Departmental Audit Research Articles

HPB SO57 - Imaging in Acute Pancreatitis: Are We Getting It Right?

Abstract Background Guidelines indicate that routine use of imaging is unwarranted in patients with acute uncomplicated pancreatitis presenting with abdominal pain and increased serum amylase or lipase levels without signs of severe disease. Moreover, early CT scans may fail to accurately reflect disease severity and provide no diagnostic advantage. Method We performed a retrospective clinical audit at a district general hospital in the United Kingdom to find out the current practice regarding the use of imaging in patients presenting with acute pancreatitis. The patients were studied from January 2023 to March 2023 for the 1st cycle, and from April 2024 to May 2024 for the 2nd cycle. The list was identified by the clinical audit department – adult patients who presented to the A&E with symptoms of acute pancreatitis were included. Results Between January - March 2023, 44 patients presented to A&E with symptoms of acute pancreatitis. Of these, 25 (56%) had a CT-scan within 72-hours, with 80% showing evidence of acute pancreatitis —1 with pancreatic necrosis, 7 with intra-peritoneal fluid, & 5 with peri-pancreatic fat-stranding. The study revealed poor compliance with standards, prompting efforts to raise awareness. Findings were shared at the departmental audit meeting, & posters were displayed in A&E and GeneralSurgery departments. In the 2nd-cycle (April-May 2024), 32 patients presented, with 14 (53%) having a CT-scan within 72-hours & all had serum amylase levels checked, with 11 within normal limits. Conclusion This closed-loop clinical audit demonstrated that with appropriate measures and improved awareness of current guidelines, there can be increased compliance to the guidelines by the clinicians. This, in turn, reduces the risk of radiation exposure to patients and optimizes the use of CT scans.

Do we consent to change? An evaluation of oral and maxillofacial outpatient department dentoalveolar consent forms

Obtaining informed consent before performing any dentoalveolar procedure is a professional, ethical, and legal obligation. Prior to this work, in this oral and maxillofacial department, no standardised consent process existed for dentoalveolar procedures. A targeted literature review established localised gold standards for dentoalveolar procedures, and retrospective data from 56 dentoalveolar consent forms over a four-week period assessed baseline compliance with these standards. Data analysis identified that risks of dry socket and trismus were documented in only 7% of cases, and maxillary tuberosity fracture was never documented. Thirty-three per cent of lower third molar cases did not include consent for inferior alveolar nerve injury. Findings were discussed in a departmental audit meeting, and a root cause analysis identified memory failure, repetition fatigue, and varying clinician knowledge and experience, as key drivers. The evidence base and localised gold standards were discussed. A standardised, bilingual, triple-copy dentoalveolar consent form was developed, including predefined indications, additional procedures, and risks, in a tick-box format. This form was presented to the Department of Patient Safety and Quality and gained local approval. Cases completed with the new form will now be evaluated against the localised gold standards, with a mixed-methods feedback survey investigating staff and patient opinions. Local processes for obtaining and documenting valid consent for dentoalveolar treatment were found to be inconsistent and frequently inadequate. Fifteen localised gold standards were set, and a new standardised consent form developed, which will be evaluated for effectiveness and acceptability.

Psychological and functional outcomes of horizontal squint surgery in adults with no preoperative diplopia using Quality-of-Life AS-20 questionnaire

BackgroundCorrective squint surgery has a significant psychological impact, affecting both the quality of life and mental health of patients. This study highlights the quantitative and subjective assessment of both the...

Embracing Digital Transformation: A Three-Cycle Audit on Improving Intraoperative Tourniquet Documentation Following BOAST (British Orthopaedic Association Standards for Trauma) Guidelines.

Introduction Tourniquets are vital devices in orthopaedic surgery that aid in creating a bloodless field.While they reduce operative time and outcomes, improper use can lead to severe complications. The British Orthopaedic Association Standards for Trauma (BOAST) offers guidelines for safe intraoperative tourniquet usage, emphasising proper application and accurate documentation. With the push for a paperless National Health Service (NHS), orthopaedic units across the UK are transitioning to electronic patient records (EPR). In this audit, we aim to evaluate the impact of electronic patient records (EPR) implementation on tourniquet documentation and subsequent interventions to enhance guideline adherence. Methods This closed-loop audit evaluated 159 emergency trauma cases at a single UK-based district general hospital across three different cycles. The first cycle (n=50) was collected before the trust-wide adoption of an EPR system (EPIC HIVE). Upon collecting the second cycle (n=59), local intraoperative tourniquet usage results compared to BOAST were presented at a departmental audit meeting. A specialised smart phrase template was subsequently shared with the department and the results were re-audited in the third cycle (n=50). Statistical analyses were performed to compare the cycles. Results Following the introduction of the EPR, compliance with documentation standards (fully and partially adhered to) initially declined from 38.0% to 17.0%. Post-intervention, compliance increased to 62.0% (p=0.0005). Individual aspects of documentation revealed notable improvements, including increases in skin assessment pre- and post-tourniquet application (0% to 56% and 0% to 60%, respectively, p<0.0001), isolation method (0% to 60%, p<0.0001), exsanguination method (2% to 24%, p=0.0003), tourniquet pressure (39% to 76%, p=0.0001) and tourniquet time (59% to 94%, p=0.0001). Lower limb tourniquet pressures significantly decreased between audit cycles (mean: 287.06 vs mean: 265.91, p=0.007)while upper limb pressures remained relatively stable (mean: 236.67 vs mean: 236.56, p=0.993). No tourniquet-related complications were reported across all audit cycles. Conclusion While the introduction of new EPR systems may initially present challenges in upholding accurate operative records, the incorporation of specialised electronic templates and active staff engagement has shown to be instrumental in improving tourniquet safety and enhancing care standards.

EGS P39 The first cycle of an audit assessing the quality of documentation of emergency laparoscopic appendicectomies at Birmingham Heartlands Hospital, a District General Hospital

Abstract Background Laparoscopic appendicectomy is a common general surgical procedure. Poor documentation can a) result in misunderstandings between healthcare workers looking after patients and b) limit fair investigation of incidents. The Get It Right First Time (GIRFT) guidance was produced to advise on the information that should be available in patient records to reduce risk of both of the above. Aims and objectives To assess how well laparoscopic appendicectomies are documented in accordance with the GIRFT criteria. To then develop interventions to improve documentation and ultimately improve communication with other healthcare workers and allow defence of good medical practice. Methods Three people collected data on 100 laparoscopic appendicectomies that took place in 2022-2023 at Heartlands Hospital. Data was collected based on the 34 GIRFT recommendations and the sources were: electronic patient notes (adults); scanned patient notes (children); electronic operation notes (all); and theatre logbooks. It was then analysed and grouped into factors that were documented well (&amp;gt;75% of the cases), moderately well (&amp;gt;50% but £75%), poorly (&amp;gt;25% but £50%) or very poorly (£25%). Results Factors that that were documented well (23%) included use of a sterile bag for appendix removal (83%), details of closure (96%), and instructions for post-operative antibiotics (88%) and recovery (97%). Those documented moderately well (19%) included port location and size (70%) and achievement of haemostasis (62%). Those documented poorly (23%) included whether ports were inserted under direct vision (38%) and whether any residual appendix was left behind (39%). Those documented very poorly (36%) included sending a sample to histology and grade of doctors. Several of these were documented primarily in paper records that are not scanned - hence not readily accessible). Conclusions While there are several aspects of documentation which we are currently doing well, there is still much scope to improve documentation as a whole. The current format of the operation note itself limits the information which can be communicated. This in combination with the documentation of some important information on paper – which is largely inaccessible outside of theatre or once a patient has been discharged – produces unnecessary ambiguity. Discussion is ongoing with electronic records teams to alter the operation note format to improve documentation quality. These findings will be discussed at a departmental audit meeting to specify changes before re-auditing.

624 Medication Cessation Post-TURP: Are We Getting It Right?

Abstract Aim Most patients who have a TURP should be advised to discontinue medication for bladder outflow obstruction secondary to benign prostate hyperplasia (BPH) after their surgery. This closed loop QIP audited whether this was the case, presented the findings to the department and re-audited to see whether there had been a decrease in continuing unnecessary post-TURP medication. Method The QIP began in October 2020 with a retrospective review of 50 patients that underwent a TURP at a large district general hospital. Patient records were reviewed to ascertain if patients were taking alpha-blockers (ABs) or 5 alpha-reductase inhibitors (5ARIs) pre-operatively, and if these were discontinued post-procedure. Any instruction to continue medication post-operatively was noted in the data collection. This data was presented at a departmental research and audit meeting. The second QIP cycle used the same data collection methodology for the subsequent 50 patients who underwent a TURP (June 2021). Results The presentation resulted in a statistically significant decrease in unclear documentation 30% to 10% (p = .0124). Although there was an increase medication discontinuation post-TURP (27.3% to 48%) this wasn’t statistically significant (p = .246). The percentage of patients who were continued on an AB or 5ARI post-op without documentation decreased from 63.3% to 48%, but this change was also not statistically significant (p = .384). Conclusions Simple departmental audits help improve patient safety through clearer documentation and presentation of new literature. It would be beneficial to produce clear guidelines to patients and their primary care physicians to advise to discontinue BPH medication TURP unless otherwise advised by the urologist.

589 Medication Prescribing for Patients Undergoing Cardiac Surgery with Heart Failure with Reduced Ejection Fraction (HFrEF) and Review of Left Ventricular (LV) Function Documentation - A Departmental Audit

Abstract Aim This study aims to audit the prescribing practices for patients with heart failure with reduced ejection fraction (HFrEF) who have undergone cardiac surgery at our department in accordance with European Society for Cardiology (ESC) guidelines for titrating heart failure medication in this cohort of patients. Method Data was collected from patients (n = 217) who have undergone cardiac surgery at our department between 20 May 2021 to 20 August 2021. This was collected from Tomcat Systems (Philips) and left ventricular ejection fraction (LVEF) was noted. ESC guidelines define HFrEF as LVEF≤40% and 15 patients met this criterion. These patients had their medications and electronic patient records reviewed to assess whether they are prescribed, considered for titration, or had a contraindication to the following medications (grouped as compliance rate) as per the 2016 ESC guidelines: ACE-inhibitor (or Angiotensin Receptor-Neprilysin Inhibitor - ACEi/ARNI), beta-blocker (BB) and mineralocorticoid receptor antagonist (MRA). Results This audit found a compliance rate of 67% (10/15) patients for ACEi/ARNI, 80% (12/15) patients for BB and 67% (10/15) patients for MRA. Following a departmental meeting, significant barriers were identified to optimal prescribing of these medications including lack of LVEF information readily available for ward round, lack of awareness and miscommunication of responsibility. Conclusions Having identified the challenges to optimal titrating of these medications, we have implemented interventions to improve communication of LVEF status to the clinical team. We have also encouraged the referral of these patients to heart failure clinic. The next cycle of audit will assess the efficacy of these changes.

237 Delay in Ankle Fracture Fixation Against BOAST Guidelines for Ankle Fractures

Abstract Aim Ankle fractures are common, and the majority are the result of low energy torsional trauma. The aim of treatment is to restore and maintain stability and alignment of the joint, ideally with normal anatomy of the ankle mortise. According to BOAST guidelines for ankle fractures, Early fixation within 24-48 hours is recommended in the majority of patients under 60 years when the ankle mortise is unstable. This study aimed at assessing our practice in managing ankle fractures against BOAST guidelines and infection rate assessment. Method Data was collected respectively from electronic patient records for three months period and entered excel. First cycle results were presented in a departmental audit meeting and recommendations to improve practice were acted upon. Second cycle data was collected three months later and for three months period. Final re-audited results were presented in a departmental audit meeting. Results First cycle results: only 11% of patients had their ankle fractures fixed within 48 hours and none of them had surgical site infection. 65.2 % of patients had their operations over a week with an Infection rate of 10.6%. Second cycle results: 19% of patients had their ankle fractures fixed within 48 hours and none had surgical site infection. 47.6 % of patients had their operations over a week with an Infection rate of 4.8%. Conclusions Second cycle results showed improvement in operative timing and surgical site infections rate against BOAST guidelines compared to initial first cycle results. Early fixation for ankle fractures is associated with lower infection rates.

888 Improving the Documentation of Skin Closure and the Plan for Its Removal for Trauma &amp; Orthopaedic Patients

Abstract Aim Surgical patients require closure of wounds with skin clips or sutures. Removal at an appropriate time can prevent complications, namely infection. Our goal is to ensure clear documentation of closure type and plan for removal. The Royal College of Surgeons states that “details of closure technique” and “detailed post-operative care instructions” are required. Method Retrospective data collections were undertaken in January and September 2022 for trauma patients in Altnagelvin Hospital. Data was gathered from Operation Notes. The first collection included 30 patients, the second included 24 patients. Two main interventions were implemented. The first of these was presentation of the initial findings at a departmental audit meeting for the purpose of education. The second was to amend operative proformas to include different types of skin closure and its removal at a prescribed time in the post-op plan as “delete as appropriate” options. Results Following our interventions, the correct skin closure was documented in 100% of patients. Plan for removal of closure was documented in 84.6% overall between both written and typed notes. Typed operative notes had 100% plan for removal documentation compared with only 66.67% of written notes. In the first collection, only 55% of patients had adequate removal plans documented on typed notes so the amended operative notes being introduced have resulted in a clear improvement. Conclusions Accurate documentation is essential for patient safety and simple interventions can result in a drastic improvement in quality. Pre-typed operative notes were superior to written operative notes and should be used where available and appropriate.

FTP1.2 Delay in ankle fracture fixation against BOAST guidelines for ankle fractures

Abstract Aim Ankle fractures are common, and the majority are the result of low energy torsional trauma. The aim of treatment is to restore and maintain stability and alignment of the joint, ideally with normal anatomy of the ankle mortise. According to BOAST guidelines for ankle fractures, Early fixation within 24-48 hours is recommended in the majority of patients under 60 years when the ankle mortise is unstable. This study aimed at assessing our practice in managing ankle fractures against BOAST guidelines and infection rate assessment. Methods Data was collected respectively from electronic patient records for three months period and entered excel. First cycle results were presented in a departmental audit meeting and recommendations to improve practice were acted upon. Second cycle data was collected three months later and for three months period. Final re-audited results were presented in a departmental audit meeting. Results First cycle results: only 11% of patients had their ankle fractures fixed within 48 hours and none of them had surgical site infection. 65.2 % of patients had their operations over a week with an Infection rate of 10.6%. Second cycle results: 19% of patients had their ankle fractures fixed within 48 hours and none had surgical site infection. 47.6 % of patients had their operations over a week with an Infection rate of 4.8%. Conclusions Second cycle results showed improvement in operative timing and surgical site infections rate against BOAST guidelines compared to initial first cycle results. Early fixation for ankle fractures is associated with lower infection rates.

OGC P18 Feeding jejunostomy complications after oesophagectomy: a quality improvement project at a tertiary referral centre

Abstract Background A feeding jejunostomy is one method to provide adequate nutrition after oesophagectomy. This bypasses the anastomosis allowing healing before oral feeding resumes. However, routinely using feeding jejunostomies may not be appropriate for patients within an Enhanced Recovery After Surgery protocol due to complications. Feeding jejunostomies have 3–61% morbidity, with mechanical (i.e tube dislodgement) and non-mechanical (i.e. site infection) complications plus associated increased length of stay. The local standard after oesophagectomy is routine feeding jejunostomy placement. However, selective, rather than routine feeding jejunostomy placement may therefore be warranted. Aim Conduct a quality improvement project addressing the local feeding jejunostomy complication rate after oesophagectomy. Methods Cycle 1: A review of oesophagectomies between 2018–2021 assessing complications using the Clavien-Dindo classification. An existing database of oesophagectomies was screened for patients undergoing concurrent feeding jejunostomy insertion. Patients ≥18 were included, whilst any indication for oesophagectomy was included. Patients lacking information on type and bore of jejunostomy tube inserted were excluded. Demographics, jejunstomy tube type and bore, complication and Clavien-Dindo grade of complication were recorded. The Charlson comorbidity score of each patient was determined to help find a population at risk. Intervention: Findings to be presented at a departmental audit meeting, with patient risk stratification to identify a cohort at risk. Cycle 2: re-audit (July 2022 - July 2023) as per cycle 1 after presentation. Improvement = fewer jejunostomy-specific complications. Results 110 patients were included, with a median age of 65.5 (IQR 61.0–72.0). 81.8% patients (n=90) sustained a complication, mostly Clavien-Dindo grade II. Jejunostomy-specific complications occurred in 21.8% patients (n=24), with the commonest jejunostomy-specific complication being a leak (44.8%). 4 ‘major’ (Clavien-Dindo ≥III) jejunostomy-specific complications were reported. No ischaemic small bowel necrosis was reported, significantly less than a prior audit (0.0% vs. 3.74%, p=0.029). Demographics/ Charlson comorbidity score, jejunostomy type inserted (JJ tube, 15F or 9F) and jejunostomy insertion method (open/ laparoscopic) did not impact overall or major feeding jejunostomy-specific complication rate. Conclusions This first cycle agrees with the reported complication rate in the literature. Though a population at risk could not be determined, reviewing local non-specialist centres may aid this, to reduce future complications. The literature would support a more selective approach to feeding jejunostomy insertion and as such this should be taken to reduce post-insertion complications. Continued prominent advice regarding inotropes may prevent ischaemic bowel. We aim to introduce clear warnings to the local ERAS protocol over the concurrent use of jejunostomy feed and inotropes, whilst electronic warnings flagging concurrent jejunostomy feed and inotrope prescribing are being worked upon. Moreover, poor hospital coding of jejunostomies may have limited the cohort, preventing determining a cohort at risk of feeding jejunostomy insertion.

903 Improving Documentation of Tourniquet Use in a Trauma Unit in Line with New BOAST Guidelines

Abstract Aim Local tissue damage is a significant potential consequence of intraoperative pneumatic tourniquet use, via pressure-related damage or chemical injury. The British Orthopaedic Association released a guideline relating to the safe intraoperative tourniquet use in October 2021, dictating standards for documentation in operative records. Initial audit suggested that only 15% of the required information was documented. With updated operative record paperwork and electronic templates, we aimed to improve adherence to updated BOAST guidance. Method Following analysis of 14 days' worth of trauma operation records, results of local documentation of tourniquet use were presented at a departmental audit meeting. With departmental permission, changes were made to the operation notes template, to include tickboxes relating to the use of tourniquets, skin condition pre/post-operatively, method of isolation, method of exsanguination, and the pressure of tourniquet and duration of use in line with new guidelines. Additionally, a new, time-efficient template was designed for those using electronic records. Results were re-audited over a 14-day period following dissemination of the relevant templates. Results Initial results suggested that only 15% of required data surrounding tourniquet use was being documented, with none recording information relating to skin condition pre/post-operatively, method of isolation or exsanguination. Following aforementioned interventions led to an improvement in documentation from 15% compliance to 64% compliance. Conclusions Further efforts are required in order to further improve documentation of tourniquet use, particularly when in electronic format, initial re-audit results are encouraging for improved adherence to new BOAST guidance in a local trauma unit.

1048 REDUCING RISK FROM WARFARIN- A COMPLETED AUDIT CYCLE ON NICE COMPLIANCE WITH WARFARIN FOR NVAF IN HOSPITALISED OLDER PEOPLE

Abstract Introduction Traditionally Warfarin has been mainly used for stroke thromboprophylaxis in patients with atrial fibrillation but direct oral anticoagulant (DOAC) are increasingly being used as they have improved safety profiles with comparable efficacy. Recent data from National Reporting and Learning System (NRLS) have discovered safety incidents related to anticoagulation, predominantly Warfarin, contributing in excess of 10% of all medication errors. National institute for clinical excellence (NICE) recommends reassessing anticoagulation choice for patients on Warfarin with poor anticoagulation control, indicated by any of the following: 1 &amp;gt; 2 INR values &amp;lt;1.5 or &amp;gt; 5 or 1 INR value &amp;gt;8, within the past 6 months 2 &amp;gt; Time in therapeutic range (TTR) &amp;lt;65% Intervention An initial retrospective audit on 50 patients on Warfarin for NVAF performed between June—September 18 showed poor compliance with NICE. We reviewed the previous 6 months INR values and recorded any significant deviations outside of the therapeutic range as per NICE. TTR over the last 6 months was calculated using the Rosendaal method. Following departmental audit presentation, a reaudit was carried out between Jan-Aug 2019 to assess improvement. Results Median age was 87.5 compared to 83 in the first audit. Warfarin was correctly continued in 7/38(18%) in the 1st audit which improved to 9/28 (32%) in the second. Number of patients discharged on warfarin with unstable INRs decreased significantly from 26/32 (81%) patients in the 1st audit to 10/24 (42%) in the 2nd. Discussion Our reaudit shows significant reduction in continuation of warfarin on discharge in patients with unstable INRs (p = 0.0043 Fisher exact test). Although, there is a trend towards improvement with NICE compliance; in general, the compliance with NICE remains poor. We suggest geriatricians to proactively review the appropriateness of warfarin prescription and to consider a DOAC in preference to Warfarin in all elderly patients.

P014 Giant Cell Arteritis Patient Pathway: A Multi-Disciplinary Approach to Service Improvement in the time of COVID-19

Abstract Background/Aims The RNHRD is a tertiary rheumatology centre offering a fast-track GCA assessment service. A 2018 departmental audit highlighted areas of good practice including timely assessment of cases but demonstrated irregularities in follow up processes. COVID-19 dramatically changed the way we could deliver our GCA service. Additionally, we saw increases in referrals, confirmed diagnoses and complex disease in our local population during the pandemic. This prompted us to undertake a service improvement project. Our main aims were to optimise follow up in line with national guidelines, enhance patient safety and improve the patient experience. Methods We undertook a service review, starting by mapping the patients’ journey. Guidelines were reviewed and stakeholders consulted. We identified several areas for improvement including; consultant-led risk stratification of patients, formalised follow up pathways and closer collaborative working with relevant departments. Additionally, we sought to streamline our processes to accommodate the increased COVID-19 workload. Results A risk stratified follow up pathway was created. Patients are stratified at initial review, by consultants, into low and high-risk pathways. Follow up intervals have been standardised in line with BSR guidance. Follow up patients are reviewed in a dedicated clinic; medical and nursing clinics run supervised by a vasculitis specialist. Patients transfer between different clinics, dependent on clinical stability. Patient information provided has been standardised, with increased emphasis on flare management and steroid side effects. In collaboration with patients this is being incorporated into a “GCA patient passport”, offering a consistent information resource for patients and clinicians. The nurse-led patient advice line is used frequently by GCA patients. All GCA queries are now directed to the on-call registrar, to ensure same day responses. Temporal artery ultrasound is well utilised and completed efficiently; 82% of scans between September 2019 and September 2021 occurred within 48 hours of referral. Via close working with vascular ultrasound, we have been able to create dedicated daily ultrasound capacity. Collaborative working with our Ophthalmology department has increased; communication channels between departments have been agreed, and education sessions have been provided. Processes for new GCA patients were streamlined, for example moving location of reviews. This ensured ongoing timely review of new GCA patients despite increased referral numbers. Conclusion COVID-19 had a significant impact on service delivery but provided a catalyst to develop our service. By engaging with stakeholders across disciplines, and reacting to patient feedback, we have been able to institute effective and meaningful change. This process is iterative and we plan further assessment of outcomes including co-morbidities and complications. Further formal patient surveys and development of a GCA expert patient group are underway and will inform further service development. Disclosure B. Mulhearn: None. J. Ellis: None. S. Smith: None. S.L. Tansley: None. S. Skeoch: None.

706 IMPROVING PRESCRIPTION OF PARKINSON’S DISEASE MEDICATIONS FOR PATIENTS ON ELDERLY CARE WARDS AT ROYAL STOKE UNIVERSITY HOSPITAL

Abstract Introduction Patients with Parkinson’s disease (PD) are commonly admitted into hospital with various acute medical conditions. Inaccurate prescription can result in adverse effects, increased hospital stay, and increased morbidity and mortality. We present a QIP conducted to improve PD medication prescription pattern among doctors and medication delivery from the nursing staff. Method In PDSA 1, we conducted a survey among doctors and nurses to assess their initial knowledge on PD medications. A baseline review of PD prescriptions on our Frail Elderly Assessment Unit (FEAU) was conducted. Our interventions include Introduction: of PD medication alert sticker attached to drug charts and recorded drug chart when they are taken off the wards. In PDSA 2, repeat survey was carried on Elderly care wards. We also reviewed PD prescriptions over a 2-week period on Elderly care wards. Results During the surveys, there were 55 respondents in PDSA 1 and 51 respondents in PDSA 2. The percentage of those who feel PD medications are critical medications remain similar in both cycles (98%). There was an improvement in the awareness of PD stickers from 44% to 83%. Those who feel PD alert stickers are appropriate improved from 93% to 100%. Respondents who chose all included appropriate PD medication sources for improving prescription pattern improved from 38% to 62%. There were 8 prescriptions during PDSA 1 and 21 prescriptions during PDSA 2. The use of PD stickers improved from 0% to 76%. The numbers of PD medications prescribed appropriately improved from 50% to 65%. Conclusion An improvement in prescription pattern was demonstrated, as we hope to improve patient safety and increase awareness across the trust. Our recommendations include use of PD medication alert sticker and recorded drug chart. We discussed our plans in Medicine Governance meeting, departmental newsletter, and presented in departmental audit meeting.

Audit on complete excision of Head and Neck skin cancers

Background: Squamous Cell Carcinomas (SCC’s) and Basal Cell Carcinomas (BCC’s) are routinely removed on the Oral and Maxillofacial department. To ensure a favourable outcome the correct pre-operative diagnosis and complete excision of the cancer is critical. This departmental audit determined the accuracy of pre-operative diagnosis and whether surgical management is meeting the set standard of 97% complete excision. The quality of pathological reports was also reviewed.

413 The Clinical Efficacy of Intra-Operative Peritoneal Fluid Sampling in Abdominal infections

Abstract Aim To uncover the practical efficacy of intra-operative peritoneal fluid sampling and the impact on antibiotic prescription and clinical outcomes in patients undergoing emergency surgery due to intra-abdominal infections. Method Our retrospective study included all patients undergoing emergency surgery for intra-abdominal infections at Southend University Hospital over 6 months (January – July 2019). Data was collected from electronic patient records, case notes and microbiology reports and included the following information: patient age demographics; type of infection; peritoneal fluid sampling indication; samples taken; details of swab culture report including organisms grown and antibiotic sensitivity; clinical course and incidence of subsequent intra-abdominal infection to include readmission and/or further procedures; the type, duration and route of antibiotic prescribed and duration of hospital stay. This audit was approved by the Departmental Audit Lead. Results 441 patients undergoing emergency surgery for intra-abdominal infection were identified. After exclusions, intra-operative peritoneal fluid samples were indicated in 77 patients (mean age 39.4 years). Of these only 3 had samples taken (3.9%). The most common organisms isolated were mixed anaerobes followed by Streptococcus angiosus. The most common antibiotic sensitivity was Metronidazole and Penicillin. One readmission occurred due to an intra-abdominal tubo-ovarian abscess. Conclusions The study shows that the current practice in our hospital regarding intra-operative peritoneal fluid sampling in intra-abdominal infections reflects the present widely held attitudes regarding its reduced practical utility. Abandoning routine sampling had no significant impact on the clinical course and may be more cost-effective. The study may help surgeons reflect on changing perspectives on this traditional practice.

An analysis of individual and department triage variances to identify, quantify, and improve markers of triage nurse accuracy

An analysis of individual and department triage variances to identify, quantify, and improve markers of nurse triage accuracy. Rebecca Cotton, Richard Drew, Matthew Douma, Domhnall O’Dochartaigh, Candice Keddie, Karen Muncaster, Christopher Picard Background: Canadian Emergency Departments (ED) use the five-point Canadian Triage Acuity Scale (CTAS) to sort and prioritize patients according to acuity. CTAS scores are used to make decisions on patient flow, staffing complement, and funding. Despite this, there is a paucity of literature describing how CTAS data can be audited, and how the data can inform quality improvement/assurance (QI/QA). Implementation: Triage data downloaded from Tableau were analyzed using Microsoft Excel and IBM SPSS 26. Staff were informed of the audit using email and social media, and invited to discuss the results with educators and administrators. Staff identified for intervention were approached individually with the administrative plan. Anonymized versions of the work plan were posted on the departmental audit board. Nurses triaging greater than 50% department average were offered the option to triage less frequently, while nurses triaging less than 50% the department average were preferentially placed in triage. Nurses triaging fewer than 100 patients per year were informed they would be relieved of triage responsibility unless their rates increased above threshold. Nurses “down-triaging” patients at rates greater than 2 SD were informed that if their practice remained outside 2 SD at repeat audit they would be relieved of triage responsibility until they voluntarily completed CTAS refresher training. Nurses with average assigned CTAS scores &gt; 2 SD department average had 20 visits randomly audited per month for error/appropriateness. Evaluation Method: Computer-assisted analysis of complete triage records was conducted for August 2019 to August 2020 at the Misericordia Hospital Emergency. Complete triage entries of every patient triaged by all triage trained nurses in the department were examined. Nurse’s with practice variation two deviations from department mean were identified and received additional detailed audits. Items examined for error were: FTE adjusted triage frequency; average CTAS score assigned; triage score manual override “down/up-triage” rate; proportion of absent Numeric Pain Scores (NPS) for patients with primary presenting complaints of pain; and vital signs modifier error rates. Initial department averages were used for benchmarking individual nurses; zone averages were used to benchmark department performance. Nurses were interviewed, audit results and action plans were posted. Repeat audits were performed on a three-month basis and benchmarked to initial measures, and a staff awareness campaign was enacted to improve NPS scoring. Data were extracted using text-parsing algorithms programmed into Microsoft Excel and analyzed using IBM SPSS 26. Data were normally distributed and descriptive statistics were calculated using means and standard deviations. T-testing was used for comparisons, and all testing was two-tailed with a pre-defined significance set at 0.05. Results: After the 3rd quarterly audit and associated interventions, global improvements were appreciated in triage nurse practice. There was a 68% reduction in the need for administrative action (n=51, n=18) with reduced variance in individual nurse triage rates and a 50% reduction in nurses who triaged &gt;50% more patients than their peers. 50% fewer nurses had a mean triage rate &gt;.02 above or below department average, there was an 86% reduction in high risk vital sign error rates, a 78% reduction in ”down-triage” rates, and a 6.5% improvement in documentation of numerical pain scores. Advice and Lessons Learned:1) Triage data analytics can rapidly identify staff with significant deviations from the average,making auditing and QI/QA activities more efficient and effective. 2) Having a concrete performance management framework and dissemination plan in place areessential for auditing to have a significant impact on triage consistency and quality over time. 3) Future QI/QA work should consider expanding computer-assisted text parsing to identifypatients at risk for mis-triage for reasons other than vital sign derangement, which will allowfor broader ED rollout across the Edmonton Zone and beyond.

A retrospective audit of the timescales involved in the diagnosis and management of suspected Achilles tendon ruptures at a single National Health Service trust: A quality service improvement and redesign project.

The Achilles tendon is the most frequently ruptured tendon. Prompt diagnosis of this injury ensures optimal management decisions are instituted early ensuring the best outcome and patient experience, at minimal cost to the United Kingdom National Health Service. Despite this, regional and national variations to diagnosis and management exist, with anecdotal evidence of inefficiencies in the local patient pathway. To explore this further, a retrospective departmental audit of timescales from presentation to ultrasound diagnosis and definitive treatment decision was undertaken. All suspected Achilles tendon ruptures in 2018 were identified through electronic and written patient records, and information on timescales involved in the diagnosis and management of each compiled. Descriptive statistics were used to map each step of the pathway and timescales involved, with performance assessed against local departmental standards and the Swansea Morriston Achilles Rupture Treatment (SMART) protocol. In total, 119 patients were identified, of which 113 received an ultrasound examination. Local departmental standards were met in the majority of cases, with 78% (n = 88) diagnosed by ultrasound within one week of the request and 83% (n = 91) given a treatment decision within two weeks of presentation. However, this was suboptimal when compared with timeframes utilised for developing the SMART protocol, with only 7% (n = 8) scanned within 48 hours of presentation. Key areas of the patient pathway were identified for quality service improvement and redesign, with multidisciplinary discussion resulting in the development of a revised patient pathway which expedites diagnosis and treatment for these injuries.

992 Short Term Effectiveness of Interventions Aimed at Preventing Post-Operative Acute Kidney Injury (AKI) In Patients Undergoing Elective Lower Limb Arthroplasty

Abstract Introduction Acute kidney injury (AKI) is a potentially avoidable complication in patients undergoing elective lower limb arthroplasty. The National Institute for Health and Care Excellence (NICE) offers guidelines to identity and manage AKI. This is a closed loop audit aiming to assess i) adherence to NICE guidelines and ii) whether simple interventions will improve compliance. Method We closed the loop on a departmental audit carried out in 2017. NICE guidelines were applied to stratify patients at risk of post-operative AKI. High risk patients included those on nephrotoxic drugs and with pre-existing co-morbidities. We then applied the AKIN criteria to identify post-operative AKI. We presented this data at our departmental trauma meeting. Following this we implemented the following interventions i) poster &amp; ii) aid memoir on patient admission proformas to identity those at risk. Results In 2017, post-operative AKI incidence was found to be 11.7%. Following intervention, in 2019 the incidence was 10% at 1 month and 5% at 7 months. Additionally, 80% of AKIs were identified on day 1 post-arthroplasty, compared to only 30% in 2017. Conclusions This audit showed that simple interventions reduced the incidence of post-operative AKI. Moving forward, we plan to assess long term effectiveness including the effect of junior doctor rotations.