Morning Lists Research Articles

872 Audit - Unexpected Overnight Stay After Day-Case Surgery In ENT

Abstract Introduction The aim of this audit was to determine the compliance with guidelines regarding patient selection for day-case surgeries in ENT. Method Data was collected retrospectively and included all patients who underwent elective ENT surgeries over a one-year period at an NHS hospital. Factors considered included nature of the operation, timing, surgeon’s preference, as well as social circumstances. Results Out of 1101 intended day cases, 113 (10%) had an unexpected overnight stay. The major factor contributing to these overnight stays was the timing of the operation, where 85 cases had undergone surgery in the afternoon. Other factors included drain siting, saturation monitoring, post-operative complications, and social circumstances. Tonsillectomy-related and nasal procedures formed the majority of the procedures, with 74 cases in total. Conclusions We concluded that most overnight stay cases included in this audit could have been prevented. Careful theatre list planning by prioritizing day cases for morning lists may reduce these numbers significantly. Co-morbidities and social aspects may need to be explored when booking patients for theatres.

Same-day discharge in selected patients undergoing atrial fibrillation ablation.

Atrial fibrillation (AF) ablation is a complex procedure, generally requiring at least one overnight hospital stay. We investigated the safety and feasibility of early mobilization and same-day discharge following streamlined peri-ablation management for AF. From 2014, we offered same-day discharge to selected patients who underwent uncomplicated AF ablation on the morning lists, with ultrasound-guided femoral access, uninterrupted warfarin or minimal interruption in novel oral anticoagulants, and reversal of intraprocedural heparin with protamine. Patients were discharged 6-8h postprocedure and offered access to a dedicated nurse helpline. Of 1599 AF ablation cases performed from April 2014 to March 2017, 811 (50.7%) were performed on the morning lists and 169/811 (20.8%) were discharged on the same day. Excluding 26 research cases, 1/143 (0.7%) had transient right phrenic nerve palsy and five (3.5%) cases experienced minor problems that did not preclude same-day discharge; three (2.1%) needed rehospitalization postdischarge: one for pericarditic chest pain and two for nausea/vomiting. Compared to 642 overnight cases, day-case procedures were shorter, more likely to be redos, to be performed under sedation rather than general anesthesia, and less likely to involve linear lesions and electrical cardioversion. There were no significant differences in patient age, gender, body mass index, CHA2 DS2 -VASc, in preprocedural anticoagulation regimen (warfarin vs novel anticoagulants vs no anticoagulation) and in choice of ablation method (cryoballoon vs radiofrequency). Selective same-day discharge after AF ablation is safe and feasible using a streamlined peri-procedural care protocol. Wider adoption can potentially reduce health-care costs while improving patient experience.

Prolonged fasting of children before anaesthesia is common in private practice.

Fasting guidelines for children are well established. Despite these guidelines, previous studies have shown children are often fasted for prolonged periods before anaesthesia, potentially causing discomfort and distress. Moreover, recent publications indicate shorter fasting times for oral clear fluids in children may be safe. We audited fasting times of children having elective surgery at a local large private hospital that provides care for both adults and children. We gave feedback and education to our caregivers, then repeated the audit. Data were collected from 307 children (age 6.0 ± 4.1 years) in an initial eight-week audit, and from 153 children (age 6.7 ± 4.5 years) in a follow-up four-week audit. We found fasting durations were excessive in many children. Sixty-two percent of children in each audit fasted longer than four hours for clear fluids. Children on morning lists fasted longer than children on afternoon lists. Fasting from solids was also excessively long. In the initial audit, 30% fasted more than 12 hours for solids, including 18 who last ate more than 16 hours before surgery. Data from the follow-up audit were similar. We conclude that fasting of children at our hospital is excessive, despite our efforts to shorten the duration. We suspect that our hospital is not the only one with a high incidence of prolonged fasting for children and suggest possible solutions.

PWE-357 Variation in quality of bowel preparation between different sessions of the day in the bowelscope screening programme

Introduction NHS Bowelscope screening was recently piloted in 2013 to complement the existing NHS bowel cancer screening programme. Currently there is a paucity of data on whether the timing of the procedure (Morning, afternoon or evening lists) has any impact on the quality of bowel preparation. This study examined the difference in quality of bowel preparation between different sessions of the day, and also whether opening the bowels prior to phosphate enema would have any impact on the quality of subsequent bowel preparation. Method Patients who participated in the NHS Bowelscope screening programme in the West Kent and Medway bowel cancer screening centres were included. We prospectively gathered data over a 2 months period between 8/12/14 to 7/2/15, looking at the quality of bowel preparation in the AM, PM and evening lists. We also examined whether patients have had their bowels opened prior to phosphate enema, as this may affect the quality. Results Over the 2 months study period, 574 patients attended for flexible sigmoidoscopy (AM: 242; PM: 277; Evening: 55). In the AM lists (F: 118 (49%); M: 124 (51%)), 131 patients had good bowel preparation (54%), 68 had adequate bowel preparation (28%), and 43 were deemed inadequate (18%). In the PM lists (F: 128 (46%); M: 149 (54%)), 173 patients had good bowel preparation (63%), 90 patients had adequate bowel preparation (32%) and 14 were deemed inadequate (5%). In the evening lists (F: 26 (47%); M: 29 (53%)), 37 patients had good bowel preparation (67%), 16 patients had adequate bowel preparation (29%), and only 2 were deemed inadequate (4%). Both PM and evening lists had significantly less inadequate preparation compared to the morning lists (p In the morning lists, only 160 patients (66%) had their bowels opened prior to phosphate enema. Whereas in the afternoon and evening lists, 233 (84%) and 39 patients (71%) had their bowels opened prior to phosphate enema respectively (p Conclusion Our study has shown that the quality of bowel preparation was significantly worse in the AM lists compared with the PM and evening lists (Inadequate bowel preparation in 18% of patients in the AM lists, 5% PM lists, 4% evening lists). Furthermore, less patients had their bowels opened prior to phosphate enema in the AM group (AM 66%, PM 84%, evening 71%). In light of these findings, changes in practice, such as booking less patients in the morning lists in the event that re-enema is required in order to avoid list overrunning, or, offering double enema, may provide better outcome and ultimately improves adenoma detection rate. Disclosure of interest None Declared.

Stapled anopexy: An effective treatment for symptomatic haemorrhoidal disease – A district general hospital experience

Stapled anopexy: An effective treatment for symptomatic haemorrhoidal disease – A district general hospital experience

PTH-063 Is Evening Endoscopy Cost Effective?

IntroductionCurrently in the UK we are seeing an increasing demand for endoscopy services that is set to continue to rise over the coming years.1 Our aim as an endoscopy department...

A Prospective Audit of the Efficacy, Safety, and Acceptability of Low-volume Polyethylene Glycol (2 L) Versus Standard Volume Polyethylene Glycol (4 L) Versus Magnesium Citrate Plus Stimulant Laxative as Bowel Preparation for Colonoscopy

High-quality video colonoscopy requires adequate preparation of the bowel to ensure both adequate procedure completion rates and polyp detection rates. We sought to examine our practice to determine which bowel preparation cleansed most effectively in our patients. A prospective audit of the efficacy, safety, and acceptability of low-volume polyethylene glycol (2-L Moviprep; Norgine Pharmaceuticals) versus standard volume polyethylene glycol (4-L KleanPrep; Norgine Pharmaceuticals) versus magnesium citrate (Citramag; Sanochemia UK Ltd.) plus stimulant laxative as bowel preparation for colonoscopy. District General Hospital. Patients attending for day case colonoscopy. Not applicable. Overall cleansing grades of preparations used: patient compliance, taste, and acceptability. A prospective audit of patient experience of taking bowel preparation and blinded colonic scoring assessment of bowel cleansing of each of the tested regimes. A total of 258 (female,138; 53.5%) patients were recruited, 91 in the KleanPrep group (F:45, 49.5%), 86 patients in the Moviprep group (female, 45; 52.3%), and 81 in the Senna/Citramag group (female, 44; 54.3%). Significantly more patients were unable to take the prescribed dose of KleanPrep when compared with the other 2 regimes (19.6%; P<0.0001 vs. Moviprep; P<0.0001 vs. Senna/Citramag). A total of 45.65% of patients reported KleanPrep as tasting unpleasant. This was significantly more than both Moviprep (10.47%; P=0.008) and Senna/Citramag (9.88%; P<0.0001). The overall cleansing efficacy across the 3 groups (those with grades A or B) was 73.9%, 74.5%, and 86.5% for KleanPrep, Moviprep, and Senna/Citramag, respectively. In this series Senna/Citramag proved significantly better at bowel cleansing than KleanPrep (P<0.05) and it showed a trend toward better cleansing when compared with Moviprep (P=0.08). Nonrandomized trial. Split-dosing regime for morning and afternoon lists may have confounded results. In summary, low-volume PEG (Moviprep) and Senna/Citramag combination were better tolerated than large volume PEG with Senna/Citramag providing superior mucosal cleansing.

OC-048 Adenoma detection reduces during a colonoscopy list

IntroductionRecent studies have provided conflicting data on whether colonoscopy lesion detection varies with time of day.1–3 We aimed to assess whether the time of procedure within a list affected polyp...

PTU-211 Patient preparation prior to gastroscopy: a UK wide survey

IntroductionBackground: Optimal patient preparation for colonoscopy is shown to improve polyp detection in the colon. In Japan, it is widely accepted practice to administer a mucolytic agent prior to gastroscopy...

Theater Sending: How Long Does It Take and What Is the Cost of Late Starts?

Last minute cancellations of scheduled surgery are a waste of health care resources and an emotional burden on patients. A common reason for cancellation is poor theater time utilization. Several studies have demonstrated that in some cases 50% of lists overran their scheduled time and more than 40% started late. In a recent prospective study of 55 elective gynecological operations, 25% of the theater session was wasted by delays related to transfer of patients to and from the operating theater; the median waiting time between cases was 22.5 minutes for surgeons and 7 minutes for anesthetists. The aim of this retrospective study was to examine the theater transit of patients through theaters and estimate the cost of delays, especially the cost of late starts. The study subjects were 238 patients undergoing elective gynecological operations during a 3-month period in 2008 at a single hospital. After exclusions, 164 patients were included in the final analysis. Primary study outcome measures included time to send, time for anesthesia, and procedure time. Secondary outcome measures included time to send for the first patient (calculated as waiting time resulting from late starts) and the estimated cost of late starts. The mean time to send (time between sending and arrival in anesthetic room) was 19 ± 8.1 minutes; the 95% confidence interval [CI] was 18 to 20. The mean time for anesthesia (time between arrival in anesthesia room and arrival in theater) was 9 ± 6.4 minutes (95% CI: 8–10). The mean procedure time (time between arrival in theater and end of procedure) was 60 ± 35 minutes (95% CI: 55–65). The mean time to send for the first patient on the morning list (representing the mean wait time of the surgical team for the first patient) was 20 ± 9.83 minutes (95% CI: 17–23). The delayed arrival of the first patient resulted in a late start in 93% of morning lists. The mean wait time of the surgical team after the first patient on the morning list was due to start was 22 ± 19 minutes (95% CI: 17–27). During the 3-month study period, the total time wasted as a result of late starts was 910 minutes (15 h) at an estimated cost of £3640. The investigators conclude from these findings that sending patients 30 minutes before the list is due to start could increase theater efficiency and save 15 hours of currently wasted time.

ENT day surgery in England and Wales--an audit by the Royal College of Surgeons (Eng.) Comparative Audit Service.

An audit of day surgery was carried out by the Royal College of Surgeons (Eng.) Comparative Audit service. Data from 121 respondents on over 3,962 day cases were analysed from both retrospective information and from prospective individual patient proformas. The day surgery rate is 31 per cent. The variability of facilities for day-surgery, the timing of lists, type of anaesthetic used and case-mix are discussed. Outcome and the reasons for admission to an overnight bed are analysed. The overall admission rate was found to be 2.8 per cent (range 0.6-19.5 per cent between consultants). Seventy per cent of ENT day-surgery was performed on morning lists which have a lower admission rate than afternoon lists. The main reasons for admission are vomiting 30 per cent, haemorrhage 20 per cent and inadequate recovery from anaesthetic 22 per cent. A more detailed analysis of reasons for admission were given for tonsillectomy, adenoidectomy, FESS, and grommets. Recommendations are given which might increase the scope of safe day-surgery and reduce admission rate.

The Relationship of Duration of Fast to the Volume and pH of Gastric Contents

Volume and pH of gastric contents were measured after anaesthetic induction in 99 in-patients undergoing general and vascular surgery scheduled for either morning (50) or afternoon (49) lists. Significantly fewer patients in the morning group had pH values below 2.5. The mean pH value of the morning group was significantly higher than that of the afternoon group. There was a positive correlation between duration of fast and pH (the longer the more alkaline) for the groups combined. No significant relationship could be shown for any factor with volume.