Surgical Assessment Unit Research Articles

WTP7.2 Post COVID-19 Pandemic Impact on Surgical Assessment Unit (SAU) Activity

Abstract Aim Emergency surgical services were consolidated to one of our two hospital sites at the onset of the COVID-19 pandemic. All hospital services are under increasing pressure. This study aimed to assess the ongoing post-pandemic impact on the activity of our surgical assessment unit (SAU). Method Data was recorded prospectively on patients attending SAU. Comparison was made between the first three months of the pandemic (March-May 2020) and the two 15-month periods since (June 2020-August 2021 and September 2021-November 2022 respectively). The number attending, proportion admitted, and time taken to see a senior decision maker were recorded. Results The average number of patients attending per month in the first three months was 364. This rose to 760 and 880 per month respectively in the two post-pandemic periods. The proportion admitted was initially 28.3% but fell to 22.7% and 20.4% in the following periods. Admission numbers in the two 15-month periods were similar (173 vs 180). There was a reduction in the proportion seen by a senior decision maker within two hours across the three time periods (60%, 52% and 35% respectively). Conclusions SAU attendances have more than doubled since the onset of the pandemic. Attendances have continued to rise in the 30 months since the initial outbreak, with little effect on admission numbers. Consequently, fewer patients are seen quickly which likely has a detrimental impact on patient experience. Lack of access to other areas of healthcare may have influenced these changes. This increased activity should inform future service planning.

ThTP5.9 Are readmission rates in a new surgical SDEC department acceptable? A service evaluation of a Healthboard’s new department

Abstract Aims Unplanned patient readmission after discharge is a costly and potentially preventable occurrence, which can negatively impact both the patient’s experience and overall outcomes. Readmission rates across the country vary depending on location, population demographics and presenting complaint, but most departments have rates between 4 – 10%. Our health board has recently implemented a new surgical Same Day Emergency Care (SDEC) department in response to rising pressures on beds. There have already been promising drops in patient waiting times since its inception, however patient readmission rates have not been formally evaluated. We aimed to investigate 30 day unplanned patient readmission rates in this new SDEC department. Methods All patients that came in to the SDEC department in October 2022 were placed on a prospective database. We used the healthboard’s Clinical Workstation (CWS) database application to track whether they had re-presented to the Emergency or surgical departments within 30 days of their discharge from SDEC. Results 344 patients were seen in SDEC over the course of 31 days. Of these 238 were discharged, 34 were planned readmissions and 71 were admitted. Of the discharged patients 13 came back as unplanned readmissions within 30 days. This gives an unplanned readmission rate of 5.5%. Conclusion SDEC is providing an excellent surgical service, with low unplanned readmission rates. SDEC has proven to be an effective way to divert patients from the Surgical Assessment Unit and ease the acute on call surgical take pressures.

ThTP8.14 Microbiology pus swab sampling in incision and drainage of abscesses

Abstract Background Obtaining microbiology swabs during emergency incision and drainage (I&D) is commonplace for general surgeons. Its necessity is controversial but despite this, abscess swabbing is still routine despite little evidence of follow up of results. Methods All abscess I&D procedures admitted to Surgical Assessment Unit (SAU) at RDH over the period of 3 months from May 2022 to June 2022 were reviewed. Data collection included demographics, admission white cell count (WCC), C-reactive protein (CRP) levels, temperature and co-morbid status as well as any perioperative antibiotic regime. Results 97 patients underwent I&D either under local or general anaesthesia. The most commonly encountered abscess site was perianal (20%) followed by pilonidal (13%). 22% were admitted on antibiotics started elsewhere. 71% had a recorded microbiology swab taken. 59% of microbiology swabs demonstrated no significant growth. 2 swabs (3%) grew MRSA. There was no documented evidence of GP or patient information of this result. 11 patients who were admitted with a temperature of ⩾ 37.5°C (11%); 7 (64%) grew a named organism on pus sampling. 12 patients had a WCC ⩾13 x109/L, and samples were sent in 9. 6 patients grew the following; mixed anaerobes, E.coli, Citrobacter, and Gram positive cocci. Conclusions Microbiology pus sampling for I&D cases is performed ad hoc and results are not routinely chased. For well ambulatory patients I&D can be performed without the need for pus swab sampling at surgeon discretion. If it is performed there should be named clear instruction on follow up of the outstanding results.

WTP6.5 Facile strategies implemented to improve pharmacological venous thromboembolism prescribing practices in an acute surgical assessment unit

Abstract Introduction Venous thromboembolism (VTE) represents a major cause of preventable morbidity and mortality in acute surgical admissions. Whilst previous national audits/NHS campaigns have greatly increased admission VTE prophylaxis assessment (VTEPA), critical reassessment within 24 hours of admission in high bleeding/thrombosis risk patients as advocated by NICE/SIGN/Trust guidelines remains poor; thus, serving as the study aim. Methods Data collection was undertaken retrospectively post-discharge (n=269) at admission (within 14 hours post-admission) and reassessment (within 24 hours post-admission). The first cycle determined baseline practices; intradepartmental poster education/sessions and discussion awareness formed the mainstay intervention with a further 2 cycles (2 months/4 months post-intervention) to assess change. An unpaired T-test determined significance (p<0.05) of averaged VTEPA rates across cycles. Results Baseline VTEPA practices 92% (admission) and 16% (reassessment) of patients respectively. VTEPA rates significantly improved to 98% (admission, p<0.05) and 86% (reassessment, p<0.001) 2 months post-intervention. At 6 months VTEPA rates decreased to 96% (admission) and 62% (reassessment); p<0.05, p<0.001 compared to baseline practice respectively. Discussion VTEPA significantly improved post intradepartmental poster-education and discussion awareness at admission and reassessment, in accordance with national guidelines. We consider the decline in VTEPA at 6-months, partly attributed to the influx of the new cohort of FY1 junior doctors in August with limited exposure to the departmental VTE education sessions. Overall, however, this audit demonstrates that facile, inexpensive, and quick interventions can yield highly effective results translating into improved patient safety; particularly in preventable inpatient VTE events. Further consideration should be given to incorporate such strategies across trusts to maximise VTEPA compliance.

Under Pressure–TrolleyGar, a Metric Reflecting a Hospital System at Crisis-Capacity

Introduction:Health service capacity has been an issue in Ireland since the 1980s swinging cuts. Government reports from 2003 have consistently identified a requirement for 3,000-5,000 extra beds on top of the current approximately 10,500 capacity. Acute hospital bed capacity issues have escalated, the formal system of recording “over capacity” patients or “patients on trolleys” has developed. A “Trolleygar” reports issues from the Health Service Executive (HSE) three times daily. This count is an underestimate as patients temporarily housed in day care units, surgical, or medical assessment units, discharge lounges and other clinical areas which have a bed space are not counted in this overcapacity measure. This study's aim is to calculate the annual number of days on which no patients were lodged on trolleys in Wexford General Hospital.Method:Descriptive study using anonymized freely available data from the national HSE Trolley GAR reports on trolley patients in Wexford General Hospital from January 2019 until September 2022. A Golden Zero trolley day was stated as a day on which there were no reported trolley-patients at the three time points, Silver Zero trolley day when two of the time periods recorded no trolleys and a Bronze Zero Trolley day when one period recorded a zero trolley count.Results:Data was collected on 1,369 days, with 90 days excluded due to missing data sets. There were 162 Golden days recorded (12.67% of total days). The year 2020 recorded the highest number of Golden days at 28.69% (105 days), followed by 2021 with 11.23% (41 days). During 2019 there were 3.84% (14 days) Golden days and 2022 had the lowest number (January-September) with 0.73% (2 days).Conclusion:Despite a zero-tolerance policy, Golden days are disappearing rapidly, capacity is urgently required with post-pandemic ED attendance surges worldwide. True recording of overcapacity patients is required for appropriate capacity modeling.

EGS P09 An Ambulatory General Surgical Service, Reducing the On-Call Burden and Improving Patient Experience

Abstract Background The management of acute General Surgical patients is dramatically changing with the emergence of Emergency General Surgery departments. The trend is moving towards consultant-led services, and managing patients on ambulatory pathways. This prospective study aims to demonstrate the impact of a consultant-led ambulatory surgical clinic and primary care telephone access on the acute surgical take in a busy tertiary hospital. Methods Data was collected from March 2021-March 2022. Patients were included via the primary care access line, as well as patient attendances either via surgical assessment unit (SAU), or ambulatory surgical clinic (ASC). Their pathways were recorded i.e. admit, discharge, further ambulatory investigation, listed for surgery. Results Consultants took 6,948 calls from primary care from March 2021–22. 43.7% of patients were given an appointment for ASC, 37.3% admitted to SAU, 3.5% directed to ED, and 15.5% given advice or redirected elsewhere. 54.6% of those seen in ASC were discharged without further follow up, the other 45.4% were either admitted, followed up or added to a waiting list. General Surgery patient attendances to SAU fell from an average of 1020 per month between March to October 2021 to 542 attendances November 2021 to present. Conclusions The introduction of a consultant-led ambulatory service has reduced the on-call burden by half. The dramatic reduction in SAU attendances is likely to be the result of developed ambulatory pathways, improved communication with primary care and Consultant Emergency General Surgeons, and autonomy of Junior Surgical Trainees to redirect ED referrals onto refined and supported ambulatory pathways. A Consultant-led primary care access line has reduced ED attendances and allowed for effective streaming of patients. These changes have improved the patient experience significantly, by directing them straight to specialty with same or next day consultant clinics, and reduced waiting times overall. There has been a significant reduction in complaints and consistent improvement in patient feedback.

EGS P07 Management of cutaneous abscesses using the Green Whistle: A Pilot Study

Abstract Background Cutaneous abscesses form a significant volume of emergency general surgery operating throughout the UK. They are most commonly managed with an ‘incision and drainage’ (I&D) procedure which tends to be performed with a general anaesthetic (GA). As expected with the unpredictable nature of emergency general surgery, abscesses booked for I&D under GA are often delayed to accommodate a more urgent procedure or unwell patient. Costs and theatre utilisation of abscesses managed under a general anaesthetic were obtained and analysed. A pilot study was then designed to utilise Methoxyflurane (Penthrox/Green Whistle) as an alternative to general anaesthetic for the management of abscesses. Methods Retrospective data of patients requiring I&D of abscesses under GA between January 2020 and January 2021 was collected. Length of stay (LOS), length of surgery (entry into theatre to out of theatre), time spent in theatre (anaesthetic room and operating theatre) and theatre complex (holding bay, anaesthetic room, operating theatre and recovery) were collected. Financial costs were also obtained. Abscesses were organised into different degrees of complexity: complex, medium and simple. ‘Simple’ abscesses were defined as such if the patient met the following criteria: >18 years, ASA 2 or less, non-perianal or ischiorectal and a surgical time of 10 minutes or less. Following the results, a pilot study was designed and proposed. 20 patients were recruited to this pilot study. Recruitment was performed on admission via the emergency portal (surgical assessment unit). To be eligible for this study, patients would need to meet the following criteria: A patient satisfaction survey was conducted via telephone at a later date. Results 381 patients underwent an I&D under GA. Ratio of M:F was 1.12:1. Majority of abscesses drained were perianal (n=120) and pilonidal (n=81). Majority of patients were ASA 1 or 2. 100 ‘simple’ abscesses were identified. The sum of length of stay (LOS) was 949 days. The sum of surgery time (ST) was 4.6 days. The sum of total theatre time (TT) was 14 days. The sum of time in theatre complex (TC) was 48 days. ‘Simple abscesses’ had a total LOS of 144 days, total ST of 12 hours, total TT of 69 hours and total TC of 12 days. Pilot study: 20 patients had cutaneous abscesses drained between July and September 2021 with Penthrox. M:F ratio was 11:9. 19 patients underwent successful drainage of their abscesses whereas 1 procedure had to be abandoned due to pain. Abscess drainage was performed on the 1st day of presentation in 15 patients. There were no 30-day readmissions noted within this pilot group. 83.3% of respondents to the patient satisfaction survey rated their experience as ‘Very Good’. Costing Overall savings of £4,150 were calculated per patient. Conclusions This study aimed to look into the feasibility of a dedicated abscess pathway for patients meeting specific inclusion criteria. Overall, the results have shown that this is feasible and cost-effective. It reduces length of stay, waiting times and costs. Patients are usually discharged home the same day without any complications. Our data has shown that performing an I&D of an abscess under the Green Whistle pathway costs 30-times as less than the same abscess being managed under a GA in the theatre complex. The pilot study has been ratified at management level and we are currently in the process of stocking Green Whistles in our Surgical Ambulatory Unit and we will shortly begin widespread training and use.

EGS P20 Emergency General Surgery – A state of the nation survey

Abstract Background ERAS (enhanced recovery after surgery) programmes have delivered improved outcomes across the elective surgery landscape but emergency surgery has historically lagged behind with its improvements. The introduction of acute care surgery principles in the United States and projects such as NELA (National Emergency Laparotomy Audit) in the United Kingdom are working to change this. Despite the improvement in outcomes seen by NELA there lacks clarity over the structure and provision of services across the UK. No study to date has examined how Emergency General Surgery care is currently organised and therefore how these organisational structures are changing as new innovations to patient care are delivered. This study aims to ascertain the current organisation structures of emergency surgical care within England and whether there are plans for this to change. Methods A survey was defined and sent to hospitals across England via Freedom of Information (FOI) Requests. Trusts were identified from the online NHS Service Directory and cross referenced with the NELA list of participating hospitals. This led to FOIs sent to 123 acute Trusts in England. Responses not received within 8 weeks were not included in the study. Questions were identified and wording agreed by the authors. Trusts were asked their current working structure and whether they have plans to change within the next five years. Organisational structures were categorised as A; Mixed general surgical take under a non-specific general surgery consultant, B; Daily allocation of acute admission to a general surgery subspecialty (Upper GI / Colorectal / Hepatobiliary), C; Dedicated Emergency General Surgery consultants / service during weekdays only (Monday to Thursday, or Monday to Friday), D; Dedicated Emergency General Surgery consultants / service weekdays and weekends, or E; Other. Results 101 out of 124 trusts responded within the 8-week timeframe. 3 trusts declined to supply information on organisational structure. The remaining reported organisational structures of A; n=36, B; n= 16, C; n=10, D; n=30, E; n=5. In total 41.24% of hospitals reported having an active EGS service in place. Mean bed numbers across different organisational types were Group A; 617.62, Group B; 867, Group C; 648, Group D; 559.5, Group E; 800.71. Mean admissions were Group A; 3983.08, Group B; 6088.29, Group C; 4432.14, Group D; 4123.52, Group E; 4578. Mean NELA cases were Group A; 134.29, Group B; 187, Group C; 164, Group D; 142.11, Group E; 187.17. Regarding number of consultants in place to run an EGS service group C reported a range of 2 to 14 consultants, with a mean of 6. Group D reported a range of 3 to 13 consultants, with a mean of 8.14. Regarding plans to move towards an EGS service group A reported Yes; 9 (25%), No; 22 (61.11%), TBD; 2 (5.56%), no answer given; 3 (8.33%). Group B reported Yes; 3 (18.75%), No; 10 (62.5%), TBD; 3 (18.75%). Conclusions The speciality of Emergency General Surgery (EGS) within the United Kingdom is expanding with annual EGS symposiums being held by professional bodies such as ASGBI, EGS trainee groups forming such as the Moynihan Academy, and large institutions altering their service specifically towards hiring consultants in EGS positions. This follows the Royal College's Acute and Emergency Care joint position statement, the consensus statement from ASGBI and the Getting It Right First Time (GIRFT) emergency surgery report which explicitly state that a dedicated surgical assessment unit, with senior surgeon directing patient throughput has been shown to reduce costs and increase effectiveness of a surgical department. This study shows that 41.24% of trusts in England deliver an EGS service but in heterogenous structured formats. What is clear is that a dedicated EGS service is becoming more popular, with 25% of group A services, and 18.75% of group B services reporting active plans in the next 5 years to create this service. This further impresses the need for categorisation of service provision types, and the sharing of information, to ensure that England does not end with a patchwork of service types confusing patients and rotating clinical practitioners alike.

Improving Patient Flow in the Surgical Assessment Unit by Facilitating Access to Computer Tomography Scanning.

Introduction Patient flow is "the ability of healthcare systems to manage patients effectively and with minimal delays as they move through stages of care". National Health Service (NHS) England has highlighted the importance of improving patient flow, and the many benefits to both staff and patients, including: "improved clinical outcome and experience of patients"; "eliminating waits and delays"; "saving time and effort by avoiding duplication of work"; "saving money"; and "improving the reputation of the NHS". Limited access to computerised tomography (CT) imaging for surgical patients can disrupt patient flow through delayed diagnosis, management, and discharge.The aims of this quality improvement project were to assess the effect of a dedicated Surgical Assessment Unit (SAU) radiologist on access to CT scanning and its impact on patient flow. The measured outcomes were time from admission to CT scanning, and length of admission. Method In June 2020, a radiology registrar was allocated to the SAU to vet and report CT imaging. CT requests from the SAU were identified from Picture Archiving and Communication System (PACS) in the first two weeks of June 2019 and 2020 during normal working hours (Monday to Friday, between 0900 and 1700). We performed a retrospective audit and compared data from 2019 and 2020. The measured primary outcome was time from admission to imaging. The secondary outcome was the length of admission. Results In the two-week period in June 2019, 25 patients requiring a CT scan presented to SAU during normal working hours. In 2020, this number increased to 40 patients. In 2019, 5 patients had a CT scan performed within four hours of admission (20%). In 2020, following the allocation of a radiologist to the SAU, 33 patients (82.5%) had their CT performed within four hours of admission.In 2019, one patient (4%) was discharged within six hours of admission. A further 16% had a length of admission between six and 12 hours. The majority of patients (80%) remained in the hospital for more than 12 hours. In 2020, 45% of patients were discharged within four hours following a CT scan. More than half of the patients (57.5%) were discharged within 12 hours. Conclusion The allocation of a radiologist in the SAU led to both areduction in time to perform CT scans and an increased number of patients being discharged within 12 hours. These results suggest that early access to imaging improves patient flow. Further research will help to establish whether the allocation of a radiologist in the SAU is a beneficial and cost-effective method of improving patient flow, and whether this may help reduce the current pressure on NHS services.

483 Surgical Virtual Clinic: A Safe and Effective Alternative to Acute Surgical Clinics for Semi-Urgent, Ambulatory Patients

Abstract Introduction Many ‘Hot Clinics’ deal with ambulatory patients only requiring semi-urgent investigation and treatment, potentially avoiding hospital admission. These clinics often use the same staff and resources being utilised for acute surgical admission and treatment. We present data showing that “Virtual Clinics” (VC) are safe alternatives to this system, improving patient service and relieving a significant burden on the acute surgical units. Method 78 patients who came through the established VC between 23/12/2020 and 19/01/2021 (4 weeks), were assessed for delays in scan date, call-backs, diagnosis, referral patterns, readmission rates and eventual outcomes for those who needed surgical interventions. Results 83% of patients had their scans within the set-out time of 72 hours. 89.7% of scans were reported on the same day. Only 18% of the patients had a surgical diagnosis. 51% had no diagnosis at all and were discharged safely from the clinic. 16.7% were still symptomatic at the time of the VC with 3.8% of these having a surgical pathology. 22% were referred to other specialities. 2 patients were referred to MDT. In total, 6 patients were re-admitted to the hospital (7.6%). 4 patients were listed for surgery following the VC. Conclusions The VC proves to be a safe and effective system for semi-urgent, ambulatory patients. Re-admission rates are low, justifying the discharge of these patients from the acute surgical assessment unit to a virtual follow up environment.

323 Post-Take Pause Quality Improvement Project

Abstract Aim To introduce a structured review of important clinical factors on the post-take surgical ward round for each patient, to reduce their risk of adverse events. Method In a surgical assessment unit of a district general hospital, QI methodology was used to gather baseline data from 31 post-take interactions; monitoring 13 clinical domains. Additionally, surveys were circulated among staff. Cycle two implemented the ‘Post-Take Pause’, a ten-point checklist requiring a consultant signature, with all medical staff receiving information about its use. Cycle three incorporated further involvement of the nursing and advanced nurse practitioner team. The final fourth cycle implemented a revised checklist based on feedback from users. Results Baseline data collection and surveys showed that a number of important clinical factors were not being routinely reviewed on the post-take surgical ward round. Areas of particular concern included: medicine reconciliation, venous-thromboembolism prophylaxis, and prescription chart review. Inadequate time for documentation was also highlighted. Cycle two and three reviewed 21 post-take interactions each and found completion of 33% and 66% respectively. Cycle four reviewed 18 interactions with 72% of checklists completed. Common themes identified through the Post-Take Pause included: anticoagulant and steroid use, missed thromboprophylaxis and regular medicines, hyperglycaemia, ECG review and escalation plans. Conclusions The Post-Take Pause ensures a consultant led systematic review of important clinical information in the post-take surgical ward round. Our results show that the involvement of the wider surgical team, alongside checklist edits based on feedback, significantly improved the compliance of the Post-Take Pause.

TH6.8 The Utility and Impact of Advanced Nurse Practitioners in Unplanned Surgical Admissions: A Review of the Literature

Abstract Aims Advanced Nurse Practitioners (ANP) are well established within acute medical and Critical Care environments. The evolution of surgical ANPs have tended towards preoperative roles, such as anaesthesia or scrub, with few clinical roles involving the assessment of acute patients or inpatient care. The Royal College of Surgeons of England have recently recognised, by professional membership, the roles of non-medical members of the surgical team, such as ANPs and physician associates. This review explores the areas of impact of ANPs on the emergency General Surgery service provision to help develop the role of the modern surgical ANP. Methods A scoping literature review was performed to identify themes of ANP function and outcome. Search terms such as “Advanced Nurse Practitioners”, “Surgical Assessment Units” and “outcomes” were combined with Boolean operators to query PubMed, BNI, CINAHL, Google Scholar and HMIC databases. Studies in the last decade were included. Results We identified and screened 54 unique articles. 40 articles were reviewed for eligibility and 21 were included in this review. A thematic analysis identified the impact of ANPs on the process of care (such as assessment and treatment waiting times and patient satisfaction) and outcomes of care (readmission rates, length of stay and cost-effectiveness). Conclusion Research into the impact of ANPs are largely focused on objective outcome measures and within non-surgical specialties. Whilst this review demonstrates the positive aspects of ANP care on emergency care, we identify a paucity of evidence on patient-focused outcomes and the impact of ANPs on the patient journey within surgery.

TH3.2 Audit of acute lower GI bleed admissions - outcomes and management

Abstract Background Lower GI bleeding (LGIB) is a common surgical emergency. The British Society of Gastroenterology (BSG) in 2019 developed a UK national guideline on the management of LGIB. Our aim is to audit the current practice and standards for patients admitted with LGIB. Methods This retrospective audit identified patients presenting to the Emergency department and Surgical assessment unit between September 2020 to February 2021 with LGIB. The shock index and Oakland score (OS) at first presentation were calculated. Results A total of 27 patients satisfied the inclusion criteria. Average age of patients was 64.7 years. Three patients had an OS of ≤8 with 1 patient being hospitalised. 21 patients had an OS of >8 and 7 out of the 21 patients were discharged instead. 14 patients (51.8%) were on anticoagulants/antiplatelets of which 1 was on dual antiplatelet therapy. 10 patients had their drugs suspended appropriately and 2 did not. Eight patients were referred for OP endoscopy. Conclusion We found that improvements can be made with respect to suspension of anticoagulant and antiplatelet drugs and duration to colonoscopy. A more pragmatic approach to both intervention and interval to endoscopy may have to be applied due to service constraints. A checklist has been developed based upon the guidelines to

SP4.2.1 Emergency management of lower GI bleeds: a full-cycle audit of practice at a district general hospital

Abstract Introduction Lower GI bleeds (LGIB) are a common cause of emergency surgical admission. National Guidelines on the management of LGIB were published by the British Society of Gastroenterologists (BSG) in 2019. The aim of our audit was to determine whether local practice of managing LGIB adhered to these guidelines. Method Our initial audit cycle retrospectively reviewed 47 patients with LGIB who had presented to our Hospital. Subsequently, a departmental teaching session was conducted and posters outlining BSG guidelines were placed on surgical wards and the surgical assessment unit. A re-audit of local practice was prospectively undertaken with 30 patients. Results In the initial audit cycle 37/47 (78.7%) patients had a major LGIB (Oakland score >8) where admission is advised. Of these, 6 (16%) were discharged on the same day. Of the 10/47 (21.3%) patients who had a minor LGIB, 6 (60%) were discharged on the same day. In the re-audit cycle, 29/30 (96.7%) patients had a major LGIB and 1/30 had a minor LGIB, none of these patients were discharged on the same day. The re-audit population had a higher rate of inpatient endoscopy, 66.7% vs 14.9%. 50% of unstable patients had a CT angiogram on admission in the re-audit vs 0% patients in the first cycle. Discussion Following education, compliance to BSG guidelines improved. Discharges in patients with major LGIB reduced to zero following this audit and more patients received appropriate inpatient investigations. Further work is required to see if change in local practice has an impact on clinical outcomes.

WE8.8 Analgesia prescribing in a Surgical Assessment Unit

Abstract Aim Efficient analgesia administration is paramount to delivering good patient care and is an important factor in the safe assessment of patients. The aim of this audit was to assess analgesia prescribing and administration in the local Surgical Assessment Unit (SAU) and compare it with the standard of care set out by the Royal College of Emergency Medicine guidelines. Methods A retrospective audit was performed. Paper and electronic notes, including electronic prescribing data via HEPMA and pain scores were analysed for all patients referred with abdominal pain to SAU by GP's between the 21st of October and the 30th of October 2021. Data was compared with the RCEM best practice guidelines. Results A total of 33 patients were included. 39% of patients had a documented first pain score within 15 minutes of arrival, with a median time of 20 minutes. Of all patients presenting with moderate to severe pain, none received analgesia within 20 minutes. Earliest analgesia administration for this group was 1 hour 42 minutes. Overall median time to first analgesia prescription was 2 hours and 4 minutes and median time to administration was 4 hours and 8 minutes. Conclusion Since the COVID pandemic, NHS hospital staff- and bed shortages have put increased pressure on the delivery of safe patient care. This audit has found significant delays in both prescribing and administering analgesia for patients presenting to SAU. An electronic prescribing protocol was developed to increase efficiency in prescribing and another audit will be conducted to assess impact.

TH5.14 Surgical Telephone Virtual Clinic: A Safe and Effective Alternative to Hot Clinics for Semi-Urgent, Ambulatory Patients

Abstract Introduction Many ‘Hot Clinics' deal with ambulatory patients only requiring semi-urgent investigation and treatment, potentially avoiding hospital admission. These clinics often use the same staff and resources being utilised for acute surgical admission and treatment. We present data showing that “Virtual Clinics” (VC) are safe alternatives to this system, improving patient service and relieving a significant burden on the acute surgical units. Method 78 patients who came through the established VC between 23/12/2020 and 19/01/2021 (4 weeks), were assessed for delays in scan date, call-backs, diagnosis, referral patterns, readmission rates and eventual outcomes for those who needed surgical interventions. Results 83% of patients had their scans within the set-out time of 72 hours. 89.7% of scans were reported on the same day. Only 18% of the patients had a surgical diagnosis. 51% had no diagnosis at all and were discharged safely from the clinic. 16.7% were still symptomatic at the time of the VC with 3.8% of these having a surgical pathology. 22% were referred to other specialities. 2 patients were referred to MDT. In total, 6 patients were re-admitted to the hospital (7.6%). 4 patients were listed for surgery following the VC. Conclusion The VC proves to be a safe and effective system for semi-urgent, ambulatory patients. Re-admission rates are low, justifying the discharge of these patients from the acute surgical assessment unit to a virtual follow up environment.

TH7.7 Pre-operative Coagulation Screening in General Surgery

Abstract Aim Routine preoperative coagulation screening is considered standard practice to predict peri-operative bleeding. However, according to British Society of Haematology, indiscriminate coagulation screening is not recommended as it may to inappropriate delay of surgery, lead to further unnecessary tests and is also associated with significant costs. Instead, they recommend detailed bleeding history, including family history and use of medications. Methodology A retrospective audit of 148 post-operative patients in Northwick Park Hospital admitted under the General Surgical who presented to Surgical Assessment Unit between 01.04.2021 to 14.05.2021 at the initial audit and between 20.09.2021 to 07.10.2021 at the re-audit. Results The initial audit was done over a 6 week period with 98 cases selected. 19% of them had appropriate requests with 81% of the tests done being inappropriate. There was significant improvement by the re-audit with appropriate requests increasing to 56% and inappropriate tests dropping at 44%. The criteria for appropriate were: a) Not requested as no significant medical history. b) Requested as clinically indicated. With each coagulation screening costing an average of £29.42, an overall estimate of £2971.42 was expended in inappropriate requests Conclusion All patients had relevant blood requests and PMH were documented but many inappropriate requests were made. It was recommended that instead of indiscriminate coagulation testing, a thorough history was advised to determine appropriate testing. There was a marked improvement at the re-audit with more appropriate requests being made. Recommendations

AB053. SOH22ABS048. Role of imaging in patient presented to acute surgical assessment unit (ASAU) with abdominal pain

Background: Acute surgical assessment unit (ASAU) provides an easy and fast access to the surgical patients. Early assessment and proper investigation of surgical patients lead to decrease burden on health service and timely management of deserved surgical patient. The aim of this study is to find out the amount of imaging performed as diagnostic work up with positive results for patient presented with abdominal pain in ASAU.

AB054. SOH22ABS055. Five minutes acute surgical assessment unit (ASAU) situation awareness for everyone (SAFE) huddle

Background: Situation awareness for everyone (SAFE) initiative was taken by Royal College of Physician Ireland (RCPI) to improve patient safety and to identify vulnerable situations. This helps to take appropriate action in timely manner to void near miss and improve patient’s outcome. The aim of this quality improvement project is to implement SAFE huddle and to assess outcome.

282 Audit for the Management of Acute Gallstone Disease

Abstract Aim The aim of this audit was to investigate how patients referred by the Emergency Department (ED) with biliary disease were managed. Also, to identify a cohort of patients which could be safely discharged from ED with an outpatient US and follow up with the Surgical Assessment Unit. Method Data was collected from 23/11/20 to 11/12/20. The inclusion criteria were patients referred by ED with abdominal pain and a diagnosis of biliary disease. Data collected included blood results, US results and if they underwent a laparoscopic cholecystectomy (LC). Results There were 22 patients identified; 5 had biliary colic, 4 had cholangitis and 13 had cholecystitis. The 5 patients with biliary colic had almost completely normal bloods on admission. While 16/17 patients with cholecystitis/cholangitis had elevated FBC, CRP or LFTs. US was performed on 3 patients with biliary colic within 3 days of ED attendance. US was performed on 16/17 patients with cholecystitis/cholangitis, mainly within 2 days. None of the patients with biliary colic received antibiotics and 2 had an inpatient LC. All patients with cholecystitis and cholangitis were admitted and treated with antibiotics. 1 patient with cholecystitis had a LC and 7 were on the waiting list. Conclusions This has shown that patients are being imaged with US efficiently and are treated appropriately with antibiotics. It has demonstrated that a blood test in ED is effective at differentiating between biliary colic and other diseases that require admission. However, improvements need to be made to increase access for patients to undergo timely LCs.