NICE Guidelines Research Articles

An audit to evaluate the prescribing of antibiotics for acne against NICE guidelines in a digital setting

Abstract Introduction According to NICE guidelines, individuals with moderate to severe acne may be recommended a fixed combination of topical treatment along with either oral lymecycline or doxycycline for a 12-week regimen1. If improvement is observed in these patients, continuation of the oral antibiotic and non-antibiotic-topical treatment for an additional 12 weeks is advised. It's important to adhere to these guidelines and avoid prescribing monotherapy topical antibiotics, monotherapy oral antibiotics, or the combination of topical antibiotics with oral antibiotics2. This audit aims to verify our compliance with these guidelines and ensure the appropriate use of antibiotics in our prescribing within a digital setting where patients undergo photo assessment consultations. Aim The objective of this audit is to ascertain our adherence to the NICE acne guidelines regarding the duration of oral antibiotic therapy prescribed and the accurate prescribing of topical treatments in conjunction with the oral antibiotic1. The audit criteria entail ensuring that 100% of consultations result in prescriptions aligning with the following: oral antibiotic treatment not exceeding 6 months, a prescribed non-antibiotic topical treatment alongside oral antibiotics, and avoidance of prescribing a combination of topical antibiotics with oral antibiotics. Method A retrospective review was conducted on all consultations involving the prescribing of oral and topical antibiotics from 22.4.2023 to 18.4.2024. Each consultation was assessed for the quantity of oral antibiotics prescribed over a 12-month period and examined for the accompanying topical treatments. Additionally, checks were made to determine if the patient was currently taking any oral or topical antibiotics from other sources, ensuring that antibiotics were not overprescribed and that co-prescribing practices adhered to guidelines. Ethical approval was not required since this is a clinical audit. Results The data extraction identified 427 consultations in which patients were prescribed either oral antibiotics (361 cases) or topical antibiotics (Duac-66 cases). In 99% of the consultations, patients were not prescribed oral antibiotics for more than six months. The remaining 1% of patients had already been prescribed oral antibiotics from other sources. It is noted that additional queries should have been conducted to ascertain the duration of antibiotic use prescribed elsewhere. Furthermore, 99% of consultations adhered to the criteria of prescribing a non-antibiotic topical treatment alongside an oral antibiotic. The remaining 1% involved patients who were already using a topical antibiotic from another source, which should have been further investigated to ensure cessation upon initiation of the prescribed oral antibiotics. In all cases, patients were prescribed an appropriate topical treatment in conjunction with an oral antibiotic from our digital setting. Discussion This audit confirms high compliance with NICE guidelines for acne treatment within our digital consultation framework1. Specifically, 99% of consultations adhered to the duration regimen of oral antibiotics, ensuring prescriptions did not exceed six months. Additionally, the majority of cases, correctly included non-antibiotic topical treatments alongside oral antibiotics, minimising the risk of antibiotic resistance. However, slight differences were noted in cases where patients had existing prescriptions from other sources. These findings highlight the effectiveness of our prescribing practices and the importance of thorough patient medication history reviews.

Relative analgesic effectiveness of pharmacological interventions in knee osteoarthritis: a component network meta-analysis

Abstract Introduction Knee osteoarthritis (KNOA) is a chronic, burdensome, highly prevalent degenerative disease1. As there is no current cure for KNOA, treatments are primarily focused on pain management. While pharmacological interventions typically demonstrate superiority to placebo for pain relief, evidence regarding their relative effectiveness is lacking. Component Network Meta-Analysis (CNMA) is a relatively new technique that uses all available evidence to estimate effects of each treatment against all other treatments via its performance relative to a common comparator such as placebo. Aim To evaluate relative analgesic effectiveness of pharmacotherapies for KNOA using CNMA to provide comprehensive, evidence-based information for clinical decisions and inform future guidelines. Methods We performed a comprehensive search of major electronic databases (MEDLINE, EMBASE and CENTRAL) and trial registries from inception to January 2021 without language restriction for RCTs that compared treatment for adults with KNOA with another treatment or control listed in NICE guidelines: paracetamol, NSAIDs (with and without gastroprotection), COX2-inhibitors, opioids, duloxetine, capsaicin, hyaluronic acid (HA) and corticosteroids (CS), administered via oral, topical, transdermal or intra-articular (IA) routes2. Assessment at the following time windows: immediate (up to two weeks), short (closest to 3 months), medium (closest to 6 months) and long (closest to 12 months). A random-effects CNMA was used to estimate relative treatment effects; mean differences (MD) for a primary outcome of pain (0-10) within a frequentist framework3. Certainty of evidence was evaluated using the Confidence in Network Meta-Analysis (CINeMA) with risk of bias (RoB) assessed using the revised Cochrane RoB2 tool. This study does not require ethical approval as it is a systematic review and CNMA of already approved trials and is registered with PROSPERO, CRD42020184192. Results Screening initially identified 33298 citations, reduced to 202 studies after a full-text review. In the immediate-term relative effectiveness ranged between -1.41 (95% confidence interval [CI] -2.23, -0.60) for transdermal NSAIDs and -0.25 (-0.48, -0.02) for IAHA. In the short term, we found evidence of significant effects for all interventions except topical capsaicin and transdermal opioids; effects ranged from -2.09 (-3.69, -0.49) for transdermal NSAIDs to -0.31 (-0.57, -0.04) for IACS. In the medium term, we only found a significant effect for IAHA with MD -0.36 (-0.62, -0.10). We did not find evidence of a significant effect in the long term. 137 (67.8%) of 202 studies included were rated at high risk of bias, 50 (24.7%) at some concerns, and 15 (7.5%) at low, and the certainty of evidence ranged from moderate to very low. Discussion/Conclusion This large-scale and first CNMA provides comprehensive evidence for KNOA pain management. We found evidence of significant effects for several single and multicomponent interventions for immediate and short-term effectiveness. However, their effect diminished over time. While we employed ranking metrics, we could not declare a clear winner among competing interventions due to the between-study heterogeneity, strength of evidence, and the complex nature of KNOA pain. Findings from this study should serve as a tool to inform future guideline developments and clinical decisions, emphasising a holistic approach towards managing KNOA pain with considerations to routes of administration, comorbidities, polypharmacy, and patient needs.

Evaluating the Risk of Traumatic Brain Injury in Adults Following a Fall With Concomitant Use of Anti-Coagulation: A Retrospective Cohort Study.

Introduction Falls and fractures are major health challenges for older adults in England. Despite the advantages of anticoagulants, their use in the elderly is often restricted due to concerns about fall-related injuries. However, there is a lack of clear data on the risk of discontinuing anticoagulation therapy solely due to fall risk. NICE guidelines (2021) advise that anticoagulation should not be withheld solely based on age or fall risk. This study aims to assess the incidence of significant brain injuries or intracranial haemorrhages in patients on anticoagulant therapy, also comparing the independent risk factors for traumatic brain injury. Objective This study aims to assess the incidence of TBI following falls in patients on anticoagulant therapy, comparing outcomes between those using DOACs and Vitamin K antagonists. Methods A retrospective cohort study was conducted at Queen Alexandra Hospital, University Hospitals Portsmouth NHS Trust, from November 2023 to May 2024. Data were collected from 3,468 CT head scans performed on patients with a history of falls, including 801 on anticoagulation therapy. Results Of the 801 patients on anticoagulation, 763 (95.2%) were aged 65 or older, with a mean age of 83.1 years. Acute hemorrhage was detected in 3.1% (25/801) of patients. Patients on Warfarin and Dabigatran had significantly higher TBI risk compared to those on Apixaban (6.7%, p=0.02; and 7.6%, p=0.01, respectively), while Edoxaban and Rivaroxaban showed no significant difference. Also, older age (≥65 years) and higher frailty scores (CFS 6 and 7) were associated with increased TBI risk (p<0.05). All patients with acute hemorrhage received conservative management, and two patients experienced mortality within six months. Discussion The study indicates that the risk of TBI following falls in anticoagulated patients is 3.1% relatively low, aligning with existing literature. This underscores the need for careful consideration before discontinuing anticoagulation therapy solely based on fall risk. Hence, discontinuation of anticoagulation should be a patient-specific decision that carefully considers the balance between the risk of traumatic brain injury (TBI) and the benefits of anticoagulation therapy. Factors such as age, frailty, and the type of anticoagulant should all be taken into account. Clinical judgment and selective CT imaging can help balance patient safety with healthcare costs. Conclusion The incidence of adverse outcomes following head injury in patients on anticoagulant therapy is 3.1% and relatively low. Careful decision-making regarding the discontinuation of anticoagulation therapy, informed by patient background and presentation and selective CT imaging, is essential to manage risks effectively and optimize healthcare resource utilization.

Clinical characteristics of patients with raised BNP referred from primary care to an outpatient heart failure with potential heart failure using NICE guidelines

Abstract Introduction UK NICE guidelines (1) mandate the referral of patients with potential heart failure (signs, symptoms and raised BNP) for specialist opinion including diagnostic echocardiography. We have analysed the demographic and clinical characteristics of 233 consecutive referrals over a nine month period of such patients from primary care to our outpatient cardiology service. Purpose To identify any differences between those who are subsequently identified as having reduced LV systolic function (HFrEF) and those with preserved LV systolic function. We have further explored any potential differences between those with moderately raised (&amp;gt;440 &amp;lt;2000ng/L) and those with grossly raised levels (&amp;gt;2000ng/L) of BNP as NICE guidance proposes a difference in urgency of assessment for these two patient cohorts. Methods All patients had diagnostic echocardiography following the British Society of Echocardiography guidelines (2) and were clinically assessed by a consultant cardiologist and specialist heart failure nurse. Results Of the 233 patients, 64 (27%) were identified as having HFrEF with the remaining 169 having preserved LV systolic function. In patients with HFrEF the majority had grossly raised BNP (62.5%) whereas with preserved LV systolic function the majority had moderately raised BNP (70.5%); Table 1. Within the referred population, demographics and clinical characteristics were broadly similar for patients with HFrEF and those with preserved LV systolic function for age and cardiovascular comorbidities (IHD, diabetes mellitus, hypertension) but were different for gender and heart rhythm. Patients with HFrEF and moderately raised BNP were twice as likely to be in sinus rhythm (75%) than those with grossly raised BNP (37.5%). In patients with moderately raised BNP those with preserved LV systolic function were more likely to be in AF than those with HFrEF (41% v. 25%). No gender difference was seen in patients with preserved LV systolic function whereas patients with HFrEF were twice as likely to be male; Table 2. Conclusions 1. The majority of patients with raised BNP and potential heart failure referred from primary care do not have HFrEF (72.5%) 2. Regardless of their LV systolic function those patients with the highest BNP levels are more likely to be in AF 3. Of patients with a raised BNP and HFrEF twice as many are male whereas no gender difference is seen in those with a raised BNP and preserved LV systolic 4. Whilst the mean age of both groups (preserved and reduced LV systolic function) is the same, in both groups those with grossly raised BNP are on average 5 years older than those with moderately raised BNP.

Experiences of access to care, diagnosis and rehabilitation among a multiethnic patient population with long-COVID in Denmark

Abstract Background and aim The aim of the study was to explore the experiences of accessing care, diagnosis, and rehabilitation among patients with long-COVID in a multiethnic population in Denmark. Methods Qualitative research using semi-structured interviews among a purposive sample of 18 people diagnosed with long-COVID, according to the NICE guideline, in the Capital Region of Denmark. Participants were sampled to secure variation in sex, age, ethnicity, migration status and education. Our interview guide was developed using the theoretical framework of candidacy. Interviews were transcribed verbatim, and member checked, and subsequently analyzed using thematic framework analysis and NVivo software. Results The analysis generated four categories: i) living with long-COVID, ii) access to care, iii) experiences in the healthcare system, and iv) experiences with rehabilitation. A main category was identified from these categories: limited knowledge of COVID resulting in uncertainty, which challenged nearly all aspects of access to diagnosis, care and rehabilitation among the informants. In particular, ethnic minorities experienced that their motives for seeking care were questioned or had the experience of differential treatment. In general, participants perceived to be themselves responsible of recovering, while also struggling with the mental, social and work-related consequences of their long-COVID. Conclusions Our study demonstrated how the emergence of a new viral disease with unknown long-term sequelae results in a group of patients who to a great extend carry the burden of getting better themselves. More research into relevant diagnosis, care and support for long-COVID patients is needed, especially among ethnic minorities.

Institutionalising guideline development in a new universal healthcare system: a study in Cyprus

Abstract Issue Guideline development is a lengthy and diligent process that involves the assessment and interpretation of evidence by a committee. Whilst the implementation of high quality healthcare guidelines ensures consistency and quality in healthcare delivery, many countries worldwide, including Cyprus, lack the capacity and resources to develop de novo guidelines. Description of the problem Guidelines developed by internationally recognised organisations, such as NICE, are a valuable resource for countries like Cyprus. The collaboration between NICE and the newly established healthcare system in Cyprus introduced a process for guideline institutionalisation, taking advantage of existing human resources and building guideline development capability in Cyprus. Results This process involved recruiting local professionals to form a guideline secretariat. The secretariat, supported by NICE, is responsible for overseeing the guideline development process including technical expert committee (TEC) recruitment and stakeholder consultation. The TEC contextualise an existing NICE guidelines to reflect local considerations. NICE provides quality assurance to ensure changes are contextual in nature and consistent with the underpinning evidence. Despite initial challenges, getting stakeholder buy-in and engaging healthcare professionals in the TEC, one contextualised guideline has been produced and two others are at the final stage. Lessons Guideline contextualisation is an efficient and sustainable way of building guideline development capability to institutionalize guidelines in settings with limited capacity. Key messages • De-novo guideline development is time consuming and demanding and many countries require an alternative process for producing locally relevant guidelines, capitalising on existing resources. • Support by an established organisation ensures quality, is less resource intensive, and builds capability for the sustainability of the process.

Predictive Value of Cord Blood Bilirubin for Hyperbilirubinemia in Term Neonates with ABO Incompatibility

Introduction: Jaundice affects 60% of full-term and 80% of preterm neonates. Feto-maternal ABO incompatibilities occur in 20-25% of pregnancies, but severe haemolytic disease develops in only 10%. ABO-incompatible babies have doubled the risk of jaundice requiring treatment and a 5-10 times increased risk of exchange transfusions. Objective: Aim of this study was to determine if cord blood bilirubin (CBB) can predict hyperbilirubinemia in term babies with ABO setup prior to discharge that would help to decrease readmission and subsequently complications due to jaundice. Methods: A hospital-based prospective observational study was conducted at Patan Hospital. Cord blood group and bilirubin levels were collected from newborns of O positive mothers. Babies with A positive and B positive blood groups had their CBB levels measured and were followed daily for 72 hours. Serum bilirubin was tested based on clinical judgment to detect hyperbilirubinemia and treated per NICE guidelines. Data were analysed using SPSS v21.0, Mann-Whitney test, ANOVA, and ROC analysis. Results: Among 66 cases, significant hyperbilirubinemia was seen in 7 neonates (10.6%). It was more common in B positive babies (12.2%) compared to A positive (8%). Mean CBB was 3.45 ± 0.57 in those developing significant hyperbilirubinemia. A CBB of 2.95 mg/dL had the highest sensitivity (86%), specificity (94%), and negative predictive value (98%) for predicting hyperbilirubinemia in ABO setup babies. Conclusion: Term babies with ABO incompatibility and CBB&lt;2.95 mg /dL are unlikely to need further evaluation, while those with cord bilirubin level ≥2.95 mg/dL should have frequent early follow-ups.

Lessons to learn from the 2024 NICE guideline on adrenal insufficiency.

Lessons to learn from the 2024 NICE guideline on adrenal insufficiency.

Retrospective Review of Falls in Medical Inpatients Following Introduction of a Falls Proforma at Wexford General Hospital

Abstract Background Inpatient falls are the largest category of preventable inpatient adverse events in hospitals coming at both great financial and safety cost to a healthcare system. Approximately 30% of inpatient falls result in injury, 4-6% resulting in serious injury with older patients have the highest risk of falling and injury. The aim of this retrospective audit cycle was to improve standards of falls assessments performed by junior doctors. Methods We initially conducted a retrospective review of 7 medical inpatient falls in July 2023. Standards were compared against NICE Guidelines on Assessment and Prevention of Falls in older people 2013 and NICE guidelines on Assessment and early management of head injury 2023. 15 key elements were analysed: doctor identifier, date and time, history of fall, confusion, pain, loss of consciousness, amnesia, seizure, vomiting, medication review, hip fracture, wrist fracture, skull fracture, Glasgow Coma Scale and neurological deficit. One point was given for each of the 15 key elements noted in the falls review. Following introduction of a falls proforma, we re-audited 18 falls in February 2024 to analyse differences in scores. Results Prior to proforma introduction, 7 falls reviewed had an average score of 3 points. 4 falls were reviewed by SHOs, 1 each by an SpR and Intern and 1 NCHD review was unidentifiable. Mean age was 72. Following proforma introduction, 18 falls in 13 patients were analysed. 2 patients did not have a falls review, 15 were reviewed by SHOs, 1 by an Intern. Average age was 81. Proforma was used in 7 cases with an average score of 12.7, and no proforma was used in 11 cases with an average score of 5. Conclusion These findings demonstrate improved quality of falls reviews using proformas in line with guidelines compared to those without. More education is needed to incorporate proformas into standard practice.

“Addressing the Silent Need”

Abstract Background Clinical Specialist Teams (CST) are a foundational component of the Integrated Care Programme for Older Persons (ICPOP) providing care for older adults with complex needs, completing Comprehensive Geriatric Assessments (CGA) and supporting goals until outcomes are optimised (HSE, 2021). WHO (2014) estimates 400 million individuals worldwide are affected by hearing loss, with prevalence increasing with age. The WHO in 2024 recommended targeted hearing screening and interventions in older age. NICE guidelines (2023) issued specific recommendations for adults with suspected or diagnosed dementia or mild cognitive impairment (MCI). The aim of this study was to review current practice of sensory assessment with respect to these recommendations. Methods This is a retrospective audit to evaluate current practice against established standards and to identify areas for improvement to achieve best practice. This will form part of an ongoing quality improvement initiative. Data was collected using a team designed tool gathering information on sensory assessment, interventions and onward referrals. A sample of 65 ICPOP clients was chosen from the last quarter of 2023. Results Preliminary results: Conclusion Screening rates for sensory impairment in the CST is high but needs improvement to reach the target of 100%. Referral onto appropriate services for specialised sensory intervention is actioned adequately, but there is need for the CST to advise timely hearing and vision testing to clients in order to adhere to international guidelines, especially those clients with dementia/MCI.

An Audit Of Post Fall Medical Reviews In Older Hospital Inpatients

Abstract Background After an older person falls in hospital, the post-fall medical review is critical to assess injury and to put a plan in place to prevent further falls. We performed an audit to assess the post fall medical review and management of patients ≥65 years in a large university teaching hospital compared to national standard “Service User Falls: A Practical Guide for Review” and NICE Guidelines. Methods In a consecutive cohort of patients with falls, the post-fall medical review note was examined for crucial details from the history (mechanism, head/hip strike, loss of consciousness, pain) and examination (confusion, vital signs, joint assessment). In addition, we audited if there was an indication for CT Brain and compared to NICE criteria. Results 49 post fall medical review notes were audited (Mean age 79 years, range 66-96). 27% of patients who fell had a CT Brain. 6% (3/49) of patients who fell met NICE criteria for CT Brain, but it was not performed. Conclusion A significant proportion of post fall medical reviews omit important details that could help diagnostically and to inform a plan to prevent further falls. There is limited guidance for clinicians as to when to order a CT Brain for inpatient falls. We plan to introduce a post fall medical review pro forma/checklist and to standardise a CT Brain decision tool. We will then re-audit post introduction of these to assess for quality improvement.

Preventing Emergency Department Visits: Success Of A Community Dementia Care Model

Abstract Background Advanced dementia care in the community is an extremely complex task. NICE guidelines 2021 suggested that a gap in care was evident bridging between clinic attendance and end of life care. Secondary to a required need- a new advanced dementia care model was created in 2021.This was co-developed by an ANP with a specialist interest in gerontology, an integrated care team for older persons (ICPOP) consultant and palliative care in the community. Joint governance remains to this day. My aim is to review unexpected emergency department (ED) attendances of patients accepted to this pathway. Methods Patient records were reviewed of all cases accepted for review and managed under this model of care, time frame Jan 2023- May-2024. All patients &amp;gt; 65. Outcomes of management interventions were assessed. Those found to have an ED attendance during their time engaging with this model of care had closer review of their notes to assess reason why. Results 81 patients. Of which 75% were female. Average age – 89. Of these 48% died at home and are 37% still alive. Of the 81 patients only 5 (6%) had ED attendances. Of these 5 patients - 3 had unexpected traumatic falls- 2 resulting in hip fracture and 1 in humeral fracture. 2 were admitted with worsening delirium. Conclusion The advanced dementia care model has proved very successful in preventing ED attendances prior to direct end of life care engagement. Of those who were admitted – fractures appropriately warrant admission and the remaining 2 cases, had families who were resistant to accepting overall aims of treatment. This interdisciplinary model of care saves bed days. Expanding this care model further to ensure appropriate management of complex dementia cases is maintained in the community would further reduce hospital overcrowding and grant many patient and family wishes.

WP4.6 - Reducing Unnecessary Transfusion of Blood Products – A Quality Improvement Project in a General Surgical Department in a District General Hospital

Abstract Aims To audit adherence of transfusion of blood products against NICE guideline thresholds. To reduce unnecessary blood transfusions following departmental teaching sessions and installation of posters on surgical wards. Methods We retrospectively audited all patients receiving packed red cells transfusions consecutively across two consecutive four-month periods in a general surgery department. Departmental teaching sessions were held after the first audit cycle, supplemented by installation of posters including NICE guideline thresholds on surgical wards. The medical notes for each patient were assessed for pre-transfusion haemoglobin, indication for transfusion, and whether each transfusion was prescribed according to NICE guidelines. Results A total of 112 units of packed red blood cells in 42 patients and 133 units in 43 patients were transfused, respectively, before and after intervention. 45 units (40.2%) were prescribed according to NICE guidelines on first audit, improving to 67 units (50.4%) following intervention. 23 units of blood (20.5% of total) were transfused back-to-back inappropriately on first audit, reducing to 6 units (4.51% of total) after intervention. There were 2 self-limiting transfusion-related reactions (1.79%) on first audit, both in patients transfused above guidance thresholds, and no reactions following intervention. At a raw cost of approximately £135 per unit of donated blood, savings of £1830 were made over a four-month period (£5493pa), not including nursing and administration costs Conclusions Through simple local interventions and stricter adherence to transfusion thresholds, we reduced inappropriate above-threshold blood product transfusions in our hospital. This corresponded to a reduction in unnecessary blood-transfusion reactions and significant hospital savings.

EP274 - A clinical audit on nasogastric tube placement documentation and adherence with NICE guidelines in general surgical patients across a district general hospital

Abstract Aims NICE provide clear guidelines on confirming correct nasogastric (NG) tube siting using pH testing of aspirates or with X-rays where indeterminate samples are drawn. We aimed to audit documentation following nasogastric tube insertion to ascertain adherence to NICE guidelines. Methods A single-cycle snapshot audit was conducted on all surgical inpatients who had nasogastric tubes inserted over their admission across a single-centre district general hospital general surgery department. Data was collected on indication for NG tube insertion (drainage or feeding), length of initial tube insertion, whether pH testing was used to confirm position, and whether correct tube placement has been confirmed by a competent person through x-ray where indeterminate samples were tested from NG aspirate (pH &amp;gt; 5.5). Results A total of 15 patients had an NG tube inserted over their admission with mean age 77.3 years (range 47-97). 60% of patients had correctly documented confirmation of NG tube siting. 4/15 NG tubes were inserted for feeding purposes (26.7%), all of which were documented correctly. Only 45.5% of NG tubes for drainage were documented correctly and only 33.3% of all NG tubes had length of insertion documented. Where pH testing was inconclusive, a chest X-ray was requested for all patients and sufficiently documented by a doctor qualified to confirm position. No complications relating to NG tubes occurred across the audit study. Conclusions Implementation of improvement measures are warranted to improve overall adherence with NICE guidelines and prevent risk of incorrect confirmation of NG tube siting.

ThP8.2 - Degree of Lymphatic dysfunction in severe obesity

Abstract Aim Obesity can affect the lymphatic system through a multitude of ways with patients presenting to lymphoedema clinics. The aim of this present study is to assess the degree of lymphatic dysfunction through Lymphoscinigraphy (LSG) scans in severely obese patients. Methods All obese patients who presented with leg swelling and underwent LSG scans were included in the study. Based on NICE guidelines they were graded as class 1 (BMI of 30-34.9 kg/m2), class 2 (35-39.9 kg/m2) and class 3 (40 kg/m2 or more). Severity of their Lymphoedema were categorised as mild (uptake 5-8%), moderate (uptake 2-5%), and severe (Uptake &amp;lt;2%) in accordance with the worst affected leg. These two variables were then compared. Results Of the 133 patients with BMI provided, the average BMI was 37.18Kg/m2. 54.89% of patients with BMI provided were classed as Obese.19 (26.03%) of these patients were classed as class 1 obesity and of these 68% had severe Lymphoedema. 14 (19.18%) were classed as class 2 obesity and 28% had severe Lymphoedema. 40 (54.79%) were classed as class 3 obesity and 28% had severe Lymphoedema. Conclusion Majority (75%) of obese patients had lymphatic dysfunction on LSG scans. Majority (62%) had mild to moderate Lymphatic dysfunction. Only 38% of patients with severe Obesity (40 kg/m2 or more) had severe Lymphatic dysfunction. Lymphoedema in Obesity is often not constitutional lymphoedema.

EP465 - Transfusion Associated Circulatory Overload (TACO) Audit - A prospective analysis of adherence to standards ensuring safe transfusions

Abstract Aims TACO is defined as acute or worsening respiratory compromise during or up to 12 hours of transfusion, with additional features including cardiovascular system changes not explained by the patient’s underlying medical condition. In the UK, TACO remains a major cause of Morbidity in surgical post operative patients. The aim of this audit was to assess whether the current trust transfusion practices are synchronous with the NICE guidelines and SHOT recommendations. Methods We reviewed 27 incidences of transfusion during the whole month in acute general surgical ward. Patient’s notes, trust intranet and EPMA were used for data collection. The adherence to Ng24 as well as latest SHOT recommendations was checked. Following standards were taken into account: A formal pre-transfusion risk assessment for transfusion-associated circulatory overload (TACO) should be undertaken for all patients receiving blood transfusion and mitigating actions taken. (Serious hazards of transfusion SHOT recommendation) Patients who develop respiratory distress during or up to 24 hours following transfusion where transfusion is suspected to be the cause must be reported to SHOT. A structured incident review should be undertaken for every case of TACO. Weight-adjusted red cell dosing should be used. (NICE Guidelines Ng24) Result TACO assessment checklist was only completed for 15% of transfusions (compared to 35% nationally) while mitigation actions were only considered for 4% of patients. There appeared discordance among junior doctors regarding TACO Management. Conclusions Interventions like teaching sessions, information leaflets and posters, presentation for induction pack and liaison with Transfusion practitioner team to modify transfusion pathway significantly reduced inconsistencies regarding safe transfusions and immensely improved patient management.

FP2.3 - Is the Oakland score a reliable tool for safe discharge in lower gastrointestinal bleed patients?

Abstract Aim There are no NICE guidelines regarding safe discharge of patients with lower gastrointestinal bleeds (LGIB). The aim of this study was to investigate the effectiveness and safety of the Oakland score, as suggested by the British Society of Gastroenterology guidelines, in patients presenting with LGIB at William Harvey hospital. Methods Patients with LGIB who presented to A&amp;E or inpatient referral from January to December 2023 were included in this retrospective study. Data was extracted from patient’s Sunrise documentation. The Oakland score for each patient was calculated. Those with a score of ≤8 were deemed safe for discharge; those with a higher score were deemed unsuitable. Patients’ admission, safe discharges and adverse outcomes, such as representation, blood transfusion, or further intervention, were investigated. The area under the receiver-operating characteristic curve (AUROC) for the Oakland score and adverse outcome was calculated. Results 123 patients were included. A total of 144 presentations to hospital, 29 had an Oakland score ≤8; 17 (58.6%) cases were safely discharged, 8 (27.6%) admitted and 4 (13.8%) represented. 115 had a score &amp;gt;8; 37 (32.2%) were safely discharged, 72 (62.6%) admitted and 41 (35.7%) experienced at least one adverse outcome. The AUROC for safe discharge was 0.84. Conclusion The Oakland score seems to be a safe and reliable tool for identifying LGIB patients who could be safely discharged home without hospital intervention. However, further research is required to assess whether a score &amp;gt;8 could be used as many higher risk patients did not experience adverse outcomes.

EP51 - Uses of pharmaceutical and mechanical VTE prophylaxis - A clinical audit

Abstract Aim Venous thromboembolism (VTE) is a serious global health care safety concern for both patients and staff. Although it has been amply demonstrated that pharmaceutical and mechanical methods of prophylaxis against VTE are effective, their application has been uneven and insufficient. The purpose of this audit was to assess junior physicians working in general surgery, regarding their adherence to local and NICE guidelines regarding the pharmacological VTE prophylaxis practice as well as the mechanical prophylaxis Methodology Pre-intervention audit took place for two weeks. Throughout the course, it covered every adult general surgical emergency inpatient admission at conquest hospital who were deemed indicated for VTE prophylaxis. Each evening while the patients were still in the hospital, data was collected using the prescription charts, nursing and medical notes. The proforma used for data collection detailed the characteristics of VTE risk, the prophylactic medication prescribed for each patient, TED stockings and whether or not this aligned with the NICE clinical guideline (CG) 46,6.8. Post intervention took place for two weeks after teaching of junior doctors and the same as above was carried out, using the new proforma Results Pre-intervention showed that 87% of patients had the proforma filled in and 100% of patients received the appropriate dose of pharmaceutical prophylaxis. However, less than 40% of patients received the appropriate mechanical prophylaxis. Therefore, intervention was made in the form of a new proforma and teaching to junior. Post intervention data is currently being carried out Conclusion Implementation was necessary to ensure that at-risk patients receive appropriate prophylaxis.

WP3.5 - Laparoscopic cholecystectomy: analysis of indications, time to surgery (TTS) and complications

Abstract Aims Our aims are to establish whether current waiting times for cholecystectomy in our local trust between 01/2021 and 01/2022 are in line with NICE guidelines and compare with average national waiting times. We aim to establish the indications for cholecystectomy (CBD stones, cholecystitis, biliary colic, pancreatitis) and compare waiting times and readmission rates during the waiting period; estimate the rate of conversion to open/subtotal cholecystectomy and any subsequent complications. Methods Data collection and analysis for the period of 01/2021 – 01/2022: average waiting times, rate of conversion, indications, complications. Results 269 patients were analysed after exclusions. Of these, mean waiting time from booking to TTS for uncomplicated biliary colic was 63.26 days. The median TTS from booking was 14 days for hot gallbladders. Of patients diagnosed as biliary colic, the TTS following an acute hospital admission was 63.26 days. Similarly, the patients referred via GP to the outpatient surgical clinic for the same diagnosis was 78.88 days. 5 patients who were referred routinely via GP to the outpatient surgical clinic had complications requiring an acute surgical admission during the waiting period. The rate of conversion to open was 0% during the 1-year period. 2 patients had subtotal cholecystectomies, one of which had persistent bile leak managed with drains and subsequent ERCP. Conclusion The median TTS for hot gallbladder is in line with national standard. There is a tendency to opt for subtotal cholecystectomy as bail out as compared to the previous years.

ThP4.8 - Establishing a Hot Gallbladder Pathway: An Optimal and Advantageous Intervention

Abstract Introduction NICE, AUGIS and Tokyo guidelines recommend early laparoscopic cholecystectomy (ELC) in symptomatic gallstone disease. We highlight our implementation of a hot gallbladder (HGB) pathway, dedicated to HGB cases in a district general hospital with a 550-bed capacity. Methods To implement a HGB service we established a formal evidence-based SOP alongside two theatre lists and six clinic slots a week. Ongoing retrospective data collection allowed us to analyse the efficacy of our interventions between January and December 2023 (n=244). Results In our cohort, biliary colic remains the commonest diagnosis (51.2%) versus acute cholecystitis (27.5%), with female predominance (80% v 20%). Prior to HGB pathway introduction in April (January–March, n=73), 13.7% underwent HGB surgery. After HGB pathway implementation (May–Dec, n=171), 28.7% had HGB surgery with a mean waiting time of 9.6 days from admission. There has additionally been an 18% decrease in patients awaiting cholecystectomy since HGB pathway implementation. Significant delays exist in obtaining an MRCP (8.48 days) and ERCP (5.87 days) when required. Complication and readmission rates were consistent with those published in literature. Conclusion Establishing a HGB pathway facilitated earlier treatment for patients and notably decreased the numbers awaiting cholecystectomy. Significant delays in obtaining MRCP/ERCP could be improved with dedicated MRCP or ERCP slots. Favourable patient outcomes alongside the almost double NHS tariff payments given to ELC compared to elective cholecystectomy, provides incentive for hospitals to implement HGB lists.