NCEPOD Report Research Articles

EP421 - The multidisciplinary management of acute pancreatitis at a district general hospital – an NCEPOD audit

Abstract Aim To assess adherence to NCEPOD Acute Pancreatitis 2016 guidelines in order to optimise the multidisciplinary care of patients presenting with acute pancreatitis. Methods A retrospective case-based audit was conducted of the last 10 admissions with acute pancreatitis. Data on demographics, investigations and management were collected and audited against the NCEPOD evidence-based recommendations. Results The average age was 54 years (33-84) and 70% were male. The cause of the acute pancreatitis was identified as gallstones in 40%, alcohol in 30% and was unknown in the remaining 30%. All patients with alcoholic pancreatitis were referred to alcohol support services. 80% of all patients had significant co-morbidities at presentation: in 63% of patients these were well-controlled; of those uncontrolled, none received onwards referrals. Nutritional assessment only occurred in 10% of patients. Conclusions Our audit showed that we successfully identified a cause of acute pancreatitis in 70% of patients and involved alcohol services in 100% of alcoholic pancreatitis cases. This demonstrates good organisational infrastructure in managing these patients. However, despite the highlighted importance in the NCEPOD report, patients were not appropriately referred to dietitians or other medical specialities. We have therefore developed a series of multi-disciplinary team teaching sessions and an admission proforma to address these areas of the report and improve compliance. A second audit loop will be conducted to demonstrate impact.

EP.FRI.82 Using NCEPOD guidelines to develop an evidence based pathway for acute bowel obstruction

Abstract Bowel obstruction is a common presentation and poses a significant challenge for clinicians. This condition is associated with a high level of mortality and morbidity. The aim of this project was to assess the clinical pathway for patients presenting with bowel obstruction and improve the overall care they received. This was achieved using guidance from the 2020 NCEPOD report looking at bowel obstruction management. Best practice guidelines from the NCEPOD report were used to assess aspects of patient care such as the time to senior review, assessment of nutrition/fluid status and risk of mortality/morbidity assessment. This identified areas where the standard of care was good, such as the majority of patients being assessed by a consultant within 14 hours. However, it also identified areas such as hydration and nutritional status assessment, documentation of ceilings of care/treatment escalation plans and calculation of risk of mortality and morbidity, which required improvement. An admission checklist and nutritional scoring sheet was created to help prompt clerking doctors when admitting patients with acute bowel obstruction. All cases of bowel obstruction were then prospectively audited over a 2 month period to assess the impact of these changes. The findings were presented at the departmental meetings to increase clinician awareness. Following the audit period, local guidelines were amended to incorporate the NCEPOD recommendations, specific pathways were also made for adhesive small bowel obstruction and malignant large bowel obstruction due to the specific requirements of these conditions.

633 Improving the Quality of AKI Management Within a District General Surgery Department

Abstract Introduction Acute kidney injuries (AKI) affect 1/5 patients requiring acute hospital admission. The NCEPOD report (2009) described only 50% of AKI care as “good”. Swift identification and appropriate management of AKI is vital. We aimed to assess and improve our adherence to NICE guidance(QS76, NG48) on managing AKI. Method Retrospective review of paper notes was conducted in patients admitted under general surgery at Royal Alexandra Hospital found to have a > 50% increase in the serum creatinine. We assessed the completion of a urinalysis and withholding of nephrotoxic medications within 24 hours of AKI identification, and duration of AKI. First cycle was conducted in August 2020. An AKI alert card was introduced outlining the identification of an AKI and initial management. This provided an effective method of recording interventions in patient notes and accessible education on current guidelines to foundation doctors. The second cycle commenced mid-December and is ongoing. Results First cycle included 30 patients; median age was 77(IQR:67-85). Adherence to urinalysis and nephrotoxic guidance was completed in 9/30(30%) and 13/30(43%) respectively. Median duration of AKI was 7(IQR:5-12) days. Second cycle has identified 17 patients so far; median age is 75(IQR:68-91). Adherence to urine dip and nephrotoxic guidance improved to 11/17(65%)(p < 0.05) and 16/17(94%)(p < 0.05) respectively. Median duration of AKI also improved to 3(IQR:2-7) days (p < 0.05). Conclusions Our interim results show a positive effect to the management of AKI following the introduction of our AKI Alert Cards. Reduction in overall duration of AKI highlights patient benefit.

P0629ESTABLISHING MORTALITY ASSOCIATED WITH AKI IN A DGH AND THEN TRYING TO DO SOMETHING ABOUT IT- INTRODUCTION AND AUDIT OF THE AKI7 CARE BUNDLE

Abstract Background and Aims Acute kidney injury (AKI) is a prevalent and treatable contributor to inpatient mortality. Simple management steps for AKI are frequently omitted or delayed in patient care due to its insidious onset and lack of symptoms. The NCEPOD report in 2009 found that only 50% of patients with AKI received good care. One response to this has been increased use across trusts of the electronic medical record for recognition and monitoring of AKI. Such systems also enable collection of reproducible datasets for audit as well as a platform for prompting the use of best practice guidelines. We sought to establish mortality for patients with AKI and to audit the introduction of an electronic alert system and order set proforma for AKI: the AKI7 care bundle. Method We collated data from all inpatients in West Suffolk Hospital (WSH) flagged as developing AKI by the recording system ‘eCare’ over a 2-year period and present a mortality analysis for this cohort. Data was collected retrospectively from eCare and statistical analysis conducted in ‘R’. Results Of 3527 individuals who developed AKI over a 2 year period in WSH; 79% did not progress beyond AKI stage 1, 13% stage 2 and 8% stage 3, the mean age was 74 years and mean length of stay 13 days. Across all stages of AKI, 75% were investigated with urinalysis, 94% received fluid balance monitoring, 5% were investigated with renal tract US and 58% were referred to a nephrologist for specialist input. Mortality analysis for this same cohort revealed an association between survival at 60 days and use of urinalysis p=<0.001, fluid balance monitoring p=<0.001 and investigation with renal tract US p=<0.001. The 1 year mortality associated with AKI increased significantly with severity; 29% for AKI stage 1, 51% for AKI stage 2 and 65% for AKI stage 3 (Figure.1). The all cause 1 year mortality for all stages of AKI combined was 39.1%. Following launch of the AKI7 care bundle we found that use of the document template promoted requests for renal tract US (20% versus 5%), urinalysis (83% versus 75%) and requests for input by renal physicians (75% versus 65%). Conclusion The AKI7 care bundle improves clinician awareness of AKI and promotes the use of important steps in AKI management. Since mortality increases with AKI stage, management targeted to ameliorate progression of AKI is vital and can be supported by well designed electronic care bundles. The association of improved survival with fluid balance monitoring and investigations for AKI further supports measures to promote the use of these steps. We intend to encourage use of the AKI7 care bundle during induction for junior doctors coupled with distribution of cards as an aide-memoire.

A regional survey of parenteral nutrition services in the South East BAPEN region

Our regional BAPEN meetings have indicated that we have different practices when it comes to the provision and delivery of parenteral nutrition (PN). The NCEPOD report “A Mixed Bag” in 2010 (1) gave several recommendations for PN services. We designed a survey regarding PN services and sent it to all 10 acute hospital trusts in the South East BAPEN region.

Test to prescribe nutrition safely (T.P.N.S.) – A quality improvement project to improve biochemical monitoring in inpatients on parenteral nutrition

Parenteral nutrition (PN) has undoubtedly saved lives since its development in the twentieth century. However, it has significant complications, and at times is not used appropriately or safely. The 2010 NCEPOD report A Mixed Bag (which reviewed use of parenteral nutrition in inpatients in the UK) concluded that only 19% of adults had PN care that was considered to represent good practice1. The report also identified deficiencies in assessment and monitoring in 54% of patients on PN; metabolic complications occurred in 40% of patients and in 49% these were judged by the advisors to be avoidable1.

CN50 - Overview of an acute oncology service in a UK cancer centre

Background: In the UK there has been increasing emphasis on the ability to review oncology patients who are admitted as an emergency. Two reports, NCEPOD report into systemic Anti-Cancer Therapy: For better, for worse? (2008) and the NPSA Report 'Patient safety risks of incorrect dosing of oral anti-cancer medicines' (2008) identified shortcomings in the manner in which patients presenting to emergency departments following systemic anti-cancer treatmentrs (SACT) were cared for. This had led to increased mortality, morbidity and extended lengths of stay. In addition to the above patients presenting as an emergency with Metastatic Spinal cord compression were found to have delays in urgent treatment and patients who had a cancer diagnosis following an emergency admission had poortrer outcomes than those identified in a more controlled fashion. At the Royal Berkshire NHS Foundation trust we responded to NHS England guidance by establishing an oncologist-led acute oncology service with nursing support. We have been succesful in reducing length of stay for oncology patients, forming sucesaful partnerships with acute physicians, succeasfully auditing and treating neutropaenic sepsis and bringing in a 7 day Acute Oncology service. This poster p[resentation will provide an overview of this service as part of the Oncology Nursing Track. Methods: The presentation will cover a narrative overview of our experience of establishing, auditing and developing an Acute Oncology Service at a busy District General Hospital with a Cancer Centre. We will present audit information to support this narrative review. Results: We will present data covering Acute Oncology activity, effectiveness, presentation and referral by tumour group, referral type and source. This will be presented in graphical format in order to support the narrative review. Conclusions: The overall conclusions will outline our generally positive exprience of establishing and developing Acute Oncology services. We hope that this will be relevant to others wishing to do the same across Europe. Legal entity responsible for the study: Mark Foulkes (Macmillan Lead Cancer Nurse and Nurse Consultant in Acute Oncology). Funding: Has not received any funding Disclosure: The author has declared no conflicts of interest.

Inadvertent passage of a tracheostomy tube through Murphy's eye during percutaneous tracheostomy tube insertion

SummaryPercutaneous tracheostomies are commonly performed at the bedside in Critical Care Units. The use of bronchoscopy during the procedure is variable. We describe a case of inadvertent cannulation of Murphy's eye with a tracheostomy which initially went unrecognised. Recommendations from the NCEPOD report “On the right Trach” related to the use of bronchoscopy during percutaneous tracheostomy insertion and awareness of the nuances of different endotracheal tubes may have prevented this complication.

46 Inpatient admissions for lower gastrointestinal bleeding in the belfast trust

Background Traditionally, lower GI bleeding (LGIB) is admitted surgically but the recent NCEPOD report has recommended an integrated pathway for all gastrointestinal bleeds. Aim To retrospectively assess how LGIB is managed within the Trust. Method Inpatient discharge data were gathered over a 12 month period (March 2015-March 2016). Cases included were those with LGIB as the primary reason for admission. Factors including length of stay, inpatient and/or outpatient endoscopic and radiological investigations. 30 day mortality rate was assessed. Results 350 patients were identified, 174 were excluded (UGIB or not primary reason for admission). 176 patients were included, age range 17–100 (median 66). Median length of stay=3.19 days (range 0–27). Total bed days 562. 30 day mortality=3.9% (n=7, 2 secondary to PR bleeding and 5 due to co-morbidities). n=86 (48.9%) patients had inpatient investigations. See Figure 1. 50 patients had only inpatient endoscopic procedures, 15 had both endoscopic and radiological investigations and 15 had only radiological investigations. Others included EUA and haemorrhoidectomy. n=46 (26.1%) had only outpatient investigations. Total bed days=83. n=44 (25%) had no investigations. Reasons included known pathology, recent endoscopy or CT imaging, recent intervention (surgical or endoscopic) or not fit for investigation. Most common diagnoses were diverticular bleed n=59, haemorrhoids n=12, malignancy n=10. Conclusions Less than half had inpatient investigations suggesting that many admissions could have been avoided. The current results show a low mortality rate consistent with other published data. A pathway for the management of stable LGIB bleeding could be developed to minimise unnecessary admissions and streamline access to intervention where needed.

PWE-128 The Out-of-Hours Gastrointestinal Bleed Service in South-West London: A Model for Regional Emergency Endoscopy Cover: Abstract PWE-128 Table 1

Introduction Gastrointestinal (GI) bleeding is associated with a mortality of 10–30%. An NCEPOD report recently recommended that management of GI bleeds should be directed by a named GI bleed clinician, although wasn’t implicit that procedures be performed by a consultant. 1 In SW London, 5 hospitals developed a network service to cover out-of-hours emergency endoscopy requirements for the region. It is a registrar-delivered, consultant-supported service. We present the key service outputs over a 10 month period in 2015. Methods OGDs were performed by registrars accredited with appropriate skills in upper endoscopy. Endoscopists prospectively collected data on all out-of-hours OGDs performed including age and sex of patient, Rockall score, time to OGD, primary endoscopic findings and therapeutic intervention. Data on mortality and re-bleed rates were retrospectively collected for the last 2 months of the study. Results 172 out-of-hours OGDs were performed between March and December 2015. 57% occured during the weekend, giving rise to a procedure rate of 1.12 OGD/weekend day and 0.33 OGD/week day. Mean age of patient was 59.5 years (range 16–94). 64% were male. Median Rockall score was 4. Mean time to OGD was 4hrs 15 mins (range 1 hr-16hrs). Table 1 shows the primary pathologies at OGD. Therapeutic intervention was needed in 52% of cases. Failure to achieve haemostasis endoscopically occured in 1.7%. Consultant assistance was required in 3 cases. Data from Nov to Dec 2015, which included 40 OGDs (mean age 59 years, 63% males, intervention rate 53%) indicated an inpatient re-bleed rate of 10% (NCEPOD audit rate 23%), an interventional radiology requirement in 6% (NCEPOD 8%) and a surgical intervention rate of 2.5% (NCEPOD 6%). All-cause 30 day mortality rate was 15%, although only one patient (2.5%) died as a direct result of uncontrolled bleeding. Conclusion The results indicate that an effective and safe regional out-of-hours emergency GI bleed service can be provided via a registrar-delivered, consultant-supported model. This has important implications when considering the development of consultant on-call rosters, and maximising training opportunities for registrars. Reference 1 NCEPOD ‘Time to get control’ – a review of the care received by patients who had a severe gastrointestinal haemorrhage 2015. Disclosure of Interest None Declared

PTH-156 Impact of BSG and BASL Liver Care Bundle Introduction on Clinical Practice: A University Hospital Experience: Abstract PTH-156 Table 1

Introduction The National Confidential Enquiry into Patient Outcome and Death for alcohol related liver disease highlighted the need to improve care of patients with decompensated liver disease. BSG and BASL thereafter developed the Liver Care Bundle toolkit to aid provision of evidence-based care within 24 hours of admission. We performed an audit of care delivered to such patients before and after introduction of the Bundle into clinical practice in our hospital. Methods For the initial audit (August 2014-March 2015), patients presenting with decompensated liver disease were retrospectively identified from ward lists, blood bank data for Human Albumin Solution (HAS), and the endoscopy database. Electronic patient records were reviewed against the toolkit. The results were presented at hospital Grand round alongside presentation of the Liver Care Bundle which was, thereafter, implemented throughout the Trust from July 2015. Re-audit using the same methodology was performed September to December 2015. The significance of impact of the Bundle on clinical practice was evaluated using Fisher’s exact test. Results 45 patients were identified for the first part of the audit. The average length of stay was 11 days. Notes for 20 patients with 25 in-patient episodes were reviewed for the re-audit. Average length of stay was 18 days. Conclusion The introduction of the Liver Care Bundle at our institution led to improvement in several aspects of care- especially in the management of variceal haemorrhage. Recognition of patients with excess alcohol consumption and use of Pabrinex was improved upon too. There, however, remain clear areas for improvement. Experiences with the Liver Care Bundle should continue to be widely reported in an attempt to standardise and improve in-patient morbidity and mortality in liver disease. Reference 1 McPherson S, et al. Response to the NCEPOD report: development of a care bundle for patients admitted with decompensated cirrhosis—the first 24 h. Frontline Gastroenterol. 2016 Jan;7(1):16–23. Epub 2014 Dec 2. Disclosure of Interest None Declared

PTH-037 The Shock Index: A Novel and Useful Predictor of Mortality and Morbidity in Upper Gastrointestinal Bleeds?

Introduction The aim of this study was to evaluate the usefulness of the Shock Index (heart rate/systolic blood pressure), a widely used measure of haemodynamic stability in trauma and sepsis, in triaging patients with suspected upper gastrointestinal (UGI) bleeds. Compliance with assigning Blatchford and Pre-Rockall scores, the current risk assessment scores for UGI bleeds, is poor despite being mandated by national guidelines. We therefore wished to assess whether the Shock Index, a quick and easy measure, was as accurate at triaging these patients in determining the severity of the bleed. Methods Data from 46 patients who underwent oesophago-gastro-duodenoscopies (OGD) between January and October 2015 was retrospectively analysed and the Blatchford, Pre-Rockall and Shock Index scores calculated. In our cohort, 19 patients were admitted via A&E and there was only one incidence of variceal bleeding and an additional case of cirrhosis. Sensitivity and specificity were calculated and Fischer’s Exact Test was performed to ascertain which of the scores was most correlated with adverse outcome (defined as needing transfusion). The cutoff point for an abnormal Shock index score was defined as >0.7, as used in the 2015 NCEPOD report. Results Of the 46 patients reviewed, 17 had adverse outcomes indicating a severe UGI bleed. The Shock Index was raised in 8/17 of these patients (sensitivity 47.1%) whereas the Blatchford score was elevated (>0) in 16/17 (sensitivity 94.1%) and the Pre-Rockall score was raised (>0) in 15/17 (sensitivity 88.4%). However, of the 29 patients without a severe UGI bleed, the Shock index was Conclusion The Shock Index, a novel tool to assess the severity of UGI bleeds, lacks the sensitivity of the Blatchford and Pre-Rockall scores but is a better differentiator of those with mild UGI bleeds, as reflected in its greater specificity. The 2015 NCEPOD study demonstrated a sensitivity of 64.2% for the shock index when looking at patients requiring 4 or more units of blood, suggesting that it is better at identifying more serious bleeds. The role of the shock index could be as a useful adjunct to the more widely used Blatchford and Pre-Rockall scores and have a role in stratifying patients in which these scores are raised. Disclosure of Interest None Declared

PTH-043 A Comparative Study of Risk Assessment Scores for Acute Upper GI Bleeds, in Predicting Need & Time for Intervention

Introduction While managing patients with acute upper GI bleed (AUGIB) a simple numerical score can be helpful to identify high risk groups & need for intervention as recommended by NICE.Recent NCEPOD report for AUGIB reported that only 32% patients had a Pre-endoscopy risk assessment performed. Two commonly used scoring systems in UK are GBS (Glasgow Blatchford score) and RCS (Rockall score). Recent comparisons have shown that the GBS was superior in identifying need for hospital-based intervention1 while RCS was better in predicting mortality.2 Methods We conducted a retrospective study of 893 patients, admitted to the hospital and treated in endoscopy unit of Cardiff & Vale health board between September 2010 to September 2013 with AUGIB. We calculated the GBS and pre & post endoscopy RCS for each and compared several outcomes. Results Overall, GI bleed related mortality was only 3.1% in our study, with chronic liver disease being one of the main risk factor. GBS was superior in identifying patients suitable for safe discharge with outpatient management. The GBS was also better at predicting the need for endoscopic intervention. Our study also found that very early endoscopy (ie 10), and in fact had a significantly worse mortality rate of 28% versus 7.4% . Conclusion The GBS score is superior to the pre-endoscopy Rockall in rationalising need & timeliness of intervention. The post-Rockall score is shown to be the better predictor of mortality. This study also reinforced the importance of access to rapid endoscopic intervention within 24 hours, but did not demonstrate the need for very early gastroscopy. References 1 Camellini L, et al. Dig Liver Dis. 2004;36(4):271–7. 2 Rockall TA, et.al. Gut. 1996;38(3):316–21. Disclosure of Interest None Declared

Exploring the experiences of surgical patients admitted with non-trauma gastrointestinal disorders: A qualitative study

s / International Journal of Surgery 23 (2015) S15eS134 S111 0146: EXPLORING THE EXPERIENCES OF SURGICAL PATIENTS ADMITTED WITH NON-TRAUMA GASTROINTESTINAL DISORDERS: A QUALITATIVE STUDY J. Mason, A. McNair, N. Blencowe, D. Stevens, K. Avery, A. Pullyblank, J. Blazeby. University of Bristol, UK Aim: The RCSEng recommends the use patient reported outcome data in surgical trials, although there are no validated questionnaires to measure these outcomes within emergency surgery. The aim of this study, therefore, was to explore the views of patients admitted with unplanned abdominal problems. Methods: Semi-structured interviews were conducted with a purposive sample of patients admitted to SAU at 2 acute hospitals in the South West of England. Interviews explored patients’ experiences regarding their illness, treatment and recovery. Analysis was an on-going iterative process, occurring concurrently alongside data collection. Results: Fourteen semi-structured patient interviews were carried out (10 females, median age 51.5, range 27e77) covering the spectrum of nontrauma emergency surgery presentations. Six patients were treated conservatively, while 8 patients underwent either endoscopy or surgery. All patients reported abdominal pain as the primary reason for seeking medical attention. Immobilisation was the main consequence of pain regardless of age. Treatment related complications were more common in patients who underwent surgery, and were associated with a prolonged period of immobility during recovery. Conclusion: Patients admitted with unplanned abdominal problems report a similar collection of experiences. Future work should focus on the development of a core outcome set for this patient population. 0160: WHO DOES IT BETTER? COMPARISON OF TRAUMA CARE AND PELVIC BINDER USE AT TWO HOSPITALS IN WALES J. Clutton , L. Moulton , J. Organ , C. Carpenter . University Hospital of Wales, UK; Ysbyty Gwynedd, UK Aim: To compare the standard of care of the Severely Injured Patient (SIP) between a DGH and a teaching hospital. Methods: All trauma calls for a one-year period were reviewed retrospectively. Attendance distribution, proportion of trauma calls undergoing CT, time to CT, and initial management of suspected pelvic injuries were reviewed. Our standards were Royal College of Radiologists' guidelines, and the 2007 NCEPOD report. Results: We reviewed 270 trauma patients in total (190 at the teaching hospital, 80 at the DGH). Incidence of pelvic fractures was equal at both sites (10%). At the DGH, SIPs were more likely to have a CT scan, have a pelvic binder applied, and have this applied correctly. At the teaching hospital, time to CT was significantly faster (p <0.01), and patients were more likely to have a binder on a fractured pelvis. Time to CT increased by 30% at both sites out of hours. Conclusion: Both hospitals have room to improve care of SIPs. Delay to CT at the DGH is likely to be due to hospital layout, and increased time to CT out of hours due to decreased resources. Improvements are needed at both sites to decrease the delay to CT. 0182: THE EMERGENCY LAPAROTOMY; POST-OPERATIVE MORTALITY AND LENGTH OF STAY IN HOSPITAL N. Stephens, R. Dolan, H. Dorrance. Victoria Infirmary, UK Aim: A contemporary study in England showed a 30 day mortality rate of 15.6% for patients undergoing emergency laparotomies. We aim to assess the mortality and length of stay following emergency laparotomies. Methods: Electronic and paper based theatre logbooks were searched to identifyall consecutivepatientsundergoingemergency laparotomiesovera6 month period. Patients’ online electronic clinical records were also reviewed and demographics, diagnosis, procedure and outcome documented. Results: 70 patients (male: 32, female: 38) were included in the study. Median (SD) age was 61 (19) years (range 21e92 years). The most common reason for a laparotomy was for bowel obstruction which accounted for 15.7% of cases. Perforated diverticular disease accounted for 14.3% of cases, while stabbings and blunt force trauma accounted for 4.3% of cases. Median length of stay in hospital was 17 (19) days (range 1e115), while the median time from laparotomy to dischargewas 15 (17) days (range 1e109). 30 day mortality rate was 11%. Conclusion: This study has demonstrated low post-operative mortality rates following emergency laparotomy at our institution. Although length of stay in hospital post-operatively was just over 2 weeks, therewas awide range (up to 109 days) which deserves further exploration. 0213: APPENDICECTOMY PRE AND POST INTRODUCTION OF A DEDICATED EMERGENCY SURGICAL UNIT P. Karayiannis, N. McKinley, R. Lambon, B. Clements. Royal Victoria

Feedback on ‘Tracheostomy management’, BJA Education, June 2015

Editor®I wish to comment on behalf of my colleagues who work with the National Tracheostomy Safety Project in response to the article by Katharine Hunt and Sue McGowan in the June edition of BJA Education.1Hunt K McGowan S. Tracheostomy management.BJA Education. 2015; 15: 149-153Abstract Full Text Full Text PDF Scopus (5) Google Scholar The article updates the reader on some of the progress in multidisciplinary tracheostomy care in the intervening years since a similar article in April 2008's CEACCP journal. It was refreshing to see the contribution of a nationally recognized Speech and Language Therapist in this latest article, emphasizing some of the progress in multidisciplinary care and management of tracheostomy patients. We were very surprised however not to find any mention of the National Tracheostomy Safety Project (NTSP), especially when many of the NTSP resources were considered as the benchmark in the 2014 NCEPOD report ‘On the right trach?’ referred to in the article. The Intensive Care Society Guidelines referenced in the article were updated in June 2014 and again emphasize the importance of standardized (NTSP) guidelines. The reproduction of Hunt and Regan's 2008 emergency management guideline figure was also surprising and potentially misleading for the readership of BJA Education. The NTSP published multidisciplinary emergency guidelines in 2012 (Fig. 1) which were endorsed by the Royal College of Anaesthetists, the Difficult Airway Society, the Intensive Care Society, ENT UK, the British Association of Oral and Maxillofacial Surgeons, the College of Emergency Medicine, the Resuscitation Council (UK) the Royal College of Nursing, the Royal College of Speech and Language Therapists, the Association of Chartered Physiotherapists in Respiratory Care, and the National Patient Safety Agency.2McGrath BA Bates L Atkinson D Moore JA Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies.Anaesthesia. 2012; 67: 1025-1041Crossref PubMed Scopus (134) Google Scholar The algorithms are universally taught in this country and beyond and were developed primarily in an attempt to standardize the response to tracheostomy emergencies. Whilst we certainly do not claim ownership of emergency care for tracheostomy patients, to publish alternative guidance without reference to the current national standard is confusing at best. The NTSP algorithms have been tested in both Anaesthetic and Intensive Care Medicine examinations and we would like to draw attention to this for your readership, especially those who are searching for up-to-date resources or specifically revising for such examinations. The article also makes valid reference to role anaesthetists can play as part of a multidisciplinary team managing in patients with a tracheostomy. The weaning process described is one of many published strategies and we would direct the reader searching for additional resources to the websites of the NTSP (www.tracheostomy.org.uk) or that of the Global Tracheostomy Collaborative (www.globaltrach.org).

PWE-084 Itu escalation and renal replacement therapy in decompensated liver disease – utility or futility

Introduction Liver-related mortality continues to increase in the UK with alcohol remaining the leading cause. A recent NCEPOD report highlighted deficiencies in the acute care received by patients with decompensated ALD, including early management and access to specialist review and ITU care. In our instituition, a large DGH, we have a dedicated HDU/ITU and 2 hepatologists. We sought to assess outcomes and predictors of survival of patients admitted to ITU with decompensated CLD and utility of mechanical ventilation (MV) and renal replacement therapy (RRT.) Method We interrogated a prospective ITU-admissions database and identified 64 patients with decompensated CLD of any aetiology admitted bewteen 2008 and 2013. We conducted a case note analysis collecting data on demographics, aetiology of CLD, cause for decompensation, Child–s and MELD scores, interventions received and 30-day and 1-year mortality. We compared outcome to previous study between 2003–07. Results Of 64 patients, 42 (66%) were male. 55 (86%) had ALD. Mean age was 47.7 for ALD and 50.8 for non-ALD. The most common precipitant was UGI bleed (27%), sepsis (20%) and alcoholic hepatitis (17%). AKI was present in 32 (50%; 55% ALD vs 22% non-ALD; p 28 patients (44%) were ventilated and 10 (16%) received RRT (all ALD patients.) The 30-day mortality was 58% for ALD and 66% for non-ALD with 1-year mortalities of 71% and 77%. Overall, survival to hosptial discharge was 20/64 (31%). The best predictor of survival was escalation to ITU within 48 h 17/24 (71%) vs 7/40 (17.5%) (p-value 60 did not survive. Prognosis was better if previously under hepatology service. Receiving either MV or RRT were not predictive of a worse prognosis. As expected, higher MELD score also predicted poorer outcome. Overall survival of ALD patients of 40% over this study period is favourable compared the previous study period (29%). There was an increase in the number of admissions from 35 to 55 patients over the same period. Conclusion Outcomes for patients with decompensated CLD including ALD are improving and ITU escalation should be offered early to all appropriate patients. Ventilation or RRT should be considered as not always predictive of poor outcome. The best chance for survival was in patients escalated within 48 h and those who had been been under the care of hepatology prior to presentation. Disclosure of interest None Declared.

Parenteral nutrition.

Over the last 50 years, parenteral nutrition has been recognised as an invaluable and potentially lifesaving tool in the physician's arsenal in the management of patients with intestinal failure or inaccessibility; however, it may also be associated with a number of potentially life-threatening complications. A recent NCEPOD report (2010) identified a number of inadequacies in the overall provision and management of parenteral nutrition and recommendations were made with the aim of improving clinical practice in the future. This paper focuses on the practical aspects relating to parenteral nutrition for adults, including important concepts, such as patient selection, as well as general management. We also explore the various pitfalls and potential complications and how these may be minimised.

PC.114 Audit of Neonatal Parenteral Nutrition in Northern Ireland

The practices and support for delivery of Neonatal Parenteral Nutrition (PN) in Northern Ireland were audited against standards derived from the ESPGHAN guidelines, NCEPOD Report on PN and the NICE...

OC-052 Universal Screening For Alcohol Misuse In Acute Medical Admissions Is Feasible And Identifies Patients At High Risk Of Liver Disease

IntroductionThe 2013 NCEPOD report into deaths from Alcohol Related Liver Disease (ARLD) highlighted missed opportunities for detecting alcohol misuse in recurrent hospital admissions. Universal screening of medical patients was advised...

PTU-111 Determining Ceiling Of Care In Decompensated Cirrhosis – Right Decisions, Right People, Right Time

IntroductionDecisions to initiate intensive care measures in patients with decompensated liver cirrhosis are often controversial, with mortality approaching 90% in cirrhotics with 3 organ failure. The 2013 NCEPOD report ‘Measuring...