Clinical Excellence Guidelines Research Articles

Exploring health professionals' knowledge, practices and attitudes regarding gestational diabetes: A cross-sectional Irish national survey.

Gestational diabetes confers short- and long-term risk of mother and offspring health complications. Healthcare professionals such as endocrinologists, diabetes nurses, dietitians, midwives and general practitioners provide gestational diabetes care. We sought to explore healthcare professionals' perspectives on gestational diabetes care during pregnancy and postpartum. Healthcare professionals in the Republic of Ireland, whose role included gestational diabetes care were invited to complete an online 20-item survey between June and September 2022. Social media, professional organisations and personal networks were used for recruitment. Questions included guideline use, postpartum diabetes screening and advice practices. Analyses were performed using SPSS statistical software and free text was coded using NVivo. Seventeen healthcare professions across primary and secondary care settings participated (n = 127). No differences were noted between groups (medical, nursing/midwifery, allied health/other); therefore, findings were reported as a single group. Healthcare professionals reported using multiple different guidelines to support gestational diabetes management (n = 14). The most cited were 'Health Service Executive guidelines' (24.5%), 'local guidelines' (13.2%) and National Institute for Clinical Excellence guidelines (11.3%); 12.3% cited uncertainty, and 27.5% reported not to follow any named guidelines. For postpartum follow-up, 39% felt clear guidelines were available to support practice, 37% felt appropriate systems were in place and 29% reported effective communication between primary and secondary care services. Qualitative findings emphasised a desire for improved communication between systems, participants and providers, clear interdisciplinary guidelines, and adequate resourcing for gestational diabetes management and postpartum diabetes prevention, including comprehensive support and follow-up. System-level challenges and ineffective communication across settings are barriers to optimum postpartum care. Nationally agreed guidelines for best practice gestational diabetes management including postpartum diabetes prevention are needed.

Diagnosis and management of infertility: NICE-adapted guidelines from the Italian Society of Human Reproduction

In Italy the fertility rate is very low, and an increasing number of patients are infertile and require treatments. The Italian Law concerning the safety of patient care, and the professional liability of health professionals, indicates that health professionals must comply with the recommendations set out in the guidelines developed by public and private bodies and institutions, as well as scientific societies and technical-scientific associations of the health professions, except for specific cases. Unfortunately, no guideline for the diagnosis and the management of infertility is currently available in Italy. In 2019, the Italian Society of Human Reproduction pointed out the need to produce Italian guidelines and subsequently approved the establishment of a multidisciplinary and multiprofessional working group (MMWG) to develop such a guideline. The MMWG was representative of 5 scientific societies, one national federation of professional orders, 3 citizens' and patients' associations, 5 professions (including lawyer, biologist, doctor, midwife, and psychologist), and 3 medical specialties (including medical genetics, obstetrics and gynecology, and urology). The MMWG chose to adapt a high-quality guideline to the Italian context instead of developing one from scratch. Using the Italian version of the Appraisal of Guidelines for Research and Evaluation II scoring system, the National Institute of Clinical Excellence guidelines were selected and adapted to the Italian context. The document was improved upon by incorporating comments and suggestions where needed. This study presents the process of adaptation and discusses the pros and cons of the often-neglected choice of adapting rather than developing new guidelines.

A STUDY TO ASSESS THE KNOWLEDGE ON URINARY TRACT INFECTION REGARDING ITS PREVENTION AND MANAGEMENT AMONG THE 1ST YEAR B.SC NURSING AT SMT. NAGARATHNAMMA COLLEGE OF NURSING, BENGALURU

Good health is the fundamental right of every human being and it is essential to lead a successful life. The preamble to the WHO constitution also affirms that it is one of the fundamental rights of every human being is to enjoy The highest attainable standards of health. Moreover, emphasis is based on health promotion andpreventivehealthcare.Goodphysicalandmentalhealthofchildrenandadolescentsmakesforgoodhealth in adulthood. Agreeably, adolescence is a transitional period from dependent childhood to independent adulthood,thatis,agegroupfrom10-19years.Aboutone-fifthofIndiaspopulationisintheadolescenceage group and this is the earliest age where we can prevent morbidity in later life by means of health. According to 2022–2023-year statical data, the human body gets rid of liquid waste products through the urinary system, and so, it is important to protect this system from infections. Urinary tract infections are the secondmostcommonbacterialdiseasewhichaccountsformorethaneightmillionofficevisitsperyear.More than one lakh (1,00,000) people are hospitalized annually because of urinary tract infection and it is an importantcauseofmorbidityandmortalityinIndiansubjects.Youngageandfemalesexarethetwoimportant factors that contributes to the development of urinary tract infection and therefore it is the most common infection among adolescent girls, which distresses them, concerns their parents, and may cause permanent kidney damage, if there is any delay in treatment. According to the National Institute of Health and Clinical Excellence guidelines urinary tract infection is defined by a combination of clinical symptoms of urinary tract infection that usually include frequency, dysuria, pyuria, abdominal pain, back pain, fever, or urgency. Most urinary tract infections result from ascending infection by single gram-negative bacteria such as Escherichia coli, Klebsiella, Proteus, Enterobacter,orPseudomonas.Staphylococcalinfections,especiallyduetostaphylococcalsaprophyticus are common cause of urinary tract infection among adolescent girls. The two broad categories of urinary tract infectionarepyelonephritisorupperurinarytractinfectionandcystitisorlowerurinarytractinfection.Lower urinary tract infections are common among adolescent girls.

Audit of Emergency Laparoscopic Cholecystectomy in a District General Hospital.

Introduction Acute gallstone diseases are common surgical emergencies, accounting for approximately one-third of emergency surgical admissions. Laparoscopic cholecystectomy is thestandard choice of treatment for gallstone diseases and is currently one of the most commonly performed surgical procedures in the United Kingdom.Majority of these procedures are carried out as elective cases. National Institute of Clinical Excellence (NICE) guidelines and other upper gastrointestinal surgery specialty bodies encourage early emergency surgery inacute symptomatic gallstone disease. Weassessed emergency laparoscopic cholecystectomiesperformed at Birmingham Heartlands Hospital, United Kingdom andcompared the practice against NICE and British Benign Upper Gastrointestinal Surgery Society (BBUGSS) recommendations. Methods This is a snapshot retrospective audit, assessing emergency laparoscopic cholecystectomy practice over a nine-month periodfrom November 2022 to July 2023.Variables assessed were demographics, duration of symptoms prior to surgery, imaging modality, indications, C-reactive protein (CRP) levels, operative difficulty, intraoperative and postoperative complications, length of hospital stay and readmission rates. These variables were compared against both NICE and BBUGSS standards.We aimed to establish baseline data to encourage emergency laparoscopic cholecystectomies in our hospital and reduce repeated hospital visits for patients with acute gallbladder disease. Results Forty-eight patients had emergency laparoscopic cholecystectomy in the period reviewed, mean age was 44.3 years and females accounted for approximately 71% (n=34) of the group. 66.7% (n=32) of patients had their surgery within seven days of diagnosiswith acute gallstone disease; 50% (n=24)of patients had no adverse intraoperative event.No patient had biliary tract injury despite a high number of difficult cases. Overall there was no correlation between duration before surgery and intraoperative difficulty or readmission rates.

Menopause as a window of opportunity: the benefits of designing more effective theory-driven behaviour change interventions to promote healthier lifestyle choices at midlife.

Menopause is a natural developmental phase that all women go through from their early forties to mid-fifties, marking the transition from the reproductive to the non-reproductive years. This is characterised as the permanent cessation of menses due to progressive ovarian failure. Each woman's experience of the menopause is unique. Biopsychosocial changes occur during this time with some symptoms affecting up to 80 % of women and lasting for 4-5 years from the peri- to post-menopause. Reduced oestrogen may predispose some women to health issues following menopause, such as heart disease, diabetes, stroke and cognitive decline. It is vital to understand how to promote health and well-being to reduce the risk of developing chronic conditions in later life. Increased symptoms and concerns about health during the menopausal transition can be cues to action for some women to actively maintain their health. Menopause represents a window of opportunity to promote health, and to support women to make healthier lifestyle choices, part of the National Institute for Clinical Excellence guidelines for menopause management. Identifying appropriate strategies to change behaviour is less clear. Theories of behaviour change can provide frameworks to gain more insight into the facilitators and barriers to behaviour and can inform the researcher on what needs to change. This information can be used to inform the design, content, implementation and evaluation of a lifestyle intervention. This review paper will explore the impact of menopause on health and well-being generally, and the benefits of designing more effective theory-driven behaviour change interventions for menopause.

Knowledge and adherence to National Institute of Clinical Excellence 2020, dyslipidaemia management guidelines and its associations among medical officers in Gampaha district, Sri Lanka: a descriptive study

Introduction: Dyslipidaemia is an important risk factor for cardiovascular diseases(CVD) and optimal management helps prevent CVD burden in a country. Knowledge of medical officers(MOs) on dyslipidaemia management is critical in this regard. We assessed knowledge and adherence of MOs of Gampaha district to the National Institute of Clinical Excellence (NICE) guideline 2020 on management of dyslipidaemia. Methods: We conducted a cross-sectional study at five secondary/tertiary-care hospitals in Gampaha District in January 2022. Knowledge and adherence were studied using a self-administered questionnaire consisting of 25 multiple-choice questions. Each question was scored "1" and the cumulative score was converted to 100. A score >80 was considered "good knowledge and adherence" and its associations were studied using logistic regression.Results: A total of 413 MOs (63.4% females, mean age 45±7.6 years) participated in the study. Of them, 73.1% had worked in a medical ward previously. The mean knowledge and adherence score was 77±9.3. Only 30% had a score >80. Good knowledge and adherence was significantly associated with being <45 years (p .004) in age, having work experience in a medical ward (p<.001), having post-graduate training (p<.001), working in a tertiary care hospital(p=.007), and involved in private practice(p=.002). There was no significant association with attendance at continuing medical education programmes (p=.320) or the duration of service(p=.120).Conclusions: Only a third of MOs of Gampaha district had good Knowledge and adherence to NICE-2020 dyslipidaemia guidelines. Knowledge and adherence to the guideline was better in MOs who are young, in postgraduate training, with previous experience in medical wards, working in tertiary care hospitals or engaged in private practice.

Analysis of Intrapartum Cardiotocography Findings in Labour, its Correlation with Umbilical Arterial Blood pH and Neonatal Outcome

Background: Cardiotocography (CTG) is being used in all labouring women to detect intrapartum hypoxemia which further requires confirmatory tests. But in a setting where these facilities are not available, umbilical artery pH analysis can help not only in identifying neonates with intrapartum hypoxemia but can also help in anticipating neonatal adverse outcomes. The aim of the study was to analyse intrapartum cardiotocography and its correlation with umbilical artery pH and neonatal outcome. Methods: Total of 317 consecutive single, term, labouring women were included in the present study. After taking CTG, it was classified into normal, non-reassuring and abnormal groups according to National Institute of Clinical Excellence (NICE) guideline 2017. At birth umbilical cord arterial blood was taken to detect neonatal hypoxemia. At the same time, APGAR score at 5 minute of birth, NICU admission and neonatal mortality was also recorded. Neonates with umbilical artery blood pH of ≤7.2 were considered as asphyxiated. Results: Among 317 women 48.8% had normal CTG, 35% had non-reassuring and 15.4% had abnormal CTG. APGAR score was found to be <7 in 17.3%, and same number of neonates had NICU admission. Out of 113 non-reassuring CTG, 5.9% had acidosis. This number was much higher in abnormal CTG group where 11% had acidosis. There were 6 neonatal mortalities. A statistically significant association was found between intrapartum CTG and umbilical artery pH and neonatal outcomes. Conclusion: Cardiotocography is an effective screening tool that is routinely used in all labouring women for screening of fetal hypoxia. By doing that timely intervention can be under taken to avoid neonatal morbidity and mortality.

Do single-case experimental designs lead to randomised controlled trials of cognitive behavioural therapy interventions for adolescent anxiety and related disorders recommended in the National Institute of Clinical Excellence guidelines? A systematic review.

Although Cognitive Behavioural Therapy (CBT) is effective for 60% of adolescents with anxiety disorders, only 36% are in remission post-intervention. This indicates that more effective treatments are needed which should be reflected in the NICE guidelines. We hypothesised that Single-case experimental designs (SCEDs) may provide a framework for accelerating the development of novel interventions. The primary purpose of this review was to investigate whether SCEDs are currently followed by randomised controlled trials (RCTs) of CBT intervention for adolescent anxiety disorders named in the NICE guidelines. The secondary objective was to investigate whether using SCEDs prior to RCTs could be a helpful approach. For the primary search of SCEDs five databases were used (PsycINFO, PubMed, PsycArticles, Web of Science and ProQuest). Nineteen articles met eligibility criteria including a total of 107 participants. For the secondary search of RCTs named in the NICE guidelines for adolescent anxiety disorders 53 articles met inclusion criteria and were included in the systematic review. The 19 SCED studies included in the review were conducted with participants with a diverse range of anxiety disorders and across a range of CBT formats. Two of the SCEDs were followed by RCTs, but neither of these were named in the NICE guidelines for anxiety disorders. All of the SCEDs identified were rated as low quality with none meeting the criteria for the highest or second highest quality rating. From the secondary searches, none of the RCTs named in the NICE guide were preceded by SCEDs. It was concluded that currently SCEDs were not followed by RCTs of CBT interventions named in the NICE guidelines for adolescent anxiety disorders. However, it was suggested that SCEDs may provide an important framework for the development of more effective interventions for adolescents with anxiety.

The Efficacy of Currently Licensed Biologics for Treatment of Ulcerative Colitis: A Literature Review.

Biologics have been emerging as promising therapies in ulcerative colitis (UC) patients who are refractory to conventional medical treatment. This literature review aims to appraise the existing evidence on the efficacy and safety of NICE approved biological therapies, of which there are currently five licensed drugs, available for the treatment of UC in adults. An initial search was performed using National Institute of Clinical Excellence (NICE) guidelines. A further literature search of EMBASE, MEDLINE, Science Direct and Cochrane Library databases was done, resulting in a total of 62 studies being included in this review. Recent and seminal papers were included. Inclusion criteria for this review were adult participants and English papers only. In most studies, anti-tumour necrosis factorɑ (TNFɑ) naïve patients were found to have improved clinical outcomes. Infliximab was found to be highly effective in inducing short-term clinical response, clinical remission as well as mucosal healing. However, loss of response was common and dose escalation was often required for achievement of long-term efficacy. Adalimumab was found to have both short-term and long-term efficacy which was also supported by real-world data. Golimumab was shown to have comparable efficacy and safety profiles to other biologics, although lack of therapeutic dose monitoring and loss of response is a barrier to optimising golimumab treatment efficacy. Vedolizumab was shown to have higher clinical remission rates when compared to adalimumab in a head-to-head trial, and the most cost-effective biologic when calculating quality-adjusted life years. Ustekinumab was found to significantly improve clinical remission rates in UC patients who were previously unresponsive to other biological treatments. However, as this is a newly licensed drug, there is limited literature currently available. Further, head-to-head studies are required to help determine the optimal treatment for patients with UC. With patents expiring, the development of biosimilars will help to reduce costs and increase the availability of these drugs to patients.

Using an algorithm to assess the rate and trend over time of inappropriate proton pump inhibitors prescription upon hospital discharge.

There is an increasing interest in inappropriate proton pump inhibitors prescription (InPPIp), as defined by the National Institute for Clinical Excellence (NICE) guidelines. To evaluate the rate, trend over time and factors associated with InPPIp upon discharge from internal medicine departments. We evaluated patients discharged from internal medicine departments with a PPI prescription in 2014 and 2017 at an academic referral center according to a developed algorithm. A total of 3,982 patients were included (50.8% women, 74% ≥ 65 years). The rate of InPPIp was 44.3% (95% CI 42.8-45.9) for the entire cohort; 68.1% for subjects aged < 65 years and 36.0% for those aged ≥ 65 years (p<0.001); 43.2% in 2014 and 45.6% in 2017 (p=0.130). In a decision-tree analysis, after the exclusion of 448 patients with gastrointestinal indications, 89.4% (1,580/1,766) of all InPPIp cases were of patients without dual antiplatelet treatment (DAPT) and 8.6% (151/1,766) were of patients younger than 65 years, who were taking aspirin. The rate of InPPIp is high, especially among patients not receiving DAPT and young patients taking aspirin. Time trend analysis showed no improvement over time. Our algorithm may serve as an automated quality measuring tool to reduce InPPIp.

MANAGEMENT OF GESTATIONAL DIABETES MELLITUS: AN INSIGHT INTO EVIDENCE-BASED PRACTICE AMONG POSTGRADUATE TRAINEES OF OBSTETRICS AND MEDICINE DISCIPLINES

OBJECTIVE: To explore the discrepancies regarding screening, diagnosis &amp; management of gestational diabetes mellitus (GDM) among postgraduate trainees of Obstetrics &amp; Gynaecology (OBG) and Medicine disciplines. METHODS: This multicentre cross-sectional study was conducted from 1st to 31st August 2022. The questionnaire regarding screening, diagnosis, management of GDM, &amp; postnatal follow-up with neonatal care were distributed among postgraduate trainees of medicine/OBG through google-form/hardcopies. Data was analysed through SPSS-22 RESULTS: Out of 236 trainees, 184 (78%) were following national institute of clinical excellence (NICE) guidelines for management of GDM. Majority of medicine (n=87/120 (72.5%) &amp; OBG (n=76/116; 65.5%) trainees failed to identify the correct cut-off of oral glucose tolerance test for GDM. A big chunk of both OBG (n=93/116; 80.2%) &amp; Medicine (n=96/120; 80%) trainees were unable to differentiate pre-existing diabetes mellitus from GDM. The clinical knowledge about carbohydrate diet (n=119/236; 50.4%), calories intake (103/236; 43.6%) &amp; low glycaemic index (138/236; 58.5%) was poor among trainees of both specialities. Surprisingly, the medicine trainee’s knowledge about insulin types, dose &amp; tocolytic agent was not evidence-based. The practicing knowledge of both specialities was poor about identification of neonatal hypoglycemia (n=30/236; 12.7%) &amp; its management (n=47; 19.9%). Trainees of both specialities had poor knowledge about postnatal follow-up (n=64/236; 27.1%) of GDM patients. CONCLUSION: GDM is a common domain for OBG &amp; medicine disciplines with no consensus guidelines for its uniform management. This study has identified some basic gaps in the clinical practice of future consultants regarding GDM management, urging the need of combined local guidelines.

PS-P13-9: A MULTI-DISCIPLINARY LIPID ADVOCATE INTERVENTION ACHIEVES A SUSTAINED INCREASE IN LIPID AND HBA1C SCREENING WITHIN AN ACS POPULATION

Objective: Cholesterol is a key risk factor for atheroma and coronary heart disease. European Society of Cardiology (ESC) and National Institute for Clinical Excellence (NICE) guidelines both recommend that a full lipid profile is obtained for all patients presenting with an acute coronary syndrome (ACS) on admission. Here, we present an intervention study that aimed to improve lipid and HbA1c assessment in patients presenting with ACS at single UK NHS trust. The primary intervention included the creation of a multi-disciplinary lipid advocate team. Design and method: Data from 194 patients admitted with the diagnostic code acute coronary syndrome was collected over 4 discrete time intervals between August 2020 and January 2022 using electronic healthcare records. Data on whether total cholesterol, high-density lipoprotein (HDL), triglycerides and HbA1c tests were requested was collected as a baseline and after implementation of each quality improvement (QI) intervention. Interventions included establishing a lipid advocate team comprised of doctors and ward nursing colleagues to ensure that patients arriving on the ward with missing test results had further bloods sent. The final cohort of ACS patients was chosen 12 months after any QI intervention to assess sustainability of the interventions. Results: Analysis of the total cholesterol, HDL, triglycerides and HbA1c results across the 4 cohorts of patients presenting with ACS revealed a significant improvement in test compliance from the baseline cohort to the final cohort across all 4 parameters. After implementation of the lipid advocate team, compliance with test requesting rose significantly for total cholesterol (69.1% to 89.5%) and remained high after 12 months (94.3% compliance). Similar improvements were also shown with triglyceride, HDL and HbA1c measurements, with final compliance measurements at 92.4%, 79.2% and 90.6% respectively (compared to respective baselines of 65.4%, 60% and 67.3%). Conclusion: This longitudinal QI study of patients with ACS from a single cardiology centre demonstrated a significant and sustained improvement in compliance of lipid and HbA1c assessment. The implementation of a multi-disciplinary lipid advocate team led to significant improvements in compliance with lipid and HbA1c assessment. Utility of a combined nursing and medical-led service requires further exploration for in-hospital management of patients with ACS.

PS-C07-4: COST EFFECTIVE SCREENING FOR BLOOD PRESSURE IN A LMIC: COMPARISON OF STANDARD AND RANDOM METHODS FOR HOME BLOOD PRESSURE MONITORING

Background: Hypertension is a leading risk factor for worldwide mortality and has become an important public health concern. Globally one billion people are suffering from hypertension and this rate may reach up to 1.56 billion by 2025. The prevalence of hypertension in Pakistani adults is upto 50%. The National Institute for Clinical Excellence and Pakistan Hypertension League guidelines recommend home blood pressure monitoring (HBPM) for screening and diagnosis of hypertension in Pakistan; whereas, the current gold standard of hypertension diagnosis is still ABPM. However, the utility of HBPM is restricted due to the cumbersome standard method for HBPM, which requires timed blood pressure measurements pre-breakfast &amp; pre dinner.. We need pragmatic ways of measuring home blood pressure which will lead to higher patient compliance. Objective: To compare the limits of agreement between standard and random methods for HBPM in patients with or without hypertension. Design &amp; Method: A cross sectional study with n = 345 participants will be conducted in The Aga Khan University Hospital. After receiving due ethical approvals, participants 18 80 years of age will be recruited with or without hypertension. A HBPM device (OMRON M7 Intelli) will be provided to each participant for 14 days. In first week, BP readings will be taken as per standard method (2 readings pre breakfast &amp; 2 pre-dinner) and random method (6 readings anytime during a day) will be followed in subsequent week. Besides demographics, history of comorbid, medications status and BP charting, international physical activity questionnaire short form will be filled. SPSS software will be used for data management and analyses. Pearson correlation coefficients, Bland Altman plots and ROC curve will be used to determine the correlation limits of agreement and level of accuracy in predicting hypertension for both methods.

Admission Cardiotocography: Its Role in Predicting Perinatal Outcome in Term, Uncomplicated (Low Risk) Pregnant Women in Spontaneous Labour

Introduction: Labour admission cardiotocography (CTG) is commonly used non-invasive method of fetal monitoring in Sri Lanka. It may have a potentialto predict perinatal outcome in low-risk term pregnancies. Objectives: Objectives of the study were to determine the perinatal outcomes of normal, suspicious and pathological admission CTGs and role of labour admission cardiotocography as a predictive test for perinatal outcome in low-risk term pregnancies in spontaneous labour. Methods: This study was a prospective observational study done involving 445 low risk, term pregnancies in spontaneous labour. Labour admission CTG was performed in each pregnancy and categorized into normal, suspicious and pathological CTG according to criteria depicted by National Institute of Clinical Excellence (NICE) guideline 2007. Apgar score less than 7 at five minutes, resuscitation at birth, admission to neonatal intensive care unit (NICU), seizure within first 24 hours of birth and meconium-stained amniotic fluid were the primary outcome measures to assess fetal asphyxia. Mode of delivery in each category, nuchal cord at birth were also assessed. Results: Majority of participants were in 25-to-29-year age group and were nulliparous. Frequencies of normal, suspicious and pathological CTG were 74.8%, 18% and 7.2% respectively. Pathological CTG was significantly associated with low Apgar score compared to non-pathological CTG group (p 0.005) while other outcome measures were not significant. Rate of operative delivery was 68% in pathological group and 20.8% in non-pathological CTG group. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of labour admission CTG to detect fetal asphyxia were 51.85%, 95.69%, 43.75% and 96.85% respectively. Conclusions: Incidence of pathological labour admission CTG was 7.2%. Apgar score less than 7 at five minutes of birth was significantly associated with pathological CTG group compared to non-pathological CTG (p 0.05). Worsening of CTG from normal to pathological showed increasing rate of operative delivery. Even though sensitivity and positive predictive values of labour admission CTG were low, specificity and negative predictive values were high for detecting low Apgar score. Therefore, labour admission CTG has a value in excluding adverse perinatal outcomes in low-risk term pregnancies in spontaneous labour.

The Use of Mechanical Bowel Preparation and Oral Antibiotic Prophylaxis in Elective Colorectal Surgery: A Call for Change in Practice

Elective colorectal surgery is associated with one of the highest rates of surgical site infections (SSIs), which result in prolonged length of stay, morbidity, and mortality for these patients and have a significant financial burden to healthcare systems. In an effort to reduce the frequency of SSI rates associated with colorectal surgery, the 2018 World Health Organisation (WHO) guidelines recommend the routine use of mechanical bowel preparation (MBP) and oral antibiotic prophylaxis (OAP) in adult patients undergoing elective colorectal surgery. However, this recommendation remains a topic of debate internationally. The National Institute of Clinical Excellence (NICE) guidelines, last revised in 2019, recommend against the routine use of MBP and do not address the issue of OAP. In this communication, we reviewed the current guidelines and examined the most recent evidence from randomised-control trials (RCTs) and meta-analyses on the effect of MBP and OAP on SSI rates since the 2019 NICE guideline review. This recent evidence clearly demonstrated an SSI-risk-reduction benefit with the additional use of OAP and the combination of MBP and OAP in this group of patients, and we therefore highlight the need for change of the current NICE guidelines.

Real World Management of Anaphylaxis Versus the National Institute for Health and Clinical Excellence (NICE) Guidelines.

Objectives Anaphylaxis is an acute, life-threatening immediate allergic reaction caused by the sudden systemic release of mediators from mast cells. This study aims to assess the current practice of emergency management of children and adults diagnosed with anaphylaxis at the Royal Hospital, Muscat, Oman, in line with the National Institute for Health and Clinical Excellence (NICE) guidelines. MethodsThis is an observational retrospective study of all anaphylaxis cases seen at the emergency department (ED) from January 2013 to January 2018 and compared with the management of anaphylaxis in the ED as per the NICE guidelines. Inclusion criteria were all patients, children (age 16 and below), and adults diagnosed with anaphylaxis based on the World Allergy Organization (WAO) criteria. Exclusion criteria are all cases labeled as anaphylaxis that did not match the WAO criteria for anaphylaxis.ResultsOf 100 patients with a preliminary diagnosis of anaphylaxis, 49 patients (49%) were true-anaphylaxis cases based on the WAO definition 16 were children (age 16 years and below), and 33 were adults ( age 16 years and above). The other 51 patients (51%) with misdiagnosed anaphylaxis were later diagnosed with spontaneous urticaria, septic shock, vocal cord dysfunction, severe asthma, and anxiety attack. All 49 patients with true-anaphylaxis appropriately received adrenaline intramuscularly at the ED. All 16 children were admitted, seen by an allergist, and received an adrenaline auto-injector when indicated. Only 5 of the 33 adults were admitted and seen by an allergist, and 4 of those required an adrenaline auto-injector upon discharge. The remaining 28 adults were discharged from the ED, and only 3 of these were referred to the allergist. None received an adrenaline auto-injector upon discharge from the ED, and no mention in the ED notes on patient education regarding allergen avoidance.ConclusionThird of the patients who presented to ED were children (<16 years), and two third were adults. Insect venom was the main reason for anaphylaxis in both age groups. There was an underutilization of adrenaline auto-injector prescriptions for adult patients. This could be very well improved by disseminating policies and guidelines to adult physicians.

WE2.8 Improving Management for Acute Cholecystitis and Biliary Pancreatitis – the ‘Hot Gallbladder Pathway’

Abstract Aim There is a wide variation between National Health Service (NHS) hospitals in the management of patients with acute cholecystitis and biliary pancreatitis. 20–33% of patients will make repeat visits to hospital with gallstone-related symptoms before any surgical intervention performed. We established a ‘Hot Gallbladder Pathway’ with the aim for improving outcome and decreasing complications of these patients. The aim of this quality improvement project was to assess if a district general hospital (DGH) could provide a safe and effective ‘hot gallbladder’ service with a clear pathway. Method Quality improvement methods were used to integrate the ‘hot gallbladder pathway’ to manage patients with acute calculous cholecystitis and biliary pancreatitis. A prospective observational study with strict inclusion/ exclusion criteria and secure online data was conducted during a 13-month period. The data were then compared against existing National Institute for Health and Clinical Excellence (NICE) guidelines and further changes were recommended. Results We achieved almost 70% of the patients undergoing emergency laparoscopic cholecystectomy in both group of patients who met the pathway criteria within the expected time frame, compared with the pre-implementation result of 23% and national average of only 16% in England. None of the patients suffered from intraoperative complications or 30-day mortality. Conclusion A clear ‘hot gall bladder pathway’ is effective at improving care for patients requiring emergency laparoscopic cholecystectomy and potentially useful for other acute Trusts which their standard is below the NICE guideline.

Diseases of the Respiratory Tract: Asthma and Chronic Obstructive Pulmonary Disease

Short acting beta2-agonists (SABAs) such as salbutamol and terbutaline are commonly used in the treatment of asthma and chronic obstructive pulmonary disease (COPD). According to the guideline produced by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN), SABAs are considered to be the first line of treatment in asthma management. The National Institute for Health and Clinical Excellence (NICE) guidelines also recommend the use of SABA as the first line of treatment for managing patients with COPD. The recommendations in NICE guidelines state that in COPD patients, breathlessness and exercise limitation should be first medicated with short-acting bronchodilators (including beta2-agonists or anticholinergics) when it is required. Both salbutamol and terbutaline have been widely used for asthma and COPD, and they have been found to be extremely beneficial in the two pathologic conditions.

Audit of music therapy in acute National Health Service (NHS) settings for people with dementia in the UK and adaptations made due to COVID-19

Music therapy research and practice is growing in the field of dementia in residential and community settings. However, less is known about the prevalence and practice of music therapy in acute inpatient settings for people living with dementia. An online survey was distributed to the membership of the British Association for Music Therapy (BAMT) in the UK. Descriptive statistics were generated for quantitative data and thematic analysis was conducted on qualitative data. Fifteen music therapists responded (12.1% of BAMT members working in dementia care). The majority (80%) of respondents were employed by NHS Trusts, and most therapists spent half to one day on acute wards per week. Results showed similarities in patterns of working and theoretical approaches, with live, interactive, instrumental music making used by all and many drawing upon psychodynamic and person-centred approaches to inform their work. Techniques used included singing precomposed songs and instrumental improvisation. All respondents worked during the COVID-19 pandemic, with much variation between NHS Trusts. The challenges and positive aspects of working during the pandemic included a negative impact on staff and patients’ physical and psychological wellbeing, and a raised profile of the arts therapies, respectively. Further research is needed to evaluate the impact of music therapy on people living with dementia in acute NHS settings and raise awareness of how music therapy could help wards to meet the needs of service users as specified in the National Institute for Health and Clinical Excellence (NICE) guidelines.

Upper tract CT urogram for the surveillance of high-risk non-muscle invasive bladder cancer–are we over-screening patients?

Objective: The European Association of Urology (EAU) recommends annual upper tract imaging for high-risk (HR), non-muscle invasive bladder cancer (NMIBC). We evaluated the incidence of upper tract recurrence found during imaging surveillance for HR NMIBC and appraised our imaging strategy and patient radiation exposure. Subjects/patients (or materials) and methods: Two hundred and eighty-six patients between 2014 and 2019 with HR NMIBC (G3 tumour or T1 tumour or CIS, as per National Institute for Clinical Excellence (NICE) guidelines), were included in the study. The total number of computed tomography (CT) scans performed, the average radiation dose administered and the incidence rate of upper tract disease for each patient were recorded and analysed using a Microsoft Excel database. Results: The incidence rate of upper tract recurrence diagnosed during CT follow-up was 4/286 (1.4%). Three had a successful laparoscopic nephroureterectomy, the fourth was medically unfit for surgery. In total, 2.8% (8/286) were found to have other urological diagnoses. Patients received a CT scan on average every 13 months, with a mean radiation dose of 11.5 mSv. Conclusion: This study found that patients with HR NMIBC have a lower risk of upper tract recurrence than previously reported, which might support a guideline change to eliminate unnecessary radiation exposure during follow-up. Level of evidence: Not applicable for this multi-centre audit