Acute NHS Trust Research Articles

EGS P16 Management of Acute Gallstone disease at an urban acute Trust during the pandemic

Abstract Background Acute gallstone disease is a surgical emergency. Management has evolved over the years with emphasis on early surgery to improve outcomes. However, due to resource limitations, cholecystectomy is often delayed leading to repeated admissions, interval complications and increased costs. Despite several nationwide initiatives to implement acute cholecystectomy pathways, the SWORD (Surgical Workload Outcomes Audit Data Tool) quality improvement project reports emergency Cholecystectomy rates for gallstone disease as low as 1.2% to 36.5% in NHS acute hospital trusts between 2012 and 2017. We analysed the current situation at Barking, Havering and Redbridge NHS Trust serving a population of 750,000 during the pandemic. Methods Patients presenting with acute gallstone disease (acute cholecystitis, biliary colic, and gallstone pancreatitis) between September and December 2021 were retrospectively audited. We measured re-admission rates, number of emergency and elective cholecystectomies performed, post-operative complications and interval between operation and initial admission. Results 240 patients were admitted with acute gallstone disease during the audit period. 133 (55%) patients were admitted with acute cholecystitis, 77 (32%) for biliary colic and 30 (13%) with gallstone pancreatitis. 91 (35%) were re-admissions while waiting surgical management. 110 (46%) patients had a definitive management, either during or following their initial admission. At 3 months following end of audit period, 49 (44.5%) patients underwent cholecystectomy, of which only 10 (20%) were performed acutely. However, 70% of acute operations were performed during re-admissions. The average time between admission and operation was 63.57 days for new presentations, compared to 49.89 days for re-admissions. 47 of the 240 patients re-presented to hospital with symptoms before their operation during the study period: 11 (23%) with biliary colic, 29 (62%) with acute cholecystitis and 7 (15%) patients with acute gallstone pancreatitis. From the main cohort of 240, 31 (13%) patients were either not deemed fit for surgery or lost to follow-up) while 99 (41%) patients were still awaiting decision about definitive management. Conclusions Provision of emergency cholecystectomies does not comply with national guidelines. Frequent re-admissions worsen patients’ experience. Cholecystectomies took place in very few patients at index admission during pandemic. More financial and cultural resources need to be allocated nationwide to surgically face the gallstone epidemic.

10. Audit Reviewing the Accuracy of Coding for Temporal Artery Biopsies at a Large Teaching Hospital

North Manchester General Hospital (NMGH) has recently undergone a change in parent trust from the Pennine Acute Hospitals NHS Trust (PAT) to Manchester University NHS Foundation Trust (MFT). Temporal Artery Biopsy (TABx), a procedure not infrequently performed at the OMFS unit, follows urgent referral from Rheumatology colleagues for suspected Giant Cell Arteritis (GCA). A review of coding applied to these procedures is performed, aiming to establish whether payments been appropriate. The gold standard is met if the the correct code/correct payment are applied.

Introduction of the Discharge Medicines Service (DMS) at acute NHS trust, does this go far enough?

Abstract Introduction The Discharge Medicines Service (DMS) is one of several initiatives being implemented as part of the NHS 5-year plan's second year to relieve the load on hospital Accident and Emergency (A&E) departments. The DMS service specification states that patients who are considered to be at risk of medication-related harm should be electronically referred by the NHS Trust to a pharmacy for assistance with their medications within 24-48 hours of being discharged from the hospital. NHS England and NHS Improvement made available £1.2 million to ensure NHS trusts have appropriate software and functionality to send referrals to community pharmacy, but the funding is not available to private providers responsible for community hospital services. However, for the DMS service to strengthen and improve medicine safety across the NHS, there is a need to involve community hospital services run by private providers. Aim The aim of this study was to investigate the medicines related risk for patients discharged from Caterham Dene Hospital (CDH), a community hospital service. Methods A retrospective analysis of patient discharge summaries was carried out to determine whether there were changes in the patient’s medication prior to being discharged from East Surrey Hospital (ESH) to CDH and then to their home. The medical records of (N=183) patients who were admitted to CDH from ESH between 1st June 2021 - 31st December 2021 were identified. 22 patients who were re-admitted to ESH through A&E and 2 patients whose discharge letter could not be found in their medical record or had missing information were excluded. Patients who were discharged to another care setting, e.g. a care home, were also excluded from this study. A data collection form was used, and the data were transferred to Microsoft Excel for descriptive statistical analysis. As a service evaluation, ethical approval was not required. Results A total of 159 patients’ medical records and discharge summaries were analysed, of whom 97% of patients had changes in their medication after admission to CDH. The most frequent changes were either having medication stopped because it was no longer required, or medication started due to new diagnosis. The top two commonly identified drug classes are laxatives and opioids. 40% of all medicines that were changed were appropriate for DMS referral on discharge from CDH. Discussion/Conclusion Although a small-scale study, the findings demonstrate that it is important for private providers of community hospital services, such as First Community, to be included to deliver the DMS referral service. Further investigation is recommended to explore whether similar results would be achieved in other community hospital services run by private providers. In response to the discharge data shared, Surrey Heartland Integrated Care System made available funds to roll out the DMS service to CDH. First Community is the only private provider currently delivering the DMS service and between mid-June and July 2022 a total of 10 patients have been referred.

Development of evidence-based UK-wide antimicrobial intravenous-to-oral switch criteria: a DELPHI consensus process

Abstract Introduction Antimicrobial intravenous-to-oral switch (IVOS) is an antimicrobial stewardship (AMS) strategy with patient safety and cost-effectiveness benefits. Studies show that IVOS decisions had no negative impact on patient outcomes,1 and pharmacist involvement brought about more appropriate antibiotic prescribing and 34% reduction in medication costs.2 Healthcare settings have developed individualised local IVOS checklists. Aim To collate IVOS criteria from local checklists, complete a rapid literature review to evaluate IVOS criteria and undertake a 3-step Delphi consensus-gathering process to agree evidence-based, UK-wide IVOS criteria for hospitalised adults. Methods Local IVOS checklists from the UK nations were sought through stratified sampling. The rapid review followed PRISMA guidance and is registered on PROSPERO [CRD42022320343]. Criteria with highest, or over 50%, appearance in checklists and literature were combined for Step 1 of the 3-step Delphi process. Step 1: Pilot/1st round questionnaire: An expert panel appraised each criterion via a 5-point Likert scale for relevance to safe and effective IVOS and ease of assessment in the clinical setting. Step 2: Virtual meeting: Step 1 respondents discussed questionnaire results and attained criteria consensus for Step 3. Step 3: 2nd round questionnaire: Healthcare professionals UK-wide stated level of agreement via a 5-point Likert scale regarding the need of each criterion for safe and effective IVOS. Results Forty-five local IVOS checklists were selected: 42 from English Acute Trusts, two from Scottish Health Boards and the All-Wales checklist. Sixteen of 477 papers were included in the rapid review. Criteria were synthesised into a 5-section framework: 1-Timing of IV antimicrobial review; 2-Clinical signs and symptoms; 3-Infection markers; 4-Enteral route; 5-Infection exclusions. Combination of IVOS criteria resulted in 41 criteria for Step 1. Step 1 had 24 respondents, 15 of those participated in Step 2. Thirty-five criteria went into Step 3, which had 242 respondents (England n=195, Northern Ireland n=18, Scotland n=18, Wales n=11). The majority were female (n=154; n=7 preferred not to say) and based in NHS Acute Teaching Trusts (n=121). Antimicrobial or infection specialist pharmacists were the highest respondents (n=65) followed by general physicians (n=55). Sixty-seven per cent of respondents (n=161) considered IVOS to have a positive impact on outcomes of clinically stable patients. Consensus was achieved for 27 IVOS criteria (66% of initial criteria). Examples of agreed criteria were: ‘IVOS should be considered within 48 hours of first dose of IV antimicrobial being administered’ and ‘Temperature between 36-38°C for past 24 hours’. Discussion/Conclusion Evidence-based consensus was achieved for IVOS criteria from a UK-wide multidisciplinary group and will be used to develop an IVOS tool for hospitalised adults. A study strength was use of the Delphi process to capture consensus; a limitation was no checklist from Northern Ireland was identified at time of the study, however Steps 1-3 had participation from Northern Ireland. Early IVOS initiatives led by ward pharmacists have previously been shown to reduce use of hospital intravenous broad-spectrum antibiotics: co-amoxiclav (-27.9%) and cefuroxime (-46.5%).3 Further research is needed to operationalise the nationally agreed criteria in UK hospitals, expand AMS roles of pharmacy and nursing teams and assess impact.

Avon Community-Acquired Pneumonia (AvonCAP) Surveillance Study: A Pan-pandemic Acute Lower Respiratory Tract Disease Surveillance Study, and the linked records of the participants in the Avon Longitudinal Study of Parents and Children (ALSPAC)

This data note describes the linking of records of the Avon Community-Acquired Pneumonia (AvonCAP) Surveillance Study – A Pan-pandemic Acute Lower Respiratory Tract Disease Surveillance Study (ISRCTN: 17354061), with the participants of the Avon Longitudinal Study of Parents and Children (ALSPAC – also known as ‘Children of the 90s’). These records were obtained from a database created specifically by AvonCAP operating within the two acute care NHS Trusts in Bristol, which is the centre of the ALSPAC study catchment area. These two trusts are the (a) North Bristol NHS Trust (NBT) based at Southmead Hospital (SMH) and (b) the University Hospitals Bristol and Weston NHS Foundation Trust (UHBWT) based at Bristol Royal Infirmary (BRI). The AvonCAP database was updated by staff using a combination of clinical records and self-reporting by the participant, which was unable to be independently verified. Data was collected using the REDCap (Research Electronic Data Capture) software program. Software code was created to transform the original files into a single data base which was reviewed for data-completeness and for its potential value as a research resource. The AvonCAP records provide a contemporaneous record of a subset of the ALSPAC cohort who experienced Lower Respiratory Tract Disease. It is available for research and may be used in conjunction with other ALSPAC data.

Simulation for preceptee physiotherapists readiness to practise

The COVID-19 pandemic has significantly impacted the clinical placement experiences of undergraduate Physiotherapists [1], many of whom started working as preceptee Physiotherapists shortly after qualifying in 2021. Consequently, it was important to provide training in the key skills required to work within an acute inpatient setting to preceptee Physiotherapists starting at an acute NHS Trust in 2021. A one-day simulation course was developed to expose preceptees to common scenarios occurring in clinical practice to increase their confidence in managing these situations. Six simulation courses were delivered with 22 preceptees each attending a single course. The course started with a group tactical decision exercise to develop caseload management skills. Participants took part in a simulated multidisciplinary team (MDT) ward handover and were provided the opportunity to gather more information from MDT colleagues, simulated medical notes, and admission systems to help them prioritise their simulated caseload. Participants then used this information to make decisions regarding the prioritisation of their simulated workload. The influence of information on participants’ decision-making was then discussed. Participants subsequently undertook five high-fidelity scenarios in pairs; examining themes of discharge planning, managing an unwitnessed fall, the acutely unwell patient, conflict resolution, and acute confusion management. Each scenario was followed by a faculty-led debriefing to facilitate learning through discussion and reflection. Participants completed a self-rating questionnaire based on the 5-point perceived self-efficacy scale before and after course attendance. It evaluated confidence and competence in aspects of inpatient care. Overall self-rated confidence and competence improved post-course in all question categories. Significant differences (R>0.5) were seen for self-rated confidence in managing a ward handover (1.2), prioritising daily workload (0.6), communicating with the multidisciplinary team (0.6), communicating with patients and relatives (0.6), and responding to unpredictable workload and environments (1.2). Significant differences were also seen for self-rated competence in managing a ward handover (0.9), prioritising a daily workload (0.5), and responding to unpredictable workload and environments (0.8). Free text analysis of participants’ course key learning points identified themes surrounding confidence in own abilities, escalation, and communication. Simulation-based training was effective in enhancing confidence for preceptee Physiotherapists in managing aspects of acute inpatient care. Further work is required to establish its utility in addressing competence. The development of preceptee simulation training for multi-professional groups is also required. For 2022, a joint Physiotherapy and Occupational Therapy preceptee induction simulation course is planned. 1. Gough S, Orr R, Stirling A, Raikos A, Schram B, Hing W. Health Sciences and Medicine Education in Lockdown: Lessons Learned During the COVID-19 Global Pandemic. In Nestel D, Reedy G, McKenna L, Gough S. Clinical education for the health professions: theory and practice. Springer; 2021.

Effect of implementing the NEWS2 escalation protocol in a large acute NHS trust: a retrospective cohort analysis of mortality, workload and ability of early warning score to predict death within 24 hours

ObjectivesTo describe the inpatient population, establish patterns in admission and mortality over a 4-year period in different cohorts and assess the prognostic ability and workload implications of introducing the National...

A Scoping Survey of BOFAS Membership: What are the Perceived Barriers and Facilitators of Day- Case Surgery for Major Foot and Ankle Procedures in the UK?

Category: Ankle Introduction/Purpose: Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to perform major foot/ ankle operations as day-case. This could have significant impact on length of stay, saving resources and is in keeping with government policy. However there is no consensus of barriers reducing foot/ankle operations being performed as day-case.The aim of this survey was to scope the practice of UK foot and ankle surgeons in terms of perceived barriers and facilitators to performing day-case surgery for major foot/ankle procedures. Methods: An online survey (19 questions) was sent to UK foot and ankle surgeons via BOFAS (British Orthopaedic Foot & Ankle Society) membership list in August 2021. Major foot/ankle procedures are defined as surgery that is usually performed as an inpatient and day-case as same day discharge, with day surgery as the intended treatment pathway. Results: A total of 132 respondents: 80% working in Acute NHS Trusts. 78% of respondents thought that more procedures could be performed as day-case at their centre (currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures). The top 2 perceived barriers to performing more major foot and ankle procedures as day-case were: no physiotherapy provision pre/ post-operatively 23%, no out of hours support for patients 21%. Conclusion: There is consensus among surgeons to do more major foot/ ankle procedures as day-case. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. Out of hours support and physiotherapy input pre/post-op were perceived as the main barriers to increasing the number day-case procedures. There is a need for nationally agreed protocols to optimise the delivery of care for this patient group and to scope the provision of physiotherapy pre/post-operatively at sites where this is a perceived barrier.

Electrocardiography Interpretation Proficiency Among Medical Doctors of Different Grades in the United Kingdom.

Electrocardiography interpretation is a core clinical skill for all doctors participating in emergency medical services. Given the majority ofECGsinitially performed in hospital on admission are reviewed by junior doctors, and the need for life-threatening pathology to be diagnosed or excluded, further understanding of the level of competency in interpretation and factors associated with this are needed. This was a cross-sectional, descriptive, analytical study. The data were collected using a structured questionnaire. This was comprised of two sections; the first section contained questions related to confidence, previous ECG learning and factors thought to be associated with ECG interpretation competence. The second section was an ECG quiz of 10 12-lead ECGs of varying complexity for interpretation assessment. Descriptive and inferential statistics were utilized for data analysis. Sixty-twodoctors from foundation year 1 to registrar level working in acute medicine across three hospitals participated. The mean overall percentage score for the ECG quiz was 45%. No association was found between junior doctor training grade and overall score on the ECG assessment. Undergraduate and postgraduate teaching strategies also did not impact competence. Only 9.7% reported themselves as "confident" interpreting ECGs. There was a trend towards higher levels of competency among those who felt they had undergone sufficient ECG teaching and those who sought regular feedback from other clinicians. This study demonstrated low overall levels of ECG interpretation competency among junior doctors in a large acute teaching NHS trust regardless of grade. Factors associated with competency remain unclear.

Evaluating Actions to Improve Air Quality at University Hospitals Birmingham NHS Foundation Trust

Air pollution is the single largest environmental risk to human health in the UK, exerting a major healthcare sector burden and exacerbating health and social inequalities. The NHS Long Term Plan commits the healthcare sector to reducing emissions from all sources, however, to date few Acute NHS Trusts have implemented air quality focused sustainability plans. In this case study, we assess potential air quality improvement actions at University Hospitals Birmingham NHS Foundation Trust’s, Queen Elizabeth Hospital in Birmingham, UK as a test case for NHS sustainability actions. We generate an evidenced based, prioritized shortlist of actions to mitigate emissions and protect patients, staff, and local communities from air pollution exposure. The project supports adoption of an evidence-based, contextually relevant, approach to air quality management within healthcare provision. The methodology used could be employed by organizations with similar goals to address environmental concerns.

58 The Unfolding Situation of Caecal Volvulus: A Review of 36 Cases

Abstract Aim Caecal Volvulus is a rare cause of bowel obstruction. However, there has been a steady rise in the number of cases over the decades. The demographic profile of patients developing Caecal Volvulus has changed to a much older population. We conducted a retrospective review to find the incidence, demographic profile, management, and outcomes of Caecal Volvulus patients in our institution during the last nine years. Method A total of 38 patients were diagnosed with Caecal Volvulus at Worcestershire Acute Hospitals NHS Trust between 01.01.2011 to 31.03.2020. Results Most of our patients were females (78%) with a median age was 76 years. The majority (86%) had at least one medical comorbidity, and 36% had a previous abdominal operation. Abdominal pain was the main complaint in 94% of patients. All patients had a CT scan to confirm their diagnosis. Most of our patients (84%) underwent surgery. Open right hemicolectomy was the most commonly performed operation (87%). Out of the six patients who did not undergo surgery, three responded to bowel rest and nasogastric tube decompression; one patient underwent successful colonoscopic decompression. In contrast, two patients, unfortunately, passed away. The median length of hospital stay was 9 days, with a 30-day mortality of 3%. Conclusion Caecal Volvulus remains a rare cause of bowel obstruction. Most of our patients were old, frail and had medical comorbidities. More than a third of them had undergone previous abdominal surgery. Early CT scan followed by surgery was associated with low mortality.

887 Design and Implementation of a Standardised Protocol to Assess the Pre-Operative Prophylactic Antimicrobial Guidelines in Vascular Surgery – a Trust-Wide Experience

Abstract Aim The project's aim was to design and implement a replicable protocol in order to assess the pre-operative prophylactic antimicrobial prescribing that could be universally applied to all patients undergoing major vascular surgery. Method A retrospective audit was undertaken to establish existing guidelines in circulation and current practice trends at Worcestershire Acute Hospitals NHS Trust. Multiple theoretical models to stratify procedure and infection risks were designed including clean verses dirty site surgery, procedure specific surgery, procedures with or without utilisation of prosthesis, universal one size fits all guidelines. A panel consisting of consultant vascular surgeons, the antimicrobial stewardship lead consultant microbiologist, and a core surgical trainee co-ordinating the project appraised the results. Criteria included ease of implementation minimising prescribing errors, anaphylaxis, and the need for a tailored guideline for different major vascular procedures to determine suitability of the guideline. Results The initial audit signified a need to standardised guidelines in order to provide patients with a standardised care pathway that utilises best practice. In this instance an anatomical approach to the pre-operative prophylactic antimicrobial guideline for major vascular surgery was adopted and implemented at Trust level. Conclusions A replicable protocol has been established in order to appraise, design, and implement antimicrobial guidelines that can be transferable between departments and trusts alike.

Online patient feedback as a safety valve: An automated language analysis of unnoticed and unresolved safety incidents.

Safety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organization. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value. Accordingly, we developed an automated language analysis method for measuring the likelihood of patient-reported safety incidents in online patient feedback. Feedback from patients and families (n=146,685, words=22,191,427, years=2013-2019) about acute NHS trusts (hospital conglomerates; n=134) in England were analyzed. The automated measure had good precision (0.69) and excellent recall (0.98) in identifying incidents; was independent of staff-reported incidents (r=-0.04 to 0.19); and was associated with hospital-level mortality rates (z=3.87; p <0.001). The identified safety incidents were often reported as unnoticed (89%) or unresolved (21%), suggesting that patients use online platforms to give visibility to safety concerns they believe have been missed or ignored. Online stakeholder feedback is akin to a safety valve; being independent and unconstrained it provides an outlet for reporting safety issues that may have been unnoticed or unresolved within formal channels.

Implementation of ‘Freedom to Speak Up Guardians’ in NHS acute and mental health trusts in England: the FTSUG mixed-methods study

Background The introduction of ‘Freedom to Speak Up Guardians’ into every NHS trust in England was intended to support workers and trusts to better raise, respond to and learn from speaking-up concerns. However, only broad guidance was provided on how to implement the role. As a result, there is the potential for important local differences to emerge as the role is implemented across England. Objectives The overall aim of this study was to better understand the implementation of Guardians in acute trusts and mental health trusts. Design The Freedom to Speak Up Guardian role was conceptualised as a complex intervention consisting of several interacting and interlocking components spanning the macro level (national organisations), the meso level (individual trusts) and the micro level (employees, teams and wards/units). A mixed-methods study was designed, which consisted of three work packages: (1) a systematic narrative review of the international literature regarding interventions promoting ‘speaking up’ by health-care employees; (2) semistructured telephone interviews with Guardians working in acute hospital trusts and mental health trusts; and (3) qualitative case studies of Freedom to Speak Up Guardian implementation, consisting of observations and interviews undertaken in four acute trusts and two mental health trusts. Interviews were also undertaken with national stakeholders. Setting Acute trusts and mental health NHS trusts in England. Participants Work package 2: Freedom to Speak Up Guardians (n = 87) were interviewed. Work package 3: 116 interviews with key stakeholders involved in pre-implementation and early implementation decision-making, workers who had spoken up to the Guardian, and national stakeholders. Results Wide variability was identified in how the Guardian role had been implemented, resourced and deployed by NHS trusts. ‘Freedom to Speak Up Guardian’ is best considered an umbrella term, and multiple versions of the role exist simultaneously across England. Any comparisons of Guardians’ effectiveness are likely to be possible or meaningful only when this variability is properly accounted for. Many Freedom to Speak Up Guardians identified how a lack of available resources, especially time scarcity, negatively and significantly affected their ability to effectively respond to concerns; their opportunities to collect, analyse and learn from speaking-up data; and, more generally, the extent to which they developed their role and speak-up culture. Limitations It is possible that those whom we interviewed were more receptive of Freedom to Speak Up Guardians or may have been biased by ‘socially desirability’, and their answers may not always have represented respondents’ true perceptions. Conclusions Optimal implementation of the Guardian role has five components: (1) establishing an early, collaborative and coherent strategy congruent with the values of Freedom to Speak Up fosters the implementation of (2) policies and robust, yet supportive, practices (3) informed by frequent and reflexive monitoring of Freedom to Speak Up implementation that is (4) underpinned by sufficient time and resource allocation that leads to (5) a positive implementation climate that is congruent with Freedom to Speak Up values and is well placed to engender positive and sustainable Freedom to Speak Up culture and the well-being of a Guardian. Future work The following recommendations for future research are considered to be of equal priority. Studies of the speaking-up experiences of minority communities and ‘seldom-heard’ workforce groups are a priority requirement. There is also value in undertaking a similar study in non-hospital settings and where peripatetic working is commonplace, such as in ambulance services and in primary care settings. The role of human resources and ‘middle managers’ in the management of concerns is an area requiring further research, especially regarding concerns relating to unprofessional and transgressive behaviours. Devolved administrations in Scotland and Wales have adopted different approaches to speaking up; research undertaken in these contexts would offer valuable comparative insights. Researching the Guardian role ≥ 5 years post implementation is recommended to understand the medium-term impact and the longer-term sustainability of the role and well-being of Guardians. Study registration This study is registered as ISRCTN38163690 and has the study registration CRD42018106311. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 23. See the NIHR Journals Library website for further project information.

Healthcare organization policy recommendations for the governance of surgical innovation: review of NHS policies.

The governance for introducing innovative surgical procedures/devices differs from the research requirements needed for new drugs. New invasive procedures/devices may be offered to patients outside of research protocols with local organization oversight alone. Such institutional arrangements exist in many countries and written policies provide guidance for their use, but little is known about their scope or standards. One hundred and fifty acute NHS trusts in England and seven health boards in Wales were systematically approached for information about their policies. A modified framework approach was used to analyse when policies considered new procedures/devices to be within local organization remit and/or requiring research ethics committee (REC) approval. Of 113 policies obtained, 109 and 34 described when local organization and REC approval was required, respectively. Procedures/devices being used for the first time in the organization (n = 69) or by a clinician (n = 67) were commonly within local remit, and only 36 stated that evidence was required. Others stated limited evidence as a rationale for needing REC approval (n = 13). External guidance categorizing procedures as 'research only' was the most common reason for gaining REC approval (n = 15). Procedures/devices with uncertain outcomes (n = 28), requiring additional training (n = 26), and not previously used (n = 6) were within the remit of policies, while others recommended REC application in these situations (n = 5, 2 and 7, respectively). This study on NHS policies for surgical innovation shows variability in the introduction of procedures/devices in terms of local oversight and/or need for REC approval. Current NHS standards allow untested innovations to occur without the safety of research oversight and thus a standard approach is urgently needed.

P140 Is NEWS2 old news? A updated review of physiological deterioration prior to adult cardiac arrest at an acute NHS Trust in Essex, UK

P140 Is NEWS2 old news? A updated review of physiological deterioration prior to adult cardiac arrest at an acute NHS Trust in Essex, UK

Do national policies for complaint handling in English hospitals support quality improvement? Lessons from a case study.

A range of public inquiries in the English National Health Service have indicated repeating failings in complaint handling, and patients are often left dissatisfied. The complex, bureaucratic nature of complaints systems is often cited as an obstacle to meaningful investigation and learning, but a detailed examination of how such bureaucratic rules, regulations, and infrastructure shape complaint handling, and where change is most needed, remains relatively unexplored. We sought to examine how national policies structure local practices of complaint handling, how they are understood by those responsible for enacting them, and if there are any discrepancies between policies-as-intended and their reality in local practice. Case study involving staff interviews and documentary analysis. A large acute and multi-site NHS Trust in England. Clinical, managerial, complaints, and patient advocacy staff involved in complaint handling at the participating NHS Trust (n=20). Not applicable. Findings illustrate four areas of practice where national policies and regulations can have adverse consequences within local practices, and partly function to undermine an improvement-focused approach to complaints. These include muddled routes for raising formal complaints, investigative procedures structured to scrutinize the 'validity' of complaints, futile data collection systems, and adverse incentives and workarounds resulting from bureaucratic performance targets. This study demonstrates how national policies and regulations for complaint handling can impede, rather than promote, quality improvement in local settings. Accordingly, we propose a number of necessary reforms, including patient involvement in complaints investigations, the establishment of independent investigation bodies, and more meaningful data analysis strategies to uncover and address systemic causes behind recurring complaints.

Standards of Care Received by People with Diabetes who Undergo Orthopaedic Surgical Procedures

Over the past ten years there have been guidelines that have been produced regarding the management of individuals with diabetes undergoing a surgical procedure. This clinical audit will be focusing on the area of orthopaedics and the standards of care received by individuals with diabetes. The audit examined retrospectively; the care received in a large acute NHS trust with a sample of 78 adult individuals with diabetes. Ten audit criteria were reviewed and evaluated and compared to the guidance that is currently available nationally. Both emergency and elective procedures were assessed to see if there were any variances in the management of individuals with diabetes. On review of the results, a number of recommendations will be put forward to the trust with regards to changes that should be implemented to enhance patient care.

Design and evaluation of an interactive quality dashboard for national clinical audit data: a realist evaluation

BackgroundNational audits aim to reduce variations in quality by stimulating quality improvement. However, varying provider engagement with audit data means that this is not being realised.AimThe aim of the study was to develop and evaluate a quality dashboard (i.e. QualDash) to support clinical teams’ and managers’ use of national audit data.DesignThe study was a realist evaluation and biography of artefacts study.SettingThe study involved five NHS acute trusts.Methods and resultsIn phase 1, we developed a theory of national audits through interviews. Data use was supported by data access, audit staff skilled to produce data visualisations, data timeliness and quality, and the importance of perceived metrics. Data were mainly used by clinical teams. Organisational-level staff questioned the legitimacy of national audits. In phase 2, QualDash was co-designed and the QualDash theory was developed. QualDash provides interactive customisable visualisations to enable the exploration of relationships between variables. Locating QualDash on site servers gave users control of data upload frequency. In phase 3, we developed an adoption strategy through focus groups. ‘Champions’, awareness-raising through e-bulletins and demonstrations, and quick reference tools were agreed. In phase 4, we tested the QualDash theory using a mixed-methods evaluation. Constraints on use were metric configurations that did not match users’ expectations, affecting champions’ willingness to promote QualDash, and limited computing resources. Easy customisability supported use. The greatest use was where data use was previously constrained. In these contexts, report preparation time was reduced and efforts to improve data quality were supported, although the interrupted time series analysis did not show improved data quality. Twenty-three questionnaires were returned, revealing positive perceptions of ease of use and usefulness. In phase 5, the feasibility of conducting a cluster randomised controlled trial of QualDash was assessed. Interviews were undertaken to understand how QualDash could be revised to support a region-wide Gold Command. Requirements included multiple real-time data sources and functionality to help to identify priorities.ConclusionsAudits seeking to widen engagement may find the following strategies beneficial: involving a range of professional groups in choosing metrics; real-time reporting; presenting ‘headline’ metrics important to organisational-level staff; using routinely collected clinical data to populate data fields; and dashboards that help staff to explore and report audit data. Those designing dashboards may find it beneficial to include the following: ‘at a glance’ visualisation of key metrics; visualisations configured in line with existing visualisations that teams use, with clear labelling; functionality that supports the creation of reports and presentations; the ability to explore relationships between variables and drill down to look at subgroups; and low requirements for computing resources. Organisations introducing a dashboard may find the following strategies beneficial: clinical champion to promote use; testing with real data by audit staff; establishing routines for integrating use into work practices; involving audit staff in adoption activities; and allowing customisation.LimitationsThe COVID-19 pandemic stopped phase 4 data collection, limiting our ability to further test and refine the QualDash theory. Questionnaire results should be treated with caution because of the small, possibly biased, sample. Control sites for the interrupted time series analysis were not possible because of research and development delays. One intervention site did not submit data. Limited uptake meant that assessing the impact on more measures was not appropriate.Future workThe extent to which national audit dashboards are used and the strategies national audits use to encourage uptake, a realist review of the impact of dashboards, and rigorous evaluations of the impact of dashboards and the effectiveness of adoption strategies should be explored.Study registrationThis study is registered as ISRCTN18289782.FundingThis project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full inHealth and Social Care Delivery Research; Vol. 10, No. 12. See the NIHR Journals Library website for further project information.

Salbutamol for analgesia in renal colic: study protocol for a prospective, randomised, placebo-controlled phase II trial (SARC)

BackgroundRenal colic is the pain experienced by a patient when a renal calculus (kidney stone) causes partial or complete obstruction of part of the renal outflow tract. The standard analgesic regimes for renal colic are often ineffective; in some studies, less than half of patients achieve complete pain relief, and a large proportion of patients require rescue analgesia within 4 h. Current analgesic regimes are also associated with significant side effects including nausea, vomiting, drowsiness and respiratory depression. It has been hypothesised that beta adrenoreceptor agonists, such as salbutamol, may reduce the pain of renal colic. They have been shown to impact a number of factors that target the physiological causes of pain in renal colic (ureteric spasm and increased peristalsis, increased pressure at the renal pelvis and prostaglandin release with inflammation). There is biological plausibility and a body of evidence sufficient to suggest that this novel treatment for the pain of renal colic should be taken to a phase II clinical trial. The aim of this trial is to test whether salbutamol is an efficacious analgesic adjunct when added to the standard analgesic regime for patients presenting to the ED with subsequently confirmed renal colic.MethodsA phase II, randomised, placebo-controlled trial will be performed in an acute NHS Trust in the East Midlands. Patients presenting to the emergency department with pain requiring IV analgesia and working diagnosis of renal colic will be randomised to receive standard analgesia ± a single intravenous injection of Salbutamol. Secondary study objectives will explore the feasibility of conducting a larger, phase III trial.DiscussionThe trial will provide important information about the efficacy of salbutamol as an analgesic adjunct in renal colic. It will also guide the development of a definitive phase III trial to test the cost and clinical effectiveness of salbutamol as an analgesic adjunct in renal colic. Salbutamol benefits from widespread use across the health service for multiple indications, extensive staff familiarity and a good side effect profile; therefore, its potential use for pain relief may have significant benefits for patient care.Trial registrationISRCTN Registry ISRCTN14552440. Registered on 22 July 2019