Surgical Assessment Unit Research Articles

370 Scrotal Ultrasound in Young Men with Acute Scrotal Pain: A Retrospective Consecutive Case Series Audit

Abstract Introduction Although not recommended by EAU guidelines, many men with acute scrotal pain undergo ultrasound (US) to screen for occult tumours. This has low diagnostic yield and must be weighed against the increased risks of coronavirus due to additional hospital attendances, inconvenience for the patient, and demand on NHS resources. We evaluated our case series to determine current practice and diagnostic yield. Method 141 consecutive cases of scrotal pain and/or swelling were identified from our Trust’s Surgical Assessment Unit (September-December 2020). Clinical diagnosis, and where performed, timing, indication and outcome of scrotal US was recorded. Results 109/141 patients underwent scrotal US; the only urgent clinical indications were suspected collection/abscess (5 cases) or testicular mass (4). Relative indications included uncertain diagnosis (27 cases), suspected missed testicular torsion (6) and suspected hernia (1). 66/109 US performed were for ‘soft’ indications, however one occult testicular tumour, one acute testicular torsion and two inguinal herniae were unexpectedly found. Conclusions Scrotal US changed immediate patient management in 1/109 cases (acute testicular torsion). Early outpatient US would be sufficient to diagnose occult testicular tumour, missed testicular torsions and groin herniae. There is too much reliance on US; more focus on history and examination is needed.

A Proposal of Revised Curriculum to Circumvent the Impact of COVID Restrictions on Final Year Medical Students

Medical education has been extraordinarily disrupted during the COVID-19 era worldwide. The pandemic limited routine ward or patient-based medical education. These limitations have resulted in new challenges for medical students, especially the final year students in completing their mandated curriculum. We are suggesting a revised curriculum for final year medical students, by following which we can address COVID restriction while making sure all competencies have been achieved by students. This revised curriculum centers around the usual placement of students in Surgical Assessment Unit (SAU), however all students will be posted in simulation wards/labs on their turn to enhance and consolidate their understanding and learning of common surgical cases in these wards, so that they can replicate these skills in SAU and wards on their turns. This article highlights how the proposed curriculum addresses the learning needs of final year medical students in their surgery rotation. The article will also summarize the critical appraisal process of our curriculum in the context of curriculum design theories. Finally, the article will highlight the quality assurance measures adhered to while developing the curriculum.

137 Simulated Surgical Assessment Unit – A Quality Improvement Project to Increase Medical Student Confidence In Assessment and Management of Acute Surgical Conditions Through High-Fidelity Simulation

The COVID-19 pandemic resulted in limited opportunities for medical students to assess patients in the Surgical Assessment Unit (SAU) at an acute teaching hospital. Inadequate exposure to acute surgical conditions affected student-reported confidence and preparedness for Objective Structured Clinical Examination (OSCE). We hypothesized that simulation-based teaching during the pandemic could supplement disrupted learning The aim of the study was to address the quality dimension of patient safety. This Quality Improvement Project (QIP) was designed to increase student confidence by 50% in the assessment and management of acute surgical conditions, and preparedness for OSCE.The educational intervention ‘Simulated SAU’, consisting of scenarios based on common acute surgical presentations, was co-designed with project champion, placement lead, teaching fellows and medical education department, utilizing transformational leadership. Model for improvement approach was utilized with Plan-Do-Study-Act (PDSA) cycles. During the first PDSA cycle, intervention was delivered over 3-hour sessions in March 2021 to 12 third-year medical students, through the use of simulated patients. The second cycle encompassed integration of learning points including amended scenario and debrief timings, and improved questionnaires, delivered in April 2021 to a further 11 third-year medical students. Students completed paired 14-item pre- and post-intervention paper questionnaires consisting of 5-point Likert scale questions on confidence and preparedness. The Wilcoxon signed-rank test was used for statistical analysis, with a p-value of <0.05 considered statistically significant.During the first cycle, student-reported median confidence in assessment increased by 50% (p = 0.01), and in management by 66.7% (p = 0.02). Students felt 50% more prepared for OSCE assessment (p = 0.02). During second cycle, median confidence in assessment increased by 100% (p = 0.003), in management by 100% (p = 0.004), and students felt 50% more prepared for OSCE assessment (p = 0.015). 100% of students felt simulated SAU is useful and future sessions would further enhance surgical learning.The QIP achieved its aim to increase student confidence with statistically significant differences, through a high-fidelity simulation intervention. Through QI methodology and leadership for improvement, this QIP has successfully bridged the educational gap resulting from the pandemic, with emphasis on delivering safe patient care. Next steps encompass integration of learning points over the following PDSA cycle, engagement of new staff and resource sharing for future implementation and sustainability. Simulated SAU intervention is low-cost, requires minimal staff and is simple to deliver, hence has the potential to become integrated within medical education across numerous educational settings and enhance patient safety.

P-EGS09 The Introduction of an Ambulatory Surgical Pathway

BackgroundSince the publication of the Emergency General Surgery Commissioning Guide by ASGBI in 2014, there has been a drive to develop ambulatory pathways for acute surgical patients, saving inpatient stays and reducing the risk of hospital-acquired infections. Many units, like ours, had a large workload increased by seeing next day returns as well as acute presentations. In October 2020 an Institute of Emergency General Surgery was formed who developed an ambulatory pathway to ameliorate some of these issues and provide a point of contact for primary care referrals, for one the busiest emergency general surgical takes in the UK.MethodsA retrospective analysis was undertaken to identify all acute referrals to general surgery over a 14-day period in February 2019 prior to (Pre-ASC) and 2021 after (Post-ASC) the introduction of an Ambulatory Surgical Clinic (ASC). All patient episodes were reviewed, and descriptive statistics on overall attendance to the surgical assessment unit (SAU), admissions to inpatient wards and referrals to ASC were analysed. Patients presenting to the acute urology take were used as a control to compare the number patients attending the surgical assessment unit both before and during the COVID-19 pandemic.Results830 patients presented over the 28-day study period (426 pre-ACS vs 404 post-ACS; 5% reduction), totalling 992 patient encounters including planned returns (525 vs 467; 11% reduction).After the introduction of the ASC total attendance to SAU was reduced by 42% (525 vs 306); next day return attendances were reduced by 87% (99 vs 13) and attendances from primary care were reduced by 68% (208 vs 67). The proportion of patients admitted was similar (46% vs 50%).146 patients attended the ASC, and 15 patients received telephone advice alone.The control group saw attendance increase by 25% (178 vs 223).ConclusionsThe results clearly show that the introduction of the ASC has decreased attendance to SAU, freeing clinicians to dedicate more time to those acutely unwell. The similar proportion of admissions after the introduction of the ASC suggests that the ambulatory pathway correctly identifies those who are well enough to be managed as outpatients. The increased attendance in the control group suggests that the data were not the results of a decrease in referrals due to COVID-19. The results shared here should encourage other large units to consider developing ambulatory pathways.

EP.FRI.271 The impact of Surgical Assessment Unit on emergency and ambulatory surgical care in a district general hospital

Abstract Aims There has been a paradigm shift in the delivery of emergency and ambulatory surgical care necessitated by paucity of beds, improved expedited diagnostics and delayed transit in Emergency departments. The objective of a surgical assessment unit (SAU) is to reduce the number of semi-urgent admissions, provide direct access to urgent surgical admissions bypassing the ED, expeditious assessment by senior clinicians and to reduce the number of OPD follow up. In our setting, the SAU came into existence on all 5 working days at 12-hour daily schedule and its impact was evaluated retrospectively. Methods Prospectively maintained data base over a 2-month period was examined. Pre and post SAU figures were compared to judge any quantitative improvement in surgical services. Results During the audit period of 2 months there were 156 emergency patients and 190 ward attenders for follow up care. Majority of these patients were assessed within 4 hours and discharged or ambulated. Numbers being admitted overnight purely to facilitate investigations showed a decrease of 44.6% post SAU establishment. There was a reduction in post discharge outpatients appointments when compared to a similar time period pre SAU (14% difference). Conclusion The SAU, although initially conceived and designed purely to cope with increased admissions and to minimise breaching of emergency department targets, has shown quantitative and qualitative improvement in emergency and ambulatory surgical care delivery.

SP10.1.4 COVID as a driver of innovation: getting the right patient to the right place at the right time. A novel Registrar-led approach to minimising unnecessary footfall in the Surgical Assessment Unit of a District General Hospital

Abstract Aim To give shielding Registrars opportunities to innovate and lead service development through telephone triage of Surgical Assessment Unit (SAU) referrals from General Practitioners and Nurse Practitioners. Prior to the COVID pandemic, referrals were taken by Nurse Coordinators. Increasing call volumes put pressure on the department and disrupted clinical duties. Furthermore, referrers often expressed difficulties in contacting SAU staff. Methods During the study, referral calls were diverted for triage by the hospital switchboard. Three outcomes were offered: Clinical advice, ‘Hot Clinic’ (HC) appointment or urgent SAU review. Prospective referral data (15/6-31/7/2020) and retrospective non-triage data (15/6-1/7/2019) were gathered. Triage effects were measured by outcome comparison with non-triage data and the associated financial implications calculated. Stakeholder feedback questionnaires were distributed. Results Non-triage data showed 56% of patients reviewed in SAU were sent home and 44% admitted, compared to 23.6% and 28.1% of referrals during the 2020 study period. Furthermore, 28.4% of admissions were avoided by triage. Only 3.1% of triaged patients presented to Emergency Department within 7 days of the triage conversation. Almost half of these had been reviewed in SAU following triage and discharged the same day. HC availability was limited during the triage study. In view of reduced admissions and overall cost savings of £8330.62/week, expanding these clinics may prove cost neutral. Triage was universally popular with stakeholders. Data will inform future development of Urgent and Emergency Care at our hospital. Conclusions Traditional ways of working should be challenged. Novel approaches can be cost effective & positively impact patient care.

SP3.1.10 Surgical Emergency Assessment Unit and Emergency Surgeon of the Week’ : A Paradigm shift to providing Emergency Surgical Care

Abstract Aims Ever increasing number of A&E attendance and admissions cause immense strain on hospital beds with drainage of our finite health resources. This prompted the need for implementation and review of alternative schemes: Surgical Emergency Assessment Unit (SEAU) and ‘Emergency Surgeon of the Week’ (ESW) and its impact on our depleted health system. Patients and Method Retrospective analysis of a prospectively collected data from SEAU activity logs, patient information center and friends and family questionnaire following implementation of SEAU (November 2014) and ESW (November 2017) in a large DGH.SEAU operates on a five day policy (Monday – Friday, 0800-2000) aided by dedicated imaging pathway and ESW works on a 1:5 (Monday – Thursday, 0800-1800) rota with full complement of the surgical team. Results SEAU has attended to 16057 patients (New 9811; Follow Up 6246) from November 2014-October 2019. Emergency general surgical admission pre and post SEAU implementation was 309* and 202*/month respectively, a drop of 35% with a further reduction after introduction of ESW by another 24% to 153*/month. Thus, a total reduction of emergency admission by almost 60%. Stay in SEAU was 4* hours and re-admission rate was 6%. SEAU received 98% friends and family recommendation to others. Conclusions A paradigm shift in providing emergency surgical care is required in the face of a strained health care system; the positive outcome achieved after implementation of SEAU and ESW could be the answer to relieving bed capacity and financial pressures, possibly a solution to providing high quality and safe patient care.

EP.FRI.949 “When it works, it works brilliantly…. on the days that it doesn’t work, it tends to just all kind of crumble” – a qualitative study of patient and staff experience of ambulatory care on the surgical assessment unit

Abstract Aims To explore patients’ experiences of being managed in an ambulatory manner and to explore medical staff’s experiences and attitudes of emergency ambulatory care. Methods Twenty patients and 12 members of staff (nurses, HCAs, junior doctors and consultants) underwent in-depth telephone (patients) and face-to-face (staff) interviews about their experience of emergency ambulatory care. The transcribed interviews underwent thematic analysis. Results Patients’ opinion on ambulatory care is influenced by factors including whether they felt that they were “ill enough” to need to stay in, a fear of staying overnight in hospital and how much they valued their individual home environment. Many thought that this sort of care had been introduced to “save the bed”. Staff were passionate about the service as a good option for many patients who would otherwise have hospital admissions. However, some thought it had been brought in to manage patients who could be managed in primary care. Some factors thought by doctors to influence their decision-making include their perception of the risk involved, previous negative experiences and external pressures such as theatre availability and bed status. There are varied views on whether the service should be more or less protocol-led. Many believe that it is “easier” for them to admit people than manage them in an ambulatory manner. Conclusions There is definitely scope to expand ambulatory care but patients may not engage with this if they feel ill enough to stay in. Decision-making in staff is influenced by a number of factors on an individual level.

EP.TH.507An Audit of Consent Documentation and Chaperone Use in Patients Presenting to Acute Settings with Breast Complaints

Abstract Aim To compare current practice of documenting consent and offering chaperones when performing breast examinations in the acute setting, with standards set by regulatory bodies (General Medical Council, Royal College of Emergency Medicine and Royal College of Surgeons). Method Data was collected retrospectively from all patients presenting with breast complaints to either the emergency department (ED) or the surgical assessment unit (SAU) over a 34-month period. From the clerk-in notes, the role (Dr/Nurse), grade (FY1 to consultant) and gender of the examiner was noted, as well as whether consent was documented and if a chaperone was offered. Results Of the 64 patients presenting in this time frame, consent was documented in 7 sets of notes (11%). Furthermore, 17 were offered a chaperone (27%), of which examiners correctly documented the name and role of the chaperone on 11 occasions. Results also demonstrated that ED trainees were most likely to offer a chaperone and GP trainees were the best at recording consent. It also revealed that although male examiners offered a chaperone 50% of the time compared to 6% of female examiners, women examiners were better at documenting consent when compared to their male counterparts. Conclusion The audit results indicate that there is significant room for improvement across all roles, grades and genders with regards to documentation of consent and the use of chaperones within the acute setting, in order to meet current standards of practice as set out by regulatory bodies.

EP.FRI.835 5 Years, 4 F1s, 3 Registrars, 2 Pandemic Waves, 1 VTE audit: Half a decade of VTE prophylaxis on a surgical ward

Abstract Aim Venous thromboembolism(VTE) is a preventable complication of hospital admission. This audit aims to compare VTE prophylaxis over 5 years in one surgical assessment unit and identify areas for improvement. Methods This was a snapshot, 5-cycle audit of the analysis of VTE risk, prescribing practice and prophylactic therapies offered at admission. We prospectively reviewed notes of patients admitted under general surgery over a snapshot period annually. Data was compared to figures collected over four previous years. Induction VTE prophylaxis teaching was introduced after the first cycle, HCA VTE champions were introduced after the second, digital reminders were introduced after the third, and monthly email reminders sent after the fourth cycle. Results VTE risk was documented for 92% of patients in 2017, 65% in 2018, 57% in 2019, 76% in 2020 and 53% in 2021. In the years 2017, 2018, 2019, 2020, 2021, Enoxaparin was prescribed for 96%, 68%, 75%, 55% and 73% of patients respectively. In 2017, 2018, 2019, 2020 and 2021, TED stockings were prescribed for 96%, 68%, 62%, 50% and 73% of patients respectively. Conclusions We utilised a multidisciplinary and digital approach against the issue of VTE prophylaxis on surgical wards. Despite best efforts, compliance was highly fluctuant with a drop during the first wave of the pandemic. This has demonstrated that with redistribution of regular nursing and medical staff, new patient filtering systems and increased healthcare pressures, previous mechanisms cannot be relied upon. We have began the process of electronic prescriptions with mandatory VTE prophylaxis checklists.

EP.FRI.464 Application of the Oakland score to a real world lower GI bleeding patient population

Abstract Aims Lower GI bleeding (LGIB) is a significant burden on healthcare resources with an estimated 21120 UK annual admissions. The Oakland score was developed in 2017 and allows patients to be triaged based on clinical and laboratory parameters to predict safe discharge; an Oakland score <8 predicts safe discharge with a 98.4% sensitivity. We aim to describe our experience at applying this scoring system to our practice. Methods This retrospective single centre study included 25 consecutive emergency LGIB referrals to a busy district general hospital. Oakland score was retrospectively calculated from case notes and clinical outcomes followed up. Results The average age of the patient group was 72.8 years, 56% were male. 64% of our patients were referred from ED with the remainder from GP. Mean Oakland score was 16.68. 40% of patients were on anti-platelets or a DOAC. The average length of stay was 2.56 days. 76% of these patients did not receive a blood transfusion and 73% did not undergo any imaging or endoscopy while an inpatient. Only 5 of the patients were sent home directly from the surgical assessment unit. Conclusions Our preliminary real world experience suggests that routine use of the Oakland score will allow for safe rationalisation of inpatient services. Further prospective data collection is required to validate this approach. Our data represents only patients admitted to hospital, therefore the low-scoring patient population is not represented; these patients will be included in prospective analysis.

EP.WE.485An Audit to Investigate the Incidence of Face-to-Face Patient Review by GPs Prior to Referral to Surgical Assessment Unit

Abstract Aims Since COVID-19, GP’s have been encouraged to do fewer face-to-face consultations to prevent unnecessary patient contact1. Anecdotally, this initially resulted in many patients being referred to SAU who had not been seen by a GP, and then being discharged back to the community the same day, causing potentially increased risk of contracting COVID-19 through hospital attendance. The aim of this audit was to investigate the incidence of patients referred to SAU not seen by a GP and discharged the same day. Methods GP referrals were identified over a 7 day period through the surgical take electronic system Aramis©. The case notes and GP documentation were reviewed to identify whether a face-to-face GP consultation occurred, and then whether the patient was admitted to SAU or discharged the same day. Results During a 7 day period, there were 24 (n = 24) GP referrals of which only 3 (12.5%) were not seen by the GP, all of whom were admitted for at least one night. However, of the patients referred and seen by GP, 7 (29%) were discharged the same day. Conclusions This demonstrates that during this 7-day period, there was no incidence of inappropriate GP referral to SAU of patients not seen by a GP, and the majority of GP referrals warranted admission. This suggests that in most cases, GPs are avoiding unnecessary emergency surgical referrals and attempt to review patients face-to-face prior to referral, thus reducing patient risk of contact with COVID-19 in the hospital setting.

EP.TH.289Diagnosis of the aetiology of acute pancreatitis at a district Hospital: A retrospective audit

Abstract Introduction The correct diagnosis of acute pancreatitis should be made in all patients within 48 hours of admission. According to recently published NICE (NG 147) guidelines for diagnosis of aetiology of acute pancreatitis should be determined in at least 80% of cases and no more than 20% should be classified as idiopathic. We aim to overview our current practice compared to guidelines. Early identification of aetiology is essential. Materials and Methods Patients diagnosed to have pancreatitis presenting to surgical assessment unit from March 1st 2019 to December 31st 2019. Sample size audited 291. The diagnosis of acute pancreatitis is made with a combination of history, physical examination and laboratory evaluation. Further investigations were done for the ethology. These patients were identified from their discharge information. They had raised amylase along with history suggestive of pancreatitis and were analysed retrospectively. Results Of all the pancreatitis patients admitted in SAU, 88 (30%) were due to biliary, 40 (16%) alcohol related, 20 (7%) other causes whereas 134 (46%) were classified as idiopathic. 3 patients self-discharged. Conclusion In our trust it seems that aetiology of acute pancreatitis is not adequately investigated. Most of other blood investigations were not performed in index admission and relevant drug history was not elicited. This failure of non-identification of gallstones could be attributed to operator dependant and they didn’t have second USS as advised. We formulated an action plan with detailed history with adequate step wise investigations which will benefit the patients.

SP3.1.9 Building the ‘LIEGS’ way – The development and delivery of ambulatory surgical services in the busiest acute surgical unit in the UK

Abstract Background Managing unplanned surgical care presents enormous challenges to trusts and continues to be resource intensive. Significant patient numbers can be managed in novel ways preventing admission with effective triage to alternative flow streams using outpatient/ambulatory models. Leeds Institute of Emergency General Surgery (LIEGS) reports its early experience. Methods Patients requiring assessment or admission from primary care are triaged directly by a consultant. GP’s are offered advice or patients are directed to appropriate assessment/triage pathways. A number of alternative pathways exist depending on pathology and patient demographics. Prospective data for all patients referred are captured and retrospective analysis of outcomes collected. We report our experience from October-November 2020. Results Consultant triage and early senior decision-making has streamlined patient pathways and flow. 51%(237) of all GP referrals(465) were assessed primarily in ASC, 8%(36) required advice only and 10%(44) were directed to other specialities. 30%(139) were seen on the Surgical Assessment Unit ward representing a reduction of 70% compared to the previous year. Outcomes from those patients seen in ASC were discharge after imaging (87,18.7%), discharge without imaging (74,15.9%), hospital admission (65,14%), acute operation (63,13.5%), referral to other specialty (64,13.8%) and Rapid Access Theatre for day case operation (32,6.9%). Conclusion 71.7% of all acute surgery primary care referrals were managed on in an ambulatory fashion providing an invaluable resource. Early senior decision making, a one-stop clinic for investigations and day case Rapid Access Theatre (RAT) lists can significantly improve the patient pathways and experience.

1651 Improving Surgical Admission Clerking in A Major Trauma Centre – The Role of a Standardised Clerking Proforma

Abstract Introduction High quality medical records are integral to Good Medical Practice in the UK, for provision of good patient care. This study assesses the effectiveness of a structured Surgical Assessment Proforma in improving documentation, within the Surgical Assessment Unit (SAU) of a major trauma centre. Method A four-phase prospective study was undertaken – using PDSA methodology. This included: initial clinician survey and proforma development, audit, re-audit post-implementation, and final user survey. Evaluation and proforma design utilised standards from the RCS(Eng) and the PRSB. Notes of all patients admitted to the SAU, over two separate one-week periods, were assessed for completeness of documentation. Statistical analysis employed T-Test, with a P value of < 0.05 considered significant. The study was considered service evaluation, and therefore exempt from ethical approval. Results Pre-Proforma Survey 100% of respondents felt a proforma would be beneficial. 77% believed key elements of clerking were missed within the previous system. Cycle 1 (n = 62) Of note, assessment categories lacking information were: Responsible Consultant, Medication History, Allergy Status and Differential Diagnosis. Cycle 2 (n = 119) Of 45 assessment criteria: 38 improved (23 significantly (P < 0.05)), 2 showed no change, 5 were reduced (2 significantly (P < 0.05)). Documentation rates in nine categories improved by over 50%. Post-Proforma Survey 73% of doctors and 86% of allied health professionals (AHPs) agreed documentation improved with proforma use. 66% of clinicians agreed proformas reduced omission of essential information and provided safe clerking guidance for doctors. 100% of AHPs agreed the proforma improved handover. Conclusions In a major trauma centre SAU, standardised proforma use improves completeness of clerking.

884 Improving the Analgesia Prescribing Compliance to NICE Guidelines (NG118) In Suspected Renal Colic Patients Using a Proforma

Abstract Aim To improve analgesia prescribing for patients admitted with suspected renal colic in line with NICE guidelines (NG118) in an acute district general hospital using a proforma. Method In the first cycle, a retrospective review of 16 patients who presented with renal colic to the emergency department or surgical assessment unit was performed and the analgesia prescribing was recorded. A unique analgesia prescribing proforma was then developed using NICE guidelines (NG118) including the use of NSAIDS as first-line when there are no contra-indications, intravenous paracetamol, opioid analgesics and omitting antispasmodics. Following implementation of the proforma, a prospective review of 18 patients were included in the second cycle and the prescribing compliance were compared. Results Study included 34 patients who presented with suspected renal colic over a 3-month period. In the first cycle, 19% of patients had appropriate analgesia prescribed which were compliant with NICE guidelines. In cycle 2, 89% of patients had appropriate analgesia prescribed. In particular, the inappropriate prescription of antispasmodics has improved significantly (38 % in cycle 1 vs 0 % in cycle 2). Conclusions A proforma can serve as a useful ‘checklist’ for analgesia prescribing and improve the symptomatic relief for patients presenting with suspected renal colic in line with NICE quality standards.

1315 Improving Efficiency of I&D of Abscesses Pathway

Abstract Background It is not always possible for patients with abscesses to undergo I&D under GA on day of attendance the majority of patients wait for a space to become available on CEPOD or asked to return the next day. In 2017 an abscess pathway was introduced in TWH to help streamline these patients. This was audited and found to improve wait times from 8hr23mins to 3hrs 59mins, with 78% of patient having their operation in < 6hrs. Method Retrospective analysis of 3 months trial of the abscess pathway. (August - October 2019). Patients were identified by searching the Theatre Man theatre database for patients with codes relating to incision and drainage of abscess under the care of the Department of General Surgery. Data was collected on time referred to surgeons, time seen by surgeons, decision to admit/or ask to return and time sent for theatres. Additional information was collected on severity of symptoms and overnight stay in hospital Results Of those managed on the abscess pathway:78% received their surgery within 6 hours of arrival (25/32) - the other 7 patients had their operations later than 6 hours due to long CEPOD lists and multiple urgent operations at the same time. Average wait time from arrival in surgical assessment unit is to theatre is 4 hours 43 minutes. 32 patients were managed on the pathway, 29 had same day discharge. Two patients stayed overnight due to late time of operation (10 pm) and 1 patient was pyrexial post op

417 Initial Choice of Imaging Investigation for Patients Presenting with Acute Pancreatitis: Should MRCP Be First Line in Selected Patients?

Abstract Introduction Current guidelines for acute pancreatitis advocate abdominal ultrasound (AUS) as the first-line imaging investigation to identify if gallstones are the cause of pancreatitis. However, many patients have a history of cholecystectomy or present with known gallstones and deranged liver function tests (LFTs). In these patients, magnetic resonance cholangiopancreatography (MRCP) is indicated due to its higher sensitivity and specificity for detecting choledocholithiasis. Method This retrospective audit reviewed all consecutive patients who presented to the surgical assessment unit with acute pancreatitis over one month. Their past surgical history, bloods and imaging were reviewed. Results Of the 30 patients, seventeen (57%) had no previous cholecystectomy or known gallstones, nine (30%) had previous cholecystectomy and eight (27%) had known gallstones, seven (88%) of which presented with deranged LFTs. Of the seventeen patients who should have had AUS first (n = 17), thirteen (76%) had AUS first, none had MRCP first and four (24%) had computerised tomography (CT) first. Of the patients in whom MRCP was indicated first-line (n = 13), seven (54%) had AUS first, none had MRCP first, four (31%) had CT first and two (15%) went straight to endoscopic retrograde cholangiopancreatography having had recent outpatient MRCPs. In the seven patients in whom MRCP was indicated but AUS was performed first, six (86%) underwent subsequent MRCP. Conclusions MRCP should be considered the first line imaging investigation for patients presenting with acute pancreatitis and a history of cholecystectomy or known gallstones with deranged LFTs, as AUS rarely prevents the need for subsequent MRCP.

1050 An Audit of the Management of Acute Epididymo-orchitis

Abstract Aim To evaluate the management of patients referred to our Surgical Assessment Unit presenting with acute epididymo-orchitis. Concordance with local antibiotic guidance, the use of ultrasound scanning, and microbiological testing were all assessed over a one-year period. Method All adult patients presenting with acute epididymo-orchitis in 2019 were identified retrospectively using ICD-10 codes and the choice of antibiotic used was compared to our own local guidance. The use of ultrasound scanning was recorded and whether this led to a change in diagnosis or management. Use of microbiological investigations including urine microscopy & culture and sexual health screening were assessed. Results After exclusion criteria were applied 64 cases were identified with an average age of 55 (16-88). Concordance with local antibiotic guidance was low with 3/64 patients receiving antibiotics in-line with local guidance. This was predominantly due to the frequent use of Ciprofloxacin (49/64) which is not advised locally, however is in-keeping with guidance from organisations such as EAU/BASHH. Ultrasound was used acutely in 46/64 patients with 28/46 showing evidence of epididymo-orchitis, 15/46 were normal and 1/46 confirmed an abscess which required surgical drainage. All normal scans were still treated with antibiotics based on clinical findings. 25/64 had a urine sample sent for MC&S and uptake of sexual health screening was low. Conclusions Urologists should be aware of differences between local prescribing policy and broader guidance from relevant organisations. Epididymo-orchitis remains a clinical diagnosis and ultrasound should be reserved acutely for diagnostic uncertainty, unwell patients, or failure to improve.

Impact of Acute Surgical Assessment Unit Dedicated Ultrasound Access at a Tertiary Care Hospital.

BackgroundDelayed diagnosis, unnecessary hospital admissions and extended length of stay are the problems associated with inappropriate access to radiological investigations. The acute surgical assessment unit (ASAU) in Limerick has two dedicated ultrasound scan (USS) slots daily to overcome this problem. The aim of the current study was to investigate the clinical impact on patient care and the cost-effectiveness of such an ASAU USS access.MethodsA retrospective review of all patients who underwent USS investigation in the ASAU between May and September 2017 was conducted. Demographic, referral source, presenting complaint, and clinical outcome data were obtained from the ASAU Log. USS data was obtained from the National Integrated Medical System (NIMIS). The Integrated Patient Management System (IPMS) and Therefore Case Manager, Therefore 2014(12.0.2) was utilized to check for any discharged ASAU patient re-presenting to the emergency department (ED) within 30 days. ResultsA total of 102 patients underwent USS investigation during the study period. The most common presenting complaint was epigastric or right upper quadrant pain (55.8%). Eighty-six patients underwent USS on the same day and the majority (51%) were discharged home with appropriate outpatient follow-up. Approximately 26,000 Euros were saved over four months. Post-discharge ED visits in the ASAU discharged group was zero in the 30 days. ConclusionThe ASAU USS dedicated slots in University Hospital Limerick has had a significant positive impact on patient diagnostics, surgical admissions rates and streamlining resource allocation. Having dedicated slots for radiological investigations in the ASAU should become standard of care across all healthcare jurisdictions.