UK Teaching Hospital Research Articles

Development and validation of a dynamic 48-hour in-hospital mortality risk stratification for COVID-19 in a UK teaching hospital: a retrospective cohort study

ObjectivesTo develop a disease stratification model for COVID-19 that updates according to changes in a patient’s condition while in hospital to facilitate patient management and resource allocation.DesignIn this retrospective cohort...

261 The Adequacy of Consenting for Inguinal Hernia Repair Relative to Surgeon's Grade of Training

Abstract Aim Inguinal hernia repair is known to be one of the most commonly performed general surgery procedures in the UK. Pre-operative consenting is essential to be aware of potential complications and for patients to make fully informed decisions. We aimed to assess the adequacy of consent for elective inguinal hernia repair in a UK-teaching hospital. Method A 4-months retrospective data analysis of consent forms was performed. Elective open and laparoscopic inguinal hernia repairs were reviewed for consent forms, including demographic data, date of surgery, grade of consenting surgeon, re-admissions, and complications. Results A total of 132 operations were included, 108 open and 24 laparoscopic. The most commonly recorded risks were bleeding (97%) and recurrence (96%). Serious testicular complications such as testicular artery injury/orchidectomy were consented in 35% of patients. The consultants consented 63% of overall complications, specialist registrars (SpR) 66.9% and senior house officers (SHO) consented the most with 77.1%. Testicular complications were mostly consented by consultants 66.7% vs registrars 16.3% and 12% SHOs. Consultants consented for the fewest complications overall (63.7%). Six patients were readmitted with postoperative complications, 2 were readmitted for orchidectomies, 3 haematoma and 1 had recurrence. Conclusion There are significant shortcomings in consenting patients for serious testicular inguinal hernia complications. SHOs consented for the most complications, followed by SpRs then consultants with the least. To mitigate these shortcomings, we would envisage having a standardised format for consenting, including patient information leaflets provided to the patients prior to their operations.

Sustainability Prize 2 Calculating the Carbon Footprint of Surgical Scrubbing

Abstract Aims This study aims to measure the estimated carbon emissions that could be saved if alcohol-based hand rubs (ABHRs), which have been shown to be as effective at antisepsis as antimicrobial soap and hot water (1), are used to scrub for all operations at a UK teaching hospital over 1 year. Methods The number of operations performed during October 2021 was obtained via hospital database. Across 25 cases, the volume of water per case was estimated by multiplying the time using water by the volume calculated per second flow. This data was used to calculate an estimate of the total volume of hot water used per year and therefore the carbon, cost, and water savings that could be made. Results Conclusion This study shows that 2.2 tonnes of carbon could be saved in a year if a single teaching hospital converted to ABHR. The outcome could contribute to the current Greener NHS trajectories: a Net Zero NHS by 2050. Reference 1. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva: World Health Organization; 2009. 13, Surgical hand preparation: state-of-the-art.

EP-21 The adequacy of consent forms for post-operative inguinal hernia complications relative surgeon's grade of training

Abstract Aims Inguinal hernia repair is known to be one of the most commonly performed general surgery procedures in the UK. Pre-operative consenting is essential to be aware of potential complications and for patients to make fully informed decisions. We aimed to assess the adequacy of consent for elective inguinal hernia repair in a UK-teaching hospital. Methods A 4-months retrospective data analysis of consent forms was performed. Elective open and laparoscopic inguinal hernia repairs were reviewed for consent forms, including demographic data, date of surgery, grade of consenting surgeon, re-admissions and complications. Results A total of 132 operations were included, 108 open and 24 laparoscopic. The most commonly recorded risks were bleeding (97%) and recurrence (96%). Serious testicular complications such as testicular artery injury/orchidectomy were consented in 35% of patients. The consultants consented 63% of overall complications, specialist registrars (SpR) 66.9% and senior house officers (SHO) consented the most with 77.1%. Testicular complications were mostly consented by consultants 66.7% vs registrars 16.3% and 12% SHOs. Consultants consented for the fewest complications overall (63.7%). Six patients were readmitted with postoperative complications, 2 were readmitted for orchidectomies, 3 haematoma and 1 had recurrence. Conclusion There are significant shortcomings in consenting patients for serious testicular inguinal hernia complications. SHOs consented for the most complications, followed by SpRs then consultants with the least. To mitigate these shortcomings we would envisage having a standardised format for consenting, including patient information leaflets provided to the patients prior to their operations.

Prevalence of wound complications following Mohs micrographic surgery (MMS): a cross-sectional study of 1000 patients undergoing MMS and wound repair in a UK teaching hospital.

BackgroundMohs micrographic surgery (MMS) for nonmelanoma skin cancer is often quoted as having an excellent safety profile.AimTo determine the complication rate of patients undergoing MMS in a large UK Mohs unit and subdivide complication rates into mild/intermediate and major, and to identify potential risk factors necessitating a clinical intervention.MethodsThis was a single‐centre, cross‐sectional study of 1000 consecutive cases of MMS performed with in‐house repair. Notes from the postsurgical dressing clinics were reviewed at Visit 1 (Days 7–14) and Visit 2 (approximately Week 6). Based upon the intervention required and effect on cosmetic/functional outcome, complications were classified as minor, intermediate or major. Logistic regression modelling was used to identify risk factors associated with a complication that needed a clinical intervention (i.e. intermediate or major).ResultsIn total, 1000 Mohs surgeries were performed on 803 patients, resulting in 1067 excisions. Complication rates in our cohort were low (minor 3.6%, intermediate 3.1% and major 0.8%) Potential risk factors for developing a complication included skin graft (unadjusted OR = 4.89, 95% CI 1.93–12.39; fully adjusted OR = 7.13, 95% CI 2.26–22.45) and patients undergoing surgery on the forehead (unadjusted OR = 3.32, 95% CI 0.95–11.58; fully adjusted OR = 5.34, 95% CI 1.40–20.42). Patients whose wounds were allowed to heal by secondary intention healing (6.8%) exhibited no complications.ConclusionWe advocate that patients should be informed during the consent procedure that less than 1 in every 100 patients (0.75%) undergoing MMS will have a serious adverse event (major complication) affecting their cosmetic or functional outcome.

Rhinovirus persistence during the COVID-19 pandemic-Impact on pediatric acute wheezing presentations.

Rhinoviruses have persisted throughout the COVID‐19 pandemic, despite other seasonal respiratory viruses (influenza, parainfluenza, respiratory syncytial virus, adenoviruses, human metapneumovirus) being mostly suppressed by pandemic restrictions, such as masking and other forms of social distancing, especially during the national lockdown periods. Rhinoviruses, as nonenveloped viruses, are known to transmit effectively via the airborne and fomite route, which has allowed infection among children and adults to continue despite pandemic restrictions. Rhinoviruses are also known to cause and exacerbate acute wheezing episodes in children predisposed to this condition. Noninfectious causes such as air pollutants (PM2.5, PM10) can also play a role. In this retrospective ecological study, we demonstrate the correlation between UK national sentinel rhinovirus surveillance, the level of airborne particulates, and the changing patterns of pediatric emergency department presentations for acute wheezing, before and during the COVID‐19 pandemic (2018–2021) in a large UK teaching hospital.

A comparison between thoracic epidural analgesia and rectus sheath catheter analgesia after open midline major abdominal surgery: randomized clinical trial.

BackgroundRectus sheath catheter analgesia (RSCA) and thoracic epidural analgesia (TEA) are both used for analgesia following laparotomy. The aim was to compare the analgesic effectiveness of RSCA with TEA after laparotomy for elective colorectal and urological surgery.MethodsPatients undergoing elective midline laparotomy were randomized in a non-blinded fashion to receive RSCA or TEA for postoperative analgesia at a single UK teaching hospital. The primary quantitative outcome measure was dynamic pain score at 24 h after surgery. A nested qualitative study (reported elsewhere) explored the dual primary outcome of patient experience and acceptability. Secondary outcome measures included rest and movement pain scores over 72 h, functional analgesia, analgesia satisfaction, opiate consumption, functional recovery, morbidity, safety, and cost-effectiveness.ResultsA total of 131 patients were randomized: 66 in the RSCA group and 65 in the TEA group. The median (interquartile range; i.q.r.) dynamic pain score at 24 h was significantly lower after TEA than RSCA (33 (11–60) versus 50.5 (24.50–77.25); P = 0.018). Resting pain score at 72 h was significantly lower after RSCA (4.5 (0.25–13.75) versus 12.5 (2–13); P = 0.019). Opiate consumption on postoperative day 3 (median (i.q.r.) morphine equivalent 17 (10–30) mg versus 40 (13.25–88.50) mg; P = 0.038), hypotension, or vasopressor dependency (29.7 versus 49.2 per cent; P = 0.023) and weight gain to day 3 (median (i.q.r.) 0 (−1–2) kg versus 1 (0–3) kg; P = 0.046) were all significantly greater after TEA, compared with RSCA. There were no significant differences between groups in other secondary outcomes, although more participants experienced serious adverse events after TEA compared with RSCA, which was also the more cost-effective.ConclusionsTEA provided superior initial postoperative analgesia but only for the first 24 h. By 72 hours RSCA provides superior analgesia, is associated with a lower incidence of unwanted effects, and may be more cost-effective.

Evaluation of in vitro activity of fosfomycin, and synergy in combination, in Gram-negative bloodstream infection isolates in a UK teaching hospital.

Introduction. Fosfomycin has retained activity against many multi-drug resistant (MDR) Gram-negatives, and may be useful against extended spectrum beta-lactamase (ESBL) producing and carbapenem-resistant Enterobacterales to improve clinical outcomes.Hypothesis/Gap Statement. There are few data from the UK on the susceptibility of invasive Gram-negative isolates to fosfomycin, especially in the era of increasing use of oral fosfomycin for urinary tract infections (UTIs).Aim. We evaluated fosfomycin susceptibility against 100 consecutive Gram-negative bloodstream isolates, both individually, and in combination with other mechanistically similar and differing antibiotics. The aim was to investigate the synergy between antibiotic combinations against several E. coli, K. pneumoniae and P. aeruginosa isolates with variable levels of resistance.Methodology. Disc diffusion and MIC test strip methods applying revised EUCAST guidelines for Fosfomycin were used, followed by the MTS™ 'cross synergy' method for 'resistant' isolates as defined below: (a) Fosfomycin resistant by MIC test strip; (b) MDR isolates defined as being resistant to ≥3 classes of antibiotics (based on routine sensitivity testing; beta lactams were considered as a single class), and/or (c) AMP C or ESBL or carbapenemase producers (or carbapenem resistant). FIC Index (Fractional Inhibitory Concentration Index) calculations were used to interpret findings, whereby: FIC = (MICA combination A+B/ MIC agent A) + (MICB combination A+B/ MIC agent B). A result of ≤0.5 was taken to indicate 'synergy', >0.5 and ≤1.0 to indicate 'additive' effect, >1.0 and ≤4.0 to indicate 'indifference', and >4.0 to indicate 'antagonism'.Results. We found that 95/100 isolates were susceptible to fosfomycin by MIC test strip, with 88/100 isolates susceptible to fosfomycin by disc, based on EUCAST guideline breakpoints. A total of 30/100 isolates (the more 'resistant' of the 100) were eligible for synergy testing according to our definitions (see Methodology), with the remaining 70 isolates not tested further. Seventeen out of 30 were MDR, 2/30 were AMP C producers and 9/30 were ESBL producers. Overall, 34/300 (11 %) of all combination tests showed synergy and 161/300 (54 %) were additive. Synergy was most commonly detected between fosfomycin and beta-lactam antibiotics, including piperacillin/tazobactam (10/30; 33 %), ceftazidime/avibactam (10/30; 30 %), and temocillin (8/30; 27 %). An additive effect was most commonly detected with aztreonam (25/30; 83 %) and meropenem (25/30; 83 %), but 100 % indifference was found with tigecycline (30/30). No antagonism was identified with any antibiotic combination.Conclusion. Fosfomycin non-susceptibility by MIC test strip was unusual. Synergy was variable when combining fosfomycin with other antibiotics against the more 'resistant' isolates. Synergistic/additive effects were detected for beta-lactam/fosfomycin combinations in >80 % of all such combinations, suggesting beta-lactams may be the preferred partner for fosfomycin. Agents with a discordant site of action were more likely to result in indifference. Antagonism was not detected.

The electronic prescribing of subcutaneous infusions: A before-and-after study assessing the impact upon patient safety and service efficiency

ObjectivesTo assess the impact of electronically prescribed mixed-drug infusions on the prevalence and types of prescription errors and staff time. Design, setting and participantsBefore-and-after study on acute medical wards of a large UK teaching hospital, utilising patient and staff data from the assessed wards. InterventionElectronically-generated mixed-drug infusions. Main outcome measures(1) Rate of prescription errors (divided into errors of commission and omission); (2) time taken to process patient discharge prescriptions containing a mixed-drug infusion; and (3) time between prescription and administration of mixed-drug infusions. Results100 errors of omission were detected pre-intervention, whilst none were detected post intervention. 6 errors of commission were identified at baseline, whilst 2 were highlighted post intervention (p = 0.149). 14 physicochemically incompatible infusions were prescribed at baseline, post-intervention all infusions were compatible (p < 0.01). Time spent processing discharge prescriptions fell from 60 min (SME±1.7) to 26 min (SME± 2.7; p < 0.01). The median time from prescription to administration reduced from 120 min (95 % CI 106–150) to 65 min (95 % CI 43–85; p < 0.01). ConclusionsThe intervention eliminated errors of omission and facilitated the prescribing of compatible multicomponent infusions. Electronically prescribed mixed-drug infusions also reduced both the time taken to complete discharge prescriptions and the time taken to commence such infusions.

Difficulties and educational challenges faced by international medical graduates in trust grade roles in the UK.

Most international medical graduates obtain a non-training job, such as a trust grade role, when they first start work in the UK. This transition into a new healthcare system comes with many sociocultural and educational challenges. The aim of this study was to learn more about the different types of challenges and propose solutions where possible. Qualitative data from a cohort of current or previous trust grade international medical graduates were collected at a UK teaching hospital. This was achieved through the use of questionnaires, interviews and obtaining views through a monthly forum meeting. Findings showed that participants lacked insight into the system and lacked clarity in relation to the role of a supervisor, career pathways, and medicolegal and ethical issues. Discrepancies in study budgets and study leave days, compared to those available to doctors in trainee posts was another issue that was raised. Communication in complex clinical scenarios was also reported to be an issue for many participants. Suggested solutions included a tailored online induction for international medical graduates in trust grade roles and a setting up a buddy system with existing or previous trust grade doctors. This study highlighted the challenges faced by international medical graduates in trust grade roles and proposed solutions where possible. Although responses varied, educational barriers were the most widely highlighted concern. To understand the full extent of these hurdles, perceptions of other healthcare professionals should be explored.

Psychological Impact on the NHS staff at a Teaching Hospital in UK during the First Wave of the COVID-19 Pandemic

Aims: To know the Psychological impact of Covid-19 Pandemic on Hospital staff. Methods: The survey was conducted during the first wave of COVID-19 between 4thJune 2020 to 5th July 2020 at St. Helens &amp; Knowsley Teaching Hospitals NHS Trust. Permission was obtained from the Audit &amp; Information Governance Department of St. Helens &amp; Knowsley Teaching Hospitals NHS Trust. Survey was done through Survey Monkey web site and used staff hospital e mail addressess to communicate with the hospital staff. Results: COVID-19 Pandemic has significant effects on the mental health and wellbeing of Front Line Health Workers in UK as shown in this study. Our study showed that major depressive symptoms were more common in non-doctors and doctors were more non-depressed. [Figure 3] There was a slightly higher sub-threshold depression among doctors over other staff members. Altogether among both groups of the front the line health workers 57.79% were non-depressed, 25.32% had sub-threshold depressive symptoms, and 16.88% had major depressive symptoms. [Figure 3] Conclusions: It is noted from our study that Front Line Health Workers do not give priority to their mental health wellbeing, hence there should be a system to regularly assess mental health of Front Line Health Workers and they should be encouraged to seek advice which appeared lacking in the respondents. It is important to mention that during the first wave, behavior, pathology and treatment of COVID-19 was not understood, and NHS staff at St. Helens &amp; Knowsley Teaching Hospitals NHS Trust, like many other health care workers risked their own lives as Front Line Health Workers. It is not surprising that there was an impact on psychological wellbeing in such challenging circumstances.

Psychological Impact on the NHS staff at a Teaching Hospital in UK during the First Wave of the COVID-19 Pandemic

Psychological Impact on the NHS staff at a Teaching Hospital in UK during the First Wave of the COVID-19 Pandemic

135 - Real world use of atezolizumab in the management of small cell lung cancer: experience from a UK teaching hospital

135 - Real world use of atezolizumab in the management of small cell lung cancer: experience from a UK teaching hospital

Early Results of Irrigating Goniectomy With TrabEx+: A Novel Device for the Treatment of Open-angle Glaucoma.

Précis:Irrigating goniectomy with the TrabEx+ device can lower intraocular pressure (IOP) in patients with glaucoma, as a standalone procedure or combined with cataract surgery.Purpose:The aim was to describe the efficacy and safety of irrigating goniectomy performed using the TrabEx+ device, either as a standalone procedure or combined with cataract surgery, in eyes with medically treated open-angle glaucoma.Methods:A retrospective case series of eyes treated by a single surgeon at a single UK teaching hospital. Data was collected at follow-up visits at 1 week, 3, 6, 12, 18, and 24 months postoperatively. Primary outcomes included IOP and glaucoma medication reduction after surgery. Proportion of eyes achieving >20% IOP reduction, IOP <21 mm Hg, and no reoperation were classified as surgical success.Results:Seventy-three consecutive eyes of 64 patients (mean age 68.4±13.7 y) were enrolled. 62% were treated as combined procedures with cataract surgery. Overall, mean IOP decreased from 31.3±7.3 to 20.9±10.4 mm Hg at the latest follow-up (34% reduction) (P<0.001) at the latest follow-up (16.1±10.3 mo) with mean preoperative medications decreased from 2.9±1.2 to 1.9±1.3 (P<0.001). 73% met the definition of success at latest follow-up. Postoperative complications were recorded including hyphaema (17%), uveitis (3%), hypotony (1%), and persistent vitreous hemorrhage (1%). Eighteen percent required reoperation because of treatment failure.Conclusion:TrabEx+ appears to be effective in lowering IOP and medication with or without cataract surgery. However, long-term safety and efficacy will be better understood in a prospective study with longer follow-up.

CT angiograms for lower GI bleeding: the experience of a large UK teaching hospital.

The clinical presentation of lower gastrointestinal bleeding (LGIB) is variable in severity, cause and potential investigations. The British Society of Gastroenterology recently published LGIB guidelines, recommending CT angiography (CT-A) for haemodynamically unstable patients, defined by shock index (SI) greater than 1. The aim of this study was to assess the use and role of CT-A in diagnosing LGIB, by assessing the pickup rate of active LGIB defined by contrast extravasation or 'blush' and to determine any association between positive CT-A with various patient and clinical characteristics. A retrospective analysis was carried out of 4 years of LGIB admissions. Demographics, inpatient observations and use of blood products were acquired. Vital signs nearest the time of CT-A plus abnormal vital signs preceding imaging were used to calculate SI, Age SI, National Early Warning Score 2 (NEWS2) and Standardised Early Warning Score (SEWS). A consultant gastrointestinal radiologist further reviewed all consultant-reported scans. In total, 930 patients were admitted with LGIB. Median age was 71 years and 51% were male; 179 (19.2%) patients received red blood cell transfusion and 93 patients (10%) underwent CT-A, who were older and were likely to be hypotensive and receive red cell transfusions. Following exclusions, 92 CT-As were included in the analysis. Nine (9.8%) were positive. Univariate analysis showed no association between positive CT-A and any scoring system. A multivariate analysis, including age and gender, showed association between both NEWS2 and SEWS scores with positive CT-A. In our analysis of the typical LGIB population, CT-A has shown relatively low pick up rate of active bleeding. CT-A clearly has a role in the investigation of LGIB, but selection remains challenging.

CT angiograms for lower GI bleeding: the experience of a large UK teaching hospital.

The clinical presentation of lower gastrointestinal bleeding (LGIB) is variable in severity, cause and potential investigations. The British Society of Gastroenterology recently published LGIB guidelines, recommending CT angiography (CT-A) for haemodynamically unstable patients, defined by shock index (SI) greater than 1. The aim of this study was to assess the use and role of CT-A in diagnosing LGIB, by assessing the pickup rate of active LGIB defined by contrast extravasation or 'blush' and to determine any association between positive CT-A with various patient and clinical characteristics. A retrospective analysis was carried out of 4 years of LGIB admissions. Demographics, inpatient observations and use of blood products were acquired. Vital signs nearest the time of CT-A plus abnormal vital signs preceding imaging were used to calculate SI, Age SI, National Early Warning Score 2 (NEWS2) and Standardised Early Warning Score (SEWS). A consultant gastrointestinal radiologist further reviewed all consultant-reported scans. In total, 930 patients were admitted with LGIB. Median age was 71 years and 51% were male; 179 (19.2%) patients received red blood cell transfusion and 93 patients (10%) underwent CT-A, who were older and were likely to be hypotensive and receive red cell transfusions. Following exclusions, 92 CT-As were included in the analysis. Nine (9.8%) were positive. Univariate analysis showed no association between positive CT-A and any scoring system. A multivariate analysis, including age and gender, showed association between both NEWS2 and SEWS scores with positive CT-A. In our analysis of the typical LGIB population, CT-A has shown relatively low pick up rate of active bleeding. CT-A clearly has a role in the investigation of LGIB, but selection remains challenging.

The management of asymptomatic radiological anastomotic leakage following anterior resection.

The evidence to guide the management of asymptomatic radiologically-detected anastomotic leakages (ARAL) following anterior resection (AR) with diverting ileostomy is deficient. This study describes the outcomes of managing ARAL one of the UK teaching hospitals. The study included all patients diagnosed with ARAL following AR during 8 years period (2012-2020). The following data were retrospectively collected: patient demographics, surgical indication, anastomotic technique, tumour staging, neoadjuvant therapy, how ARAL was managed, the outcomes and duration to heal and ileostomy reversal. A total of 35 patients (M= 24) who developed ARAL during the study period were included. In 32 patients, AR was performed for rectal cancer. All patients with ARAL were treated conservatively and in 31 (89%) patients, there was complete resolution of the leakage within a median duration of 6months. Covering loop ileostomies were reversed in 26 (74%) patients with a median interval to reversal of 10months. Most asymptomatic radiologically-detected anastomotic leakages after anterior resection heal with conservative treatment in the presence of a covering loop ileostomy with an expected average delay of 6months for the leakage to heal before covering ileostomies can be reversed.

Early-stage lung cancer associated with higher frequency of chest x-ray up to three years prior to diagnosis.

Symptom awareness campaigns have contributed to improved early detection of lung cancer. Previous research suggests that this may have been achieved partly by diagnosing lung cancer in those who were not experiencing symptoms of their cancer. This study aimed to explore the relationship between frequency of chest x-ray in the three years prior to diagnosis and stage at diagnosis. Lung cancer service in a UK teaching hospital. Patients diagnosed with lung cancer between 2010 and 2013 were identified. The number of chest x-rays for each patient in the three years prior to diagnosis was recorded. Statistical analysis of chest x-ray frequency comparing patients with early- and late-stage disease was performed. One-thousand seven-hundred fifty patients were included - 589 (33.7%) with stage I/II and 1,161 (66.3%) with stage III/IV disease. All patients had at least one chest x-ray in the six months prior to diagnosis. Those with early-stage disease had more chest x-rays in this period (1.32 vs 1.15 radiographs per patient, P = 0.009). In the period 36 months to six months prior to lung cancer diagnosis, this disparity was even greater (1.70 vs 0.92, radiographs per patient, P < 0.001). Increased rates of chest x-ray are likely to contribute to earlier detection. Given the known symptom lead time many patients diagnosed through chest x-ray may not have been experiencing symptoms caused by their cancer. The number of chest x-rays performed could reflect patient and/or clinician behaviours in response to symptoms.

130 Impact of Low-Dose High-Frequency &lt;i&gt;in situ&lt;/i&gt; Simulation on Inpatient Diabetes Management: A Pilot Study

Even in the presence of established institutional guidelines, failure of compliance by the clinical teams plays an important role in the control of diabetes. The identified gaps include contextual and biomedical knowledge, attitudes, clinical inertia, confidence and familiarity with existing hospital resources and guidelines with regards to hospital diabetes care We wanted to demonstrate the efficacy of low-dose high-frequency The exercise was a 15-minute session, delivered during working hours to individual nurses. This consisted of a 5-minute scenario, involving a standardized patient followed by a 10-minute debrief. Modified Diamond-model debrief with an advocacy-inquiry model was used by the debriefer, a trained fellow in simulation, and overseen by an expert. The scripted scenario involved a patient with Diabetic Ketoacidosis (DKA), with learning outcomes of recognizing DKA, managing the patient and adhering to the institutional guidelines including management of hypoglycaemia. The scenario was individualized based on the roles of the participants. Pre- and post-questionnaires were given to the participants. The simulation was repeated twice in the second week and once in the third week. This mixed-method study was conducted in a UK teaching hospital, in a ward designated for patients with diabetes, as a part of a quality improvement programme. In the first week, patients with diabetes, admitted for DKA, were chosen and their blood sugar recordings, dysglycaemic episodes and adherence to guidelines were noted. Every week data were collected as in the first week. GNU pspp 1.0.1 [version 3] free software was used. The confidence scores were given as mean and standard deviation with confidence interval (CI) of 98.75%. A p-value of &lt;0.0125 was considered significant based on the number of data points. The Dysglycemic episodes and protocol adherence from medical records Considering the T2 (increased recognition of diabetic emergencies and adherence to protocol) and T3 (improved patient outcomes) outcomes, the methodology was recommended as a modality of training the nursing staff involved in inpatient care of patients with diabetes. Future programmes including multi-disciplinary teams, to explore teamwork and communication, are planned.

Adrenal Incidentaloma: Prevalence and Referral Patterns From Routine Practice in a Large UK University Teaching Hospital.

ContextAdrenal incidentalomas (AIs) are increasingly being identified during unrelated imaging. Unlike AI clinical management, data on referral patterns in routine practice are lacking.ObjectiveThis work aimed to identify factors associated with AI referral.MethodsWe linked data from imaging reports and outpatient bookings from a large UK teaching hospital. We examined (i) AI prevalence and (ii) pattern of referral to endocrinology, stratified by age, imaging modality, scan anatomical site, requesting clinical specialty, and temporal trends. Using key radiology phrases to identify scans reporting potential AI, we identified 4097 individuals from 479 945 scan reports (2015-2019). Main outcome measures included prevalence of AI and referral rates.ResultsOverall, AI lesions were identified in 1.2% of scans. They were more prevalent in abdomen computed tomography and magnetic resonance imaging scans (3.0% and 0.6%, respectively). Scans performed increased 7.7% year-on-year from 2015 to 2019, with a more pronounced increase in the number with AI lesions (14.7% per year).Only 394 of 4097 patients (9.6%) had a documented endocrinology referral code within 90 days, with medical (11.8%) more likely to refer than surgical (7.2%) specialties (P < .001). Despite prevalence increasing with age, older patients were less likely to be referred (P < .001).ConclusionWhile overall AI prevalence appeared low, scan numbers are large and rising; the number with identified AI are increasing still further. The poor AI referral rates, even in centers such as ours where dedicated AI multidisciplinary team meetings and digital management systems are used, highlights the need for new streamlined, clinically effective systems and processes to appropriately manage the AI workload.