Frimley Park Research Articles

980 Audit of the Day Case Laparoscopic Cholecystectomy Pathway in Frimley Park Hospital

980 Audit of the Day Case Laparoscopic Cholecystectomy Pathway in Frimley Park Hospital

Chronic or recurrent Campylobacter enteritis in primary immunodeficiency: a UK national case-series and review of the literature.

Chronic or recurrent Campylobacter enteritis in primary immunodeficiency: a UK national case-series and review of the literature.

159 The Role of Proformas in Improving the Documentation of Surgical Ward Rounds

Abstract Introduction Several NHS trusts rely on handwritten notes, including ward round (WR) reviews. These are essential in-patient care and must be completed/documented thoroughly. The General Medical Council and Royal College of Surgeons have both published guidance on WR documentation. Method This was a prospective study aiming to review WR documentation within general surgery at Frimley Park Hospital. 17 WR entries were reviewed using an 18-point checklist. A proforma was created based on published guidance and gaps in reviewed documentation. This was introduced for two months before a repeat review was conducted. A third review was conducted after an additional month to monitor for sustained improvement. Results Strengths in the baseline included documentation of WR leads (100%) and plans (100%), legible handwriting (95%), and NEWS score (88%). Common weaknesses were documentation of full observations, anticoagulation (both 6%), and relevant bloods and imaging (both 12%). The two months post-proforma review found improvement in all 18 areas of documentation, with five elements scoring 100%. Documentation of anticoagulation improved from 6% to 94%, relevant bloods from 12% to 82%, and full observations from 6% to 76%. Higher scoring WRs were linked to pre-prepared proformas, with lower scores linked to post-take WRs. The review was repeated after an additional month, showing consistently improved results in all areas. Conclusions This project has shown significant and sustainable improvement in WR documentation with the proforma. This project would therefore recommend the continued use of the proforma, and an additional review after the junior doctor change over to show continued sustainability.

Closed-loop audit of muscle sampling in Trans-Urethral Resection of Bladder Tumour

Introduction: Our experience with the presence of detrusor muscle (DM) following Trans-Urethral Resection of Bladder Tumour (TURBT). Objectives: To evaluate the presence of DM in primary TURBT specimens as a quality improvement exercise in Frimley Park Hospital, UK. And to assess if the level of the surgeon has impact on outcomes. Methods: Retrospective and prospective analysis of the electronic records from a single urology centre, servicing a group of urologists. Data collected over three consecutive audit loops between January 2014 and May 2018. Results: A total of 301 cases were performed under the care of seven consultant urologists. Analysis revealed a significant improvement in the overall quality of resections from 39% to 66% (50–84% for intermediate and high grade) after the introduction of the following interventions: (1) analysis and improved awareness of current practice; (2) introduction of European Association of Urology (EAU) guidelines by separating samples and sending a second specimen pot marked as bladder tumour base to look for DM; (3) dedicated urologists with an interest in bladder cancer performing en-bloc resection technique in appropriate cases. Conclusion: Through our closed-loop audits, we have demonstrated a considerable improvement in the quality of resections, resulting in accurate staging from the initial resection. This could in turn lead to improved over all prognoses and negating the need for re-resection in all cases of high-risk non-muscle invasive bladder cancer (NMIBC). Level of evidence: 3

Frimley Park Hospital Quality Improvement Initiative 2019-2020: Safe management and discharge of newly diagnosed children and young people with diabetes

Frimley Park Hospital Quality Improvement Initiative 2019-2020: Safe management and discharge of newly diagnosed children and young people with diabetes

TP6.2.1 Does the use of Negative Pressure Wound Dressings decrease superficial Surgical Site Infections in the Emergency Laparotomy?

Abstract Aims Surgical site infection (SSI) can be a significant cause of morbidity in the emergency laparotomy patient. Previous research into the role of negative pressure wound dressings to improve the rate of SSI culminated with NICE guidelines in 2019 recommending the use of negative pressure wound dressings in people who would be considered high risk for developing an SSI. Based on this guideline, we changed our policy to recommend the use of PICO dressings for all emergency laparotomies in order to decrease our rate of SSI. Our aim of this study was to assess the success of this policy change. Methods In this closed-loop audit we analysed data from all laparotomy patients at Frimley Park Hospital over 12 months. We retrospectively analysed the data of the pre-intervention group between January – June 2019, and prospectively audited all laparotomy patients between July – December 2019. Results We found that there was no significant decrease in the rate of superficial SSI, from a pre intervention rate of 22.2% to a post intervention 24.1%. Similarly, we found no significant decrease in the rate of wound dehiscence, which increased from 13.8% to 17.7%. In further assessment we saw no significant difference in the rates of contamination, ASA grades, or closure techniques to account for these increased rates. Conclusion While other studies have demonstrated a decrease in SSIs following the use of PICO dressings, we did not show such a result, leading us to question the cost-effectiveness of negative pressure wound dressings in the emergency laparotomy patient.

An assessment of referrals to a liaison psychiatry team within a large district general hospital – Completing the Cycle

AimsIn 2019 members of the Liaison Psychiatry Department at Frimley Park Hospital completed an audit of the referrals to the service1. The quality of referrals was found to be highly variable, for example only 28% included a risk assessment and frequently omitted both past psychiatric and past medical histories. As such an intervention was designed involving three parts;Multidisciplinary education of staffNew and more readily available referral guidelinesNew referral formThis re-audit seeks to complete the audit cycle and assess the impact of the intervention.MethodThe first 50 referrals to the Liaison Psychiatry Department of Frimley Park Hospital during February 2021 were assessed using the following criteria:Staff type, referral source, physically fit for assessment, physical cause ruled out, drugs / alcohol involved, appropriate reason for referral, clinical question asked, did final diagnosis match referral diagnosis, risk assessment included, information about admission included, past psychiatric history included and past medical history included.The percentage of referrals received for each criterion (e.g. the percentage with a risk assessment completed) was then derived from the data.ResultThere has been a marked improvement in a variety of areas. The percentage of referrals containing a risk assessment increased from 28% to 96%. This is likely due to the risk box now requiring an entry prior to being able to submit the referral form. Similarly the percentage containing past psychiatric history has risen from 38.8% to 90%. Previously 46.2% of referrals contained a working diagnosis which was not consistent with the clinical picture, but again this has improved, with 60% of initial diagnoses now matching the final outcome. There are however areas for improvement. Only 14% of referrals contained a specific clinical question, which is lower than the 20% achieved previously. This may be because the new referral form does not provide a specific free text box for this.ConclusionThe intervention yielded a marked improvement in the quality of referrals received by the Liaison Psychiatry Department at Frimley Park Hospital, and it is the intention to continue to use the current process. Based on the new results we will look to make small adjustments, for example adding a free text box for a specific clinical question and emphasising the importance of this information.

73 An Audit Evaluating the Management of Pre-Operative Anaemia in Elective Bowel Resections at Frimley Park Hospital

Abstract Introduction Pre-operative anaemia is common within the surgical population, particularly those scheduled for elective bowel resections. National and local guidelines recommend the treatment of pre-operative anaemia, as it is an independent risk factor for poor post-operative outcomes, including length of stay in hospital. Method A retrospective study of all NHS patients over the age of 18 scheduled for an elective bowel resection at Frimley Park Hospital between 1st May-31st October 2019. Results 85 patients met the inclusion criteria, with 29 recorded as anaemic. Of these patients, 55% (n = 16) received iron replacement, all of which were intravenous and did not include mildly anaemic patients. The median rise in haemoglobin post-infusion was 14g/L, with only one patient achieving a normal haemoglobin. The median length of stay for patients with a normal haemoglobin was six days, which increased to eight for those with anaemia of any severity. A statistically significant relationship was found between severity of anaemia and increased length of stay, particularly in the female population. Conclusions Pre-operative anaemia was linked to increased length of stay in hospital. The findings support the intravenous treatment of all severities of anaemia pre-operatively and therefore suggest treating mild anaemia patients, as normalising their haemoglobin will improve outcomes.

P011. Is repeating axillary us for screen-detected cancers in the treating hospital necessary?

Introduction: Jarvis Breast Centre (JC) is a breast screening centre for women living in Surrey and Hampshire. All newly diagnosed breast cancer patients have Axillary USS at JC. The Axillary USS is repeated at Frimley Park Hospital (FPH) before treatment to check for nodal spread and to escalate management. The aim of our study is to compare results of axillary USS of both institutions to determine whether repeat scan is necessary.

Head home: a prospective cohort study of a nurse-led paediatric head injury clinical decision tool at a district general hospital

ObjectivesTo assess if a nurse-led application of a paediatric head injury clinical decision tool would be safe compared with current practice.MethodsAll paediatric (<17 years) patients with head injuries presenting to...

Medium term outcome of a military population following ankle ligament repair using the modified Broström-Gould procedure

AbstractAimsLateral ankle ligament instability is a common and often debilitating condition affecting service personnel. This study aimed to assess the outcome of surgical repair utilising a modified Broström-Gould technique for patients in whom conservative therapies had failed.MethodsMilitary patients who underwent ankle surgery at Frimley Park Hospital between 2011-2016 were identified. Patients were contacted and asked to complete a retrospective Visual Analogue Score and Manchester Oxford Foot Questionnaire (MOxFQ). DMICP data were reviewed to identify return to fitness.Results109 military patients underwent surgery during this period, of whom 46 were contactable and completed the questionnaires. The median satisfaction score was 9/10, with 89% acknowledging that they would have the same procedure again. The mean increase in stability was 3 to 8 (out of 10), p&lt;0.005. 66% of respondents were still serving in the armed forces, but poor residual ankle function contributed to 23% leaving the military. Of those remaining in service, 50% had returned to a medically fully deployable status at an average of 9.9 months from the date of surgery.ConclusionsThis study has defined outcomes from ankle ligament repair that should help clinicians to manage the expectations of patients referred for this type of surgery.

OC-082 The results of a multi-centre study of surgery for full thickness rectal prolapse: Abstract OC-082 Table 1

Introduction Rectal prolapse is a disabling condition which is under-reported and affects the quality of life of our ageing population. Despite this there is ‘no accepted standard procedure’1a given patient should receive. The perceived risk of surgery has meant that elderly patients often undergo a perineal operation with an abdominal operation being reserved for younger patients or those with recurrence. Randomised controlled trials have found it challenging to recruit patients making comparison between outcomes difficult for abdominal and perineal operations. Method The Surrey and South West London Pelvic floor group was founded in 2014 and includes the following hospitals – Ashford and St Peters Hospital, Croydon University Hospital, East Surrey Hospital, Epsom and St Heliers Hospital, Frimley Park Hospital, Kingston Hospital, Royal Berkshire Hospital, St Georges Hospital and Wexham Park Hospital. All patients who underwent surgery for full thickness rectal prolapse between April 2011 and March 2013 were included. Data was collected retrospectively from the notes using a standardised proforma. Results 244 patients underwent surgery for full thickness rectal prolapse in the study period. Seven patients were excluded due to incomplete data leaving 237 patients. All but four patients were female. Median age at time of operation was 78.4 years with an average ASA of 2.1. The recorded overall recurrence for all surgery was 17.7%. Median length of stay (LOS) was 2 days. Conclusion In this retrospective multicentre study abdominal operations for full thickness rectal prolapse had a significantly lower rate of recurrence than the perineal approach. This was despite there being a higher proportion of patients in the abdominal group who had had previous surgery for rectal prolapse. Although patients in the abdominal group were younger and fitter there was no difference in length of stay and complication rates. The rates of recurrence for perineal operations were similar1but the recurrence rate after abdominal operations was higher than previousy reported in the literature.1This may be a reflection of the individual learning curves for laparoscopic rectal prolapse surgery during the study period (2011–2013). Disclosure of interest None Declared. Reference Senapati A, Gray RG, Middleton LJ, et al.; PROSPER Collaborative Group. PROSPER: a randomised comparison of surgical treatments for rectal prolapse. Colorectal Dis. 2013;15(7):858–68

PWE-117 The role of repeat liver biopsies in autoimmune hepatitis: clinical practice and outcomes

Introduction The role of repeat liver biopsies in established Autoimmune hepatitis (AIH) is unclear, with limited data on clinical practice and outcomes, and with variation in biopsy practice between physicians. Method We undertook a retrospective review of all patients with AIH who underwent a repeat liver biopsy between 2002–2013 at Frimley Park Hospital (Surrey, England); serving a population 430,000. The indication for repeat biopsy, liver histology and serological markers were recorded, as well as the clinical outcome/management resulting from each procedure. Results 17 patients were identified, all who were on treatment for AIH at the time of repeat biopsy. Clinical indications for repeat biopsy included: disease assessment/staging (34%) clinical deterioration (24%), diagnostic uncertainty (24%), medication withdrawal/remission (12%) and insufficient (Bx) sample (6%). Median time between 1 st and repeat biopsy was 24 months (range 1–108 months). Overall 10/17 (59%) patients had normal LFTs and 12/17 (71%) had normal IgG levels at the time of repeat biopsy. Repeat biopsy led to a change in treatment (dose/regime) in 11/17(65%) patients. Baseline cirrhosis was seen in 3/17 (biopsy/imaging), and developed in a further 2 patients (12%) over 24–48months; both with raised IgG levels at the time of repeat biopsy. 9 patients had a repeat biopsy at ≤ 24months. Within this group 4/9(44%) patients had normal LFTs, and 6/9 (67%) had normal IgG levels. Repeat biopsy led to a change in treatment in 2/4 (50%) patients with normal LFTs and 4/6 (67%) with normal IgG levels. Fibrosis progression was seen in 1/4 (25%) with normal LFTs, and 2/6 (33%) with normal IgG levels. Interface hepatitis/periportal inflammation was present in all repeat biopsies. Conclusion BSG and AASLD guidance suggest the use of repeat biopsies at 12–24 months following normalised transaminases to guide treatment withdrawal/maintenance, with IgG levels also thought predictive of histological response. However, the majority of repeat biopsies in our study were requested due to concerns of disease progression, rather than to assess for treatment withdrawal. Despite normalised LFTs/IgG levels, repeat biopsy led to treatment modification in more than half of this group; as well as demonstrating fibrosis progression and on-going histological activity. Our results support the need to individualise repeat liver biopsies to the needs of each patient. Disclosure of interest None Declared.

P101 How soon are patients testing outside gum receiving a positive HIV result?

Introduction UK national guidelines for HIV testing 2008, recommend that any individual testing positive for HIV should see a specialist preferably within 48 h and certainly two weeks of receiving the result. Methods All HIV positive test results performed outside the GUM clinic between January 2013 and December 2014 were obtained from the microbiology database at Frimley Park Hospital. 35 patients were identified. 20 were excluded because they were previously known to have HIV, had a “non-specific” or “weakly reactive” result. Results Of the 15 new diagnosis, 8/15 were inpatients, 4/15 outpatients and 3/15 GP diagnosis. Two-thirds were male, 53% White British and 73% heterosexual. The average age was 46 (31–65) years. All the patients had a fourth generation HIV test and a confirmatory test. The majority (87%) were late diagnosis with symptomatic HIV/AIDS and an average CD4 count of 50 cells/mm³. One inpatient diagnosis was missed for 5 weeks until the patient re-presented with PCP. The rest were all seen by a specialist (HIV consultant or health advisor) within 2 weeks of receiving their diagnosis with 64% seen within 24–48 h. Discussion/conclusion The majority were late, symptomatic patients with AIDS. All but one result which was initially missed were seen by a specialist within the recommended 2 to 14 days after diagnosis. The recommendation now is that all positive results are phoned to the named consultant/GP responsible for the patient as well as the HIV/GUM team.

P154 The Impact Of A Discharge Care Bundle On The 30-day Readmission Rate Following Hospitalisation For Acute Copd Exacerbation

Introduction National audit reports high rates of early readmission following hospitalisation for chronic obstructive pulmonary disease (COPD) exacerbation. Discharge bundles aim to optimise care and reduce readmission. Frimley Park Hospital NHS Foundation Trust interacts with different community respiratory teams across three counties. Aims We hypothesised that a novel COPD discharge bundle would reduce re-admission. We also wished to see if the bundle was effective across multiple community administrations, and in patients with a history of frequent exacerbation. Methods Admissions with a primary COPD diagnostic code and cases referred to the COPD nurse were collated during Q4 2013/14. Patients were classified according to whether they were assessed by the COPD nurse using the discharge bundle. Readmissions within 30-days and 3-months were identified using a hospital clinical database. Readmissions with COPD exacerbation (infective or non-infective) were included, as well as COPD associated lower respiratory tract infection or pneumonia. The database identified frequent severe exacerbators (patients with >1 admission in the previous year), and recorded age and length of stay as surrogates of disease complexity. Results 24 patients were excluded (18 had other diagnoses, 4 died, and 2 lived out of area). Table 1 shows the characteristics of the remaining 156 patients according to whether they completed the bundle. There was no overrepresentation of short (zero or one day) length of stay patients in the group not completing the bundle. 17.5% of patients completing the bundle were re-admitted within 30-days, compared to 34% who did not (p = 0.027). A similar trend was seen at 3-months. No difference was observed in the timing or duration of readmissions. Logistic regression using covariates of age, length of stay, history of frequent severe exacerbation and discharge bundle use, suggested the latter two variables were both independent predictors of re-admission at 30-days: OR 5.70 (95% CI 2.46 to 13.2, p Discussion Two-thirds of patients completed a discharge bundle during the Trust’s busiest quarter for COPD admission. Patients completing the discharge bundle had a significantly lower rate of 30-day readmission.

An analysis of a nationwide survey of current trend in breast reconstruction

An analysis of a nationwide survey of current trend in breast reconstruction

MRI for the pre-operative workup of invasive lobular breast cancer: Change in diagnosis

MRI for the pre-operative workup of invasive lobular breast cancer: Change in diagnosis

VitaminKdeficiency in cancer patients referred to a hospital palliative care team with bleeding and the impact of vitaminKreplacement on laboratory indicators of vitaminKstatus

International Journal of Laboratory HematologyVolume 35, Issue 4 p. 457-459 Letter to the Editor Vitamin K deficiency in cancer patients referred to a hospital palliative care team with bleeding and the impact of vitamin K replacement on laboratory indicators of vitamin K status D. J. Harrington, D. J. Harrington dominic.harrngton@gstt.nhs.uk Nutristasis Department, St. Thomas' Hospital, London, UKSearch for more papers by this authorL. Booth, L. Booth Eastern Health, Wantirna, Vic., AustraliaSearch for more papers by this authorN. Dando, N. Dando Phyllis Tuckwell Hospice and Frimley Park Hospital, Frimley, UKSearch for more papers by this authorL. Cottingham, L. Cottingham Department of Palliative Care, St. George's Hospital, London, UKSearch for more papers by this authorT. Beynon, T. Beynon Department of Palliative Care, St. Thomas' Hospital, London, UKSearch for more papers by this author D. J. Harrington, D. J. Harrington dominic.harrngton@gstt.nhs.uk Nutristasis Department, St. Thomas' Hospital, London, UKSearch for more papers by this authorL. Booth, L. Booth Eastern Health, Wantirna, Vic., AustraliaSearch for more papers by this authorN. Dando, N. Dando Phyllis Tuckwell Hospice and Frimley Park Hospital, Frimley, UKSearch for more papers by this authorL. Cottingham, L. Cottingham Department of Palliative Care, St. George's Hospital, London, UKSearch for more papers by this authorT. Beynon, T. Beynon Department of Palliative Care, St. Thomas' Hospital, London, UKSearch for more papers by this author First published: 07 December 2012 https://doi.org/10.1111/ijlh.12035Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume35, Issue4August 2013Pages 457-459 RelatedInformation

'I used to take so much for granted'.

Elaine Edwards (pictured) is a gynaecology nurse specialist, nurse hsyteroscopist and staff governor at Frimley Park Hospital NHS Foundation Trust in Surrey: 'I became a governor nine months ago. It has put a lot of things into perspective for me. I took so much for granted before. For example, I did not realise how important the patient pathway codings are for ensuring the trust is paid accurately for GP-commissioned work. I am updated on all the changes that are going on. Meanwhile, the council of governors can learn from me about what is happening on the shop-floor.'

Measures of Outcome in Rectal Cancer Surgery

Surrey, United Kingdom Correspondence: H. S. Tilney, M.D., F.R.C.S., Consultant Colorectal Surgeon, Frimley Park Hospital NHS Foundation Trust, Surrey, United Kingdom. E-mail: [email protected]