UK Tertiary Hospital Research Articles

QOL-19. RETURNING TO WORK AFTER A BRAIN TUMOUR – “I THOUGHT I WOULD BE BACK AT WORK THE NEXT WEEK, HOW WRONG I WAS!”

Abstract BACKGROUND Returning to work is important for patients' and their families’ well-being, financial circumstances and quality of life. Side-effects of brain tumour (BT) treatment or clinical deterioration from BT progression often causes temporary or permanent inability to work. Aim: To explore the occupational expectations, experiences and satisfaction of BT patients (and their caregivers) following diagnosis/treatment. METHODS Qualitative semi-structured interviews were conducted with adults diagnosed with a primary BT, in employment/self-employed before diagnosis, currently in follow-up care; and their caregivers. Purposive sampling ensured a mixed BT sample. Participants were recruited from two UK tertiary referral hospitals. Data collection and thematic analysis are ongoing and will be completed by August 2022. RESULTS To date, 17 interviews (13 patient/4 caregiver) have taken place (59% female, aged 26-73,M= 43). Early findings: 1) Managing expectations: Patients underestimated the impact of surgery and how long it would take to return to work (if they had). Many would have liked more information prior to treatment about potential side-effects (e.g., extreme fatigue). 2) Prior financial support: Most patients suffered financially, often resulting in returning to work before they felt ready. Patients wanted more information prior to treatment about financial support. 3) Ongoing communication: Employers who were emotionally and practically supportive throughout the BT trajectory were highly valued. Some interviewees believed their employers needed to receive better education about BTs. 4) Flexible working: Patients returning to work with enhanced employer support (e.g., reduced hours, working from home and lighter duties) were more satisfied. 5) Better caregiver support: Many caregivers were unsupported by their employers to take carer leave, some worked more to support the family financially. CONCLUSIONS Preliminary findings offer novel data in an under-researched area. More knowledge around the experiences, barriers and facilitators influencing patients’ return to work will allow the planning of tailored occupational support and resources.

The neutrophil-to-lymphocyte ratio: A low-cost antenatal indicator of placental chorioamnionitis in women who deliver preterm without clinical signs and symptoms of infection

Chorioamnionitis is present in up to 70% of spontaneous preterm births and is associated with poor maternal, fetal and neonatal outcomes. ObjectiveTo explore the relationship between the neutrophil-to-lymphocyte ratio and histological chorioamnionitis in women who delivered preterm with no clinical signs or symptoms of infection. Study designThis was a retrospective analysis of a cohort of women who delivered spontaneously between 16 and 36+6 weeks at a tertiary UK hospital. Only women with placental histology and no signs of clinical infection were included. The neutrophil-to-lymphocyte ratio was calculated from a full blood count sample taken routinely within 24 h of delivery. The neutrophil-to-lymphocyte ratio was also calculated from first trimester booking bloods (<13 + 6 weeks) in a subgroup. Placental histopathology was categorised as either inflammatory (i.e. histologic chorioamnionitis, with or without evidence of fetal inflammatory response) or non-inflammatory (vascular pathology or a normal placenta). Results169 women had available placental pathology and were included in the analysis. 70 % (118/169) had confirmed placental inflammation. The mean neutrophil-to-lymphocyte ratio was significantly raised in this group compared to those with normal (n = 24) or vascular (n = 27) pathology (inflammatory neutrophil-to-lymphocyte ratio 9.81 vs non-inflammatory neutrophil-to-lymphocyte ratio 6.53, p = 0.002.The delivery neutrophil-to-lymphocyte ratio had an area under the receiver operating characteristic curve of 0.69 (0.60 to 0.78) for predicting placental inflammation. A raised neutrophil-to-lymphocyte ratio (>6) was associated with an odds ratio of 5.2 (95 % CI 2.55 to 10.56) for histological chorioamnionitis, with a sensitivity of 80 % and negative predictive value of 86 %. A higher cut-off of 9 had a negative predictive value of 79 % for fetal inflammatory response. ConclusionsA raised neutrophil-to-lymphocyte ratio is associated with a 5-fold increased risk of histological chorioamnionitis in women who delivered early without signs or symptoms of infection. It was also raised at the time of preterm labour compared to the first trimester. A full blood count is an almost universal investigation in women admitted in preterm labour, often repeated, making this inexpensive and non-invasive ratio a useful additional antenatal biomarker in women admitted in spontaneous preterm labour at risk of subclinical chorioamnionitis and its associated poor outcomes.

Left ventricular dysfunction, heart failure, and mortality risk factors in de novo pacemaker recipients and those requiring pacemaker generator replacement

Abstract Background Pacing the right ventricle (RV) can lead to adverse remodelling of the left ventricle (LV), LV dysfunction, increased risk of heart failure hospitalisation (HFH) and mortality. Despite RV pacing avoidance programming becoming commonplace, pacemaker patients remain at risk of pacing-induced cardiomyopathy. New pacing strategies and cardiac resynchronisation therapy are available therapeutic options, but it is unclear which patients should be targeted, and when. Purpose This study examined the effects of RV pacing on LV function, the risk of heart failure requiring hospitalisation and all-cause mortality in patients during the first 12 months of pacemaker therapy, compared to those at pacemaker generator replacement (PGR). Methods Data were obtained from a cohort of patients who underwent de novo pacemaker implantation between 2014 and 2017, and patients requiring PGR between 2008 and 2011 at a single tertiary UK hospital, with follow-up from 12 months. Clinical, echocardiographic, and pacemaker variables, medication, and past medical history data were collected. Predictors of a combined endpoint of all-cause mortality or HFH were assessed using cox-regression analysis, with predictors of impaired LV function analysed using multivariable regression analysis. Results 514 newly implanted (NI) patients (mean age, 75 years; 66% male) were recruited, and 491 patients (mean age, 76 years; 56% male) requiring PGR. After a mean follow up of 887 days, 79 NI patients (16%) were deceased (n=27) or had been hospitalised for HF (n=52), whereas after a mean follow up of 668 days, 56 patients after PGR (12%) were deceased (n=34) or had been hospitalised (n=22) for HF. After 12 months of pacemaker therapy, 182 (35%) NI patients had a LV ejection fraction (LVEF) &amp;lt;50%, which had a higher incidence at PGR of 197 (40%). Age was the only significant predictor of mortality or HFH for both NI and PGR (hazard ratio (HR), 1.068; 95% confidence interval (CI), 1.039 to 1.098; p&amp;lt;0.001 vs 1.035; 95% CI, 1.007 to 1.064; p=0.014), respectively). Univariate analysis revealed baseline LVEF (2.439; 95 percent CI, 1.279 to 4.659; p=0.007), RV pacing burden, medication and blood chemistry were significant predictors of the combined outcome at PGR but not at NI (Table 2). Multivariable analysis of predictors of LV impairment (&amp;lt;50% LVEF) showed history of MI (odds ratio (OR), 0.47; 95% CI, 0.29 to 0.78; p=0.003), RV pacing burden (1.01; 95% CI, 1.01 to 1.02; p&amp;lt;0.001) and creatinine (1.06; 95% CI, 1.02 to 1.10; p=0.004) were independently associated in both cohorts. Conclusions Our data suggest that there remains a similar subgroup of people from initial implantation to PGR at risk of LV impairment that might benefit from medication optimisation or novel pacing strategies. Further research is required to better identifying these people to direct more complex therapies to those with the most to gain. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The research is supported by a National Institute for Health Research (NIHR) clinician scientist fellowship (NIHRCS-2012-032). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. This research was supported by the NIHR Leeds Clinical Research Facility.

Endonasal endoscopic management of spontaneous cerebrospinal fluid rhinorrhoea: The Birmingham UK experience.

Spontaneous cerebrospinal fluid (CSF) leaks (SCSFL) occur in the absence of trauma, surgery, or underlying intracranial pathology. They represent a significant healthcare burden on patients with complications such as meningitis. We present our experience of SCSFL repair via the endonasal endoscopic approach. All patients who underwent CSF fistula repair at a tertiary UK hospital, between 1st January 2012 to 31st December 2019, were identified and had their case notes analyzed retrospectively. There were 33 patients included consisting of 27 (81.8%) females, with age range from 31 to 81 years (mean 55.2). Mean body mass index (BMI) was 35.2kg/m2 , with 32 (97.0%) patients overweight (BMI >25). All patients presented with intermittent watery rhinorrhoea and had a positive biochemical analysis. Computed tomography (CT) and/or magnetic resonance imaging (MRI) identified leak sites in 29 patients (87.9%). The most common intraoperative defect site was the cribriform plate (42.4%). A variety of closing techniques were used including onlay grafts (72.7%), tissue glue (87.9%), nasoseptal flaps (63.6%), mucosal free grafts (21.2%), fat grafts (21.2%), and additional support materials (87.9%). Nasal packing was used in all patients. The average length of stay was 1.6 days. Postoperative complications occurred in two patients (6.1%) (meningitis, epistaxis). Overall, there was a successful primary repair in 32 (97.0%) patients with most cases employing a multilayered reconstruction method (78.8%). Our results demonstrate excellent success rates with the endoscopic endonasal approach to SCSFL. This adds to the literature by demonstrating a detailed analysis of the experience in SCSFL management in one of the largest UK centres.

Suboptimal CT imaging due to contrast medium allergy: A UK tertiary hospital experience

Suboptimal CT imaging due to contrast medium allergy: A UK tertiary hospital experience

Functional Laryngeal Assessment in Patients with Tracheostomy Following COVID-19 a Prospective Cohort Study

To explore laryngeal function of tracheostomised patients with COVID-19 in the acute phase, to identify ways teams may facilitate and expedite tracheostomy weaning and rehabilitation of upper airway function. Consecutive tracheostomised patients underwent laryngeal examination during mechanical ventilation weaning. Primary outcomes included prevalence of upper aerodigestive oedema and airway protection during swallow, tracheostomy duration, ICU frailty scores, and oral intake type. Analyses included bivariate associations and exploratory multivariable regressions. 48 consecutive patients who underwent tracheostomy insertion as part of their respiratory wean following invasive ventilation in a single UK tertiary hospital were included. 21 (43.8%) had impaired airway protection on swallow (PAS ≥ 3) with 32 (66.7%) having marked airway oedema in at least one laryngeal area. Impaired airway protection was associated with longer total artificial airway duration (p = 0.008), longer tracheostomy tube duration (p = 0.007), multiple intubations (p = 0.006) and was associated with persistent ICU acquired weakness at ICU discharge (p = 0.03). Impaired airway protection was also an independent predictor for longer tracheostomy tube duration (p = 0.02, Beta 0.38, 95% CI 2.36 to 27.16). The majority of our study patients presented with complex laryngeal findings which were associated with impaired airway protection. We suggest a proactive standardized scoring and review protocol to manage this complex group of patients in order to maximize health outcomes and ICU resources. Early laryngeal assessment may facilitate weaning from invasive mechanical ventilation and liberation from tracheostomy, as well as practical and objective risk stratification for patients regarding decannulation and feeding.

Palliative care virtual ward: early evaluation of a novel model of care to support patients with complex symptom management known to a UK tertiary hospital specialist palliative care team

Palliative care virtual ward: early evaluation of a novel model of care to support patients with complex symptom management known to a UK tertiary hospital specialist palliative care team

OTHR-12. Incidentalomas; should benign, indeterminate MRI findings be discussed at the paediatric neuro-oncology MDT

BACKGROUND: In 2020, 503 patients were discussed at the weekly neuro-oncology MDT meeting, at a UK tertiary paediatric hospital. This was a 50% increase from 2016. Anecdotally, an increased number of non-tumours were being discussed. OBJECTIVES: To determine whether Paediatric Neuro-oncology MDT is consistent with follow up of benign, incidental findings on MRI scan and whether these lesions become significant.METHODS: MDT discussion notes reviewed for all incidental and benign MRI head findings between 05/09/18 and 02/09/20.RESULTS: 59 MRI head lesions, that were deemed to be both incidental and benign were discussed at the MDT. 44% of referrals were from the local hospital; this may be due to availability of the MDT or complexity of the patient cohort. Findings discussed included pineal cysts (24), arachnoid cysts (3), epidermoid cysts (1), pituitary lesions (4) and other indeterminate lesions or signal change (27). The majority of children received serial MRI imaging after MDT. There were large inconsistencies in the follow-up interval recommended, even within similar pathologies. For example, pineal cysts follow up ranged from no repeat imaging to multiple repeat scans with 6 and 12 month intervals. ‘Complex’ cysts were more likely to receive follow up but there is little consensus between radiologists about criteria for a ‘complex cyst’. None of the lesions reviewed changed significantly over time. Perhaps most strikingly, only 2/27 of the ‘indeterminate lesions’ have been discharged from the MDT. CONCLUSIONS: As clinical reasoning is seldom recorded in reports or MDT discussion notes the reasons for different surveillance recommendations is difficult to ascertain retrospectively. However, as MRI scans become more readily available incidental and being findings will increase, potentially putting great pressure on an already stretched service. Serial MRI imaging also creates unnecessary anxiety for both the child and their family.

P05 The impact of COVID-19 on antifungal stewardship in a UK tertiary teaching hospital: a review of prescribing practices and therapeutic drug monitoring of posaconazole

BackgroundPosaconazole is a triazole antifungal licensed for the prevention of invasive fungal infections (IFI) in haemato-oncology patients and treatment of IFI where first-line therapy has failed. In January 2020 COVID-19 hit the UK, with many NHS services reduced to meet the unprecedented challenges of the pandemic. We audited prescriptions and therapeutic drug monitoring (TDM) of posaconazole and compared the results with an audit conducted pre-COVID-19 to assess the impact of the pandemic on antifungal stewardship (AFS).MethodsInpatients prescribed posaconazole over two 3 month periods (1 October to 31 December 2019 and 2020) at Addenbrooke's Hospital, Cambridge, were identified using an electronic computer system and their records reviewed for demographic, diagnostic and therapeutic data. Posaconazole levels were performed at the national Mycology Reference Laboratory, Bristol, using guide levels of 0.7–3.75 mg/L (prophylaxis) and 1–3.75 mg/L (treatment). The first pre-dose level for each patient was used in analyses. Audit standards included (i) all inpatients on posaconazole to have an indication in local guidelines; (ii) to have the correct loading dose prescribed; (iii) to have a pre-dose level taken (iv) at the correct time (i.e. between Day 3–8) after commencing therapy or a dose change; (v) to have a turnaround time of ≤5 days; and (vi) to stop posaconazole appropriately.ResultsForty-two 42 inpatients received posaconazole in 2020 (49, 2019). In total, 39/42 (93%) patients had an appropriate indication [46/49, (94%), 2019]: 38/40 (95%) for prophylaxis [45/45, (100%) 2019]; 1/2 (50%) for treatment [1/1, (100%) 2019]. In 2020, 34/42 (81%) of patients received the correct loading dose [41/46 (89%), 2019). TDM was performed on 33/42 (79%) patients [46/46 (100%), 2019], 18/42 (43%) 3–8 days after starting [25/46 (54%), 2019] and 3/13 (23%) after a dose change [9/10 (90%), 2019]; 32/33 (97%) of TDM results were reported in ≤5 days [32/46 (70%), 2019]. Posaconazole was stopped in 24/26 (92%) patients who were no longer receiving immunosuppression and/or neutropenia had resolved [23/23 (100%), 2019].ConclusionsDespite the pressures of COVID-19, there were good standards of care with only slight reductions in compliance, with the exception of TDM. This may have reflected the change from face-to-face to virtual meetings with haemato-oncology, as well as representing issues of staff shortages and changes in hospital priorities. Such data have highlighted the usefulness of technology to facilitate AFS, e.g. electronic prescribing order sets, which would provide us with quality assurance in a system that will be facing ongoing pressures from the pandemic for years to come.

The prevalence of hyperprolactinaemia in subfertile ovulatory women and its impact on fertility treatment outcome

Subtle hyperprolactinaemia is not an uncommon finding in ovulatory subfertile women. The objective of this study is to evaluate the prevalence of hyperprolactinaemia in subfertile ovulatory and oligo-anovulatory women, and to determine if hyperprolactinaemia influences fertility treatment outcome. All women (n = 1010) who attended the fertility clinic of a UK tertiary hospital during 2015–2019 were included. Out of 804 eligible women analysed, 575 women (71.5%) were ovulatory and 229 (28.5%) were oligo-anovulatory. Prevalence of hyperprolactinaemia was higher in the ovulatory group than in the oligo-anovulatory group (26.8% vs. 14.4%; OR: 2.2; 95% confidence interval (CI): 1.4–3.2). On sub-group analysis, the prevalence of mild, moderate and severe hyperprolactinaemia was 23.0%, 3.7% and 0.2% in ovulatory women and 11.8%, 1.7% and 0.9% in oligo-anovulatory women. Mild hyperprolactinaemia was found to be more prevalent in the ovulatory group (OR: 2.2; 95%CI: 1.4–3.5). Ongoing pregnancy/livebirth rates were similar between hyperprolactinaemic and normoprolactinaemic women (42.8% vs. 46.7%). Hyperprolactinaemia did not have an impact on ongoing pregnancy/livebirth rates in both ovulatory and oligo-anovulatory women (OR:0.8; 95%CI: 0.5–1.1; OR: 1.2; 95%CI: 0.6–2.5, respectively). Hyperprolactinaemia is prevalent among ovulatory women, although most had mildly raised clinically insignificant levels. Elevated prolactin levels in ovulatory women do not seem to impact on pregnancy outcome. Impact Statement What is already known on this subject? Prolactin has been linked to ovulation and fertility. Prolactin testing is not generally recommended for subfertile women with regular menstrual cycles, which is a surrogate marker of ovulation. However, some clinicians, particularly in the general practice, still perform prolactin test as part of baseline endocrine profile. What do the results of this study add? Prevalence of hyperprolactinaemia in subfertile ovulatory women was 26.8% (154/575), of which 86% (132/154) were mild. Further, the livebirth/ongoing pregnancy rates were similar between hyperprolactinaemic and normoprolactinaemic women. Prolactin being a sensitive hormone, responsive to even minimal stress and its high levels not influencing clinical pregnancy outcome, prolactin measurement is not needed in women having regular menstrual cycles. What are the implications of these findings for clinical practice and/or further research? Hyperprolactinaemia was not uncommon in ovulatory women, although most had mildly elevated levels. Hyperprolactinaemia did not have any impact on fertility treatment outcome. Serum prolactin should not be tested in ovulating women, as mild elevations are commonly present and have no clinical significance.

Adopting low dose CT in evaluating renal calculi-progress from 2008-18 in a large UK tertiary hospital

Background: Computed tomography (CT) of the urinary tract is a commonly performed investigation and it is crucial to adhere to low dose protocols to avoid unnecessary radiation burden. Aims: To review the adoption of low-dose techniques over time, defined as a dose length product (DLP) &lt; 200mGy.cm, in a large teaching hospital over three locations with 12 CT scanners. Methods: Data were obtained from the radiology information system for exams completed under the coding for unenhanced CT evaluation for renal calculi between 14 Feb 2008 and 31 December 2018. Examinations where the DLP was not correctly recorded, was below 40mGy.cm, or where the equipment used could not be identified were excluded. The distribution of doses and the median DLP per scanner was calculated. Results: In all, 20,080 studies were available across 12 CT scanners in the 10- year period. The average Median DLP has reduced from 501mGy.cm in 2008 to 178mGy.cm in 2018. Conclusions: Improvements in CT technology and implementation of low-dose protocols have resulted in significantly lower doses for evaluation of kidney stones since 2008. Although this study demonstrates significant variation between scanners, the overall adoption of low dose techniques is excellent. Level of evidence: Not applicable

348 Continuity of care - impact of continuity of obstetrician on unplanned attendances in high-risk pregnancies; A qualitative cohort study in a uk tertiary hospital

Introduction and Aims of the Study: We hypothesise that women with longitudinal continuity of obstetric care are less likely to have unplanned maternity attendances than those with poor continuity. Benefits of continuity of midwifery have been extensively publicised following the 2016 Cochrane Review. Continuity of doctor has been associated with improved outcomes in primary care, however has not been described in obstetrics. Continuity of obstetrician has been linked to a decrease in emergency attendances in a cohort of women attending a ‘Rainbow Clinic’.

Biomarker identification using dynamic time warping analysis: a longitudinal cohort study of patients with COVID-19 in a UK tertiary hospital

ObjectivesCOVID-19 is a heterogeneous disease, and many reports have described variations in demographic, biochemical and clinical features at presentation influencing overall hospital mortality. However, there is little information regarding longitudinal...

Early Pars Plana Vitrectomy in Acute Endophthalmitis: The Manchester Series.

Current literature lacks good-quality evidence regarding the outcomes of early pars plana vitrectomy (PPV) for acute exogenous endophthalmitis. The aim for this study was to analyze and discuss the outcomes of PPV for endophthalmitis in a UK tertiary hospital. This study was a retrospective case series. The clinical records of consecutive patients who had PPV for acute exogenous endophthalmitis were reviewed. Demographic data, etiology, timing of onset, timing of PPV, intraand postoperative complications, baseline and final best-corrected visual acuity (BCVA), therapeutic regimens, and microbiology details were collected. Primary efficacy and safety outcome measures were BCVA improvement of two or more logMAR lines and intra- or postoperative complications, respectively. Forty-one patients with a median age of 76 (interquartile range, 64 to 82) years were studied. The most common etiology was intravitreal injection (41%), followed by phacoemulsification (34%). Median interval to PPV was 1.0 (interquartile range, 1.0 to 3.0) days. In a multivariate model controlling for age, baseline BCVA, microbiology positivity, and etiology (post-intravitreal injection), PPV after 24 hours was seven times more likely to achieve significant BCVA improvement (odds ratio, 7.47; 95% confidence interval, 1.12 to 49.66; P = .038). PPV within 24 hours of presentation was associated with more intraoperative complications. Favorable outcomes may be achieved with current antibiotic regimens and PPV for endophthalmitis. The series suggests that an early surgical intervention may be associated with poorer functional outcomes. Tap and inject at presentation, followed by a semi-urgent PPV as required, seems to be a sensible approach. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:96-102.].

Identification and evaluation of medication-related issues relating to patient’s own drugs by pharmacy students while on placement in a tertiary hospital

Background Pharmacy students require knowledge of prescribing and supply of medicines; this is achievable through work-based learning. In UK hospitals, pharmacy technicians assess patient's own drugs (PODs) so medicines can be used as they would be at home. Student-led POD checks have not yet been considered as an opportunity for legitimate peripheral participation (LPP). Aim To evaluate an undergraduate pharmacy placement model using POD checking as a way of gaining LPP within a UK tertiary hospital. Method Students (n = 100) attended nine placements over academic year 2020-2021; they were supervised by a pharmacy technician to complete POD checks. Data were collected concerning student activities and resulting medication-related issues (MRIs); data were descriptively analysed. Results 1094 patients were seen by pharmacy students and 296 MRIs identified. Omitted (non-prescribed) medicines were the most common MRI (32.1%), followed by incorrect stock items (16.2%). Most MRIs were medium risk (65.5%). The most common actions/outcomes were handover to another ward member (41.6%) or medication removal (25.3%). Conclusion Clinically relevant MRIs relating to PODs can be identified by pharmacy students while experiencing LPP. These activities illustrate scalable work-based learning where pharmacy students can contribute to patient care in relation to the use and supply of medicines.

O-EGS08 Endoluminal Vacuum Therapy (EVT) for leaks in the upper gastrointestinal (UGI) tract; 10-years’ experience in a specialist Oesphagogastric centre

Abstract Background Endoluminal vacuum therapy (EVT) is an emerging treatment strategy for UGI leaks. When compared to traditional treatments strategies EVT is reported to reduce morbidity and mortality, especially in patients with delayed presentation and established sepsis. We report the outcomes for patients with UGI leaks and perforations treated with EVT using an ad-hoc endoluminal vacuum device (EVD) in a tertiary UK hospital over a 10-year period. Methods Sixty-seven patients with UGI leaks from disparate causes were treated with EVT between April 2011 and July 2021. The ad-hoc EVD was constructed using a piece of open cell foam sutured around the distal end of a nasogastric tube, and placed endoscopically either through the perforation and into the extra-luminal leak cavity OR intraluminally depending on the morphology of the leak cavity. Continuous negative pressure (125mmHg) was applied. Endoscopic re-evaluation of the leak cavity with change of EVD was performed every 48-120 hours depending on the patients clinical condition. Information related to treatment and outcome was recorded prospectively. Results Patients had a median age of 66 years (range 23-92), and median Apache II score of 21 (range 4-36) at presentation. Fifty-two leaks were oesophageal (78%), 12 gastric (18%), 2 duodenal (3%), and 1 pharangeal (1%). The leak cause was anastomotic in 26 (39%), iatrogenic in 20 (30%), spontaneous in 19 (28%), and traumatic in 2 (3%). The median number of EVD changes required to heal the leak was 6 (range 1-27), and median length of hospital stay was 42 days (range 1-182). Successful resolution of the leak was achieved in 59 patients (88%). Eight (12%) patients died during treatment. There were no complications related to insertion of the EVD. Conclusions EVT is an effective treatment for UGI leaks which can be delivered safely in a tertiary oesophagogastric centre, and used to treat a wide range of leak causes in critically unwell patients. Further studies are required to develop a standardized procedure to improve the ease with which EVT can be delivered. This will enable broader adoption of EVT for this group of patients.

Clinical and biochemical profile of 786 sequential episodes of diabetic ketoacidosis in adults with type 1 and type 2 diabetes mellitus

IntroductionWe explored the clinical and biochemical differences in demographics, presentation and management of diabetic ketoacidosis (DKA) in adults with type 1 and type 2 diabetes.Research design and methodsThis observational study...

Beyond audit: Embracing QI methodology to drive improvements in lung-protective ventilation.

Mechanical ventilation supports patients with respiratory failure during critical illness. Evidence suggests that excessive tidal volumes (regarded as >8 mL/kg predicted body weight [PBW]) cause lung damage through increased lung stretch and alveolar inflammation. Lung-protective ventilation strategies have been shown to decrease morbidity and mortality, and that all patients should receive tidal volumes between 6 and 8 mls/kg PBW. Despite this, studies demonstrate that fewer than half of patients in critical care successfully receive lung-protective ventilation. The primary aim was to reduce tidal volumes delivered to all patients receiving mandatory ventilation, with a target of >85% of tidal volumes delivered to be compliant with lung-protective ventilation strategies by the end of November 2019. A multidisciplinary team of nurses and doctors, based in a UK tertiary hospital, utilized the Institute for Healthcare Improvement's (IHI) quality improvement methodology to improve compliance with lung-protective ventilation. Baseline data demonstrated that only 60.1% of tidal volumes recorded were compliant with lung-protective ventilation. Quality improvement (QI) methodology was utilized to systematically diagnose the aetiology of poor compliance and to produce and implement solutions. Real-time data collection and reporting were utilized to monitor and report improvement. Following 8 months of continuous data collection and repeated PDSA cycles, sustainable compliance with lung-protective ventilation for >85% of tidal volumes was achieved. The use of QI methodology to implement low tidal volume ventilation has shown a significant improvement in the delivery of lung-protective ventilation. Using QI methodology is central to this sustained improvement and offers a useful tool to systematically approach complex clinical problems. Lung protective ventilation is critically important in the management of ventilated patients, although compliance in intensive care is variable. Here, we describe how quality improvement methodology can lead to consistent and sustainable improvement in the delivery of lung protective ventilation.

Management of Upper Gastrointestinal Tract Leaks Using Endoluminal Vacuum Therapy: 10-years’ Experience of a Specialist Esophago-gastric Center

Introduction: Management of upper gastrointestinal (UGI) leaks is challenging, especially in patients with delayed presentation and established sepsis. Endoluminal vacuum therapy (EVT) is an emerging treatment strategy which may reduce morbidity and mortality compared to traditional treatments in this patient group. We report the outcomes for patients with UGI leaks treated with EVT in a tertiary UK hospital over a 10-year period. Methods: Between April 2011 and February 2021, 63 patients with UGI leaks from different causes were treated with EVT using an ad-hoc endoluminal vacuum device (EVD). Information related to treatment and outcome was recorded prospectively. Results: Patients had a median age of 67 years (25-92), and mean Apache II score of 20.7 (6-36) at the time of leak diagnosis. The cause of the leak was anastomotic (n=23;37%), iatrogenic (n=20;32%), spontaneous (n=19;30%), and traumatic (n=1;2%). Forty-seven (75%) leaks were oesophageal, 12 (19%) gastric, 2 (3%) duodenal, and 1 (2%) pharyngeal. The median number of EVD changes required to heal the leak was 9 (1-27), and median length of hospital stay was 31 days (1-196). Successful resolution of the leak occurred in 55 (87%) patients. Eight (13%) patients died during treatment. There were no complications related to insertion of the EVD. Eight (13%) patients had complications during treatment which required further intervention including bleeding (n=4;6%), stroke (n=1;2%), pulmonary embolus (n=1;2%), myocardial infarction (n=1;2%) and COVID-19 (n=1;2%). Conclusion: EVT is safe, and can be used to successfully treat UGI leaks from a disparate range of leak causes in critically unwell patients. Further studies are required to develop a standardized procedure to enable broader adoption of EVT in this group of patients.

698 ENDOLUMINAL VACUUM THERAPY (EVT) AS A TREATMENT FOR ESOPHAGEAL LEAKS; 10-YEARS’ EXPERIENCE FROM A TERTIARY UK ESPHAGOGASTRIC CENTRE

Esophageal leaks present a significant management challenge, especially in patients with delayed presentation and established sepsis. Endoluminal vacuum therapy (EVT) is an emerging treatment strategy which may reduce morbidity and mortality compared to traditional treatments in this patient group. We report the outcomes for patients with esophageal leaks from a range of different causes that were treated with EVT in a tertiary UK hospital over a 10-year period.MethodsBetween April 2011 and March 2021, 45 patients with a median age of 67 years (31–92) who had an esophageal leak were treated with EVT. All patients were treated with an ad-hoc endoluminal vacuum device (EVD) constructed using V.A.C GRANUFOAMTM (KCI) and a standard nasogastric (Ryles) tube. The median Apache II score for patients at the time of leak diagnosis was 20 (6–36). The cause of the leak was anastomotic in 16 patients (36%), iatrogenic in 14 patients (31%), spontaneous in 14 patients (31%), and traumatic in 1 patient (2%). Information related to treatment and outcome was recorded prospectively.ResultsSuccessful resolution of the leak was achieved in 39 (87%) patients. The median number of EVD changes required to heal the leak was 6 (1–17). There were no complications related to insertion of the EVD. The median length of hospital stay was 49 days (1–108). Six (13%) patients died during treatment. Six (13%) patients had complications during treatment requiring further intervention; 2 (4%) had a significant bleed requiring angiography and aortic stent placement, 1 (2%) had a stroke, 1 (2%) had a pulmonary embolism, 1 (2%) had a myocardial infarction, and 1 (2%) contracted COVID-19.ConclusionEVT is a safe and effective treatment that can be used successfully to treat esophageal leaks from a disparate range of leak causes in selected critically unwell patients. Further studies are required to develop a standardized procedure and management pathway which will enable broader adoption of EVT in this group of patients.