ordered and incorrectly ordered tests decreased from 35.7% to 23.8%. Conclusions Through the process of this audit an improvement was seen in practice of the department. More tests ordered adhered to indications in guidelines.

TU1.4 Adequacy of endoscopic photo-documentation in an OGD: Closing the loop!

Abstract Aims The technical competence of Oesophago-Gastro-Duodenoscopy (OGD) is rapidly acquired but to support the practice of complete examination, the British Society of Gastroenterology (BSG) and Association of Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) recommend documentation of 8 anatomical stations. Photo-documentation ensures a complete examination, gives an opportunity to inspect area of interest and serves as legal record of an adequate procedure. Our Aim was to assess the hospitals practice of photo-documentation against the BSG and AUGIS guidelines and to improve practice by conducting teaching sessions and designing a poster for the endoscopy rooms. Methods 1st Cycle: 100 OGD reports were randomly selected from 1/1/2018 to 31/3/2020 and were reviewed on the hospitals electronic reporting system (Endorad). Data on patients demographics, speciality of Endoscopist and the documented stations was collected. Data was presented at the departments meeting and a simultaneous teaching session was conducted. A poster was designed and displayed outside the endoscopy rooms. 2nd Cycle: 100 OGD reports were selected from 1st January to 30th June 2021 and re audited. Results 66% of the OGD reports had photo-documentation of all 8 stations and 81% of reports had 7 documented stations which was a significant improvement in practice as the first audit had no report with photographic documentation of all the stations. The highest number of stations documented in the first audit were 5 and that too in only 40% of the cases. Conclusions The audit cycle showed significant improvement in photo-documentation of all the stations, highlighting the benefit of the process.

SP2.2.2 Thyroid Ultrasound reporting – an audit of practice

Abstract Aims Ultrasound (US) is the first line investigation for evaluating thyroid nodules. British Thyroid Association (BTA) guidelines set out a structured characterisation of thyroid nodules to guide further investigation. We conducted a closed loop audit at a District General Hospital to assess compliance of US reporting with BTA guidelines. Methods 208 examinations were retrospectively analysed in the initial audit cycle. The reports were assessed for U status; number, measurements, characteristics and locations of nodules; comment on lymph nodes; whether FNA was performed or recommended; FNA histology; and the number of examinations performed by each radiologist/radiographer. Departmental teaching was then provided. A re-audit of 100 thyroid ultrasounds was then conducted. Results In the initial audit and re-audit, respectively, the number of reporting clinicians decreased from 21 to 15, however the vast majority had reported fewer than 5 scans in each time period. Where nodules were present, the use of U classification in reports increased from 32.5% to 85.3%. Reporting of measurements, characteristics and location of nodules increased from 86.4%, 92.9% and 96.8% to 96.0%, 100.0% and 100.0% of reports, respectively. In both audits, 4.5% of U1/2 nodules were recommended for FNA. For U3–5 nodules, FNA or referral to specialty increased from 71.4% to 75.0%. Comment on lymph nodes increased from 89.4% to 95.9%. Conclusions Following education, improvement in compliance was seen in nearly all domains, particularly in the utilisation of U classification. Further work is needed regarding the appropriate use of FNA, and caseload variation between clinicians.

TH1.4 Indication for clinical biopsy in symptomatic breast disease- A closed loop audit

Abstract Aims Royal College of Radiologists states core biopsy is indicated where imaging is normal, but clinical assessment is P3 and above. However, many clinicians opt for clinical biopsy following normal imaging results despite clinical assessment under P3. We recommended: reserving clinical biopsies following normal imaging for women >50 year; performing ultrasound and mammogram in women <40 years with clinically (P3-P5) or ultrasonically (U3-U5) findings. Here we look at the impact of our recommendations on clinical practice and patient diagnosis. Methods All patients who had clinical biopsies were analysed within a six-month time period in 2019 and 2020. 43 patients were included in 2019. 78 patients were identified in 2020. 14 were excluded as they had history of breast malignancy, or a biopsy diagnosis of non-breast malignancy. Results 64 patients were included in our analysis. Improvements in the 2020 audit cycle compared to 2019 included: Lesser women <40 years with P3/U3 not getting MMG prior to clinical breast biopsy (15.4% compared to 80.0%); higher rates of both MMG and targeted US were performed in women 340 years with score 3U3 (86.8% compared to 41.9%). Only 6 (9.4%) patients returned with malignant biopsy results. No patients (compared to 1) who underwent clinical biopsy for symptomatic breast disease following normal imaging showed malignant biopsy results. Conclusion Our findings indicate a low test positivity rate for clinical biopsies performed following normal imaging. Being prudent and selective in the type of patients clinical biopsies are carried out have a positive impact on clinical practice and patient diagnosis.