Inpatient Lists Research Articles

982 Timing of MRI Spine for Patients Presenting with Suspected Cauda Equina Syndrome (CES)

Abstract Introduction Cauda Equina Syndrome (CES) is a neurosurgical emergency requiring urgent intervention within 24 to 48 hours to prevent irreversible paralysis and incontinence. Recognizing the gravity of CES, The Society of British Neurosurgeons and the British Association of Spine Surgeons set care standards in 2017, emphasizing the necessity for a 24/7 MRI service in every healthcare trust. The recently released GIRFT National Suspected CES Pathway also advocates for performing an MRI scan within 4 hours of presentation. Aim This study aimed to assess adherence to the 4-hour target for MRI scans in suspected CES cases at the Royal Surrey Hospital and examine the impact of delays on hospital stay length. Method Data from a 6-month period (August 2022 to January 2023) involving 70 patients were collected using the Cerner electronic system and inpatient lists, excluding cases of outpatient MRI and urgent transfers to Saint George's Hospital. Results Results showed an average time from Emergency Department admission to scanning of 21.3 hours (range: 3.5 to 87.4 hours), with a mean wait from request to scan of 14.5 hours (range: 0.7 to 76.7 hours). Hospital stay duration averaged 4.5 days (range: 1 to 22 days). Conclusions Recommendations include empowering ED clinicians to order MRI scans, implementing an MRI Safety questionnaire on Cerner, collaborating with radiographers to meet the 4-hour target, and advocating for a 24/7 MRI service within the trust. Subsequent re-audit efforts will evaluate the impact of these recommendations and identify factors influencing the achievement or non-achievement of the 4-hour target.

Medication Reconciliation during Transitions of Care Across Institutions: A Quantitative Analysis of Challenges and Opportunities.

Medication discrepancies between clinical systems may pose a patient safety hazard. In this paper, we identify challenges and quantify medication discrepancies across transitions of care. We used structured clinical data and free-text hospital discharge summaries to compare active medications' lists at four time points: preadmission (outpatient), at-admission (inpatient), at-discharge (inpatient), and postdischarge (outpatient). Medication lists were normalized to RxNorm. RxNorm identifiers were further processed using the RxNav API to identify the ingredient. The specific drugs and ingredients from inpatient and outpatient medication lists were compared. Using RxNorm drugs, the median percentage intersection when comparing active medication lists within the same electronic health record system ranged between 94.1 and 100% indicating substantial overlap. Similarly, when using RxNorm ingredients the median percentage intersection was 94.1 to 100%. In contrast, the median percentage intersection when comparing active medication lists across EHR systems was significantly lower (RxNorm drugs: 6.1-7.1%; RxNorm ingredients: 29.4-35.0%) indicating that the active medication lists were significantly less similar (p < 0.05).Medication lists in the same EHR system are more similar to each other (fewer discrepancies) than medication lists in different EHR systems when comparing specific RxNorm drug and the more general RxNorm ingredients at transitions of care. Transitions of care that require interoperability between two EHR systems are associated with more discrepancies than transitions where medication changes are expected (e.g., at-admission vs. at-discharge). Challenges included lack of access to structured, standardized medication data across systems, and difficulty distinguishing medications from orderable supplies such as lancets and diabetic test strips. Despite the challenges to medication normalization, there are opportunities to identify and assist with medication reconciliation across transitions of care between institutions.

Expansion of the fertility preservation program to all newly diagnosed prepubertal oncology patients at a pediatric hospital.

10064 Background: As the majority of pediatric oncology patients survive their disease, generating a population of over 500,000 survivors in the United States, it is imperative to minimize the lifelong consequences of treatment, which includes temporary or permanent infertility caused by certain cancer treatments. Fertility preservation (FP), the opportunity to preserve one’s ability to have genetically-related children prior to damaging the reproductive system, is a young but rapidly expanding field and recent scientific advances have led to an expansion of options for prepubertal patients. A fertility consultation at diagnosis can provide patients and families with the opportunity to be informed regarding likelihood of gonadal dysfunction and to consider FP. Methods: After our pediatric hospital started to offer tissue cryopreservation, we initiated this evidence-based interventional quality improvement project. Our primary aim was to ensure that all newly diagnosed prepubertal oncology patients who met criteria for FP were correctly identified and offered an educational consultation and preservation. Inpatient admission lists and provider schedules were reviewed daily to identify patients. Treatment plans were discussed with providers to calculate infertility risk. All procedures were to be completed at the time of another procedure to increase likelihood of insurance coverage and minimize delays. Results: Between 07/15/22 and 11/30/22, 54 newly diagnosed prepubertal patients’ treatment plans were evaluated to determine treatment-related infertility risk using the Oncofertility Consortium Pediatric Initiative Network’s Risk Assessment tool. 15 patients were at a high level of significantly increased risk and were therefore eligible for consultation. 7 patients and their families received an educational consultation and 6 elected to undergo FP (3 TTCs; 3 OTCs). FP procedures did not cause a delay in starting treatment for any of these patients. 8 patients did not receive consultations. Reasons included the provider electing to proceed with treatment without consultation (4), the patient’s comorbidities (1), the inability to bundle FP with another procedure (1), and the family decision to decline consultation (1). Conclusions: Of the patients at high risk of infertility, only 46% received consultation with lack of referral prior to initiating treatment as the primary reason. Of the patients offered preservation methods, 86% elected to preserve their fertility, illustrating patient and family interest. Providers must acknowledge changes in practice and be informed on the impact that high-risk treatment protocols can have on fertility. An FP program with established policies processes can increase the likelihood that prepubertal patients at high risk for infertility are correctly identified, educated, and offered preservation.

A93 IMPROVING INPATIENT ENDOSCOPY PROCEDURAL THROUGHPUT: A QUALITY IMPROVEMENT INITIATIVE AT AN ACADEMIC MEDICAL CENTER

Abstract Background Currently, due to pandemic-related supply and personnel constraints, increased strain is being placed on inpatient endoscopic services. At our academic center, inpatient procedural throughput/efficiency is only 65%, which is leading to excess procedures being completed on-call or on weekends. Purpose Our quality improvement study attempted to improve throughput of the inpatient endoscopy suite by 1 additional procedure completed per day, over a period of 12 months of study. Method An interprofessional team of gastroenterology fellows, attending physicians, nurses and nurse managers was created to investigate throughput concerns. Baseline data was collected via direct observation and completion of a time study over a period of 1-2 months. Subsequently, a process flow diagram was completed. A combination of root cause analysis tools (ie. Stakeholder interviews, Pareto chart and Driver Diagram were then utilized to identify areas for improvement. A delay in procedural start time was identified as a strong culprit for reduced patient throughput. Potential interventions proposed included: early physician handover start time, constructing a standardized patient procedure list, and improving timeliness of patient transfer to the endoscopy suite. Result(s) Stakeholder Interview(s): Completed via Anonymous Survey/Google Forms: See https://docs.google.com/forms/d/e/1FAIpQLSe-PDL31ClU8g-BChdBoBYhPoBhGBZVmlToTTZJnYKlEHz-GQ/viewform?usp=sf_link Concerns: - Inpatient procedure list not consistently being completed prior to starting endoscopy - Physician handover in the morning can cause significant delays in starting inpatient endoscopy - Concern patient/porter transfer related delays Conclusion(s) Our current data identifies that the most effective intervention included developing a standardized procedure list and mandating the first case is an EGD, minimizing delay due to inadequate bowel preparation. Concordantly, arranging timely patient transfer to the endoscopy suite, thereby minimizing delays due to patient portering services, was also found to be effective. Our average procedural time for completion of an EGD and associated recovery is approximately 25-30 minutes. After multiple interventions/PDSA cycles we obtained a more optimized procedural suite start time of 08:22 am, on average, which resulted in the completion of an additional procedure and increased the throughput of our endoscopy unit. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

The impact of the United Network of Organ Sharing allocation change on waitlist trajectories of inpatients listed with inotropic support: A single-center analysis.

In the United Network of Organ Sharing (UNOS) allocation scheme prior to October 18, 2018, heart transplant (HTx) candidates with extracorporeal membrane oxygenation (ECMO), temporary mechanical circulatory support (MCS), or pulmonary artery (PA) catheter inotropic support all received Status 1A priority. In revised scheme, patients with PA catheter and inotropic support are Status 3 after those on ECMO (Status 1) or temporary MCS (Status 2). We examined the impact of the allocation change on HTx candidates listed Status 1A versus Status 3 at a high-volume transplant center. Between January 2017 and January 2021, 75 patients were listed with a PA catheter and inotropic support prior to the allocation change (Era 1) and 48 were listed after (Era 2). Clinical characteristics and outcomes were compared for these 123 patients. Heart transplant (HTx) candidates in Era 2 had higher median inotrope doses at listing. There was no significant difference in inpatient wait list days (12vs. 20 days, P=.15), transition to temporary MCS (33.3%vs. 22.7%, P=.15), or wait list mortality (6.3%vs. 4.0%, P=.68). There was also no significant difference in survival to transplantation (91.7%vs. 94.7%, P=.71). There were no differences in post-transplant outcomes including 1-year survival (88.6%vs. 93.0%, P=.38). At a high-volume transplant center, the UNOS allocation change did not result in increased wait list time, use of temporary MCS, or mortality on the waitlist or post-transplant for candidates on inotropic support with continuous hemodynamic monitoring.

Rhapsody in Code Blue.

Anyone can call for the symphony to start.Perhaps the internal medicine intern stopping by on morning rounds.Or the telemetry operator, observing one wavy line rapidly morphing into another.More commonly, it’s the bedside nurse. As she stops by to address a chirping IV pump, finished with its antibiotic infusion, she spots that something is off. A bluish tinge to the patient’s lips. A glassy look in their eye. An unusual beat on the EKG strip.She calls his name, and instead of a grumpy ‘what?’ she is greeted with silence. She feels for a pulse. Nothing. Frantically, she presses the button on the wall. CODE BLUE.With that single note, the orchestra assembles, called to arms with jarring alerts on pagers, phones, and overhead alarms. The musicians arise from hectic ICUs, sleepy call rooms, and bustling central pharmacies, heeding the call to action.Before the conductor takes the stage, the room is adrift.The players crowd the tiny hospital room, overflowing into the hallway.But as the code leader arrives, roles are assigned, and the performance can begin.First, the percussion.One. Two. Three, the percussionist counts, beating on the patient’s chest. It’s a precise instrument—each compression must be two inches deep, no more, no less. He paces like a metronome set to exactly 100 beats-per-minute.Next, the strings.Nurses, residents, and phlebotomists unfurl their tourniquets and un-sheath their catheters, preparing to carefully thread IVs, arterial lines, and central lines into the patient’s veins. Like a bow across the strings of a violin, their lines traverse the room from fluid bag to vessel. They employ slow, guided precision as they glide tubes into vessels.The brass fills out the sound.Like the valves on a trumpet, plungers of premade syringes of epinephrine are pressed in rhythmic blasts. A cacophony of other drugs supports the melody—atropine, amiodarone, adenosine—an entire array of additional antiarrhythmics aid the ensemble, drawn up and pushed out like the slide of a trombone.CLANG go the cymbals.CLEAR yells the nurse with the defibrillator.Though the show is already underway, the ushers continue to traverse the aisles.Runners pop in and out of the room, bringing more drugs, more flushes, more line kits. With each venture out to the stock rooms, they pass by the audience, onlookers from the floor and family members of the patient. The runners remain focused on their mission, faces averted from wandering eyes, some moved to tears by the performance.After a few verses—two or three rounds of compressions—the woodwinds arrive to a glorious solo.The anesthesiologist steps forward to the head of the bed, with her instrument in hand. Her laryngoscope slides over the tongue as the percussion ceases for just one moment, giving her a few rest measures without constant beating to intubate. The endotracheal tube slips through the vocal cords and, like air through the barrel of a flute, a 400cc breath passes melodically through the tube filling the lungs.At the edge of the stage, the pianist taps away on his keys.The pharmacist stands at a computer, monitoring every dose given and scrutinizing the inpatient medication list for causes of this tragedy. He supplies the final harmony to the rest of the orchestra, providing cues to the players as the show unfolds.At the end, a sonata. A smaller ensemble takes center stage helmed by a melancholy bassoon.All the other movements have come to a close. A chaplain wearing his clergy collar understands what’s left to do. He pulls aside family members and gracefully sets the stage of expectations. The curtain will soon fall, and he wants the audience to be prepared.The song concludes.The players depart stage-left.

Carpe Communication: Seizing the Small Moments to Teach Interpersonal and Communication Skills on Inpatient Services.

Carpe Communication: Seizing the Small Moments to Teach Interpersonal and Communication Skills on Inpatient Services.

Influenza vaccine administration in a paediatric intensive care unit.

We describe the clinical profile of children and outcomes of influenza immunisation for patients in a paediatric intensive care unit (PICU). Over two influenza seasons: 19/04/2018 to 07/08/2018 and 02/05/2019 to 10/10/2019, an immunisation nurse and PICU nurse coordinator met weekly and identified patients to receive the influenza vaccine. An inpatient list of PICU patients was screened for eligible patients: greater than 6 months of age, did not have imminent procedures (e.g. surgery) or were not critically unwell, as determined by the treating team, to receive the influenza vaccine. Patients were excluded if they had undergone surgery in the previous 24 hours or were being treated palliatively. Sixty patients in PICU were identified, with 43% (26/60) receiving the vaccine while in PICU and 17% (10/60) once discharged from PICU to the general ward environment. The majority of patients immunised were in PICU due to cardiac surgery/cardiology or general medical conditions, such as cerebral palsy or RSV bronchiolitis. There were no reported adverse events following immunisation. We have demonstrated the suitability and acceptability of children in the PICU receiving the seasonal influenza vaccine and tailored interventions to follow-up once discharged from PICU to optimise protection.

236 E-Prescribing and Smart Antimicrobial Stewardship in Upper Limb Infections

Abstract Aim Upper limb infections secondary to traumatic wounds, animal bites and other causes are a common reason for admission to the plastic surgery service for intravenous antibiotics. This audit investigated the compliance of treatment of upper limb infections with trust guidance. The guidance stipulated an antibiotic treatment duration of five to seven days total and microbiology advice suggested that in cases requiring multiple washouts, this should start from the date of the last surgical washout where pus was present. Method There was retrospective sampling for four months using inpatient lists to include patients admitted for intravenous antibiotics for upper limb infections. Notes were requested by the secretaries and data was collected using patient notes, discharge summaries and electronic drug charts. Results The analysis included twenty-seven suitable patients. All patients had the correct antibiotics prescribed according to guidance, however only 22% of patients had five to seven days total of antibiotics either from the start of therapy or from the date of last infected washout in those who underwent surgical treatment. 14/27 patients had more than seven days total antibiotics. 13/27 patients were discharged with an additional seven days of oral antibiotics regardless of the total duration. Conclusions These infections are significantly over-treated with antibiotics, which has serious potential consequences for antimicrobial resistance. The findings of the audit prompted new trust guidelines to be produced and prescribing guidance was sent to the junior doctors to calculate the total antibiotic duration when preparing discharge summaries. There is a plan for re-audit in a few months’ time.

Haematuria readmission rates in DOAC patients undergoing TURP/TURBTs and urinary tract biopsies – is there any need for a bridging plan?

Aim - The purpose of our quality improvement project was to reduce readmission rates for haematuria in patients on direct oral anticoagulants (DOACs) who had undergone a urinary tract biopsy or resection. Methods - For each cycle we used operating lists, pre-assessment clerking and departmental inpatient lists to identify the proportion of patients on DOACs readmitted post-operatively within 1 month from date of surgery. Cycle 1 was completed over a six-month period. We then discussed these results with a Haematologist, who advised a bridging plan with low-molecular weight heparin to mitigate the risk. Following implementation of the bridging plan, we then completed the second cycle over a three-month period. Results - The first cycle showed that 37.5% (n=16) of all patients on DOACs who had undergone one of these procedures were readmitted with significant haematuria. After implementation of the bridging plan with Low molecular weight heparin, the second cycle showed a reduced readmission rate of 33.3% (n=9), despite a higher percentage of patients on a DOAC in this cycle. Discussion - There was no uniform practice or protocol for restarting DOACs in our hospital. After completion of this project, a uniform protocol has been established. Recommendations included: (1) rediscuss with a Haematologist whether further measures were needed; present our data at a regional meeting to survey protocol and practices in neighbouring hospitals. Limitations included: a small sample size; non-uniform duration of data collection per cycle; reduction of elective operative lists due to COVID-19.

Digital Professionalism in Patient Care: A Case Based Survey of Patients

The objective of this study was to obtain the perception of patients on the use of portable digital media devices by providers during patient care and compare the findings to a previous study that examined providers' perceptions on the use of these devices. This was a cross-sectional survey study. This study took place at a large tertiary referral center. Participants were identified via inpatient lists from general surgery services. Of those eligible to participate, 70% completed the questionnaire. While some situations were seen as less appropriate, the overall consensus from participants was that informing the patient of why the physician is using a digital media device made it more appropriate. Patients recognize digital device use in healthcare is appropriate and professional when discussed with them in advance. Overall, patients and providers are in agreement that portable digital technology can improve patient care and open communication about the use improves the provider-patient relationship. There is some risk to patient trust in using digital devices in their presence.

460 THE IMPACT OF THE BONE MDT: EXPLORING CHANGES IN BONE PROTECTION DECISIONS BETWEEN 2015 AND 2018

Abstract Introduction The Hip fracture Multidisciplinary metabolic bone Team (MDT) was developed in June 2016 as a collaboration between Orthogeriatricians and the Metabolic Bone Team. The objective was to improve the quality of bone protection treatment decisions. This audit aimed to assess the impact of the new MDT by reviewing treatment decisions prior to and post its introduction. Data collection and. Methodology Case notes were reviewed for admissions from September to October 2015 and from September to November 2018. For both time periods the inpatient list, discharge summary and blood tests were reviewed in order to collect data regarding demographics, type of surgery, co-morbidities, calcium and vitamin D levels, bone protection prior to admission and bone protection decisions at discharge. Results In 2015, 83% of patients were admitted with no form of bone protection. Around 6% of patients were admitted on a bisphosphonate and 36% were discharged on a bisphosphonate. Less than 2% of people received denosumab prior to their admission, with this number rising to 9.4% at discharge. In 2018, 77% of patients were admitted on no form of bone protection. 5.4% were admitted on a bisphosphonate rising to 16% on discharge. No patients were admitted on denosumab, but 27% were discharged having received it in hospital, or with a plan to receive it from their GP. Conclusions There was a fall in bisphosphonate use and a significant increase in the frequency of denosumab prescription after the introduction of the Bone MDT. This MDT facilitated better decision-making through access to the further specialist skills from the endocrinologist and specialist nurses. Individual case discussion enhanced the delivery of personalised medicine.

261 Using Technology to Improve Inpatient Surgical Lists

Abstract Introduction Every day in our surgical department; prior to our quality improvement project, Junior Doctors spent on average 3.26 clinical hours maintaining 5 surgical inpatient lists of different specialities with accessibility of lists rated as “neutral” based on a 5-point scale from difficult to easy. Our hospital previously had lists stored locally on designated computers causing recurrent difficulties in accessing and editing these lists. Method We used surveys sent to clinicians to collect data. Cycle 1: Surgical Assessment Units list on Microsoft Teams Cycle 2: Addition of surgical specialities and wards lists onto Microsoft Teams. Cycle 3 (current): expand the use of Microsoft Teams to other specialities. Results Utilising technology led to a 25% reduction in time spent on maintaining inpatient lists, to 2.46 hours a day, and an improvement in the accessibility of lists to “easy”. Across a year, this saves over 220 hours clinician hours which can be used towards patient care and training. Furthermore, use of Microsoft Teams has improved communication and patient care, in the form of virtual regional Multi-Disciplinary Team meetings and research projects. Conclusions Microsoft Teams is currently free to all NHS organisations in England so there is potential for these efficiency savings to be replicated nationwide.

Pediatric Inpatient Problem List Review and Accuracy Improvement.

The problem list (PL) is a meaningful use-incentivized criterion for electronic health record documentation. Inconsistent use or inaccuracy of the PL can create communication gaps among providers, potentially leading to diagnostic delays and serious safety events. The objective of the study was to increase the rate of PL review by attending physicians for inpatients discharged from hospital pediatrics and infectious disease services from a baseline of 70% to 80% by June 2018 and to sustain the rate for 6 months. The secondary aim was to improve PL accuracy by decreasing the rate of duplicate codes and red code diagnoses that should resolve before discharge from a baseline of 12% and 11%, respectively, to 5% and sustaining the rate for 6 months. A quality improvement team used the Institute for Healthcare Improvement Model for Improvement. We tracked duplicate codes and red codes as surrogate markers of PL quality. Rates of PL review and PL quality were analyzed monthly via statistical process control charts (p-charts) with 3-σ control limits to identify special cause variation. PL review improved from a baseline of 70% to 90%, and the change was sustained for 1 year. PL quality improved as duplicate codes at the time of discharge decreased from 12% to 6% and as red codes decreased from a baseline of 11% to 6%. The PL is an important communication tool that is underused. By engaging and educating stakeholders, incentivizing compliance, standardizing PL management, leveraging electronic health record enhancements, and providing physician feedback, we improved PL meaningful use and quality.

Implementation of a Health Literacy Universal Toolkit to Improve Postdischarge Care at an Urban Trauma Center.

Low health literacy impacts the financial burden of hospitals up to $238 billion annually. A trauma center located on the East Coast implemented a Transitional Care Management (TCM) model targeting individuals at risk for readmission, but not every patient receives this service. A gap analysis of the facility's discharge process identified a deficit in the formal evaluation of health literacy upon discharge. The purpose of this project was to implement a Health Literacy Universal Toolkit to assess and improve medication education for low literacy patients. Included in the toolkit were the Rapid Estimate of Adult Literacy in Medicine Short Form (REALM-SF), an evidence-based health literacy screening tool, and 2 interventions, additional education on their inpatient or discharge medication list, and a Brown Bag Medicine Review of medications at a postdischarge clinic appointment. Seventy-one patients were screened using the REALM-SF. Sixty-two percent (n = 44) of patients scored at a high school reading level, 30% (n = 21) scored at a seventh- to eighth-grade reading level, and 8% (n = 6) scored at or below a sixth-grade reading level. Eight percent of patients scored as having low health literacy, 30% scored as having marginal health literacy, and 62% scored as having adequate health literacy. Twenty patients received additional medication education with My Medicines Form or a Brown Bag Medicine Review. Regardless of literacy level, patients appreciated the additional medication education interventions. Health care providers should observe universal health literacy precautions regardless of literacy level.

Comparison of pharmacy technicians’ and doctors’ medication transcribing errors at hospital discharge

ObjectivesTo compare the transcribing error rates of discharge prescriptions between pharmacy technicians and doctors in an acute hospital setting.MethodsPharmacy technicians were trained in the transcribing of discharge medications from inpatient...

Postpartum Intrauterine Device Utilization Rate at an Academic Institution [12F

INTRODUCTION: In the first year postpartum, 70% of pregnancies are unintended. Long acting reversible contraceptives, such as intrauterine devices (IUDs), are among the most effective forms of contraception and have been successful in reducing unintended pregnancy rates. Many institutions do not place IUDs until several weeks postpartum despite the American College of Obstetricians and Gynecologists’ recent Committee Opinion No. 670. METHODS: A retrospective cohort study was performed among women who delivered from 7/2014 through 6/2015 at our institution. Those who expressed desire to use an IUD as contraception prior to discharge from the hospital following delivery were included. Billing lists with ICD-10 codes for IUD insertion were used to cross reference inpatient lists from the postpartum hospital stays. Primary outcome measure was percentage of patients who had an IUD inserted by three months postpartum. Additional reasons for not receiving an IUD were examined. RESULTS: 196 patients were identified who desired an IUD for postpartum contraception, and 86 (43.9%) received one. The most common reason for not receiving an IUD was loss to follow up (60%). Other reasons included choosing to use another form of contraception: hormonal (28.1%), barrier (9.1%), or abstinence (1.8%). CONCLUSION: More than half of our patients do not receive their desired method of postpartum contraception. As loss to follow up is the most common reason, institution of immediate postplacental IUD placement may allow for increased utilization and fewer unintended pregnancies. Further study is necessary to elucidate the barriers to immediate postpartum contraception.

Don't call me crazy! Delirium occurs outside of the intensive care unit.

Delirium has been well studied among patients in the intensive care unit (ICU); however, data beyond the ICU is limited. The purpose of this study is to prospectively evaluate the incidence and associated risk factors for delirium in noncritical care areas (NCCA). After institutional review board approval, a prospective cohort study was conducted at our urban Level I Trauma Center from December 2015 to February 2016. All patients admitted to the designated study area by a trauma surgeon were included. The Confusion Assessment Method (CAM) was administered every 12 hours until discharge. Delirious patients (CAM+) were administered the CAM-S to quantify the severity of delirium. Demographics, laboratory data, and inpatient medication lists were analyzed. Of 148 participants, 12 (8%) were CAM+ and 136 (92%) were CAM-. The average CAM-S of CAM+ patients was 7 ± 3. Included patients were aged 52 ± 20 years and 45% were men. Of patients 65 years or older, 9 (21%) were CAM+. Medications associated with delirium were: albuterol (p = 0.01), atorvastatin (p = 0.01), duloxetine (p = 0.04), sertraline (p = 0.04), folic acid (p = 0.01), thiamine (p = 0.01), vitamin D (p < 0.001), haloperidol (p = 0.04), metoprolol (p = 0.02), and vancomycin (p = 0.02). Abnormal laboratory values associated with delirium included: Albumin (p = 0.03; odds ratio [OR], 7.94, 95% confidence interval [CI], 1.1-63.20), Calcium (p = 0.01; OR, 4.95; 95% CI, 1.5-16.7), Sodium (p = 0.04; OR, 3.91; 95% CI, 1.13-13.5), hematocrit (p = 0.04), and mean corpuscular hemoglobin concentration (p < 0.05; OR, 5.29; 95% CI, 1.19-23.46). Our study demonstrated an 8% incidence of delirium overall in NCCA, increasing to 21% in patients 65 years or older. Many risk factors identified among NCCA patients are consistent with the ICU literature; however, our CAM+ patients had additional risk factors which have not been previously associated with the development of delirium. Screening of NCCA patients for delirium should be considered. Prognostic and Epidemological, level IV.

National Clinical Programme in Surgery - General Surgery Minor Ops “See &amp; Treat” Clinic

Introduction: General Surgery is currently ranked number 3 for highest numbers on Out Patient Department (OPD) waitlists. Minor operative skin procedures represent 69% of General Surgery day case activity, excluding endoscopy. A significant proportion are seen and referred by the GP to OPD first for a booking visit, then a second appointment for their operation and finally back to OPD to discuss histology. This protracted process can be simplified into “See and treat” clinics where the patient is seen and treated at their first hospital appointment post GP referral. Description of Changes: This project created a “See & Treat” clinic for General Surgery Minor Procedures Outpatient appointments. The “See and Treat” model has resulted in patients being seen and treated for minor procedures at the same appointment. This has been achieved by a streamlined referral process from primary care, enabling ‘see and treat’ on initial hospital appointment. Following treatment, patients are referred back to their GP for suture removal and histology results. The study will include an elaboration of the resourcing implications enabling the model to scale. Aim & Theory: The aim is to reduce the number of visits to hospital for outpatient minor operative procedures from 2-3 visits to one per patient. This is done by providing adequate information through e-referral to complete a procedure on the patient’s first visit to hospital, and referring patients to their GP for aftercare. Targeted Populations: Patients suitable on the OPD waitlist for selected minor operative general surgery procedures. Stakeholders include general surgery minor operative outpatients, consultants, GPs, nurses and clerical staff, National Clinical Programme in Surgery (NCPS), General Practice Information Technology (GPIT), and The National Treatment Purchase Fund (NTPF). Timeline: Project inception was August 2016. Pilot clinics began “Seeing and Treating” in October 2016. First review of data took place after 5 weeks. Data will be reviewed again at 12 weeks. Highlights: Within 5 weeks, 20% of the 241 identified appropriate patients were treated through the clinic, with a further 6% removed from the waitlist through validation. The current waitlist has been reduced from 13 months to 9 months, and is projected to reduce below best-practice guidelines of 6 months before the end of the project. Sustainability & transferability: An SOP was developed as part of the project, detailing all necessary resources, which ensures sustainability and transferability across M3 and Model 4 Acute Hospitals in Ireland. The study will include detailed consideration of cost implications for primary care & general practice, given that there is no provision at present in the current PCRS Scheme for public patients to have post operative consultations following minor surgical procedures carried out in the primary care setting. Conclusion & Discussion: The “see and treat” pilot clinic has proved effective in reducing the waiting time and number of appointments for patients waiting for a minor operative procedure. This increased efficiency also has the potential to free-up time for surgeons to attend to other inpatient, day-case and outpatient wait lists. Lessons learned: Patient flow and improving care pathways across care settings is feasible and possible given cooperation between primary and secondary care working collaboratively with GPs, Acute Hospital OPD clinics and the HSE Outpatient Services. Streamlining referral and transferring post operative care into the primary care is shown to reduce OPD waiting lists for General Surgery.

PTH-128 Gastroenterology Registrar of The Week: A Solution for AUGIB Endoscopy Training?

Introduction Much concern surrounds Gastroenterology Specialist Registrar(StR) endoscopy training, especially in regards to endoscopic management of Acute Upper Gastrointestinal Bleeding (AUGIB). Recent evidence suggests there has been a decline in exposure and experience in AUGIB endoscopy.1 In July 2013 our Hospital introduced a Consultant led and Registrar supported Monday to Friday, 9 to 5 pm in-reach service. It comprises of a morning visit to the acute medical units and a daily inpatient emergency list. This study looked at registrar AUGIB endoscopy training after its implementation. Methods Endoscopy reports of patients presenting with haematemesis, melena or both who had undergone gastroscopy during the period of 1st of March 2015 to 31st August 2015 were retrieved using the endoscopy reporting tool Unisoft and were then analysed. Reports where StRs were the primary operator were considered. Number of procedures, haemostatic intervention and nature of haemostasis was analysed. This was then compared to data from the year before implementation (01/03/2012 to 31/08/2012). Results A total of 7 StRs (5 Full Time and 2 Less than Full Time) performed gastroscopies on AUGIB patients as first operators under Consultant supervision. Over the 6 month period a total of 166 gastroscopies were undertaken(Mean 24). On 26 occasions, endoscopic intervention(EI) was performed(Mean 4). On average, 16% of the AUGIB patients required EI. In cases of Non Variceal Bleeding, Dual therapy was applied in 87.5% of the cases. In the remaining cases Haemospray was used. On average each StR was able to perform one case of oesophageal variceal banding and one case where Haemospray was utilised. Data from the 2012 cohort in comparison showed a total of 66 gastroscopies over 6 months with 13 EI by 5 StRs. On average 13 procedures and 2.6 EIs were performed by each StR.Dual therapy was applied in only 28.5% of the cases. Conclusion The introduction of the Registrar of the Week Service provides a valuable opportunity for StRs to be trained in endoscopic haemostasis and acquire exposure to AUGIB patients. As per this study each StR on an average performed endoscopy on 24 AUGIB patients. If this is extrapolated, each StR will be able to perform 48 procedures in 1 year and 240 procedures over 5 years. In the case of EI, on average a StR can perform around 4 interventions over 6 months, which comes to 8 per year and 40 in a 5 year programme which is significantly better than in the previous cohort and other centres.1 Hospitals should consider developing similar services not only to meet demands for 24/7 Consultant led AUGIB endoscopy service but provide adequate endoscopic training provision for current specialist registrars in order to ensure future competent and confident Consultants. Reference 1 Penny HA, Kurien M, Wong E, et al. Frontline Gastroenterology 2016;7:67–72. Disclosure of Interest None Declared