Royal Cornwall Hospital Research Articles

FP8.10 - Sustainability in Hand Surgery

Abstract Aims Carpal tunnel release surgery (CTR) is a widely performed procedure in the NHS with significant contributions to waste and carbon emissions within surgery. 36,704 CTRs were preformed from 2022-2023 with an average carbon footprint of 12.0 kg CO2e. The aim of this quality improvement project is to reduce the carbon footprint of CTR through a lean and green model, and examine the rates of infection with this model compared to standard practice. Methods Retrospective data was collected for CTRs performed at the Royal Cornwall Hospital between 31/05/2022 and 01/02/2023 for the first audit cycle using standard set up and equipment. The primary outcome was rates of infection post-CTR. The lean and green model included reducing the number of instruments in the handset (36 items to 14 items), use of a smaller drape, and no gown for the procedure. The second cycle will be examining rates of infection following this intervention. Results Out of 100 patients in the first cycle, 1 patient was treated with antibiotics via a General Practitioner telephone consultation. These eco-changes were well received by staff members, with significant waste reduction this far (over 50 gowns and 25 aperture drapes). Data collection for the second cycle is currently underway. Conclusions CTR surgery is a commonly performed procedure with significant contributions to waste and carbon footprint within surgery. Through simple and low-cost changes to current practice we can promote sustainability in surgery and have a lasting positive impact on the environment.

P35 Impact of IV to oral antibiotic switch optimization on nurse time and plastic waste at the Royal Cornwall Hospital Trust

P35 Impact of IV to oral antibiotic switch optimization on nurse time and plastic waste at the Royal Cornwall Hospital Trust

Optimizing Immunohistochemistry Reporting in Endometrial Cancer.

The management of endometrial cancer involves a multidisciplinary team (MDT) approach, with immunohistochemistry playing an important role in management and prognosis. Markers investigated include estrogen receptor (ER), progesterone receptor (PR), tumor protein 53 (p53), and mismatch repair(MMR)protein. Additionally, polymerase epsilon (POLE) mutations indicate treatment-responsive tumors, often with excellent prognosis. We aimed to improve the reporting of immunohistochemistry and introduce POLE testing, with a sustainable change in the long-term management of endometrial cancer at Royal Cornwall Hospitals Trust (RCHT). An initial sample of 53 patients with endometrial cancer from 2022 was analyzed. Endometrial biopsy reports were reviewed for immunohistochemistry reporting, with delays of reporting over 10 days documented. In initial results, a mean of 15.5% of cases failed to report p53 (12/53), ER (9/53), PR (10/53), and MMR (2/53). The interventions implemented in February 2023 were an immunohistochemistry proforma, the introduction of POLE testing, and departmental presentations. Data was re-collected between March and September 2023. After the project, there was a 100% (39/39) rate of reporting immunohistochemistry correctly. POLE testing was introduced to the department. In addition, the proforma developed is now standard practice in the reporting of endometrial cancer cases and is utilized in the gynae-oncology MDT meetings.

478 Improving the Prescription of Key Medications for Inpatients Admitted to the Royal Cornwall Hospital with an Acute Sore Throat: A Quality-Improvement Project

478 Improving the Prescription of Key Medications for Inpatients Admitted to the Royal Cornwall Hospital with an Acute Sore Throat: A Quality-Improvement Project

P02 Evaluating antibiotic prescribing in pancreatitis: a single-centre retrospective case series

Abstract Background Procalcitonin (PCT) has been shown to safely reduce antibiotic use in respiratory tract infections but there is little evidence for other potentially infected body systems. A recent randomized controlled trial (RCT) demonstrated the safety and efficacy of PCT in reducing antibiotic use in patients with pancreatitis. Objectives We aimed to review antibiotic prescribing in patients with pancreatitis and to estimate the potential impact of PCT on rates of antibiotic prescribing at the Royal Cornwall Hospital Trust (RCHT). Methods Patient care episodes for pancreatitis between June 2022 and May 2023 were identified using pancreatitis ICD-10 codes. An audit tool was developed using the inclusion criteria used in the RCT. Electronic notes systems were used to collect the following: patient demographics, whether diagnostic criteria for pancreatitis were met, clinical specialty, pancreatitis severity, presence of necrosis, indications for antibiotics and course lengths. Results 121 patient care episodes were identified, of which 76 (63%) were analysed. Of these, 61 (80.3%) met the diagnostic criteria for pancreatitis and analysed; median age 57 (IQR 26), 28 (45.9%) female, 51 (83.6%) managed under surgeons and 10 (16.4%) under medicine. 15 (19.7%) patient episodes were excluded: 14 did not meet diagnostic criteria for pancreatitis and 1 on long term immunosuppression. 30 (49.2%) patients with a clinical diagnosis of pancreatitis were prescribed antibiotics; 5 (16.7%) for pancreatitis and 16 (53.3%) for extra-pancreatic indications: respiratory tract 3 (18.8%), cholecystitis 7 (43.8%), suspected cholangitis 1 (6.3%), other intra-abdominal infection 5 (31.3%). The indication for antibiotics was unclear in 9 episodes (30.0%). Of those prescribed antibiotics for pancreatitis, 4 (80%) were appropriately prescribed for suspected infected necrotic pancreatitis (patients with pancreatic or extra-pancreatic necrosis who deteriorate (physiologically or blood results) or fail to improve after 7-10 days), 1 (20%) was inappropriate. The overall rate of antibiotic prescribing in the PROCAP study were 31% in the PCT group and 47% in the usual care group (non-PCT); the rate of antibiotic prescribing in the usual care group was found to be comparable to our data (47.0% verses 49.2%). However, the majority of antibiotic prescriptions in our cohort were for extra-pancreatic infections, not pancreatitis. It is not possible to determine the proportion of antibiotics prescribed for pancreatitis in the PROCAP study and therefore we are unable to compare our findings. Conclusions Rates of antibiotic prescribing for patients at RCHT with pancreatitis are comparable to those in the PROCAP non-PCT guided treatment group which might suggest that adoption of PCT in our hospital could reduce antibiotic prescribing, as per the findings of the PROCAP study. Rates of antibiotic prescribing for pancreatitis at RCHT are low, with the majority of prescribing for extra-pancreatic indications, although the indication was unclear in approximately one third of episodes. The PROCAP study does not report rates of prescribing for pancreatitis which prevents estimating the impact of PCT on antimicrobial prescribing for pancreatitis at RCHT. Whether PCT has a role in reducing antimicrobial prescribing for patients with pancreatitis at RCHT is unclear.

Impact of technology interventions on technology sensitive dispensing errors

Abstract Introduction Technology has the potential to impact significantly on dispensing error rates. Technology systems are already widely established in UK hospitals such as automated dispensing systems (robots) and electronic prescribing systems. A single technology system cannot achieve error reduction across all dispensing error types, for example, using a robot can only have impact on picking (contents) errors and not labelling errors. Quantifying the technology sensitive errors after implementation of technology systems enables us to focus on the highest risk error types and combine the most useful risk reduction strategies1. Aim To quantify the technology sensitive error rate found in dispensed items after different technological interventions. Methods Prevented dispensing errors were collected at the Royal Cornwall Hospital in 2021 over four days. Errors were documented at the final checking stage of dispensing on a standardised data collection tool used as part of the hospital usual governance processes. Errors were categorised by error type and the technology interventions involved in the dispensing process; robot picked, robot picked and labelled, or entered by barcode. An error was defined as technology sensitive if that technology could have had a direct impact on that error type2. Data was analysed in Excel. Chi-square significance testing was undertaken on those cohorts that were sized appropriately. Ethics approval was not required as the study met the definition of a service evaluation. Results 2461 items were dispensed in the study period. The overall dispensing error rate for the period was 2.64% (N=65). Labelling errors represented 66.9% of errors whereas contents errors 33.1%. The overall difference in the error rate in items picked by the robot versus manually was not significant. However, when excluding errors that are not sensitive to the technology e.g., label direction errors, the results become significant with a reduction of 0.86% (manually picked) to 0.05% (robot picked). Items that were entered into the stock control system by barcode showed a technology sensitive error reduction of 0.31% to 0%. It was significant that items that were packed down were associated with more dispensing errors (4.37%) compared with those dispensed as original packs (1.14%). Due to small sample size, the reduction in technology sensitive error rate from 0.34%-0.2% when using robotic labelling with robotic picking could not be tested for significance. Discussion/Conclusion Translation of medication orders from a prescription to a stock control system is one of the highest risk areas for error substantiated by labelling errors contributing to 66.9% of the overall errors in this study. A study has demonstrated significant reduction in dispensing error rate using integrated prescribing systems and stock control systems1. This study and previous work found bar-coded data entry to be similarly effective3. Part pack, manual dispensing shows the greatest risk of dispensing errors and therefore technologies that can impact in this area would likely have great benefit. The study was limited by sample size in some of the technology cohorts. With the correct combination of technologies we aim to reduce errors at the point of dispensing to negligible levels.

A Service Evaluation of the Implementation of E-sign for Homecare Prescriptions in Secondary Care

Abstract Introduction Homecare Medicine Services allow patients with chronic conditions, reliant on specialist medicines prescribed by secondary care, to manage their symptoms at home rather than requiring regular attendance to a hospital for treatment1. The Royal Cornwall Hospital NHS Trust (RCHT) manages over 3000 patients on homecare services across a range of specialties. Traditional homecare processes required prescriptions to be printed on paper at the hospital, signed by hand by a prescriber and then securely couriered to the homecare provider for processing. The secondary care Electronic Prescription Service (EPS) is coming but in the interim a solution was commissioned by the National Homecare Medicines Committee to improve processes, reduce administrative burden, and improve the timeliness of prescriptions for direct patient benefit. The product selected was E-sign (E-Sign (UK) Ltd) which allows prescriptions, as PDF files, to be signed with an advanced electronic signature and tracked through a managed workflow compliant with applicable legislation2. Working collaboratively with Sciensus we introduced E-sign in March 2022. In the last year we have processed approximately 3500 prescriptions via this process. We sought to evaluate E-sign prior to wider adoption within the Trust. Aim To evaluate the acceptability, benefits or drawbacks of the new E-sign process for prescribers and patients. Methods In January 2022 (pre- implementation) we audited 100 homecare prescriptions recording the time between prescribing on our electronic prescribing system (ePMA) and collection by the Sciensus courier. Post-implementation data was gathered by comparing the time of prescribing on ePMA and time of release to Sciensus on the E-sign workflow for 142 prescriptions in May 2023. Data was analysed in Microsoft Excel and a T-test was used to test significance. A short survey was sent to all prescriber and pharmacist users of the E-sign system (12) to evaluate the speed, flexibility and ease of use of the system. As this project falls under the definition of a service evaluation, according to UK NHS Research Ethics Committees, formal ethical approval was not required, it was registered with the Trust’s clinical audit database. Results There was a statistically significant (p < 0.05) decrease in the average time taken for prescription transmission, from 200 hours pre-implementation to 25 hours post-implementation. All respondents to the survey (N=8) agreed it was easier to use than the manual system and would recommend it to colleagues. Most (75%) felt the system was faster and more flexible than the paper system. 50% believed it improved the service to patients. All respondents would recommend the system to their colleagues. Discussion/Conclusion The E-sign system has brought benefits to prescribers and ultimately patients. Prescriptions are now transferred significantly more quickly to homecare providers, and the risk of lost prescriptions is removed. E-sign has allowed for service transformation; we now have prescribers who work entirely remotely using E-sign. Future developments will include collaborating with additional homecare providers, including a new patient workflow, and migrating to EPS when available. Study limitations were due to the sample size of prescribers available for survey.

Surveillance reports to identify duplicate anticoagulant prescribing

Abstract Introduction A number of patients admitted to hospital on direct oral anticoagulants (DOACs) are often switched to low molecular weight heparin (LMWH) for a limited period of time as part of their clinical management. Electronic prescribing systems (EPMA) allow DOACs to be suspended temporarily and then re-started when clinically indicated. However the system does not generate an alert when DOACs are re-started, leading to unintentional co-prescribing of LMWH which could lead to severe patient harm.1,2 Aim To determine whether anticoagulation surveillance reports reduce the number of inappropriate duplicate anticoagulation prescriptions. Methods A retrospective review of duplicate anticoagulation errors was carried out between September 2017 and March 2022 across the 3 main Royal Cornwall hospital sites. Data on all anticoagulant administrations and the administration time was collected from EPMA via Crystal Reporting pre and post intervention with each period covering 831 days. Data was analysed using Excel. As part of the intervention, surveillance reports were set up in December 2019 to identify patients who were prescribed both LMWHs and DOACs. Reports were generated twice a day, 7 days a week and reviewed for patients who were prescribed both LMWHs and DOACs. The ward pharmacists were then alerted of co-prescribing to complete the necessary interventions. As this project falls under the definition of a service evaluation, according to UK NHS Research Ethics Committees, formal ethical approval was not required. This project was registered on the hospital’s clinical audit database. Results 948,036 doses of LMWH and DOACs were administered (September 2017 to March 2022) with 817 duplicate prescribing identified, a 0.09% error rate. The longest time on duplicate therapy was dramatically reduced pre and post intervention from 322 hrs to 36 hrs with mean number of hours reduced from 14.03 to 8.07. The number of patients receiving more than two doses of co-prescribed LMWH and DOAC before the error was rectified, also reduced from 56 (pre-intervention) to 30 (post-intervention). Likewise, the average duration of more than 2 doses of co-prescription reduced from 48.3 to 18.7 hours before the error was corrected. Discussion/Conclusion Some limitations of the study are that staffing is more limited on weekends which may have prevented pharmacists actioning these alerts over weekends. Data will only include anticoagulants prescribed on EPMA so excludes some infusions such as unfractionated heparin. Timestamps associated with administrations on EPMA are user-entered so may not be exact to the time given. Although EPMA generates an alert when patients on DOACs are prescribed LMWHs, it does not provide a similar alert when suspended DOACs are re-started. EPMA providers are planning to develop alerts to correct this. In the interim we have shown that surveillance reports capture co-prescribing of DOACs and LMWH at an earlier stage preventing potential serious patient harm. It also allows for pharmacists to educate prescribers on risks of anticoagulation co-prescribing. This report is now routine practice, including additional monitoring - patients on warfarin, fondaparinux, LMWH prescribed twice daily and INR levels. We will re-evaluate to include new parameters.

Mental Health Triage Form Use in Emergency Department Clerking – Audit at Royal Cornwall Hospital

AimsThe aim of this audit is to assess use of the Mental Health Triage Form (MHTF) at the Royal Cornwall Hospital Emergency Department (ED), during June 2021 and to determine whether MHTF use increases rates of psychiatric-specific information being documented by ED staff. Patient attendances to Accident and Emergency (A&E) departments in the UK during 2020-21 decreased by 30.3% in comparison to 2019-20. However, attendances to A&E at the Royal Cornwall Hospital (RCH) in June 2021 increased by 51.2% compared to June 2020. Psychiatric patients accounted for 2% of attendances to A&E at RCH in June 2021. The Royal College of Emergency Medicine (RCEM) have recommended use of a mental health proforma document in line with recommendations from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) document ‘Treat as One’. Based on these guidelines, the Psychiatric Liaison department at RCH have a produced a local Mental Health Triage Form (MHTF) to be used in A&E when assessing and clerking psychiatric patients.MethodsThis was a retrospective audit of clinical records of 125 mental health cases attending the Accident & Emergency Department (A&E) at Royal Cornwall Hospital during June 2021, which were referred to Psychiatric Liaison.NHS numbers were identified for each referral made during the study period. Each referral's A&E clerking documents were reviewed on an online patient records system. Information was recorded on whether each question in the Mental Health Triage Form had been answered with or without use of the form.ResultsThe Mental Health Triage Form (MHTF) was used in 44 out of 125 patients (35%). 15 patients (12%) had missing Accident & Emergency Department documentation on online records. Where the MHTF was used, there was an 25% average increase in information recorded. Over half of the questions on the MHTF were answered more when the form was used versus when it was not used.Questions relating to the patients ‘Triage Code’, which are used to determine the level of observation, urgency of referral, and appropriate place of assessment, had the highest rates of improvement using the form.ConclusionOverall use of the Mental Health Triage Form during June 2021 reduced to 35% in comparison to 46% use during June 2020. This implied that patients attending the Accident & Emergency Department at the Royal Cornwall Hospital with psychiatric presentations were not being assessed fully. This may be due to various reasons such as staff unfamiliarity with the triage form and increasing pressure on Emergency Department services.

P12 Partial implementation of procalcitonin measurement as an antibiotic stewardship in the ICU

Abstract Background Procalcitonin (PCT) was introduced to the Royal Cornwall Hospital ICU in April 2020. A local PCT testing and decision support algorithm was developed using published consensus guidelines. We report our adherence to this algorithm in the ICU. Methods This retrospective observational study included all patients discharged from ICU from 1 February 2022 to 28 February 2022. Patients who received antibiotics during their admission were identified. Data on antibiotic indication, antibiotic course length in the ICU and pre-ICU and PCT testing were collected and compared with local PCT-based antibiotic prescribing guideline. Results Of 50 patients discharged, 34 (68%) received antibiotics and 26 for acute infections and 8 for deep-seated infections or surgical prophylaxis. A baseline PCT was sent in 10 (38%) patients with acute infections, with 4 having repeat PCT testing. Of four patients with a low baseline PCT, three were repeated and remained low. Two of these patients had antibiotics stopped as per PCT algorithm. A further patient with a low PCT was not initiated on antibiotics. Six patients had a high baseline PCT (>0.5) and one had a repeat PCT which remained high. Antibiotics were continued in all 6 patients. 16 patients with acute infections did not have baseline PCT testing with one having a random PCT during the antibiotic course. Five patients had deep-seated infections, and therefore, PCT testing was not indicated. However, 2 had baseline and repeat PCTs, with repeat PCTs low (<0.5) and antibiotics continued. Median course lengths were 5 days in the ICU and 6 days when pre-ICU antibiotics were included. Conclusions PCT testing in our ICU is low with only a third of eligible patients having a baseline PCT test with repeat PCT testing in accordance with local guidelines in the minority of these. There is some limited evidence that PCT testing is impacting antibiotic decision making in our ICU. We have identified that antibiotic course lengths in our ICU are relatively short. We have introduced PCT measurement as part of antimicrobial stewardship in our ICU. Fully embedding PCT testing, and PCT-guided antibiotic decision making, may further reduce antibiotic use. How to achieve this is challenging—there is a paucity of published PCT implementation studies.

Interview: Hannah Gower

Hannah Gower | Cardiology and Internal Medicine Speciality Registrar, Royal Cornwall Hospitals NHS Trust, UK

Index admission vs elective laparoscopic common bileductexploration: adistrictgeneralhospitalexperience over 6years.

Laparoscopic common bile duct exploration (LCBDE) is relatively a new approach for clearing choledocholithiasis. The aim of this study is to assess the safety ofthisapproachtoclearing common bile duct (CBD) stones on an index admission including emergency setting. Retrospective data collectionand analysiswerecarried out for 207 consecutive cases of LCBDE performed in Royal Cornwall Hospital over 6years (2015-2020).Patientswere dividedinto two groups (Index admission vs elective) then both groups compared. A total of 207 cases of LCBDEwereperformed in our unitduring the time period.One hundred twenty-two operations were performed on the index admission and 85 on a subsequent elective list. Mean operative time was 146 ± 64minin the index admission group and 145 ± 65minin the elective group(p = 0.913). Length of stay post-operatively was 3.3 ± 6.3daysin the index admission cases and 3.5 ± 4.6daysafter elective cases. Successful clearance was achieved at the end of the operation in 116 patients in the index admission group, clearance failed in one case and negative exploration in 5 patients. In the elective group 83 patients had a successful clearance at the end of the operation, and 2 patients has had a negative exploration. Twelve patients(index admission group) and 8 patients of the elective cases required post-operative Endoscopic Retrograde Cholangiopancreatography (ERCP) to manage retained stones, recurrent stones and bile leak(p = 0.921). Three patients required re-operation for post-operative complications in each group. Common bile duct exploration in index admissionis safe with high success rateif performed by well-trained surgeons with advanced laparoscopic skills.

The Nomadic Digital Pathologist. Validation of a simple, dual slide scanner with remote reporting for a regional upper gastrointestinal specialist multidisciplinary meeting

Background: This article describes how a simple slide scanner with remote viewing software enabled a remote “nomadic” pathologist to continue his role as specialist lead for a regional gastrointestinal multidisciplinary team meeting (MDTM) after relocating to another site in the 5 hospital Southwest UK Peninsula cancer network just prior to the COVID-19 pandemic.Materials and methods: The author used digital pathology (DP) to supplement a conventional workflow as a way of minimising delay in reporting and reviewing slides for a regional specialist Oesophagogastric MDTM (the OGSMDT). The specialist centre at University Hospital Plymouth (UHP) is 58 miles from the author’s new workplace at Royal Cornwall Hospital (RCHT). Slides from the 44 cases (10% of this specialist annual workload) in this validation study were reported or reviewed digitally using the slide scanner. All were listed for the OGSMDT due to being clinically suspicious for upper gastrointestinal malignancy, having been processed at UHP, or one of the other hospitals in the cancer network.Results: The scanner allowed the author who was only on site at UHP 1 day per week to prevent delays in reporting/reviewing glass slides, using remote DP. Confidence in digital diagnosis was assessed using the Royal College of Pathologists recommendations. The author was the primary pathologist signing out 31, and second opinion for the remaining 13 cases. These comprised a mixture of biopsies as well as endoscopic and surgical excision specimens. The DP system enabled the author to report the cases digitally with an equivalent degree of confidence to glass slides and no significant discrepancies were identified between the author’s digital and final glass slide diagnosis.Conclusions: The scanner was found to be safe and effective for remote reporting and review for OGSMDT cases. It was recognised that DP was advantageous to enable this role to continue remotely but that a fully integrated digital reporting system capable of high-capacity scanning would be preferable to the simple system used.

Implementation of the Antimicrobial Review Kit (ARK) to optimise antimicrobial prescribing at the Royal Cornwall Hospital: a behavioural change odyssey

Antibiotic use drives antimicrobial resistance (AMR). The Antimicrobial Review Kit (ARK) study is a complex intervention based on national antibiotic stewardship guidance. We describe the implementation of ARK at a 760-bed teaching hospital that uses electronic prescribing. An online education module was disseminated to healthcare workers, and the ARK decision tool was incorporated into the medical clerking pro forma. From July 2018, junior doctors audited the frequency, the outcomes of pre-72-hour antibiotic reviews and the use of the ARK tool. The data were used to formulate specialty-level feedback and bench marking. First-phase data were plotted on statistical process control (SPC) charts to distinguish between common and special cause variation. There was significant improvement in antibiotic review rates (81% to 93%) and stop rates (10% to 15%). The stop rate reached 25% in the most recent data. Given the promising trends, it may be possible to achieve the target stop rate of 30%.

Fostering greener gastroenterology and hepatology practices

Fostering greener gastroenterology and hepatology practices

The Negative Bidirectional Interaction Between Climate Change and the Prevalence and Care of Liver Disease: A Joint BSG, BASL, EASL, and AASLD Commentary

The Negative Bidirectional Interaction Between Climate Change and the Prevalence and Care of Liver Disease: A Joint BSG, BASL, EASL, and AASLD Commentary

Abstract P4-07-28: Early relapse and predictors of relapse-free survival in neoadjuvant chemotherapy-treated breast cancer patients

Abstract RationaleNeoadjuvant chemotherapy (NAC) for the treatment of early and locally advanced breast cancer is shown to cause effective tumour shrinkage, allowing breast conserving surgery. However, rates of recurrence remain high following surgical excision of NAC-treated breast tumours. We investigated relapse-free survival (RFS) in NAC-treated breast cancer patients; the primary aim of this study was to estimate probability of early relapse (<5 years) and identify possible predictor variables. MethodsWe retrospectively reviewed NAC-treated breast cancer patients diagnosed between January 2013 and August 2018 at the Royal Cornwall Hospital, UK. Patients met inclusion criteria with >3 cycles of NAC, surgery and follow-up >1 year. Demographic, histopathological and surgical data were collected including age, TNM classification, tumour histology, breast cancer immunohistochemical marker receptor status (ER, PR, HER2), NAC dose, adjuvant radiotherapy, type of breast and nodal surgery, pathologic response to NAC, number of positive lymph nodes (LN) at surgical removal and lymph node ratio (LNR). Tumour histology was categorised by inflammatory versus non-inflammatory. TNM classification was used for tumour staging. TNM nodal classification was categorised as N0 or N1 according to axillary LN cytology. LN classification data was missing for patients with inconclusive LN status at diagnosis. LNR was calculated as the ratio of positive LN to total number of LN removed at surgery. NAC response was categorised as pathologic complete (pCR) or incomplete (no-pCR). Kaplan-Meier method was used to compare survival functions for categorical variables. The Cox proportional hazards model was used at univariate and multivariate analysis for predictor variables that satisfied the proportional hazards assumption, to calculate hazard ratios for RFS. p-values <0.05 were taken as statistically significant. Results165 of 190 women were eligible for analysis. Median (IQR) age at diagnosis was 51.7 years (45.5-60.3). 68 patients (41.2%) achieved pCR following NAC and 147 (89.1%) received adjuvant RT. 30 relapses (18.2%) were recorded during follow-up, of which 24 (80%) were distant metastases. The Kaplan-Meier survival function estimated a 25% (95% CI, 17-36) probability of relapse by year five post-surgery. At univariate Cox analysis, RFS was associated with fewer positive LN (p = 0.001), lower LNR (p < 0.001) and TNM node classification N0 at diagnosis (p < 0.001). Table 1 below shows the results of multivariate Cox proportional hazards regression. Small sample size might conceal statistical significance of some covariates. ConclusionsOver 1 in 4 NAC-treated breast cancer patients relapsed within 5 years of surgery, usually with distant metastases. At univariate analysis, relapse-free survival (RFS) was individually associated with decreased LNR, fewer positive LN and TNM node classification N0. LNR remained a significant predictor of RFS at multivariate analysis with risk of relapse for a LNR of 1, 9-fold higher than a LNR of 0. Age, tumour histology, HER2 receptor status, TNM tumour classification, NAC dose and response to NAC had no significant association with RFS in this sample size. Risk FactorSubjectsHazard Ratio (95% CI)p-valueAge1651.042 (0.998 - 1.088)0.064Tumour histology (inflammatory = 1, other = 0)1651.268 (0.302 - 5.331)0.746HER2 receptor status (HER2+ = 1, HER2- = 0)1651.217 (0.357 - 4.150)0.754TNM tumour classification (T3-4 = 1, T1-2 = 0)1650.852 (0.298 - 2.442)0.766TNM node classification (N1 = 1, N0 = 0)1021.684 (0.428 - 6.622)0.455NAC dose (full dose = 1, reduced dose = 0)1651.091 (0.393 - 3.028)0.866NAC response in breast (pCR = 1, no-pCR = 0)1650.696 (0.199 - 2.442)0.572Lymph node ratio1649.426 (2.061 - 43.099)0.004 Citation Format: Natalie Martin, Julia Pasztorova, Isabella Hibell, Duncan Wheatley. Early relapse and predictors of relapse-free survival in neoadjuvant chemotherapy-treated breast cancer patients [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-07-28.

Single-use plastic and COVID-19 in the NHS: Barriers and opportunities.

Background: Single-use personal protective equipment (PPE) has been essential to protect healthcare workers during the COVID-19 pandemic. However, intensified use of PPE could counteract the previous efforts made by the UK NHS Trusts to reduce their plastic footprint.Design and methods: In this study, we conducted an in-depth case study in the Royal Cornwall Hospitals NHS Trust to investigate plastic-related issues in a typical NHS Trust before, during and after the pandemic. We first collected hospital routine data on both procurement and usage of single-use PPE (including face masks, aprons, and gowns) for the time period between April 2019 and August 2020. We then interviewed 12 hospital staff across a wide remit, from senior managers to consultants, nurses and catering staff, to gather qualitative evidence on the overall impact of COVID-19 on the Trust regarding plastic use.Results:We found that although COVID-19 had increased the procurement and the use of single-use plastic substantially during the pandemic, it did not appear to have changed the focus of the hospital on implementing measures to reduce single-use plastic in the long term. We then discussed the barriers and opportunities to tackle plastic issues within the NHS in the post-COVID world, for example, a circular healthcare model.Conclusion: Investment is needed in technologies and processes that can recycle and reuse a wider range of single-use plastics, and innovate sustainable alternatives to replace singleuse consumables used in the NHS to construct a fully operational closed material loop healthcare system. Significance for public health This study provides novel empirical evidence on the procurement and use of single-use plastic before and during COVID-19 pandemic from a typical UK publicly funded healthcare provider. Through the interviews which we conducted with the frontline workers, we elicited both antecedent and concurrent attitudes towards single-use plastics to investigate the impact of COVID-19. In the face of both climate change and pandemic crises, we argue that a closed-loop system, also known as the circular economy, must be implemented in our healthcare.

Hyperparathyroid service evaluation at the Royal Cornwall Hospital Trust from 2013 to 2021

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

P.84 Managing maternal anaemia at Royal Cornwall Hospital: Iterative improvements year on year

Introduction: Maternal anaemia remains common despite associations with adverse maternal and fetal outcomes. [1] Pavord S, Daru J, Prasannan N et al. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol 2020;188:819-30. Google Scholar Recently, conventional definitions of anaemia ( < 110g/L) have been questioned and a higher haemoglobin threshold ( > 120g/L) suggested. [2] Ferguson MT, Dennis AT. Defining peri-operative anaemia in pregnant women - challenging the status quo. Anaesthesia 2019;74:237–45. Google Scholar This is likely to benefit a population at risk of significant blood loss.