Initial Audit Research Articles

1908 Documentation in Clinical Frailty scores in patients aged >65 admitted to surgical assessment unit

Abstract Introduction According to the latest NELA report, frailty doubles the risk of mortality in patients >65 and above, but review by a geriatrician can significantly reduce this risk. To identify patients at risk, the report recommended that a formal frailty assessment for all patients>65 should be performed. The aim of this audit was to check compliance with this recommendation. Methods Data were collected retrospectively from a prospectively maintained electronic hospital records. Patients > 65 years admitted acutely under general surgery were identified from handover lists spanning a period of two weeks. The admission documents were reviewed to check for a formal assessment of clinical frailty score (CFS) had been completed. Following initial results, posters were put up in the SAU doctors’ office and all clerking doctors made aware via e-mails, WhatsApp groups and teaching to complete a CFS for patients >65 years. Results In the first cycle, 50 patients were identified and compliance rate was 18%. Following intervention, 51 patients were identified in the subsequent cycle with a compliance rate of 47%. After a second intervention, 99 patients were identified with a compliance rate of 61%. Discussion The NELA report highlighted only 23% of patients had a CFS documented and this was similar to the results of the initial audit. The main reason was lack of awareness, which was addressed by creating an awareness among the colleagues via poster, group chats and emails. This brought compliance up to 47%. Another reason was doctors being unable to locate the CFS on the electronic clerking document. A second round of intervention by poster, group chat, email communication and teaching achieved a 61% completion rate. The recommendation is to continue to improve the documentation of CFS further and utilize this to get input from geriatricians.

1957 Brushing up on oral health: Improving oral health practices in geriatric inpatients

Abstract Introduction Poor oral health is linked to multiple health conditions, for example pneumonia, cardiovascular and cerebrovascular disease, cancer and diabetes. Older people are particularly vulnerable to developing poor oral health due to comorbidities, medications used, and access to dental services, an effect magnified during hospital admissions. The aim of this project is to improve oral health and care received by inpatients on Healthcare for Older People (HfOP) wards. Methods A baseline audit of patient-response surveys on oral health access and behaviours, and care during hospital admissions was performed. HfOP inpatients aged >75 with capacity to consent were included. Plan-Do-Study-Act cycles informed interventions, focusing on education of multidisciplinary staff. First round interventions included presenting/discussing initial audit findings at a regional HfOP meeting, and working with Oral Health Practitioners to do ward-based micro-teaching and develop/distribute posters raising awareness. Second round interventions included a more in-depth certified educational session available to all HfOP staff on oral health care and promotion, and posters on how to document oral health aspects on the electronic patient record. Results 82% (82/100) patients reported being registered with a dentist, 50% attending a dentist in the last 12 months. Initially, only 17% (17/100) reported ward staff taking measures to ensure/help support their oral health, rising to 46% (46/50) in the second audit. Conclusions Though patient surveys may under-represent oral health access/issues by excluding people unable to consent, and may under-represent staff support offered/provided by recall bias, our audit did highlight gaps in staff awareness/practice. Our interventions were designed to benefit all inpatients, via opportunistic ward-based education through the audit process and formal educational sessions. Limitations included logistics of ensuring access to all staff groups. Our goal is to formalise oral health training in core MDT teaching to generate systemic lasting improvement. Other information Registered with local trust audit programme.

Sequential Compression Device Compliance for Venous Thromboembolism in High-Risk Trauma: A Quality Improvement Study.

Hospital-acquired, perioperative venous thromboembolism is a recognized patient safety indicator in the adult trauma patient population. Mechanical prophylaxis has been identified as a standard intervention to reduce the incidence of venous thromboembolism when prescribed along with anticoagulation or if anticoagulation is contraindicated in the surgical population. Adherence to consistent mechanical prophylaxis remains a nursing issue impacted by numerous factors in patient care. The purpose of this quality improvement project was to improve the compliance of sequential compression device utilization to decrease the hospital-acquired, perioperative venous thromboembolism rate in the adult hospitalized trauma patient population. A pre- and postintervention quality improvement approach utilized a nurse-led strategy to engage multidisciplinary team members to increase the consistency of sequential compression device utilization on patients within trauma units. The patient safety indicator rate per 1,000 for hospital-acquired, perioperative venous thromboembolism was monitored for improvement. The patient safety indicator rate per 1,000 for hospital-acquired, perioperative venous thromboembolism demonstrated a decline from 10.60 to 4.95 rate per 1,000 over 12 months. In the trauma units, sequential compression device compliance increased from an initial direct observation audit of only 12% to an average of 65% compliance rate during the last 16-week audits. We found that a multidisciplinary, nurse-driven approach in the trauma units was effective in improving the compliance of sequential compression device utilization and impacted the hospital acquired, perioperative venous thromboembolism rate in the adult trauma patient population.

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BackgroundUnwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.MethodsRealist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.ResultsThe program’s audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.ConclusionsAudit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

A Clinical Audit of Orthopaedic Clinical Documentation of Acute Ankle Fractures: A Quality Improvement Project.

Background Orthopaedic ankle fractures are common injuries that require careful assessment, management, and documentation to ensure optimal patient outcomes. Proper documentation plays a critical role in facilitating communication among healthcare professionals, ensuring accurate diagnosis, treatment planning, and monitoring patient progress. Moreover, it is essential for medico-legal purposes and quality improvement initiatives. This article presents a comprehensive clinical audit aimed at evaluating the quality of orthopaedic ankle fracture documentation within a healthcare setting. The aim of this project was to assess the quality and accuracy of ankle fracture documentation within a single centreagainst the audit standards set by the British Orthopaedic Association (BOA) and the National Institute for Health and Care Excellence (NICE). Methods The study was a closed-loop audit utilising both retrospective and prospective analysis of ankle fracture clerking documentation performed by members of the trauma and orthopaedics team. Two audit cycles were completed in total; the first cycle was carried out in January 2020 where data were collected retrospectively from all orthopaedic admissions of ankle fractures. This was then re-audited against the BOA and NICE guidelines and presented to the local clinical governance meeting. A targeted educational intervention was then implemented with the goal of educating and reinforcing to key team members the documentation standards and the importance of accurate clerking documentation. The second cycle was carried out during July 2020 prospectively. All data were collected and collated with a total of nine data parameters analysed. Patients were included if they were skeletally mature and presented with closed malleolar and syndesmotic ankle injuries. Excluded patients were those who presented with open fractures, pilon fractures, and/or were skeletally immature. Data were then re-presented at the clinical governance meeting. Results A total of 23 patients were identified in the initial audit cycle and 22 patients in re-audit. On admission, it was found that 86% of patients presenting with ankle fractures had adequate documentation of their injury mechanism, which subsequently improved to 100% following the intervention. Similarly, there was a 71% improvement in precise documentation of clinical findings of ankle fractures. There was a marked improvement in the consistency of examination findings as well, with over 30% improvement in the rate of documentation for sensation status, skin integrity, circulation, and motor function. Results also revealed a 71% improvement in the documentation rates of vascular examinations where a Doppler ultrasound was used or pulses named in the documentation. Conclusion Through a targeted educational scheme focussing on the proposed documentation guidelines, we noted a significant improvement in documentation standards and accuracy of ankle fractures in the trauma and orthopaedic department. With ongoing educational input and reinforcement, team members can be supported to maintain a high level of documentation that meets all available standards, which will ultimately lead to improved patient care.

Re-audit of the quality of neuropsychological assessment practice using a self-assessment audit tool: 18 months after an initial audit

BackgroundKing et al. (2022) developed an audit tool, listing standards against which individuals and services can benchmark their neuropsychological assessment practice. Our adult neuropsychology outpatient service in Stoke-on-Trent, utilised the tool to assess our current practice, and to assess the impact of completing the audit over two time-points, 18 months apart.MethodAll service users assessed by us within a sample month were included in the retrospective clinical audits: N=22 at time-point 1 (July 2020) and N=17 at time-point 2 (February 2022). The yes/no tick list was completed for each core and supplementary standard, for each assessment. Percentage compliance was calculated for each standard, to benchmark practice and appraise changes over time.ResultsAll service users gave verbal consent for their data to be used for research purposes. The service largely scored 100% compliance on most standards at both time-points, with improvements observed in seven standards between the two audits, and some areas of reduced standard compliance over time, prompting further discussion about different report styles for different contexts.Conclusion and RecommendationsOur service has discussed the audit results and are planning to improve our practice in terms of report length, waiting times for feedback sessions, use of performance validity tests and provision of service leaflets.

Adherence of Radiological Investigation Requests from Medical Wards, to Royal College of Radiologists’ Guidelines

Background: Radiological investigation requests get rejected by vetting radiologists, if they do not adhere to Royal College of Radiologists (RCR) guidelines and Ionizing Radiation (Medical Exposure) Regulations - IR(ME)R 2017 guidelines. This leads to significant delays for all three parties involved: the requesting clinician, the radiologist who vets the investigation, and the patient whose management is affected. Hence radiological investigation requests, which are the main means of communication between the referring clinician and the radiologist, should be appropriately filled in to facilitate the justification process and to optimize patient management. Aims/purpose: To evaluate the adherence of radiological investigation requests of inpatients from medical wards at University Hospitals of Leicester, to RCR guidelines and identify improvement areas, thereby reducing preventable patient delays. Methods: Data from 500 investigation requests of adult inpatients for common modalities of imaging (CT, X-Ray, and MRI) from medical wards at University Hospitals of Leicester were collected across two audit cycles, omitting any patient-identifiable information, and were analyzed for their completeness and adherence to RCR protocols. Results: Based on the analysis, inadequacies of imaging requests were identified, both in completion and adherence to RCR guidelines. In the initial audit cycle, even though more than 90% of the 250 investigation requests analysed contained clinical history, the name of requesting clinician and the question to be answered, only 64% of the investigation requests contained clinical examination or relevant investigation findings. In comparison to more than 94% of MRI and X-Ray requests, only 68.6% of CT requests adhered to RCR and IR(ME)R 2017 guidelines. In order to raise awareness and educate, the audit findings and recommendations were presented in a local medical teaching session within the hospital, and the same was propagated among medical doctors, through an online flyer. During the re-audit, another 250 radiological investigation requests were evaluated, where 73.3% of the requests included relevant clinical examination and/or investigation results and 76% of the CT requests adhered to iRefer guidelines for indication. Conclusion: Radiological investigation requests get rejected if it does not adhere to RCR guidelines for completeness (1) or indication (in compliance with IR(ME)R 2017)(3). This in turn results in delays in patient management. This could be minimized by increasing awareness about the above guidelines and the need for adhering to the same, thereby making sure all the necessary details are filled in and the investigation being requested is appropriate for the clinical indication. Keywords: Radiology, Audit, Medicine.

감사인 특성과 계속감사기간의 감사보수

[Purpose]This paper examines the change of audit fee after the introduction of ‘International Financial Reporting Standards’. Specifically, this paper examines wheter the audit fee after initial audit changes according to the characteristics of auditors.
 [Methodology]Using listed firms in KOSPI market from 2011 to 2018 to examine the relationship between auditor characteristics and audit fee after initial audit engagement. The information of auditors are collected manually from the Financial Supervisory Service’s accounting portal and KIND system.
 [Findings]This paper shows that the audit fee increased even in the case of initial audit engagements since the introduction of the ｢International Financial Reporting Standards｣. Meanwhile, the audit fee in the second and third year after initial audit engagements showed that the audit fee of large audit firms increased, but the higher the average audit experience of their certified public accountants, the lower the audit fee was.
 [Implications]This paper provides the policy implication to the supervisory authorities by presenting the changed audit fee behavior.

330 Evaluating anticoagulant prescribing errors in older adults in a rehabilitation setting

Abstract Background Anticoagulant use is common in older adults for the prevention or treatment of a number of conditions, most commonly Venous Thrombo-Embolism (VTE) or to prevent stroke in atrial fibrillation. Our audit aimed to review anticoagulation prescribing practices, identify errors and areas for improvement. Methods The initial retrospective audit of all inpatients in a medical gerontology ward took place from 15/11/2022–30/12/22. Data collected included age, sex, weight, renal profile, anticoagulation type, dose and indication. Information was collected from medication records, clinical notes and online laboratory system. After initial audit, multiple education sessions were conducted with the medical team. Re-audit of all inpatients occurred from 05/04/2023–25/04/2023. The guidelines used were the HSE Prescribing Tips for Anticoagulation and local Hospital Guidelines on VTE prophylaxis. Results The initial audit of 73 patients showed 15% (11) rate of prescribing error with 7 subtherapeutic and 4 supratherapeutic doses. Of these 11 errors, 4 doses were corrected recently prior to audit. Average age was 82.6 (64–100) and 55% (40) were female. The re-audit of 51 patients showed the rate of error improved to 7.84%(4) with 4 supratherapeutic doses. 1 dose was corrected on admission and 5.88%(3) required dose adjustment due to fluctuations in weight and renal function throughout admission. Average age was 83.1(66–103) and 69%(35) were female. Conclusion The re-audit demonstrated ongoing education sessions reduces prescribing error with a 48% reduction. However ongoing monitoring throughout admission is required to account for fluctuations in weight and renal function. Suggestions for further improvements include ongoing regular education sessions with the medical team. Further sessions are planned with the wider multidisciplinary team members to highlight importance of regularly monitoring weight and renal function and medication dosages. This audit also reinforces the importance of the role of pharmacist in the multidisciplinary team in Rehabilitation Units and would support regular pharmacist input on an regular basis.

305 Assessing patient attire in a medical gerontology ward: impact of an ‘End PJ Paralysis’ audit

Abstract Background Richard Asher’s influential essay, ‘The Dangers of Going to Bed’, highlighted the risks of bed rest for inpatients, including deconditioning and pressure areas. This audit evaluates whether patients are sitting out of bed and wearing personal clothes during mealtimes. Methods Using the ‘End PJ Paralysis’ campaign as the audit standard, a single-day audit recorded patients’ positioning and attire at breakfast and lunch. All inpatients on our medical gerontology ward were included. Interventions involved staff education on pyjama (PJ) paralysis implications, promoting the day room’s use at lunchtime, facilitating communication with patients/relatives regarding personal clothes/footwear, and organising a clothing donation drive. A re-audit occurred after one month. Results The initial audit included 39 patients (mean age: 81.8 years). At breakfast, 38.5% sat out, with 25.6% in their own clothes, 69.2% in pyjamas, and 5.1% in hospital gowns. The lunchtime audit included 38 patients: 84.2% sat out, with 78.9% in their own clothes, 25% in pyjamas, and 2.6% in a hospital gown. In the re-audit with 44 patients, 56.8% sat out at breakfast, with 18.2% in their own clothes and 81.8% in pyjamas. For lunch, 81.8% sat out, with 75% in their own clothes and 25% in pyjamas. No patients wore hospital gowns in the reaudit. Conclusion The re-audit demonstrated an improvement with 18.3% more patients sitting out at breakfast. In both audits, most patients opted for pyjamas at breakfast (69.2% in the initial audit and 81.8% in the re-audit) and their own clothes at lunch (78.9% in the initial audit and 75% in the re-audit). Hospital gowns were eliminated in the re-audit. Overall, this suggests that the ‘End PJ Paralysis’ campaign has positively influenced patients sitting out and the use of hospital gowns. Future plans involve education sessions for the broader multidisciplinary team, displaying posters, developing patient information leaflets, and conducting a re-audit to assess sustained impact.

60 Surgical inpatient delirium: a re-audit of the documentation of the 4AT score

Abstract Background Postoperative delirium and perioperative neurocognitive disorder are the commonest postoperative complications in patients over 65. This has implications for brain health, hospital length of stay and incidences of morbidity and mortality. Our aim was to perform a re-audit of the documentation of 4AT scores for surgical inpatients >65 following educational sessions across key ward-based staff (medical, nursing, and allied-health). Methods Using the guidelines for Perioperative Care for People Living with Frailty undergoing Elective and Emergency Surgery from the Centre of Perioperative Care (CPOC) and the British-Geriatric-Society (BGS) as a standard, a re-audit of surgical inpatients >65 was performed on four surgical wards over two weeks. Data was collected on 4AT documentation on admission, day one and day three post-operatively, type-of-surgery, anaesthesia and risk factors for delirium (dementia, polypharmacy, opioid & benzodiazepine use, alcohol excess, ≥2 medical co-morbidities, number of ward moves and surgery >2 hours). Results Of the 55 surgical patients, the average age was 76 (65–93). 32.7% of patients presented for hip fracture surgery (n = 18), 40% abdominal/pelvic surgery (n = 22), 15% other surgeries (n = 15). 35% of patients (n = 19) had baseline 4AT documented preoperatively compared to 25%(n = 9) in the initial audit. 4AT score documentation during admission was 47.3%(n = 26) compared to 33%(n = 11). ≥2 surgical risk factors for delirium were found in all patients. The incidence of delirium was 14.5% with eight patients having a 4AT score > 4. Patients who developed delirium had 3–8 risk factors. Four of eight patients with delirium had pre-existing cognitive impairment and/or dementia. Conclusion There was an increase in frequency of 4AT assessments as a delirium screening tool in our cohort following successful collaboration between medical, surgical, anaesthesia, nursing and allied-health staff. Regular educational sessions to maintain awareness and screening of delirium peri-operatively in surgical patients >65 will be a focus for continued quality improvement.

174 A silver lining: the identification of silver trauma at triage for older persons (>65) presenting to the emergency department

Abstract Background Trauma in patients over 65 (silver trauma), can result in serious injury from lower impact mechanisms. The NOCA Major Trauma report highlights that 58% of major trauma is a result of a fall from 2 metres or less and mortality increases with age and comorbidities. Failure to identify, rapidly assess and treat older persons who have suffered silver trauma results in prolonged emergency department stays with an increase in morbidity and mortality. We therefore, performed a completed audit cycle to assess the identification of Silver Trauma in our emergency department. Methods A focus group involving key stakeholders was established, including Emergency Physicians, nurses and members of the Gerontological Emergency Department Intervention team. An audit assessed patients triaged as ‘major trauma’ from October to December 2022. We established silver trauma guidelines for triage. Teaching sessions on the recognition of silver trauma were provided, daily briefings were given, and information leaflets were placed in all triage areas. A triage discriminator of ‘Silver Trauma’ was introduced to prompt recognition and review by clinicians. A full audit cycle was completed. Results Our initial audit (October to December 2022) revealed 25 patients triaged as ‘Major Trauma’ who were aged over 65. After the completion of the initial audit and implementation of measures, 122 patients were triaged as ‘Silver Trauma’ between January 20th and March 31st. We identified that 59% (N = 72) were due to falls from 2 meters or less. Other mechanisms of injury included unwitnessed fall (21% N = 25), syncope (7% N = 8), fall from height (11% N = 13) and Major Trauma (3% N = 4). Seventy-one (58.19%) were admitted and 51 (41.80%) were discharged home. Conclusion This audit demonstrates that departmental education and implementation of a triage discriminator has significantly improved the recognition of silver trauma within the ED setting.

297 Assessing continence care in a rehabilitation unit: insights from an audit

Abstract Background Urinary incontinence, a prevalent condition and one of the original geriatric giants, remains a taboo topic and is frequently underreported. Urinary incontinence significantly impacts patients and often times their discharge destination. However, urinary incontinence is neither inevitable nor always irreversible. This audit aimed to assess continence and incontinence wear in a rehabilitation facility. Methods The continence care quality in a medical gerontology ward was assessed using the Royal College of Physicians (RCP) National Audit of Continence Care (NACC) standard. A prospective audit was conducted over a five-day period, documenting incontinence wear and urinary continence on a medical gerontology ward. Two interventions were implemented prior to re-auditing. Firstly, continence was incorporated as a teaching topic on the Non-Consultant Hospital Doctor (NCHD) teaching schedule. Secondly, the Multi-Disciplinary Team (MDT) proforma was adjusted to include a patient-specific continence record. A snapshot re-audit was conducted to evaluate any changes resulting from these interventions. Results In the initial audit, 31 patients were included. Among them, 26 (83.9%) wore incontinence wear, with 21 (80.8%) voluntarily opting for it. Urinary incontinence was documented in 13 patients (41.9%). In the re-audit, 40 patients were included. Among them, 27 (67.5%) wore incontinence wear, with 19 (70%) choosing it. Urinary incontinence was documented in 18 patients (45.7%). Conclusion The re-audit revealed a slight decrease in incontinence wear usage (67.5% compared to 83.9% initially). Many patients wearing incontinence wear expressed a preference for it in both audit cycles. The prevalence of urinary incontinence remained similar between audits (41.9% and 45.7% respectively). The persisting prevalence of urinary incontinence calls for effective strategies to address this issue. Additionally, the patients’ preference for incontinence wear emphasises the importance of engaging not only the MDT but also the patients themselves in future interventions. Future projects should focus on gaining a deeper understanding of patients’ perspectives on continence care and evaluating the impact of incontinence on patient outcomes.

Supporting service integration through early childhood education: challenges and opportunities in regional contexts

IntroductionChildren and families residing in regional Australia experience higher rates of vulnerabilities coupled with inadequate access to the early childhood health and early intervention services which pose increased risk to their health, development and wellbeing. The current study was designed to respond to the inherent complexity of supporting effective integrated service provision in regional communities, with a view to develop a model of effective service integration that leverages the capacity and opportunity of universal early childhood education (ECE) provision.MethodThe study adopted a qualitative multiple case study design to explore the perceptions of ECE professionals across six regional ECE services and two early intervention professionals operating from a regional early childhood intervention (ECI) organization. Data included an initial audit of the service system landscape coupled with facilitated discussions (focus groups and interviews) to identify facilitators and challenges to service integration and current patterns of service usage and engagement.ResultsFindings highlighted the foundational importance of relationships for establishing trust, engagement and service sustainability, as well as the need for embedding structural supports, including the professionalization of educators, the utilization of a key worker model, and staff retention. Systemic constraints, including limitations and inconsistencies in community infrastructure, program atrophy, and the complexity of referral systems, were seen to undermine effective service integration.DiscussionFindings speak to the potentiality of the ECE context as a hub for effective service integration within a functional practice framework for ECE. We conclude by offering a suggested model to ensure service connections, and enhance professional capacity and sustainability.

104 Oxygen prescription on a specialist geriatric Ward

Abstract Background Oxygen delivery is an extremely useful tool in treating hypoxaemia. While it has beneficial effects when administered at correct doses it can also lead to serious adverse outcomes when not delivered correctly. Given this, oxygen should be treated as any other drug we use in practice and prescribed accordingly. Studies done around the world show very poor rates of appropriate oxygen prescription. This is particularly important on a ward which specialises in care for the older adult, where neurocognitive disorders, delirium and multi-morbidity is common. Methods An audit was carried out on all patients admitted to the specialist geriatric ward over a two week period, documenting whether the patient was receiving oxygen therapy and if so whether it was charted appropriately. Following this education was provided to staff on the ward and posters were hung at the oxygen ports as a reminder to ensure oxygen was prescribed in the Kardex. A re-audit was then carried out, measuring any change in practice. Results Following the initial audit, 120 new patients were admitted to the ward, 25 of which were receiving oxygen therapy (21%). Of the 25, only 7 had oxygen prescribed (28%). Following staff education and the introduction of reminder posters at the oxygen ports a reaudit was carried out. 103 new patients were admitted to the ward, 18 of which were receiving oxygen therapy (17%). Of the 18, 17 had oxygen prescribed appropriately (94%). Conclusion Simple reminders can influence behaviour greatly. Appropriate oxygen prescription improved three-fold with an inexpensive, simple intervention.

26 Audit of osteoporosis treatment in patients undergoing Orthogeriatric rehabilitation

Abstract Background There was a perceived under-prescribing of osteoporosis treatment in this population. The transition from acute hospital to rehabilitation unit presented an opportunity to check medications and institute change. Methods Retrospective audit of patients’ medication charts. All patients on the rehabilitation ward under the care of an Ortho-geriatrician were included. Data was anonymised and recorded in an excel file. Prescription of calcium and vitamin D (single agent or combination) and targeted osteoporosis medications were recorded. Data collection performed by the specialist registrar on a ward round with the consultant. Interventions included education of Non-Consultant Hospital Doctors (NCHDs) to encourage proactive prescribing and documentation of the bone protection plan on the transfer summary. A re-audit was undertaken at a two month interval using the same methodology. Results 12 medication charts were examined as part of the initial audit. 10/12 had a neck of femur fracture and 2/12 had fragility fractures of the tibia/fibula requiring surgery. Zero patients were prescribed calcium alone, two vitamin D alone and 9/12 were on combination calcium and vitamin D. No patients were prescribed targeted osteoporosis treatment. 1/12 patients had a documented plan regarding bone protection. Re-audit examined 10 medication charts. 9/10 had a neck of femur fracture, 1/10 had a fracture of both the distal femur and the proximal humerus. Zero patients were prescribed calcium alone, three vitamin D alone and 6/10 were on combination calcium and vitamin D. 2/10 were prescribed oral bisphosphonate, 5/10 denosumab and 1/10 intravenous bisphosphonate. The remaining two patients did not yet have osteoporosis treatment prescribed. Conclusion Despite all of the initial patients being >14 days post-operative the majority did not have a plan or prescription for bone protection representing a missed opportunity to prevent further fractures. Re-audit post education demonstrated an 80% improvement in prescription of osteoporosis treatment.

1162 Management of Acute Gallstone Disease at an Urban Acute Trust During the Pandemic – Closed-Loop Audit

Abstract Aim Acute gallstone disease is a surgical emergency with emphasis on early surgery (Laparoscopic Cholecystectomy (LC)) to improve outcomes. Method Patients presenting with acute cholecystitis, biliary colic, and gallstone pancreatitis between September and December 2021 were retrospectively audited. We measured re-admission rates, emergency and elective cholecystectomies performed, and interval between operation and initial admission. This revealed a need for improvement in the service provided at this trust. An intervention was implemented with the Hot Cholecystectomy list being available for other surgeons as well as encouraging acute LC on the Emergency theatre list. A follow-up retrospective audit was carried out between July and September 2022 using the same criteria as per the initial data collection. Results 240 patients were admitted with acute gallstone disease during the initial audit period. At the end of audit period, 49 patients underwent LC, of which only 20% were performed acutely. However, 70% of acute operations were performed during re-admissions. During the re-audit, 109 patients were admitted with acute gallstone disease. Within the three months, 21% of patients underwent LC, out of which 52% were acute operations. 50% of the emergency operations were in re-admission patients. Patients from the initial audit were followed up which revealed average waiting time of 118.5 days from admission to LC Conclusions There was almost a 3-fold increase in the rate of Emergency LC post intervention. While there is an increase, provision of emergency cholecystectomies does not comply with national guidelines. Resources need to be allocated nationwide for timely treatment of acute gallstone disease.

957 Otitis Externa (Oe) Management Review in Tayside

Abstract Introduction Although otitis externa (OE) can usually be managed in the community, a large number are referred from GPs to ENT Emergency Clinics. Aim To assess primary care referrals of OE to NHS Tayside, with adherence to local guideline recommendations of investigations and management. Method The digital notes of patients with OE referred to NHS Tayside via Emergency Clinic between August 2021- February 2022 were examined, focusing on their swab sampling status, microbiology lab results and antibiotic treatment modalities. The resultant data was analysed and compared to data from the initial (Jan 2016 - Jul 2016) OE Audit. Results 53 of the 518-patient seen in ENT Emergency clinics were referred with OE. 96.2% of these patients had swabs performed for culture and sensitivity (C&S) analysis. 18.9% had been treated with oral antibiotics despite no recorded signs of external infection. Pseudomonas (17.6%) and Candida (19.6%) were the most common organisms. Conclusions Comparisons to the initial audit shows that there has been a marked improvement in patients being swabbed prior to referral (96.2% compared to < 65%). The percentage of patients with candidal growth were higher this time. However, it is possible that the previous insufficient swabbing may have led to incorrect treatment. Fewer patients were needlessly prescribed oral antibiotics when compared to the initial audit results. Oral antibiotics should only be prescribed if facial involvement is present. Swabbing and C&S aids effective treatment with an appropriate antibiotic choice.

96 Looped Prospective Audit of Compliance to the British Orthopaedics Association Standards for Trauma and Orthopaedics (BOAST): Safe Use of Intraoperative Tourniquets in Upper Limb Surgery

Abstract Background New BOAST standards were published in October 2021, advocating the need for all tourniquet pressure to be inflated 50-100mmHg above the adult patient’s systolic blood pressure when undergoing upper limb surgeries. The aim was to assess whether conformity was present towards this standard. Method A closed-loop prospective audit was implemented in a specialist hand unit from October to December 2021. Readings, including blood pressure before tourniquet inflation, final inflation pressure, tourniquet time, and level of performing surgeon, were collected from documentation and analysed. Results A total of 100 patients were assessed. The initial audit and re-audit demonstrated low compliance levels of 36% (18/50) and 38% (19/42), respectively, despite specific educational interventions regarding the newly published standard. When comparing junior and specialist hand consultants, non-compliance was more significant at the more senior level (63.4%). All non-compliance was a result of the overinflation of the tourniquet. The average overinflation was 20.6mmHg, and the average tourniquet time was 40.9 minutes. No tourniquet complications were documented in any case. Conclusions The primary rationale resulting in the non-compliance from the experienced hand surgical team was that the increased risk of obscuring the operative field from bleeding, thus leading to structural damages, outweighs the complications of overinflating the tourniquet. Furthermore, systolic blood pressure cannot always be maintained within a restricted window from the anaesthetic perspective. Therefore, we propose that the guideline be opened for further discussion and more up-to-date research implemented in this field.

295 Education and Training to Improve Compliance to the BOAST Guidelines on Assessing and Documenting Peripheral Nerve Status and Injury

Abstract Introduction Peripheral nerve injuries affect 2-3% of trauma patients, with potentially high morbidity, and associations with litigation. BOAST guidelines were introduced in December 2021 outlining standards in assessing and documenting neurovascular status in trauma patients. Key elements included nerve-specific documentation and assessments pre- and post-interventions such as manipulation. Aim This project assessed departmental performance against the BOAST standards, then presented the results to both orthopaedic and emergency departments, as well as setting up teaching sessions to orthopaedic junior doctors in the assessment of neurovascular status and updating awareness on the guidelines. Method 50 patient records were analysed retrospectively for the first arm, and 50 records prospectively for the second arm. Acute trauma presentations with a risk of peripheral nerve injury met the inclusion criteria. Intervention included practical senior-led teaching on clinically assessing neurovascular status, and the importance of detailed documentation, as well as when to repeat the examination. Results Results were improved drastically from initial audit against standards to post-intervention audit; documentation improved from 70% to 95% (n = 50 for both arms), with appropriate detail in documentation improving from 11% to 49%. Conclusions Neurovascular status is critical to be documented in detail, both pre and post-interventions. By using BOAST guidance as a standard, the initial inadequacies of the departmental practice were highlighted, and significantly improved through active teaching, distribution of the guidelines, raising the standards, clinical assessment, and documentation, thus improving patient care, and robustness of legal documentation.