Acceptance type: Oral

24 Anterior Cruciate Ligament (ACL) and Medial Patellofemoral Ligament Reconstruction (MPFL): Developing a day case pathway

Gregg Baxter, James Masters

Alder Hey Children's Hospital, Liverpool, United Kingdom

Abstract

Introduction: ACL and MPFL reconstructions are commonly viewed as day case procedures in the adult sector. However, our experience at a tertiary paediatrics hospital is that very few of these operations are done as day cases. We wanted to explore why we were failing to get patients done as day cases and how we could improve this. 

Methods: We performed a retrospective audit looking at all ACL and MPFL reconstructions performed from January 2019 to March 2020

Results: 63 ligament reconstructions were performed at our hospital during the above time period. Only 9 (14%) patients were discharged on the same day as their operation. Whilst our average length of stay was 1.34 days, 26 patients (41%) had their operations on afternoon lists and none of them went home the same day. Nearly all patients (97%) had either a femoral or adductor canal block and, whilst there were comparable pain scores (femoral 2.23, adductor canal 2.56), the femoral nerve block precipitated significantly more leg weakness (37% vs 4.5%) which inhibited engagement with physio in the post-op period. We found no benefit in pain scores from the use of intra-operative morphine (2.38 vs 2.41) and only a mild benefit from clonidine (1.94 vs 2.64). 

Conclusion: Our work demonstrates that paediatric ligament reconstructions can be performed as  day case procedures. We recommend that day case pathways for patients in this context should include placement on a morning list, administration of intra-operative adductor canal blocks and a multi-model approach to analgesia that avoids opiates.

46 Early Experience of Primary Transurethral water vapour treatment (Rezum®) for symptomatic Benign Prostatic Hyperplasia: an analysis of 332 consecutive patients

Nimlan Shanmugathas, Christopher Khoo, Martin Connor, David Eldred-Evans, Carmen Lok Tung Ho, Arsam Mahmood, Soroush Nokhodchi, Andrew Ser Jien Ting, Amar Rai, Feargus Hosking-Jervis, Deepika Reddy, Mariana Bertoncelli Tanaka, Taimur T Shah, Arnas Rakauskas, Mathias Winkler, Sanjiv Agarwal, Taimur El-Husseiny, Hashim Ahmed

Imperial College NHS Foundation Trust, London, United Kingdom

Abstract

Introduction: Transurethral water vapour treatment (Rezum®) is a novel minimally-invasive therapy for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). We report early functional outcomes and adverse events.

Methods: Retrospective analysis of 332 consecutive patients at two centres between Aug/2017-Nov/2019. Inclusion criteria: LUTS secondary to BPH (pVol<120cc), acute urinary retention (failed TWOC), long-term catheter in-situ, absence of clinically significant prostate cancer and no prior BPH treatment.

Results: Median age was 69yrs (IQR 62-74) and median pVol 53cc (IQR 41-70) with 20.8% (69/332) >80cc. Pre-operatively, 66.9% (222/332) used α-blockers, with 42.7% (99/332) using 5α-reductase inhibitors. 99.0% (329/332) procedures were successfully completed. General anaesthesia, sedation and local anaesthetic were used in 81.3% (270/332), 18.4% (61/332) and 0.3% (1/332), respectively. Median operative duration was 9 minutes (IQR 7–12). There was successful 1^st TWOC in 72.9% (242/332) a median 7 days post-operatively. 96.4% (320/332) achieved same-day discharge. Clavien-Dindo complications grade >/=2 occurred in 1.8% (6/332). 1.5% (5/332) were re-admitted for post-operative haematuria; none required blood product transfusion. In patients with paired outcomes, mean baseline IPSS was 22.7 (SD 6.6) and at 3-months 7.42 (SD 5.8) (change -15.3 (-67.4%)).  Mean baseline QMax was 10.6 ml/s (SD 5.9) and at 3-months 17.4 ml/s (SD 8.1); (change +6.8 ml/s (+64.3%)). Further BPH surgery was performed for refractory symptoms in 1.8% (6/332).

Conclusion: Early outcomes for primary Rezum® demonstrate few serious adverse events and promising improvements in LUTS. Further prospective long-term and comparative evaluation will determine validity of these findings.

 

55 Introducing Day Case Arthroplasty at a District General Hospital During the Coronavirus Pandemic

Alireza Esfandiari, Rami Ashour

Countess of Chester Hospital, Chester, United Kingdom

Abstract

Introduction: Day case arthroplasty has gained increased traction in recent years, freeing up hospital beds and reducing healthcare costs whilst maintaining excellent outcomes. The Coronavirus pandemic has forced a rethink of elective surgery in order to minimise inpatient stays and address the backlog of patients on waiting lists. Our aim has been to facilitate the restart of lower limb arthroplasty surgery during the pandemic by introducing day case surgery at our average-sized district general hospital.

Methods: Criteria were outlined to identify patients that may be suitable for day case arthroplasty surgery. Appropriate patients were counselled in the outpatient clinic, given preoperative instructions and listed accordingly. Preoperative narcotics were ceased, and patients commenced on anti-inflammatories, neuropathic analgesia and high-calorie drinks two days prior to admission. Patients were discharged on a predetermined analgesic combination based on their bodyweight. Followup was made by telephone the same night and later in the week, and in person at 6 weeks.

Results: Between October and December 2020, all total hip replacements (THR) that were planned as day cases went ahead successfully, representing 54% of THR cases and 37.5% of all joint replacements performed by the senior author. Total length of stay ranged from 9 to 12 hours. There were no readmissions, good pain control and excellent patient satisfaction. No patients contracted Coronavirus during their hospital journey.  

Conclusions: Our experience of introducing day case surgery at our hospital has thus far been successful and will be expanding to include total knee replacements in the near future.

 

58 The Coronavirus Pandemic: A catalyst for the accelerated development of a successful new Orthopaedic service in Glasgow

Lindsay Hudman, Colin Drury, Sonya McKinlay

Glasgow Royal Infirmary, Glasgow, United Kingdom

Abstract

INTRODUCTION: North Glasgow Orthopaedic services are provided at Glasgow Royal Infirmary (GRI) and New Stobhill Ambulatory Care Hospital (NSH), with arthroplasty predominantly undertaken at GRI (2019, n=586) and selected unicondylar knee replacements only at NSH (n=75).  Service reduction due to the COVID pandemic (n=22, March - August 2020) drove an accelerated effort to launch NSH hip and knee arthroplasty (THA and TKA) services.

METHODS: Multidisciplinary engagement was paramount in planning and delivering the service; careful patient selection aided by electronic note review, expansion of Physio and Occupational Therapy provision, standardised anaesthetic and prescribing guidance,  involvement of the pharmacy team, and nurse-led discharge supported by new patient information leaflets. Patient follow up was by D1 and D7 telephone calls.

RESULTS: During the 15 week period from September - December 2020, a total of 62 THA, TKA & UKR were undertaken at NSH. (n=21 at GRI).

35% achieved same day discharge, (27% of THA, 33% of TKA and 50% of UKR cases). 89% were discharged by the end of D1. Mean LOS THR 1.06, TKR 1.10, UKR 0.87.

At follow-up, 93% patients felt ‘ready’ when discharged. 97% rated their experience ‘Very good’. 2 patients attended hospital after follow up phone-call (review after a fall and delayed urinary retention).

CONCLUSION: Recent pressures motivated the multidisciplinary team to accelerate progress on expanding the arthroplasty service to NSH. Successful safe continuation of surgery with a positive patient experience has been achieved. Development of this successful new service beyond the influence of the pandemic is anticipated.

 

62 Day Case Hip and Knee Arthroplasty is Safe: Outcomes in 200 Patients

Gyorgy Lovasz¹, Attila Aros¹, Ferenc Toth¹, John Va Faye², Marco Lamalfa¹

¹Practice Plus Group Hospital, Barlborough, Barlborough, United Kingdom.
²Royal Orthopaedic Hospital Foundation Trust, Birmingham, United Kingdom

Abstract

Introduction: Day case hip and knee arthroplasty is becoming increasingly popular world-wide. The purpose of this presentation is to share our experience with hip and knee replacements performed as a day case at a high-volume arthroplasty unit with special focus on patient safety and satisfaction, and its impact on length of stay (LOS) of traditional inpatient arthroplasties treated at the same ward.

Methods: 200 hip and knee replacements (THA, n=94, TKA n=60, UKA n=46) were selected for day case arthroplasty (DCA) based on strict inclusion criteria. Patients were admitted to orthopaedic ward, treated in a mixed setting with traditional inpatient arthroplasties. Same day discharge (SDD), readmission, complication and patient satisfaction rates were recorded. Changes of LOS and rate of discharges with 1-night stay in the inpatient arthroplasty group over the same time-period was analysed.

Results: 166 patients had SDD, 34 patients failed to go home (83% SDD rate) most commonly due to fainting, urine retention or lack of confidence. 4 readmissions (2.4%) occurred within 6-weeks. 4 out of 168 patients would have preferred overnight stay but the rest would opt for SDD again (97.6% satisfaction rate). Average LOS of inpatient arthroplasties reduced to 1.7 days from 2.4 before starting DCA project and rate of inpatients with 1-night stay increased to over 50% from 12% in the same time period.

Conclusions: DCA is a safe alternative for selected patient population and may contribute to shortening of LOS of inpatient arthroplasties resulting in cost and capacity savings for the provider.

 

72 The evolution of mandibular fracture surgery during the Covid-19 pandemic.

Shilen Patel, Shree Patel, Timothy Lloyd

University College London Hospitals, London, United Kingdom

Abstract

Introduction:  The Coronavirus (COVID-19) pandemic has caused over 99 million cases globally which has ultimately impacted hospital services. Although most elective surgeries amongst hospitals have been suspended, emergency surgery provision must continue to prevent poor outcomes. 

Emergency Oral and Maxillofacial (OMFS) surgery such as mandibular fractures cannot be delayed even during these unprecedented times. 

Mandibular fractures are mainly caused by road traffic accidents and interpersonal violence. They are considered to be open fractures with communication to the oral cavity, and are managed with Open Reduction and Internal Fixation (ORIF) without delay on an inpatient emergency list. 

Methods: We present a COVID specific triaging protocol to provide day case ORIF treatment to mandibular fractures. Patients were risk stratified by complexity of fracture pattern and patient reliability factors. This allowed us to triage patients to have surgery via local anaesthetic, day surgery or conventional general anaesthetic. 

Results:   Fracture patterns and patients factors were the main variables taken into consideration. Patients presenting with simple versus comminuted fractures and patient reliability factors governed outpatient or inpatient care. Adjunct Intermaxillary fixation (IMF) was also another factor considered for the treatment provided. The cases presented in the figures show our pre- and postoperative orthopantomogram radiographs. Patients were followed up by telecommunication and face to face clinics to monitor outcomes. 

Conclusion: COVID-19 has affected emergency provision, however our cases have demonstrated fractured mandibules can be treated as a day case on an outpatient basis, thus reducing hospital stay and therefore cost to the National Health Service.

 

Acceptance type: Poster

3 Seven years of Day Case Uni-compartmental Knee Arthroplasty for all-comers within the NHS: The journey and evidence of sustained change.

Mohammed Shaath, Mohammed Aqeel Bhutta, Joanne Humphreys

Northern Care Alliance, Manchester, United Kingdom

Abstract

Uni-compartmental Knee Arthroplasty (UKA) is becoming an evermore favourable option in patients with uni-condylar arthritis compared to Total Knee Arthroplasty; enhanced recovery processes alongside a less invasive procedure have allowed quicker recovery times and reduced pain. Day Case UKAs have been successful in the United States healthcare system; increasing in popularity from 14.5% to 58.1% and proven to not increase risk of preoperative complications or readmission. 

We have provided day case UKA to all-comers within the NHS and achieved a 89% day case rate. We aim to share our experience and lessons learnt from streamlining the process.

Data was prospectively collected on all patients (N=215) who underwent UKA by a single surgeon. A Day Case rate of 16.3% was observed in our first year of practice. Changes to our intra and peri-operative management were implemented which we found remarkably improved our outcomes. These included the use of Dexamethasone, Regional Spinal anaesthesia with Prilocaine, amending the local infiltrative analgesia regimen and finally operating without the use of a Tourniquet. 

The aforementioned interventions accompanied by the implementation of a cultural change allowed us to over the next 6 years significantly increase our day case rate to over 89% with no change in complications or re-admission rates and high patient satisfaction.

 

4 Re-audit of Endotracheal cuff pressures and Monitoring

NAVEENA SUKUMARAN1, AHMAD DAOUD2, KISHORI BAWDANE2, KEERTHI PUTTIGE2

¹ROYAL HALLAMSHIRE HOSPITAL, SHEFFIELD, United Kingdom. ²RHH, SHEFFIELD, United Kingdom

Abstract

INTRODUCTION: In 2017 endotracheal cuff pressure made available in all anaeshetic rooms at Sheffield teaching hospital NHS foundation trust. In this audit we evaluated the availability of manometers, whether one was used and the measured endotracheal cuff pressures.

METHODS:100 patients  were randomly selected who were intubated for surgical procedure between October 2019 and December 2020 at the Royal Hallamshire Hospital, Sheffield.

RESULTS: The cuff pressure monitor were available in theatres in 69% of cases, however they were measured in 53% of cases. 55% of the patient had endotracheal cuff pressures in the desired range of 22-32 cm H20.

Where the cuff pressure monitors were used 75% of the patients had cuff pressures in the desired range and where the cuff pressure monitor were not used only 30% of the patients had the cuff pressures in the desired range.

CONCLUSION: when an endotracheal cuff pressure monitor is used, 75% of the cuff pressures are in the desired range. We would strongly recommend that a ETT cuff pressure manometer is used to measure cuff pressures following tracheal intubation.

5 Day case surgery in breast implant-based reconstruction following breast oncological procedure

Lay In LIM, Nidhi Leena, Fares Koussa, Amar Deshpande

Wigan Infirmary, Wigan, United Kingdom 

Abstract

Introduction:  Prolonged stay in the hospital is well known to increase the risk of nosocomial infection and deep vein thrombosis. Besides that, the cost will be higher for unnecessary overnight stay in the hospital. For the last few years we have always aim to send patients home within the same day through our well set up day case discharge pathway.

Methods: In this project, we particularly investigated the patients who have had implant-based breast reconstruction following mastectomy for carcinoma of the breast from January 2015 to December 2019. We are particularly aiming towards patients’ safety and therefore data around return to theatre and readmission were analysed too. We collected the data retrospectively. 

Results: The sample size is 123 patients in total. 78 patients were discharged on the same day (63% as against 0 in 2010).6 patients out of total 123 patients (4.8%:  no increase) were readmitted to the hospital within 30 days; 7 patients (5.7 %: no increase) out of the total patients returned to theatre within 30 days for infection or removal of implants. 0% of mortality within 30 days. 78 patients who went home the same day where normally would have stayed back has helped the hospital to save significant amount of money. One-night bed is costing the hospital approximately £500. £227550 has been saved just based on this small cohort of the patients we treated in our breast unit from 2015 to 2019. 

Conclusions: We conclude that same day discharge following reconstructive breast surgery is safe and cost efficient. 

 

6 Breast Cancer Surgery: Default to Day Case!

Amar Deshpande¹, Fares Koussa²

¹Wrightington Wigan and Leigh NHS Foundation Trust, Altrincham, United Kingdom. ²Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, United Kingdom

Abstract

Introduction: Breast cancer surgery has been traditionally performed on the inpatient basis. In our trust in year 2010, the average length of stay for the breast cancer operations  was 2.7 days.  The main aim of this project was to reduce the length of stay and the main perceived benefits were, reduce hospital acquired infections, thromboembolic problems, promote better recovery in the familiar surroundings, and improve bed availability and financial gains for the trust.

Problems identified

• Patient expectations- Lack of confidence
• Resistance to the change
• Delays in discharge due to non-availability of doctors due to on call work pressures
• Post-operative nausea and vomiting
• Variable availability of community services for wound care and drain care. 
• Social issues

Solutions and actions taken

• Discharge planning from the time of diagnosis including addressing the social issues
• Medical and nursing staff education
• Patient education and management of expectations
• Development of nurse led discharge protocols
• Reduce  peri-operatively morphine
• District nursing cooperation and collaborative working
• Pathways for access to the breast team if required

Results

• The project was implemented in 2012 with an aim to achieve a day case rate for these patients of  80% 
• The LOS reduced to 0.83 days within 12 months with 85% surgeries as day case
• LOS in 2015 around 0.7 days and returns to theatre and readmissions rates were around 1% each with no, 30 day mortality

Conclusion

With good team work, education and safety protocols in place breast cancer surgery can be performed safely on day case basis.

 

7 Implementation of new acute admissions pathway reduces length of stay for patients undergoing day case abscess drainage – an audit

Frances Dixon, Orna Ni Bhroin, Barrie Keeler

Milton Keynes University Hospital, Milton Keynes, United Kingdom

Abstract

Introduction: Incision and drainage of abscess is a common operation that is often suitable for day case surgery. There are multiple advantages of day case surgery for both the patient and the hospital, including reduced length of stay, fewer delays, improved patient flow and increased efficiency of resource utilisation. However, patients in our hospital were often staying over 24hours with little justification. 

Methods: We performed a retrospective audit of length of stay for all I&D admissions over 2-month period, and also collected data on time from admission to operation. A new admissions pathway focusing on utilisation of the Day Surgery Unit (DSU) rather than inpatient beds was implemented, and admissions over a further 2 months were re-audited

Results: There was a significant reduction in the proportion of patients staying over 24hours from 38% to 11% (p=0.01). Median length of stay also improved from 12 to 8.7hrs (p<0.01), as did time from admission to knife to skin (5.8 to 3.5hrs, p=0.01). No change in the proportion of patients admitted to inpatient beds instead of day-case beds was found. The majority (17/20) of these particular patients were admitted during a weekend.

Conclusions: Improved utilisation of DSU increased the proportion of this patient population who were admitted, treated and discharged within 24hours. It also reduced overall length of stay and delays to treatment. There is still scope to reduce the use of inpatient beds, but this would require systemic changes including the opening of DSU on weekends. 

 

8 Post-operative care following appendicectomy – Are we getting it right first time?

Aimee Lloyd, Harry Rudman, Claire Hall

Stockport NHSFT, Stockport, United Kingdom

Abstract

Background: ‘Getting It Right First Time’ (GIRFT) identified significant variation in length of stay following appendicectomy, with leading trusts ‘able to discharge over half of patients within two days of admission’¹. Our aim was to analyse length of stay (LOS) following appendicectomy at Stockport NHSFT.

Methods: We audited 98 patients undergoing appendicectomy between June and December 2017, using the GIRFT 48-hour target as our audit standard for length of stay in uncomplicated appendicitis (i.e. no perforation, empyema or abscess formation). Online case notes were used to identify length of stay, diagnosis and barriers to discharge. A model operation note was created for uncomplicated appendicitis. We conducted a re-audit of 144 patients undergoing appendicectomy between October 2018 and April 2019.

Results: Our initial audit identified 61 cases of uncomplicated appendicitis with an average stay of 2.52 days. We identified unnecessary post-operative IV antibiotic prescriptions² and inadequate analgesia as leading causes of delayed discharge. Our re-audit identified 102 cases of uncomplicated appendicitis with an average stay of 2.30 days.

Conclusion: GIRFT’s 48-hour target is achievable with diligent use of supportive therapies and avoidance of unnecessary IV antibiotic prescriptions. Our re-audit identified a significant improvement in average LOS in patients with uncomplicated appendicitis following intervention. IV antibiotic use in uncomplicated appendicitis was reduced, although post-operative pain and pre-operative delays emerged as areas for improvement. We acknowledge the comparability of our results may be affected by winter pressures, with Data Collection 2 including the busiest period of clinical activity. 

References: References available on request

9 Day Case Hip and Knee Replacements: Outcomes of 101 patients

Gyorgy Lovasz, Attila Aros, Marco La Malfa

Barlborough NHS Treatment Centre, Barlborough, United Kingdom

Abstract

Introduction: Hospital stay for elective hip and knee replacements has dramatically decreased in the last 2 decades worldwide. The introduction of enhanced recovery program has expedited this process and allowed for selected patients to go home on the day of surgery. Outpatient arthroplasty is becoming increasingly popular in the United States but gaining popularity in UK and Europe as well. The purpose of this presentation is to share our experience with performing hip and knee arthroplasty as a day case with special focus on patient satisfaction and safety issues.

Methods: We have carried out 101 hip and knee replacements (52 hips, 49 knees) with same day discharge. Readmission and complication rates and patient satisfaction were assessed based on 24-hour postoperative phone calls and 6-week follow ups. We recorded operation time, intraoperative blood loss, time of mobilization, PONV rate and use of rescue painkiller medication after discharge. Same-day discharge rate and reasons for failing to discharge was also recorded.

Results: 118 patients were booked for same day discharge. 17 patients failed to go home most commonly due to fainting, urine retention or lack of confidence. There were 3 readmissions within 30 days due to suspected wound infection (not proven), partial PE and physiotherapy. No other complications were recorded. 99 out of 101 patients were satisfied with same-day discharge and would do it again.

Conclusions: Day case hip and knee replacement is an excellent alternative for selected patient population and does not result in increased readmission rates or decreased patient satisfaction.    

 

10 Improving access to preoperative information: an audit of caudal block information received by patients in a district general hospital.

Rebecca Jackson, Ollie Masters

Royal Gwent Hospital, Newport, United Kingdom

Abstract

Introduction: Evidence suggests that providing pre-operative information to parents or carers can considerably reduce the anxiety associated with children undergoing elective day surgery [1-3]. In the Royal Gwent Hospital, a caudal block is used as a method of providing postoperative analgesia in children undergoing an orchidopexy or division of a patent processus vaginalis (PPV) as a day case procedure. However, there is a lack of clarity of what information is communicated to patients prior to surgery. Our aim was to establish what pre-operative information patients receive regarding caudal blocks.

Methods: Over a 3-month period we conducted a survey amongst the parents and carers of children presenting for day case orchidopexy or division of PPV operations. Semi-structured interviews were undertaken with parents and carers on the day of surgery identifying what pre-operative information they were given and whether they were satisfied with this.

Results: Twelve patients were included in this study. The mean age was 5 years.  No (0%) patients were provided with any information on caudal blocks prior to the day of surgery. Eleven (86%) participants expressed they would have liked to have more information.

Conclusion: Despite a small sample size, we clearly identified the need to standardise our process of providing day case patients with information on caudal blocks pre-operatively. Consequently, we produced a caudal block patient information leaflet based on guidance for the Royal College of Anaesthetists UK. It is now available on the hospital intranet system for use by the pre-assessment nurses and anaesthetists.

 

11 ‘Just because something is different, doesn’t mean it’s wrong’ –  French versus American approach for the elective laparoscopic cholecystectomy

Hannah Byrne, Wen Jie Chin, Diego Dumpierres

Northampton General Hospital, Northampton, United Kingdom

Abstract

Introduction:  In the UK laparoscopic cholecystectomies (LC) are typically performed using an ‘American’ approach, with the patient supine and surgeon operating to the patient’s left side and monitors positioned at the head of the bed, or to the patient’s right side. At our hospital over the last 2 years, LC have also been performed using an alternative ‘French’ technique. This involves the patient in the lithotomy position, with the surgeon standing between the patient’s legs. 

We aimed to determine if there were any differences in patient outcomes when comparing the two techniques, as well as review surgical trainees’ opinions of the two approaches to gallstones disease. 

Methods: We performed a retrospective review of patient/theatre records, with inclusion criteria as follows:

• Elective LC 
• Day case operations (ASA I - III, BMI <33.5)
• Operation performed by surgical trainees (skin to skin)
• Age 35 – 79 yrs old 

Results: There was no significant difference in patient outcomes when comparing the French to the American technique for elective day case LC performed by surgical trainees. 82% of surgical trainees felt learning an alternative operative approach is beneficial to their training. 27% of trainees preferred the French approach over the American and 36% had no preference.

Conclusions: Our study shows that both the French and American technique are safe and yield similar satisfactory patient outcomes. The majority of trainees would want further training in both approaches for LC and this would ultimately provide surgeons with a skillset to perform these operations independently, in the position of their choice.

12 Day-Case Mastectomy: Artiss® (Fibrin Sealant Spray)

Kasra Razi, Jack Cullen, Alex Arbis, Elizabeth Shah

East Sussex NHS Trust, Hastings, United Kingdom

Abstract

Aim: The use of drains in breast surgery is decreasing, and various methods of reducing the dead space after mastectomy have been described such as quilting of skin flaps and the use of adhesive tissue glues. The British Association of Day Surgery (BADS) outlines a 30% day-case target for simple mastectomy procedures. We conducted a feasibility study using a fibrin sealant spray (ARTISS) instead of drains in mastectomy without reconstruction, to reduce patient length of stay (LOS) & post-operative complications. 

Method: A consecutive series of 50 patients, irrespective of age, BMI, social demographics & co-morbidities were included in the study. All surgical and theatre staff had appropriate training and data including day-case rates, seromas requiring aspiration and post-operative complications were prospectively collected. 

Results: The mean age was 65 years; average BMI was 29.4kg/m² and the average mastectomy weight was 712.4g. A day-case rate of 52% (26/50) was achieved. Of the day-case patients, 7 developed seromas requiring aspiration and one was re-admitted 7 days later with a haematoma. The overall seroma rate was 28% (14/50). 

Conclusions: This study demonstrates that drain-free mastectomy is possible using ARTISS. The use of this product facilitates early discharge in all demographic groups and adherence to the national standard is achieved.

13 The Effect of WHO Surgical Safety Checklist in routine and urgent operations.

Teerajet Taechameekietichai

University of Plymouth Faculty of Medicine and Dentistry, Plymouth, United Kingdom

Abstract

Introduction: In order to decrease the number of surgical deaths across the globe the World Health Organization (WHO) developed a WHO Surgical Safety Checklist in 2008. The objective of this paper is to explore the effectiveness of the WHO Surgical Safety Checklist on routine and urgent operations.

Methods: A principal research was gathered through the electronic databases of PubMed, Medline and Google Scholar using predefined inclusion criteria Inputting these keywords in a muit-field search: WHO Checklist AND Efficiency' OR Surgical Safety Checklist OR 'Urgent Operation AND Surgical Safety Checklist OR WHO Checklist AND Adverse events in the databases resulting in a copious selection of primary research papers and systematic review articles Moreover, the results were limited to the past 10 years in order to ensure that the currency of information was not a concern. The inclusion criteria included the reliability of the research study type and relevance to the topic.

Results: Some may argue that the process of completing the checklist in an urgent operation may cause delays and put the patient at risks. However, the findings show that the use of a perioperative checklist, in fact, reduced the risk for common errors during the surgery. Additionally, it is important for healthcare professionals to understand that the checklist is not just a read and do list but rather a tool to enhance teamwork and communication.

Conclusion: There is evidence suggesting that the use of the WHO Surgical Safety Checklist helps improve patient safety in routine and urgent operations.

14 Driving forward improvement of provision and documentation of driving advice on discharge following elective day case inguinal hernia repair surgery

Vanessa Cubas, Vimal Mahendran, Susan Mattick, Moustafa Mourad

Worcestershire acute royal hospitals, Worcester, United Kingdom

Abstract

Introduction: Previous driving advice following groin hernia repair was based on concern that postoperative pain could prolong reaction times and increase the risk of early recurrence as a result of the inertial forces on impact/stopping. It is now accepted (RCSE Guidelines) that 1 week would suffice, if the patient is free from pain or the sedative effects of any medication. The GMC states: “Clinical Records should include information given to patient”. The aim of our audit is to find out if patients are receiving the correct information and if it is documented appropriately.

Methods: Retrospective study from 1^st of August-October 31^st 2019 and then again from the 1^st-29^th of February 2020 following intervention. Data collected included documentation of driving advice in clinic letters, operation note and discharge summary and questionnaire of surgical staff enquiring about knowledge of RCSE guidelines.

Results: Only 1 Consultant Surgeon was aware of formal driving guidance and gave written advice. 94% of surgical members of the team gave verbal advice in keeping with RCSE but were unaware that published guidelines existed. During phase I, (n=147) documentation in the clinical letter, operation note and discharge summary was 10%, 8% and 4% respectively. Following intervention n=29, this increased to 21%, 45% and 41%. Intervention included: departmental education and a patient leaflet was created and added to the consent and discharge bundle.

Conclusion: Intervention with patient centred leaflets and education of staff with guidelines is essential to provide patients with consistent evidence based information, verbal AND printed, on driving following inguinal surgery.

17 Elective ENT surgery during the COVID-19 pandemic: Experience from a single UK centre

Munira Ally, Anant Patel, Ravina Tanna, Olivia Kenyon, Ananth Vijendren, George Mochloulis

Lister Hospital, Stevenage, United Kingdom

Abstract

Introduction: The COVID-19 pandemic has caused significant disruption to elective surgery globally with potentially devastating population health and socioeconomic implications.  We aim to present the outcomes of elective ENT surgery, and the protocol employed, in a designated COVID free site during the first peak of the COVID-19 pandemic, to increase the evidence base for surgery during the pandemic thereby informing future preparedness efforts.  

Methods:  We conducted a single centre retrospective case review of all patients who underwent elective ENT surgery following a strict protocol, over a 16-week period between April 1^st – July 22^nd 2020.    Outcome measures included development of postoperative COVID-19 symptoms, pulmonary complications, mortality, postoperative surgical complications and hospital readmissions.   

Results:  85 patients (42 male and 43 female) underwent elective ENT surgery.  There were 78 adult patients and seven paediatric. The average age (± standard deviation) of the adult patient was 52 ± 16.4 and the average age of the paediatric patients, 6 ±   2.8. 55.3% of patients had day case surgery.  Thyroid and mastoid surgery were most frequently performed.   Fifty five percent of patients had aerosol generating surgical procedures.  No patients developed postoperative symptoms consistent with COVID-19. There were no postoperative pulmonary complications or mortalities.  10.6% of patients had post-operative surgical complications; none needed return to theatre albeit two required hospital admission.

None of the nine operating surgeons developed symptoms of COVID-19,  necessitating self isolation.

Conclusion: Our experience demonstrates that hospitals can safely manage elective operating services during the pandemic.  

 

18 Overhauling the Urology TURBT day case service: maximising discharges and financial reimbursement

Thomas Woodland, Zuzanna Holwek

Abstract

Introduction: Patient bed spaces and departmental funding are two of the most important components of any clinical service. The SARS-CoV-2 pandemic has further highlighted how precious hospital beds can be, and every effort should be made within day-case surgery to preserve it. We conducted a 2-year audit at Bath Royal United Hospital to identify and address the reasons patients undergoing TURBT surgery were being admitted overnight, whilst ensuring the department was being appropriately reimbursed via accurate clinical coding.

Methods: Patients that underwent an elective TURBT from 2018-2019 were identified, and their clinical coding was checked. Patients that were not discharged the same day had their documentation analysed to identify the underlying reasons. Based on the results of the first cycle, recommendations were made on improving operation notes, instructing day-case staff and educating doctors. The service was then re-audited for the period of 2019 –2020.

Results: The first audit cycle found that of 167 TURBT cases, 39% were booked incorrectly at a loss of £19,500. Only 37% were discharged home the same day. The re-audit recorded a reduction in incorrectly coded operations to 14%. The number of patients being discharged home on the same day rose to 55%.

Conclusions: The findings of this audit demonstrate that surgical departments may be being inadequately financially reimbursed for day-case procedures, and many patients that stay overnight could be safely discharged home the same day. The responsibility for accurate clinical coding is a shared one, and doctors should have an interest in improving coding accuracy.

19 A re-audit of cancellations on the day procedure unit (DPU) at the Norfolk and Norwich University Hospital

Jessica Maskell, Rachel Morris, Anna Lipp

Norfolk and Norwich University Hospital, Norwich, United Kingdom

Introduction: Operations cancelled on the day of surgery impacts theatre utilisation and waiting lists and decreases patient satisfaction. In 2018 we audited on the day cancellations in DPU and discovered a high number of urinary tract infections (UTI) in urology patients. 

We produced a standard operating procedure (SOP) and re-audited at the end of 2019 to assess the impact of our SOP. 

Method: We recorded the number of on the day cancellations in DPU for urology from the theatre database. Cases cancelled due to UTI were reviewed to assess adherence to the SOP. 

Results:

• 19 urology operations were cancelled on the day, this is reduced from 43 in our original audit.
• 11/19 was due to UTI. The absolute numbers have reduced but UTI still accounts for a similar proportion, 53 % vs 58% respectively. 
• 1 patient followed the SOP but the process occurred too close to the operation date. 5 patients had no pre-op assessment (POA) documentation. The paper notes were not available to be reviewed in 5 patients. 

Conclusions: In DPU the number of on the day cancellations in urology has more than halved and the number cancelled due to UTI has fallen. Introducing the SOP has had a positive effect but it is not always followed. 

Due to Covid there has been little face to face POA and this has affected the ability to follow the SOP. As elective surgery has restarted we have been creative in how we address this in order to continue to minimise cancellations. 

 

20 Delivering manipulation under anaesthesia for fracture nose (day surgery) during COVID-19 pressures

Sabarinath Vijayakumar, Mohammed Mian

Sandwell and West Birmingham hospitals, Birmingham, United Kingdom

Abstract

Introduction:  Manipulation under anaesthesia ( MUA )  for fractured nose is practised as a day care surgery, ideally within the first 14 days of injury. It was categorised as priority 4 (surgery can happen after 3 months of day of injury) during the first peak of COVID-19 by ENT UK since the elective day theatre lists were deferred. The aim of this audit was to evaluate the assessment and management of fracture nose referrals during COVID-19 after the introduction of patch and plan list (staggered ot lists).

Methods: All Emergency ENT clinic (fracture nose) referrals from A&E were considered from the month of July to December (6 months) and assessed. All  patients referred were tested for covid-19 in A&E. Parameters studied were Day of injury, Day of assessment in Emergency clinic, Outcome in Emergency clinic, Day of proposed surgery and the outcome – operated or deferred.

Results: Total 67 referrals with nose injury and suspected fracture were made from A&E. Mean period between day of injury and day of assessment in Emergency clinic was found to be 8.06 days. The outcomes were 37 discharges, 11 did not attend and 19 listed for surgery.    Mean period between day of injury and day of surgery was found to be 15.62 days.

Conclusion: During first peak of COVID 19 pandemic, there was increased morbidity as MUAs were deferred resulting in patients waiting for a definitive procedure later. Introduction of patch and plan list helped in delivery of care close to the recommended time frame (14 days).

 

21 Optimising perioperative analgesia to facilitate day case ACL repairs

Frederick Hull, Anthony Huckle, Vishal Thanawala

Nottingham University Hospital NHS, Nottingham, United Kingdom

Abstract

Introduction: Data generated by GIRFT (Get It Right First Time) showed that the average length of stay (LoS) for Nottingham University Hospitals (NUH) Trust following Anterior Cruciate Ligament Repair (ACLR) from April 2017 to March 2018 was 1.35-days. Reducing our LoS to match the national average of 0.13-day could save an estimated £45,000. We reviewed postoperative nausea and vomiting (PONV) and pain as factors which may be contributing to our increased LoS.

Methods: 113 patients underwent ACLR in NUH between March 2018 and March 2019. Pain and PONV scores were analysed alongside analgesic and antiemetic regimes, from recovery and at six-hourly intervals postoperatively using electronic observation data.

Results: Forty-seven patients (43%) experienced moderate-severe pain in the recovery room and 11 patients (10%) at 6 and 12-hours. Four patients (4%) received intraoperative local anaesthetic infiltration, none of whom (0%) experienced moderate-severe pain in the recovery room.

Conclusion: Use of intraoperative local anaesthetic infiltration has been shown to improve pain control for up to 24-hours in ACLR [1]. We suggest use of local anaesthetic infiltration or regional anaesthetic nerve block for all patients as well as the use of multi-modal postoperative analgesia consisting of paracetamol, NSAID and strong opioid for the first 48-hours to provide optimal analgesia, facilitate day case surgery and save revenue for the Trust.

[1] Ramlogan, R., Tierney, S., & McCartney, C. Anterior cruciate ligament repair and peripheral nerve blocks: time to change our practice? British Journal of Anaesthesia, 123(2), e186–e188. (2019).

22 Perioperative care of inguinal hernia repair patients and length of stay

Rebecca Janes, Vishal Thanawala

Nottingham University Hospitals, Nottingham, United Kingdom

Abstract

Introduction: The Getting It Right First Time report states that target length of stay (LoS) for inguinal hernia repair should be 0.13 days. The average LoS for patients in Nottingham in 2017-2018 was 1.22 days. This audit aimed to determine the LoS and identify reasons for admission or unplanned inpatient stay.

Method: This was a case note review of all elective inguinal hernia repair operations in 2019.

Results: The average LoS from all notes reviewed was 0.3 days. 67% of cases were carried out in dedicated day surgery unit, where LoS was 0.031, with 6 unplanned admissions. 96 cases were completed in main theatres where the average LoS was 0.94 days. 19 were discharged the same day. Reasons for admission were comorbidities/frailty (53), social factors (7), request by surgeon (4). 13 patients had no identifiable reason for planned admission. Recurring complications across both groups were urinary retention (15 patients) and post-op analgesic requirements (7 patients).

Conclusions: Our LoS is better than the result for 2017-18 and comparable to the national statistics. This is partly due to acquisition of an additional dedicated day surgery centre, but there is scope to achieve better results by implementing the latest GIRFT and BADS recommendations. For lists in main theatres, the surgeon and anaesthetist should identify at the briefing and follow up at the end of the list to ensure the appropriate patients can be safely discharged home as per the criteria and plan.

 

23 Use of arthrocentesis for temporomandibular disorders- a service evaluation project

Callum Simpson, Thomas Handley

St John's Hospital, Livingston, United Kingdom

Abstract

Introduction: The temporomandibular disorders (TMDs) are a collection of conditions affecting the temporomandibular joint, which may present with pain, restriction of mandibular movement and clicking or crepitus. Arthrocentesis is one potential treatment for arthrogenous TMDs. COVID-19 pandemic restrictions have resulted in reduced availability of theatre slots for this routine operation, and therefore there is a desire to optimise the use of our limited theatre resources.

Methods: All patients receiving arthrocentesis at St John’s Hospital between May 2018 and December 2019 were identified (n=69). Data collected from electronic patient records included patient demographics, pre-operative symptoms, diagnosis, operative details and outcomes.

Data was analysed and used to determine the factors influencing the success rate of arthrocentesis.

Results: 39% of patients’ symptoms improved such that no further treatment was required.

Factors which are predictive of a positive outcome include:

• Age <40 years
• Diagnosis of internal joint derangement
• Increased volume of saline used to irrigate the joint space
• Use of orthovisc (hyaluronic acid) 

Previous unsuccessful arthrocentesis and presence of osteoarthritic changes reduce the probability of a successful outcome.

Conclusions: Our results can be used to guide which patients are listed for arthrocentesis, based on the likelihood of success. During pandemic restrictions, when routine elective operating time is scarce, resources can be targeted to patients most likely to see resolution of symptoms following intervention. Patients can be counselled on the chance of a favourable outcome as part of the consent process, and when discussing treatment options.

 

25 Paediatric Fasting Times Audit

Rachel Heard, Surrah Leifer

Royal Preston Hospital, Manchester, United Kingdom

Abstract

Background: Current hospital fasting guidelines for elective paediatric surgical patients are 6 hours for solids, 4 hours for breast milk and 2 hours for clear fluids as per AAGBI guidance. However newer evidence led to the APAGBI releasing a consensus statement in 2018 that 1 hour fasting for clear fluids is sufficient to reduce the risk of pulmonary aspiration. Many studies have found that paediatric patients are fasted for too long, leading to agitation and a higher risk of complications such as PONV and hypoglycaemia. 

Aim: To determine the average fasting time of elective paediatric patients.

Methods: Retrospective case note review of 100 patients.

Results: The mean fasting time was 12 hours 25 minutes for solids and 7hours 19minutes for clear fluids. 12 patients developed post-operative complications; 50% had PONV, one developed hypoglycaemia, and 5 were unrelated to fasting time (e.g. post-operative bleed).

Conclusion: Paediatric patients are being fasted for too long for both solids and clear fluids. All patients with PONV had prolonged fasting times. As only one patient had a blood sugar measurement, the true issue of hypoglycaemia is unknown. There is ongoing discussion regarding the benefit of intra-op blood sugar measurement. The recommended clear fluid fasting time for paediatric patients has been reduced to one hour. There needs to be improved communication between theatres and pre-op admission teams to allow patients to have clear fluids following decision of the theatre list order. Information given to parents is being reviewed. Re-audit to determine if changes have been effective. 

 

26 Can day case elective operating lists provide efficient training opportunities for general surgical trainees?

Rachael Coulson, Catherine Gilmore, Catherine Sheridan, Anna Murray, Scott McCain, Ian McAllister

South Eastern Health and Social Care Trust, Belfast, United Kingdom

Abstract

Introduction: During the COVID-19 pandemic there has been a reduction in trainee hands-on learning opportunities due to curtailment of elective workload.  Our study aims to assess the impact of non-consultant led operating on theatre list efficiency. 

Methods: Prospective data collection over an eight week period of consecutive elective day case hernia lists at a newly established regional centre of excellence for day surgery.  Specifically recording of key time points in surgical cases including time ready, knife to skin, last suture and exit theatre. This was achieved using the Theatre Management System (TMS).

Results: 46 patients underwent open unilateral elective inguinal hernia repair. 54% (N=25) of cases were trainee led. Median trainee time was 53 minutes, vs 51 minutes for consultant led procedures; no significant difference (p>0.05).

Conclusion: Day case elective hernia lists can be efficient training opportunities for general surgical trainees. Our results demonstrate that trainee-led operating in this setting have not resulted in significantly increased surgical time or operative theatre inefficiency. It is widely acknowledged there is benefit to training in performing the same technical skill within a short time frame.

 

27 Day case laparoscopic cholecystectomies - why the admission?

Alex Newey, Gemma Maryan

Norfolk and Norwich University Hospital, Norwich, United Kingdom

Abstract

Introduction: Laparoscopic cholecystectomy (LC) is the recommended management for symptomatic gallstones. Last year, despite 94% LCs being booked as day case, our actual rate was 68%, therefore below the British Association of Day Surgery suggestion of 75%. We looked at anaesthetic management, analgesia, incidence/reason for admission/readmission following day case LCs at an English teaching hospital. 

Methods: We performed a retrospective notes review alongside a mailed post-operative follow-up survey. Causes of failed discharges, readmissions, anaesthetic practice and post-operative pain-management experience were recorded.

Results: A sample of 46 sets of notes from March, September and October 2020 were reviewed. There were 13 (28.9%) admissions (4 for pain, 2 for drains, 4 late finishes and 3 medical reasons) and 3 readmissions due to surgical complications. 43 (of 105) returned surveys found that most were advised to take regular paracetamol and ibuprofen (if able) and 2/3rds were provided with codeine-based take home medications of which 74% didn’t finish due to lack of pain.

Conclusions: Unplanned admissions create logistical and financial problems following day case surgery. Appropriate patient selection and robust post-operative plans can ensure patient flow and safe day case management. Patients should be booked earlier in the day with careful consideration of list order. Take-home analgesia with paracetamol, ibuprofen and a weak opioid should be sufficient. Our small study demonstrated that there is variation in anaesthetic technique for LCs but did not have sufficient numbers to suggest superiority. A standardised protocol could improve outcomes, but further research would be needed. 

28  Patient’s Experiences and Lessons Learned following establishment of a New Regional Centre for Day Surgery

Catherine Gilmore, Rachael Coulson, Victoria Graham, Ian McAllister

Ulster Hospital, Dundonald, Belfast, United Kingdom

Abstract

Introduction: Due to the impact of COVID-19 on elective services an exclusive day case centre has been established for the region. This study aims to review the patient experiences of the service. 

Methods: A 26 question feedback survey assessed patient outcomes, complications and experiences. All patients who underwent hernia repair from September to November 2020 were contacted 6 weeks postoperatively by telephone to participate.

Results: Over 10 weeks, 55 patients underwent unilateral inguinal hernia repair. 49 patients completed the survey, 5 patients were not contactable and 1 patient declined to participate.

Overall high levels of patient satisfaction were reported, when asked the question “Rate the overall experience (out of 10) from the time you were contacted to proceed with surgery to now?” The average patient reported score was 9.5.

Results indicated excellent use of written patient information leaflets. 92% (N=46) of participants had a travel time of less than 60 minutes and 94% (N=45) of those contacted reported the centre as a convenient location. Qualitative responses described pain at 48-72hrs following the procedure when local anaesthetic had worn off, to the detriment of overall patient satisfaction.

Conclusion: A dedicated site for day-surgery can be successful during the period of COVID-19 restrictions. High levels of patient satisfaction reported. However, lessons learned include need for improved education regarding postoperative analgesia; effects of local anesthesia and patient directed follow up via the well established local surgical hub

 

29  It’s not you, it’s me: a descriptive study of patient complaints and surgeon understanding

William McSweeney, Darius Dastouri, Matthew Leaning

Caboolture Hospital, Caboolture, Australia

Abstract

Background: Patient complaints are an underutilized and under-addressed issue in general surgery. During the COVID-19 pandemic, surgical services need to rely even more on understanding patient expectations and streamline service delivery. The aims of this study were to identify motivators of patient complaints, and understand surgeon’s awareness of this issue.  

Methods: A retrospective review of patient complaint data in a single regional general surgical department was undertaken between the periods October 2017 to June 2020, and June 2018 to October 2020 relating to patient demographics and subject of complaint. Secondly, an anonymous survey was conducted across the same department and results tabulated by seniority. 

Results: 219 complaints were received during the study period. 113 were made by patients, whilst 56 were made by family members. 159 complaints related to an inpatient episode of care, and 152 were made in writing. The majority of complainants were female, with a mean age of 52. The most common reason for complaint was “treatment” (n=102), followed by communication (n=48) and humaneness/caring (n=44). Consultant surgeons and surgical trainees placed communication, humaneness/caring and professionalism as most likely to incite complaints, whilst interns were more likely to prioritize other measures such as patient healthcare rights and medications. 

Conclusion: Patient complaints remain a relatively under-utilized resource in addressing the downfalls of general surgical departments. This study reports patient demographics that are congruent with the literature, and highlights that surgeons prioritize many non-technical skills in the maintenance of the doctor-patient relationship, in contrast to preconceptions. 

 

30 Keratinocyte skin cancer excisions: is local anaesthetic a feasible option to protect us?

William McSweeney

Caboolture Hospital, Caboolture, Australia

Abstract

Background: Keratinocyte skin cancers are common in Australia, incurring disproportionately high health expenditure in comparison to mortality. General surgeons often excise these lesions as day-surgery. Balancing individual complexities of these cancers with trainee supervision and health expenditure is key to deliver efficacious care and maintain day-surgery volume for patients during a pandemic. 

Methods: A retrospective, cross-sectional study was performed, examining 414 procedures from January 2019 to December 2020. Pathology was individually reviewed. Complete excision was based on 5mm margins for squamous cell carcinoma (SCC), 0.5mm microscopic margins for low-risk basal cell carcinoma (BCC) subtypes and 3mm for high-risk. Results of trainee-performed local anesthetic (LA) excision, and general anaesthetic (GA) excision (consultant scrubbed) were compared. 

Results: 288 excisions were reviewed for completeness, location and reconstruction modality. 69% were BCC (199), 31% were SCC (89). These were excised under GA (72.5%) and LA (27.5%). 25.6% of BCC excisions were “close” and 22.6% “positive” under GA, whilst 31% were “close” and 15.5% were “positive” under LA. 52.8% of SCC excisions were “close” and 7.8% “positive” under GA, compared with 42.8% “close” and 9.5% “positive” under LA. Complex reconstruction (graft, flap) was more common under GA (38% SCC, 36.1% BCC), but occurred at a modest rate under LA (22% BCC, 28.5% SCC).

Conclusions: The results confirm that comparable margins and reconstruction options are achievable when excising keratinocyte cancers under LA by surgical trainees. This is fundamental in cost and timesaving, as well as reducing risk of aerosolisation of virus during GA, in a pandemic. 

 

31  Evaluation of peri-operative care for hemithyroidectomy patients at Nottingham University Hospitals (NUH)

Nyssa Comber, Rebecca Binks, Vishal Thanawala

Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

Abstract

Introduction: Shorter post-operative stay leads to increased patient satisfaction and experience, and saves revenue and inpatient beds for the Trust.

According to Getting It Right First Time data for NUH from April 2017 to March 2018, the mean length of stay (LoS) after hemithyroidectomy was 1.75 days vs 1.21 days national average. If the national average were achieved at NUH, 41 bed days per year would be saved (£12,300).

Methods: Online records used to collect retrospective data for patients operated across NUH from Jan 2018 to Dec 2019 (n=134). We calculated mean LoS and analysed the reasons for delayed discharge in patients who stayed for 2-3 days post-operatively (n =47).

Results: Overall mean LoS was 1.72 days, median 2 days. The breakdown for all hemithyroidectomies was as follows: LoS 1 day 59%, LoS 2 days 30%, LoS 3 days 6%, LoS > 3 days 5%. 

No anaesthetic factors were identified as being contributory to extended length of inpatient stay and main reasons for delayed discharge were calcium monitoring and drain output.

Conclusions: Length of stay post hemithyroidectomy at NUH is longer than the national average with no anaesthetic reasons identified as being contributory. Calcium monitoring was appropriate as per British Association of Endocrine and Thyroid Surgeons guidelines. No strong evidence in the literature for drain insertion post-hemithyroidectomy. Potential to reduce LoS of patients who were in hospital for 2-3 days.

Liaise with surgeons to review use of drains, and formulate an ERAS pathway for management of patients undergoing thyroid surgery.

32  Change of routine practice to day case mastectomy: a positive change due to Covid-19

Nikki Green, James Bristol, Fiona Court, Clare Fowler, Richard Hunt, Eleanore Massey, Abigail Tomlins, Sarah Vestey

Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, United Kingdom

Abstract

Introduction: Previously mastectomies were generally considered inpatient procedures. The onset of Covid-19 expedited a planned practice change to day case.

Methods: Data was collected over a 13-month period for patients undergoing mastectomy. Other than the procedure being day case there were no changes to practice and patients were discharged home with a drain. Data was collected from electronic patient records. The significance level was set at 0.05 for statistical analysis.

Results: There was a significant difference in day case mastectomies; 32.8% prior to and 83.0% post Covid-19 onset (Chi-squared =39.2, p<0.00001). In the pre-Covid group 22.2% of patients ≥70 years were day case and 75% in the post-Covid group.

There was no significant difference between complications in the two groups. In the pre-Covid group 10.2% of mastectomies had complications compared to 6.2% in the post-Covid group (Chi-squared = 0.82, p = 0.35). There was a significant difference in seroma aspirations, 42.4% and 25.8% respectively (Chi-squared = 8.46, p = 0.0036) although the number of patient contacts were the same.

The median number of clinic appointments in both groups was 2 routine appointments and 0 appointments for complications. In the latter group 21.1% of extra appointments were virtual.

Conclusions: The Covid-19 induced switch to day case mastectomies as routine was successful and produced no negative impact on complications or resources.

 

34  Anaesthesia service evaluation: a step towards day case nephrectomies at Nottingham University Hospitals NHS Trust

Mia Davis, Nitin Sadavarte, Vishal Thanawala

Nottingham University Hospital, Nottingham, United Kingdom

Abstract

Introduction: The national GIRFT report for Nottingham University Hospitals (NUH) NHS Trust for 2017-2018 has shown that our average Length of Stay (LoS) for nephrectomies is 5.6 days compared to the national average of 5.02 days. Hence, we decided to review current anaesthetic practice for nephrectomies at NUH NHS Trust.

Method: We conducted a retrospective analysis of these procedures from April 2018 to March 2019. Our analysis included evaluation of anaesthetic factors that can potentially influence the LoS.

Results: Our analysis included a total of 127 patients (104 laparoscopic and 23 open). Overall mean LoS was 5.2 days compared to the national average of 5.02 days. 78% in the open surgery group had epidural analgesia with median duration of usage being 3 days and pain scores of 0 in the first 96 hours. 74% in the laparoscopic group had spinal anaesthetic in addition to the general anaesthesia. Of the 74% patients who had spinals, 63% patients had Diamorphine as opioid additive with higher doses (>500 micrograms) corresponding with lower pain scores in recovery room. All patients in the laparoscopic group had none or mild pain in the first 72 hours post-operatively.

Conclusion: The LoS has reduced as compared to the previous year. However, using multi-disciplinary approach, careful patient selection and formulating an ERAS pathway can help us reduce the LoS even further. We are collaborating with surgical colleagues to introduce an ERAS pathway with an aim to perform laparoscopic surgery as day case for a select few in near future.

 

35 Effect of Covid-19 on waiting list turn downs for oral surgery procedures under GA at the Royal United Hospital, Bath.

Charlotte Devine, Adam Holden

Royal United Hospital, Bath, United Kingdom

Abstract

Introduction:  When the Covid-19 pandemic started all elective operations under GA in the oral surgery department were suspended at the Royal United Hospital, Bath. When elective activity was restarted patients had to self isolate for either 3 or 14 days depending on their individual risk assessment. In October 2020 trusts had to clinically validate their surgical waiting lists in order to produce accurate figures and to record the number of patients wishing to postpone their surgery but remain on waiting lists. The aim of this project was to assess the effect of Covid-19 on waiting list turn downs for elective oral surgery procedures under GA.  

Method: Data was collected from the validated surgical waiting list and patients that turned down appointments were categorised as P5 (delay due to Covid-19) or P6 (delay for another reason) for October–December 2020. This was compared to waiting list turn downs for the same period in 2019.  

Results: 22 patients turned down appointments for surgery from October to December 2020. 18/22 turned down appointments due to Covid-19 (P5), with 7/18 citing the inability to self-isolate as the reason for their turn down. 4/22 turned down appointments for other reasons (P6).  

Conclusions: The number of waiting list turn downs for oral surgery procedures under GA was higher during October–December 2020 compared to the same period in 2019. The inability to self isolate was the most frequent reason for waiting list turn downs, highlighting the effect the Covid-19 pandemic had on waiting list turn downs. 

36 Length of stay after elective laparoscopic cholecystectomy at Peterborough City Hospital: a complete audit cycle

Francesca Muscara, Zainub Bazeer, Jade Stephenson, Akash Abraham, Lianne Davey-Smith, David Chittenden, Andrew Tsang, Ling Ong

North West Anglia NHS Foundation Trust, Peterborough, United Kingdom

Abstract

Introduction: Laparoscopic cholecystectomy (LC) is the surgical treatment of choice for symptomatic gallstones. It has been shown to be an effective day-case (DC) procedure in more than 90% of patients. The British Association of Day Surgery (BADS) directory provides 75% as target for LC performed as DC. The aim of this re-audit was to provide a comparison of DC rates between audit (A) and re-audit (RA) and to identify the factors still leading to failed discharge and readmission for LC.

Methods: Retrospective analysis of patients who underwent elective LC, between September 2017 to June 2019 (3 month comparison), at Peterborough City Hospital (PCH).  Medical records were analysed to collect the relevant data points including patient demographics, grade of operating surgeon, complications, causes of failed discharges and readmission within 30 days.

Results: A total of 110 (A) and 127 (RA) patients were analysed (mean age: 51 audit, 52 re-audit). Mean length of stay was 1.62 days (range 1- 4) and 0.62 days (range 1-11) respectively.  The yearly DC rate improved from 77.69% to 79.40%. Causes of prolonged length of stay included post-operative complications (64.5% A vs 28.9% RA) and social reasons i.e lack of carers (12.9% A vs 10.5% RA).  6 (5.4%) patients were readmitted within 30 days in the audit compared to 11 (8.46%) in re-audit.

Conclusions: Implementing a standardised patient pathway for LC has increased DC rates at PCH. Default DC booking for elective LC remains safe and effective with a minimal inpatient stay.

37 EMERGENCY DAY CASE SURGERY TO EASE PRESSURES CAUSED BY COVID-19

Lewis Powell, Geraint Rees, David Price

Prince Charles Hospital, Merthyr Tydfil, United Kingdom

Abstract

Ambulatory emergency surgical procedures often require short and uncomplicated surgical interventions that are well suited to the day surgery environment. These procedures include; emergency retrieval of products of conception (ERPCs), perianal abscess drainage and tooth extraction. Despite this, patients are often admitted to hospital for logistical reasons, awaiting COVID swabs and theatre space. These patients are often otherwise fit and well, are then excessively fasted and often have their procedure cancelled or delayed until the subsequent day. This leads to unnecessarily long hospital admission at a time where capacity limits are already being stretched like never before.

Innovative pathways are therefore required to ensure resources are used efficiently. This has led us to development an emergency day case (EDC) pathway to be used in such cases, utilising a protected bed space on the day surgery ward. On initial assessment, if deemed suitable for EDC surgery, they are seen and consented by the surgical team who organise:

• An anaesthetic review 
• Rapid COVID test 
• Book the patient as an EDC (currently one theatre slot per day). 

The patient is then discharged and asked to self-isolate with their household. On admission they have a protected bed space, are first on the morning CEPOD list (delayed only for category 1 surgery), and reviewed in a timely manner post-operatively by both the surgical and anaesthetic team to facilitate discharge. This protocol will help not only with bed capacity but improve patient experience and prevent logistical overnight admissions. 

 

38  Compliance with PROSPECT Guidelines for Rotator Cuff Repair Surgery.

James Hudson, James French

Nottingham University Hospitals, Nottingham, United Kingdom

Abstract

In August 2019 the PROSPECT Group published guidelines for the management of rotator cuff repair surgery (RCRS), outlining 5 recommendations to improve postoperative pain relief and rehabilitation:

1. RCRS should be performed arthroscopically
2. Perioperative systemic analgesia continued postoparatively
3. Interscalene block regional technique
4. Single dose iv dexamethasone
5. Opioids prescribed postoperatively for rescue analgesia 

We conducted a retrospective audit of compliance with these recommendations between 1^st January and 30^thSeptember 2019 at Nottingham City Hospital, a large teaching centre.  We searched our theatre computer system for all patients having elective shoulder surgery and reviewed the medical notes of all those having RCRS.

There were 219 shoulder operations during this period; 80 (36.5%) of which were RCRS.  All were performed arthroscopically, under an interscalene block with most only requiring minimal supplementary sedation and/or alfentanil boluses intraoperatively. Only one patient received perioperative simple analgesia and although 78 (97.5%) were prescribed post-op paracetamol, only 42 (52.5%) were prescribed NSAIDs.  22 patients (27.5%) were given intravenous dexamethasone intraoperatively of which 10 were given 6.6mg and 12 had 3.3mg.  76 patients were prescribed postoperative opioids for rescue analgesia.

We concluded that although we were doing well in certain areas with the vast majority of RCRS being performed arthroscopically, under interscalene block with rescue post-op opioids; we fell short regarding intraoperative simple analgesia and dexamethasone as well as postoperative NSAIDs.  We discussed these findings at a departmental meeting, produced a poster promoting the PROSPECT recommendations and plan to reaudit compliance in the future. 

 

39 The current impact of regional anaesthesia in breast day surgery

Euan Kerr, Miriam Stephens

University Hospital Wishaw, Lanarkshire, United Kingdom

Abstract

Prior to the COVID-19 pandemic there were plans to increase day surgery rates for breast cases within Lanarkshire. As anaesthetists, we pursued the use of more regional anaesthesia (RA) to facilitate this. The authors were interested to see if this change has impacted day surgery frequency in this surgical specialty.

Cases from May–December 2020 were requested via local Information Management using Opera coding to include mastectomies, wide local excisions +/- sentinel node biopsies.

The data show 79.3% (23/29) of breast cases were performed as day surgery. Only 17% had RA by the anaesthetist. Another 27% had local anaesthesia administered under direct visualisation by the surgeon. Of the six inpatient cases, five had RA, three were high risk patients, two had extensive surgery (radical and bilateral mastectomies) and one was a high risk patient with chronic pain issues. All but one were discharged the day following their surgery.

This audit shows our rates of RA have fallen. Our mastectomy day surgery rate has risen to 61.5% from 21.5% in 2018. COVID-19 has severely impaired service development and quality improvement. Progress made in training anaesthetists who cover these lists has been lost due to ICU redeployment and current capacity for elective surgery results in no consistency in the anaesthetist attached to the breast list. Many breast surgery cases are being done in the private sector in a fitter patient population. Re-audit will be required to assess the true impact of RA in breast day surgery once practice returns to pre-pandemic normality.

40  Day case major trauma surgery in the COVID-19 pandemic

Matthew Clark, Anil Hormis, Kingsley Draviaraj, Steve Blair, Nikhil Nanavati

Rotherham NHS Foundation Trust, Rotherham, United Kingdom

Abstract

Introduction: The COVID-19 pandemic has presented new challenges in surgery. Due to bed pressures, many Trusts have aimed to treat more patients in an ambulatory setting by increasing the use of regional anaesthesia.  Here, we describe two cases of major trauma surgery undertaken during the COVID-19 pandemic that would have usually required inpatient admission. 

Methods: A retrospective, patient note review was performed. 

Results:

Case 1

A 51-year-old female sustained a complex distal humerus fracture (AO 13C3) following a fall.  Surgical fixation was performed with 2 locking plates via a posterior approach under general anaesthetic with an ultrasound-guided supraclavicular block. Surgical time was 180 minutes. She was discharged the same day at 18:10 with oral analgesia and the regional block lasted until the following morning. Follow-up was uneventful.

Case 2

A 49-year-old male sustained a right tibial plateau fracture (Schatzker 2) following a slip on ice. Co-morbidities included high alcohol intake and high BMI. Surgical fixation with locking plate was performed 6 days following injury under a low-dose spinal anaesthetic (including opioid) and local anaesthetic infiltration on a day-case pathway. Total surgical time was 70 minutes. The patient was discharged at 16:35 with oral analgesia. The regional block lasted until 18:00 the same day. Follow-up was uneventful. 

Conclusion: With enhanced communication and agreed day-case pathways, more major trauma surgery could be performed in a day case setting. This will help protect inpatient beds and will  evolve the way in which trauma patients are managed in the post-COVID era.

41 Successful Day Case Uni-compartmental Knee Replacement (UKR) at the Rotherham Foundation Trust

Rory Colhoun1, Alex Anderson1, Matthew Hampton2, Andrew Legg1, Kim Russon1

¹The Rotherham NHS Foundation Trust, Rotherham, United Kingdom. ²Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom

Abstract

Introduction: Knee osteoarthritis is a tremendous healthcare burden. Inpatient beds are often a limited resource. BADS recommends that 40% UKR should be performed as day case. We describe our day case UKR pathway which has continued during the Covid-19 pandemic.

Method: Patients were scheduled first on a morning list. Prospective data was collected. From August 2019 post-discharge telephone call also asked about satisfaction of being a day case.

Results: 33 patients undergoing UKR utilised the pathway April 2019 – January 2021. 

88% of cases were spinal anaesthesia and 12% general anaesthesia(GA) Spinal anaesthesia was with heavy prilocaine 2% only: 15(52%) and with intrathecal opiate: 14(48%) All patients had local infiltration by the surgeon. 

Mean time from anaesthetic room to discharge was 7.5hours, 94% were ready for discharge within 9 hours. One patient was ready for discharge at 3 hours.

Low pain scores prior to recovery discharge (n=28): none 86%, mild 11% and moderate 3%.

Home pain scores 

• At rest (n=30): None 13%, mild 40%, moderate 37%, severe 10 %
• On movement (n=28): None 4%, mild 32%, moderate 43%, severe 21%. 
• Of the patients asked post data collection modification (n=17) 88% were glad they went home the same day. 
• Only one patient transferred to inpatient –they were the second UKR on the list and unable to safely mobilise.
• No readmissions.

Conclusions: Day case UKR can be done safely with good patient satisfaction despite relatively high pain scores and enables patients to have these procedure despite no inpatient Orthopaedic beds during Covid-19 pandemic.

42 Ensuring safe and timely discharge following spinal anaesthesia for day case; creation of nurse-led discharge criteria at Airedale General Hospital.

Victoria Peacock, Sally Dunlop

Airedale General Hospital, West Yorkshire, United Kingdom

Abstract

Introduction: Spinal anaesthesia for day-case has become more accessible since licensing of Prilocaine and 2-Chlorprocaine. COVID-19 has increased its popularity due to lack of aerosol generation; reducing risk to patient and staff and expediting theatre turn-around times.

BADS and AAGBI recommend that proforma-led discharge following day surgery is essential to ensure safety.  Our current proforma does not cover spinal anaesthesia.

Methods: Between August and October 2020 we audited current practice in spinal delivery and time to discharge to determine where we could improve services and create a safe discharge proforma.

Nursing staff on day-surgery ward were surveyed to ascertain understanding of agents used, recovery times and procedures for assessing block regression and safe mobilization.

Results:

Audit revealed slower times to stand with both Prilocaine and 2-chlorprocaine than quoted in the literature; 4.25hrs Prilocaine vs 2.9hrs 2-chlorprocaine.

There was large heterogeneity in knowledge, block assessment and methods for standing patients.

Action

We have developed a single sided A4 proforma for assessing block post spinal and ensuring safe mobilisation using three simple, reproducible tests; sole sensation, hallux proprioception and straight leg-raise. Tests were chosen from most reliable on literature review. 

Tea trolley teaching took place for nursing staff regarding newer spinal agents, rationale for day-case spinal, use of the proforma and how to perform the tests.

Initial feedback on the teaching and proforma has been positive. We anticipate this will standardize care and prompt timely discharge. This will be re-audited in 3 months to ascertain effect on discharge times and nurse satisfaction.

 

43 High dose Botulinium Toxin A as a pharmacological sphincterotomy for chronic anal fissure: Does it work better?

Shrinivas Kalaskar^1,2, Jacek Adamek³, Olushola Ajayi¹

¹Darent Valley Hospital, Dartford, United Kingdom. ²Queen Mary's hospital, Sidcup, United Kingdom. ³Darent Valley hospital, Dartford, United Kingdom

Abstract

INTRODUCTION:  The aim of this study was to evaluate the clinical results of two different doses of botulinum toxin for the treatment of chronic idiopathic anal fissure.

METHODS: Forty patients with chronic anal fissure were included in a nonrandomized, retrospective study of intrasphincteric injection of botulinum toxin A. All patients reviewed post-operatively in a colorectal clinic.  Twenty one patients undergoing a 50-U injection of diluted botulinum toxin A constituted the first group. In a second group 19 patients were injected 100-U injection of diluted botulinum toxin A. All patients were followed up at 6-8 weeks.

RESULTS: 21/40(52.5%) patient received 50 units of botox injection and 19/40(47.5%) patients received 100 units of botox. One patient from first group was lost to follow up. The age and sex distribution was similar in two groups. Pain relief at first follow up after treatment was  60 percent of patients in the first group and  78.9 percent in the second group. 30% percent of the patients in the first group, 16% percent in the second group were re-operated during the follow-up period. There was one patient from second group who reported incontinence but on anal manometry his resting and squeeze pressure were normal.

CONCLUSIONS: High dose injection of botulinum toxin is a reliable option in the treatment of chronic anal fissure. The healing rate is related to the dose. No permanent damage to the continence mechanism was detected in these patients. However we recommend careful selection of patient and a robust consent process.

 

44 Treatment of Microcystic Adnexal Carcinoma in a 52 year old female patient during the COVID-19 Pandemic

Laura Wade, Nick Hampton

Morecambe Bay Hospital Trust, Lancaster, United Kingdom

Abstract

Introduction:Microcystic Adnexal Carcinoma (MAC) is a rare malignant sweat gland neoplasm. It is slow growing and locally aggressive but rarely metastasises. There have only been a few hundred cases described worldwide¹. During the COVID-19 pandemic, much elective surgery has been postponed, but due to the malignant nature of the lesion, this day case surgery was able to go ahead.

Methods: A 52-year-old female patient presented with a nodular lesion of the right medial eyebrow. Punch biopsy described a moderately differentiated Squamous Cell Carcinoma. The lesion was excised and repaired with a local skin flap, and definitive histology reported MAC with 3mm margins. The case was discussed at a virtual multi-disciplinary team meeting which advised wider excision, and subsequent repair was with a supraclavicular full thickness skin graft. Both procedures were carried out as day cases; the patient was tested for COVID-19 and isolated beforehand.

Results: Histology described a highly infiltrative tumour not connecting with the overlying epidermis. It was composed of cords and nests of cells, manifesting ductular and follicular differentiation. The carcinoma invaded subcutaneous fat and perineural tissues. The cells were positive for cytokeratin AE1/AE3 and negative for BerEP4, favouring the diagnosis of MAC. Owing to the aggressive potential of this tumour, a wider margin of clearance was advised, the result of which was negative for malignancy.

Conclusion: MAC is a malignant tumour which often microscopically exceeds macroscopic margins, and presents clinically as a benign slow-growing lesion. This case follows the treatment of MAC during the COVID-19 pandemic.

45  An Audit on Prophylactic Prescribing for Third Molar Surgery

Kirandeep Nandhra^1,2, Paayal Shah³, Aruna Ubhi³

¹Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. ²Bedfordshire Hospitals NHS Trust, Dunstable, United Kingdom. ³Bedfordshire Hospitals NHS Trust, Dunstable, United Kingdom

Abstract

Introduction: Over-prescription of antibiotics gives rise to problems including increased risk of adverse antimicrobial reaction and antimicrobial resistance. Despite this, the ‘routine’ prescription of prophylactic antibiotics following lower third molar removal (LTMR) remains common practice.

The current body of evidence shows minimal to no statistically significant difference in the incidence of postoperative infection between prescribing and withholding prophylactic antibiotics for LTMR in healthy individuals. 

There is currently no published guidance on appropriate antibiotic usage following LTMR.

Method: A single centred, retrospective review of 100 successive patients undergoing LTMR.

In the absence of current guidance, standards of specific criteria to justify antibiotic prophylaxis were formed. Primary outcome measures included appropriate prescription of prophylactic antibiotics, and record of clinical indication for antibiotic prescription. 

Following dissemination of results and implementation of suggested improvements, a 2nd audit cycle has commenced. 

Results:

• Cycle 1 (n=100) (Nov 2019 - April 2020) 
• 52% of patients received prophylactic antibiotics following LTMR. 
• Only 9% had a clear appropriate justification for use. 
• 27% of antibiotics were not prescribed in accordance with BNF or SDCEP guidance. 
• There were 0 postoperative infections within this cohort. 

Conclusion: Over-prescription of antibiotic prophylaxis with inadequate documented justification for use is clear. All clinicians have a duty to consider the rising incidence of antimicrobial resistance and reflect this in their practice. The use of prophylactic systemic antibiotics in LTMR should be limited to cases where it may be deemed to show clinical benefit in patient best interest on both an individual and community scale. 

 

47  Introduction of 1% 2-chloroprocaine for day case spinals in a District General Hospital - The Rotherham NHS Foundation Trust

Maria Rehnstrom, Kim Russon, Anil Hormis

The Rotherham NHS Foundation Trust, Rotherham, United Kingdom

Abstract

Introduction: Historically the preferred anaesthetic technique for day surgery has been general anaesthesia despite  benefits offered by spinal anaesthesia, due to concerns about time delays in performing spinal anaesthesia, prolonged motor block and potential complications. The newer short acting intrathecal local anaesthetic 1% 2-chloroprocaine has transformed spinal anaesthesia for short (<1hour) day surgical procedures¹. We evaluated the introduction of intrathecal 1% 2-chloroprocaine to our hospital.

Methods: Data collection included drug dose, motor and sensory block achieved, time of spinal, surgery start and finish times, time ready for discharge home and post op follow up phone call.  

Results: Since the introduction of 1% 2-chloroprocaine in January 2019, 42 forms have been completed. It has mostly been used for orthopaedic operations(76%) and also used for gynaecology(12%), urology(7%) and general surgery(5%) procedures.

Mean time from spinal injection to patient being ready for surgery was 6minutes (Range 3-16 minutes).

Mean time from spinal injection to patient being able to stand was 138minutes (range 0-338 minutes)

Mean time to discharge was 185minutes (range 90-364 minutes).

One case was converted to general anaesthesia due to possible high spinal but no other complications were reported.

Conclusions: 1% 2-chloroprocaine is safe and reliable in providing spinal anaesthesia for suitable day surgery operations with minimal time delays until start of surgery and good patient satisfaction. Patients can generally mobilise within 2hours and be discharged within 3 hours.

References:

1. Rattenberry W, et al. Spinal anaesthesia for ambulatory surgery. BJA Education. 2019. Vol 19, issue 10, p321-329.

48  Asking day surgery patients to provide their own painkillers: Financially beneficial to the NHS and acceptable to patients

Annie Evans¹, Samahir Hussein², Kim Russon²

¹Greater Glasgow and Clyde NHS Trust, Glasgow, United Kingdom. ²The Rotherham NHS Foundation Trust, Rotherham, United Kingdom

 

Abstract

Introduction: In 2018, the National Health Service(NHS) spent over £43,000,000 on paracetamol. Average cost is £2.36 per item e.g.16-tablet pack of paracetamol^[1]. Purchased over the counter a 32-tablet pack of Boots paracetamol costs 80p. If patients purchased their paracetamol, it would save the NHS £35,000,000 annually. 

This project aimed to investigate which painkillers day surgery patients had at home and if they think it is reasonable to be asked to purchase painkillers in preparation for their surgery.

Methods: Between 13^th- 31^st January 2020 all patients having day surgery at Rotherham Foundation Trust undertook a questionnaire pre-operatively:

1.Do you have painkillers at home? 

2.Did you buy painkillers in preparation for your surgery? 

3.Are there any painkillers that you can’t take? 

4.Did anyone advise you to purchase painkillers before your surgery? 

5.If yes, did you mind being asked? If no, do you think it is reasonable to ask?

Results: 138 patients completed the questionnaire. 82% of patients had painkillers at home, predominantly paracetamol(79%) and ibuprofen(32%). 15% of patients had purchased painkillers in preparation for their surgery. 19% of patients could not take all painkillers. 15% had been advised to purchase painkillers. Of these, 100% thought this was reasonable. Of the other 85%, 94% thought this would have been reasonable to ask.

Conclusion: The NHS can benefit financially if patients purchase their own pain relief pre-operatively and most patients are happy to do this.

Reference:

[1] NHS Digital(2018). Prescription Cost Analysis [Prescription Cost Analysis 2018 – Tables] https://digital.nhs.uk/data-and-information/publications/statistical/prescription-cost-analysis/2018

 

49  Improving day surgery rates of anterior cruciate ligament reconstruction surgery

James Lucocq, Mostafa Khalil, Louise Roberts, Stephen Dalgleish, Arpit Jariwala

Ninewells hospital, dundee, United Kingdom

 

 

Abstract

Introduction: Current guidance advises that at least 90% of anterior cruciate ligament reconstructions are performed as day case operations. Same-day surgery rates achieved by surgical units have significant clinical and financial implications. The primary aim of this multi-centre study was to determine the rate of admission and causes for admissions in patients undergoing anterior cruciate ligament reconstruction.  

Methods: Patient documentations were studied for those who underwent an elective anterior cruciate ligament reconstruction between January 2015 and April 2019. Contributing factors related to admission length were investigated and included patient age, gender, body mass index (BMI), operating surgeon, operating hospital, American Society of Anaesthesiology (ASA) grade, and position of the patient on the operating list. Both univariate and multivariate analysis were conducted using the STATA/IC 16.1 statistical package.

Results: The day surgery rate of anterior cruciate ligament reconstruction was 52% (50/95). Patients positioned later on the operating list were more likely to be admitted post-operatively (OR – 4.49; p=0.002; 95% CI – 1.72-11.69) and this was the only factor associated with admission. A large majority of admitted patients (95.6%) were admitted without a clinical cause and were otherwise safe for same-day discharge. 

Conclusions: The day surgery rate for ACL reconstruction remains low, despite an extremely low complication rate. Reconfiguration of the operating lists and positioning anterior cruciate ligament reconstructions earlier in the day will likely increase the same-day discharge rate and reduce associated costs.

50  Differences in the Rates of Day Case Orchidopexy and Hypospadias Repair in a Paediatric Surgery Department compared to GIRFT data

Christopher Lewis-Lloyd, Michael John, Gregory Shepherd

Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

Abstract

Introduction: “Get It Right First Time” (GIRFT) is a programme designed to improve the quality of care within the NHS by reducing unwarranted variations. However, GIRFT 2014-2016 data reported our Paediatric Surgical Department’s day case Orchidopexy and Hypospadias repair rates as 78% and 30% respectively. A figure disproportionately less than observed in our practice. Therefore, we sort to determine these operations’ day case rates within our department.

Methods: Hospital episode data was collected retrospectively on all patients coded within the Trust’s database undergoing either orchidopexy or hypospadias repair in 2018. Patients aged >18-years-old, undergoing emergency surgery and/or planned for inpatient admission were excluded. Included patients’ medical records were reviewed to ascertain why children planned for day surgery stayed overnight. The audit was registered and approved by the Trust (19-074C).

Results: Orchidopexy: Of 149 patients, 12 were excluded with 5 planned overnight admissions. 30 attended non-day case wards (30/137, 21.9%) with 4 unplanned overnight stays. Day case rate 97.1% (133/137). Hypospadias repair: 40 patients with no exclusions. 8 attended non-day case wards (8/40, 20.0%) with 3 unplanned overnight stays. Day case rate 92.5% (37/40). Reasons for unplanned overnight admission for both procedures were anaesthetic and analgesic complications.

Conclusions: Most patients are successful day case admissions attending ambulatory/day case wards. Comparison of locally sourced data, and that obtained remotely by GIRFT has demonstrated a significant discrepancy. How such data is transferred to and analysed by GIRFT needs further review to facilitate accurate comparison of care in different centres.

51  “Do they need a bed?” Wide Local Excision of the Breast – the 2020 experience.

Matthew Leaning

Caboolture Hospital, Caboolture, Australia

Abstract

Introduction: Through the COVID-19 pandemic concerns have been raised about its impact on cancer surgery. The breast wide local excision(WLE) is a cornerstone of modern breast surgery. Maintaining elective breast surgery is vital in treating both premalignant and malignant breast lesions. 

Methods:  Retrospective study of patients who underwent planned WLE in a single Australian metropolitan hospital in 2020. Primary outcome measure was failure to discharge on day of operation. Secondary outcomes were unplanned readmission and unplanned reoperation within 30 days. 

Results:  66 patients underwent WLE. 18 patients (27.3% (95% confidence interval 16.5-38.0%)) failed to be discharged on the day. Failure of discharge was higher amongst patients undergoing concurrent sentinel lymph node biopsy (34.4%) and axillary clearance (100%) although did not reach significance. 41.2% of patients with invasive disease failed to be discharged on the day of surgery. Two patients had unplanned readmissions within 30 days and there were no unplanned returns to theatre. There was no significant difference in ASA or age between patients discharged on the day of surgery and those admitted. 

Conclusions: The reasons for admission following WLE may be psychosocial as much as surgical. Admission affords patients further support and education with particular focus on drain and wound management. This study demonstrates WLE is safe with low rates of readmission and return to theatre. With COVID-19 placing stress on hospital beds and the widespread adaptation of regional anaesthetic techniques and telehealth, perhaps these patients could be better managed at home, in the immediate post-operative period. 

 

52  Elective day-case hernia repairs in the midst of a global pandemic. A single centre experience.

Matthew Leaning

Caboolture Hospital, Brisbane, Australia

 

Abstract

Introduction: Hernia repair is one of the commonest operations globally. The COVID-19 pandemic placed significant stress upon the hospital system, both bed occupation and PPE utilisation with a reduction in operating. It is well established that elective repair of hernias reduces the rates of incarceration and strangulation and thus it is paramount that this service is maintained throughout these unprecedented times. 

Methods: Retrospective study of patients who underwent planned day-case hernia repair in a single Australian metropolitan hospital in 2020. Primary outcome measure was failure to discharge on day of operation. Secondary outcome measures included unplanned readmission and unplanned reoperation within 30 days. 

Results: 372 patients underwent elective hernia repair. Overall, 12.4% (95% confidence interval (C.I) 9.0-15.5%) of patients failed discharge. There was no significant difference in re-admission rate between patients discharged on the day of operation (5.2% (95% C.I 3.0-7.5%)) and those who remained in hospital overnight (4.2% (95% C.I -1.5-10.2%)). Three patients (0.7%) had unplanned returns to theatre. Patients who failed to discharge were significantly older (61.5 years (95% C.I 57.1-66.0) vs 51.5 years (95% C.I 49.9-53.1), there was no significant difference in ASA grade. Incisional hernia repairs had the highest rates of failure to discharge 33.3% (95% C.I 11.6-55.1%). 

Conclusions: Day-case elective hernia repair remains safe and feasible, with higher rates of readmission and reoperation likely related to advanced age and procedural complexity. The low rates of readmission and reoperation suggest that more elective hernias could be performed as day-cases and this service maintained, throughout the pandemic.

53  Left-femoral compressive neuropathy secondary to iliopsoas haematoma after elective open inguinal hernia repair with mesh.

Matthew Leaning

Caboolture Hospital, Brisbane, Australia

Abstract

Case Report: A 79-year-old, comorbid gentleman with atrial fibrillation and Parkinson’s Disease was referred with a symptomatic large left inguinoscrotal hernia. He was booked for an elective day case open mesh repair and his anticoagulation withheld prior. He underwent an uncomplicated modified Lichtenstein repair with a mesh. He was restarted on anticoagulation on day 3. He represented on day 5 with a haematoma extending from the incision into the scrotum. He was returned to theatre 4 times for wound explorations and washouts and repeated computerised tomography failed to demonstrate any arterial blushes. Later an orchidectomy was performed before finally a incision and drainage of an infected scrotal collection. Due to recurrent bleeding his anticoagulation was ceased. 

Three weeks after his final return to theatre, he developed severe left leg pain and swelling. Multiple imaging modalities revealed inflammation in the iliopsoas muscles and later an iliopsoas haematoma plus a common femoral vein thrombosis. He was restarted on anticoagulation.  The haematoma increased in size and the patient developed anaemia necessitating multiple transfusions. Clotting profile was normal. The anticoagulation was therefore ceased, an inferior vena filter placed and a radiological guided drainage of the haematoma performed. Electomyography confirmed severe degeneration of the femoral nerve. 

Conclusion: Iliopsoas haematoma resulting in femoral neuropathy is well described in the literature. This unusual case of multiple recurrent bleeding events highlights the challenges of elective day case hernia repair in the comorbid patient and the balance between preventing venous thromboembolism and the risk of haemorrhage after surgery. 

 

54  Day Case Arthroplasty: The patient perspective

Aman Jain, Peter Cay, Christopher Booth, Richard Jones

St Richards Hospital, Chichester, United Kingdom

Abstract

Day case arthroplasty can be seen as a solution to improving hospital efficiency. Reducing inpatient length of stay could lead to a reduction in waiting lists, and lead to improved outcomes. With pressure on beds halting elective activities, a day case service may provide a strategy to maintain an arthroplasty service. The aim of our study was to establish patient perspectives on day case arthroplasty, to inform the setup of a patient-centered day case service. 

Through a structured questionnaire, anonymous data was collected during preoperative assessment for patients awaiting joint replacement. Through targeted questioning key concerns were explored, including those surrounding discharge planning, anaesthetic complications and potential changes in rehabilitation protocol. Patient preference for day case arthroplasty was established. The data was analyzed using both qualitative statistics method and quantitative thematic analysis.

From the questionnaires distributed we have received 38 responses. Demographics are in-line with the expected cohort undergoing arthroplasty, with an average age of 66. The perception of post-operative pain was the main concern identified, with minor themes being wound healing and access to medical therapy via primary care. Due to patient perception of arthroplasty, 42.1% patients would choose day case arthroplasty over traditional rehabilitation protocols. 

Our results highlight potential barriers to the uptake of day case arthroplasty. For introduction of more efficient rehabilitation protocols it’s key to address these concerns, and set appropriate patient expectations pre-operatively. Through this we believe that day case arthroplasty can help provide an improvement in hospital bed pressures and improving patient outcomes.

56  Conscious Sedation During the COVID-19 Crisis

Ali Rizvi, Lucy Erskine, Adeel Mughal, Luis Bruzual

Russells Hall Hospital, Dudley, United Kingdom

Abstract

Introduction: COVID-19 has halted general anaesthetic (GA) oral surgery (OS) procedures nationwide. Our hospital offers OS to be done under intravenous sedation (IVS) with  midazolam. A current trend our department has noticed, is that patients who were previously listed to have OS under GA, have decided to reschedule their appointments to have treatment done under IVS instead. 

Why GA instead of IV? Many patients cite anxiety for infrequent dental attendance due to a previous adverse experience. “Just knock me out” is a commonplace phrase when discussing treatment options with anxious patients. Do they require unconsciousness to accept the procedure or are simply uninformed of the option of IVS to aid them with treatment? 

Discussion: Sedation offers an agreeable alternative to a GA, especially during the pandemic. Carefully performed conscious sedation is much safer, has fewer complications and is easier to reverse than a GA.  On-clinic sedation offers shorter contact time, limiting the risk of patients catching COVID-19 from other individuals. Outpatient treatment can continue when GA lists are cancelled due to the need to increase hospital bed capacity during the crisis.

Conclusion: IVS has paved the way for complex OS procedures carried out on anxious individuals in a hospital setting. Should we be looking through the waiting list of patients going for a GA and contact them to advise them that their procedures can be carried out under IVS instead? This is to reduce the GA waiting list and the expenditure for our NHS trust.

 

57 Audit of anaesthetic techniques used in day surgery laparoscopic cholecystectomies

Clementina Calabria, Amanda Bull

Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Abstract

Introduction: Laparoscopic cholecystectomies are performed routinely as day cases resulting in improved outcomes and a high level of patient satisfaction. Delayed discharge is multi-factorial: surgical complications, post-operative nausea and vomiting (PONV) and poorly controlled pain can all result in the patient’s inability to meet nurse-led discharge criteria. Recommendations by the Association of Anaesthetists and British Society of Day Surgery highlight the importance of optimising anaesthetic technique to ensure a rapid offset of anaesthesia, minimal PONV, and adequate analgesia. We reviewed the anaesthetic technique employed in our department to elucidate and highlight areas for improvement in this rapidly growing service.

Methods: Forty-four patients admitted for laparoscopic cholecystectomies were identified at the Royal Infirmary of Edinburgh over a 6-week period. Data was collected from anaesthetic charts. The project was registered with the local quality improvement team.

Results: Of the 44 patients undergoing the procedure only 13 patients (30%) were discharged on the day of surgery and 10 (23%) of patients were kept overnight due to surgical issues. Intra-operatively: 38 patients (86%) were administered morphine. Only 57% of patients were given paracetamol and 31% received a non-steroidal. 100% of patients received a volatile anaesthetic, with 4 patients receiving nitrous oxide. 13 (30%) of patients received a single anti-emetic. The majority of patients received more than 1 litre of fluid intraoperatively. 

Conclusion: To improve discharge rates in our unit, we recommend optimisation of anaesthetic technique by employing opioid- sparing multi-modal analgesia, dual anti-emetics and consideration of alternatives to volatile anaesthesia.

59  The Impact of the SARS-CoV-2 Pandemic on General Anaesthetic Day Surgery Within the Royal Gwent Maxillofacial Department

Alexandra Rawlins, Alys Evans, Sajina Ananth

Royal Gwent Hospital Oral And Maxillofacial Department, Newport, United Kingdom

Abstract

Maintaining a safe surgical environment during the SARS-CoV-2 (Covid-19) pandemic has posed substantial challenges to Oral and Maxillofacial Surgery Departments. Our primary aims were to: Identify differences in the quantity and nature of day surgery provided during Covid-19 compared to a baseline period; identify the impact of Covid-19 on cancellations and waiting times for OMFS day surgery; discuss strategies utilised to mitigate the impact of Covid-19 on day surgery.

The time period investigated (1st March – 31^st December 2020) spanned the first, second and early third waves of the Covid-19 pandemic in Wales. Data was collected using the Operating Room Management Information System (ORMIS) and digital patient records. Data inclusion required treatment to be booked during time normally allocated for OMFS general anaesthetic day surgery at the Royal Gwent Hospital in Newport.

Treatment under general anaesthesia reduced from an average of 9.8 cases per week to 0.3, 2.1, and 4.0 cases during progressive waves respectively. Maximum GA waiting times increased from 39 weeks in March 2020 to 115 weeks in January 2021 despite measures to mitigate the impact of the pandemic, including offering expedited treatment under local anaesthesia. Some GA dedicated lists were reconfigured to permit reasonable turnover of day case treatment albeit under LA. Covid-19 became the primary cause for treatment cancellation during the period studied. The restructuring of clinics during recovery from Covid-19 presents opportunities for expanding the range of treatment carried out as GA day surgery.

The COVID-19 pandemic impacted GA day surgery significantly despite extenuating measures taken.

60  Removing the barriers to a ‘greener’ anaesthesia in adult day surgery.

Aaron Sutton, Kath Stenlake

Musgrove Park Hospital, Taunton, United Kingdom

Abstract

Introduction:  In 2020 the NHS declared a climate crisis and committed to become carbon neutral by 2040. Volatile anaesthetic gases account for 5% of COF equivalent emissions (Co2e) for acute NHS trusts. Total intravenous anaesthesia (TIVA) has been shown to be 22 times less polluting than sevoflurane.  However, one of the main barriers to increased TIVA uptake has been equipment availability.  To achieve this TIVA pumps were procured to allow TIVA to always be an option for maintenance anaesthesia in our trust’s day surgery centre (DSC). Choice of maintenance was then audited following their introduction.

Methods: Case demographics, length of surgery and type of maintenance anaesthesia (TIVA or sevoflurane) were recorded electronically over a two week period in our trust’s DSC.

Results: Complete data was available for 58 adult patients. TIVA was used less than sevoflurane (43% vs 57%). Mean age (49.0 vs 49.6), mean case length (45.8 vs 45.6 minutes) and mean recovery time (29.8 vs 29.5 minutes) were similar across both groups.  

Conclusion: Whilst sevoflurane was used more frequently, TIVA use was still significant. TIVA was used 5 times more often in our DSC compared to data from NAP5 and twice as often compared to other NHS trusts. This increased use led to an estimated saving of 101.4kg CO₂e, equal to driving 504 miles in just a two week period. This demonstrates the importance of having equipment available for anaesthetists to choose a ‘greener’ anaesthetic, crucial if the NHS is to achieve carbon neutrality by 2040.

 

61 Unconscious bias: the hidden culture underpinning preoperative pain planning and day surgery practices

Dr Claire Ford

Northumbria University, Newcastle Upon Tyne, United Kingdom

Abstract

Introduction: Cultural research studies attempt to explore the shared practice of a specific group of individuals and try to explain human behaviour and the social interactions which are often deemed as the norm. However, the ‘cultural portrait’ of a specific sphere of practice can often be mispresented, as the surface image is only the tip of the iceberg and it is the invisible internal culture, found beneath the surface, which represents the greatest influence on clinical practice. 

Methods: To examine how culture influences and shapes preoperative pain planning practices; a critical ethnographic methodological approach was adopted, utilising Carspecken’s analytical enquiry framework. Qualitative and quantitative data from observations and interviews were analysed using reconstructive analysis and triangulated with the numerical data that was statistically analysed. 

Results: Over 9 months, 130 hours of practice were observed, and 20 staff interviews were conducted.  Four central themes emerged from the data; however, the finding that was hidden was a negative unconscious bias towards specific surgical specialities and patient gender, which had a direct impact on the levels and depth of preoperative pain conversations and management strategies. 

Conclusions: Unconscious and intuitive processes can serve to protect; however, biases can also be harmful, and can negatively influence clinical decisions and interactions. For the status quo to be changed, healthcare professionals need to be made aware of any potential bias or assumptions and fully understand how these impact on their interactions and pain planning and management decisions.  

 

63  Re-audit of Day Case Hernia repair: compliance with British Association of Day Surgery guidelines

Nayyaamat K Sandhu^1,2, Jezziniah Pheara¹

¹North Tees and Hartlepool NHS Foundation Trust, Stockton on Tees, United Kingdom. ²West Middlesex Hospital, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom

Abstract

Introduction: Hernia repair is our commonest day case procedure and second commonest in unplanned admissions. We viewed our practice in 2018, using British Association of Day Surgery guidance regarding: Process (Patient selection), Organisation: senior clinician involvement, Day Case-appropriate anaesthetic management, nurse-led discharge and Outcomes: Unplanned admission rate<2% Patient satisfaction>85%.

We found areas requiring improvement: High unplanned admission rate (36%), low use of simple analgesics, predominance of General over Spinal anaesthesia (>50% of hernias are open inguinal), using long-acting local anaesthetic agent for Spinals, preemptive use of Morphine. Inconsistent documentation for reason for admission and that patient satisfaction was not measured. We made recommendations to address this and repeated the audit six months later using the same methodology.

Method: The audit was registered with North Tees and Hartlepool NHS Trust. We used the electronic theatre management system, Trackcare to identify all 88 patients who have undergone elective day case hernia repair. A proforma was used to collect data from paper and online notes. Data was analysed to determine whether the recommendations were followed and if it had made any impact.

Results: The unplanned admission rate went from 36% to 33%. Use of simple analgesia increased from 53% to 70% for Paracetamol and from 19% to 30% for non-steriodal agents. No increase in spinal anaesthesia and no uptake of short acting local anaesthetic agents. No change in morphine use.

Conclusion: Recommendation that was easy to adopt (adding simple analgesics) were taken up but change in anaesthetic technique will require more work.

64  The laser ablation of fistula tract for fistula in ano: a retrospective analysis.

Shrinivas Kalaskar^1,2, Olushola Ajayi^1,2, Kazi Ahmed^1,2, jacek Adamek¹

¹Darent Valley Hospital, Dartford, United Kingdom. ²Queen Mary's Hospital, Dartford, United Kingdom

Abstract

Aim: Fistula laser-assisted closure (FiLaC) is an ablation of anal fistula tract using a radial laser-emitting probe is a sphincter-preserving technique. This was a retrospective analysis of the long-term outcomes of 68 patients who underwent laser ablation of the fistula tract. 

Method: Seventy patients with anal fistula underwent the FiLaC procedure.  A loose seton procedure was used as a bridge to laser therapy in 60 patients. An attempt was made to close the internal opening if possible. The surgical procedure consisted of slow withdrawal of Laser fiber with a 12-watt laser emitting at a wavelength of 1470 nm (FiLaC device) resulting in ablation of the fistula tract. The patients were followed up at 4-8 weeks interval. The cure rates need for reoperation, incontinence and any residual symptoms were noted.

Results:  There were no intra-operative complications reported. The median duration of follow-up was 10 (3–16) months. Primary healing was observed in 38(54%) patients. There were 14 (20%) failures after the operation. No patient reported incontinence postoperatively. Six(10%) patients had some minor residual symptoms and they are still awaiting further follow-up. Unfortunately, 12(17%) patients were lost to follow up.

Conclusion: There is an acceptable success rate with the FiLaC procedure. It is a simple, safe, and effective treatment for fistula in ano with preservation of anal sphincter.

 

65  Do Patients Having Day Surgery at The Rotherham Foundation Trust During the COVID-19 Pandemic Feel Safe?

Apurva Jain¹, Kim Russon², Frances Nolan¹, Rosalind Broe¹

¹University of Sheffield, Sheffield, United Kingdom. ²Rotherham Foundation Trust, Rotherham, United Kingdom

Abstract

Introduction: The COVID-19 pandemic has brought unprecedented levels of strain to the NHS, alongside anxieties amongst both staff and patients. As day surgery has been reintroduced, new NICE guidelines¹ have been instituted to ensure patient and staff safety, aspiring to alleviate some of these concerns. We wished to discover the impact on patient experience in day surgery.

Method: Between the 10th-17th December 2020, all patients who had attended the DSU at Rotherham Hospital were telephoned post-operatively to complete a brief questionnaire regarding COVID-19 safety measures for their surgery. Patients were asked if they had self-isolated prior to surgery and if social distancing was maintained during their time at the DSU. All patients gave consent for their responses to be included in this audit.

Results: We collected data from 73 patients. 97% of patients were asked to isolate for a minimum of 3 days prior to their surgery. 3% reported not being asked to isolate at all. 88% of patients were given some form of information regarding what isolation entailed, from various hospital sources. 99% of patients felt appropriately social distanced during their day surgery stay.

Conclusions: Overall, most patients felt adequately socially distanced in our DSU and appropriately informed about isolation. Investigation into why all patients do not receive the Trust guidance on isolation is required.

References:

1. COVID-19 rapid guideline: arranging planned care in hospitals and diagnostic services | Guidance | NICE [Internet]. Nice.org.uk. 2020 [cited 23 January 2021]. https://www.nice.org.uk/guidance/NG179

66  Effectiveness of new discharge policy to reduce length of stay for post-operative breast surgery patients

Jess Cairney-Hill, Nameer Faiz, Faisal Mihaimeed

Newham University Hospital, London, United Kingdom

Abstract

Background: GiRFT’s (Getting It Right First Time) model of analysing data was intended to uncover national best practice. This project was designed to audit the length of stay (LOS) of Breast Surgery patients at Newham University Hospital in comparison with GiRFT national best practice and analyse the root causes and implement changes.

Methods: Retrospective analysis of 6 months of either ‘mastectomy’ or ‘breast excision’ (as defined by GiRFT) cases performed by one NuH firm was performed and LOS collected and analysed. intervention was devised and re-audit undertaken to measure effect. 

Results: Of the dataset it was found that 78% of Mastectomy patients overstayed and median LOS was 4 days. For Breast Excision 43% overstayed and median LOS was 0 days. On notes review it was found that 100% of Mastectomy overstays and 15% of Breast Excision overstays were due to inpatient observation of postoperative-drain. A new policy was implemented to discharge patients with drain in-situ for outpatient review on day 4. LOS in the subsequent 4 months was then re-audited. Percentage of patients overstaying on reaudit was 43% and 27% for mastectomy and breast excision respectively. median LOS was 1 day for Mastectomy and 0 for Breast Excision. 

Conclusions: Implementing outpatient review of drains resulted in a  41% reduction of patient overstay after Mastectomy and 38% reduction in overstay after Breast Excision. Median LOS for Mastectomy fell from 4 days to 1 making this a viable day surgery procedure leading to reduced post-operative complications and better turnover of patients. 

67 A Multi-Centre Survey of Practice of Day Case Spinal Anaesthesia

Annie Evans^1,2, Abigail Forsyth³, Vicky Lowden⁴, Sarah Capper³, Kim Russon⁴, Anil Hormis⁴

¹Greater Glasgow and Clyde NHS Trust, Glasgow, United Kingdom. ²University of Sheffield Medical School, Sheffield, United Kingdom. ³Chesterfield Royal Hospital, Chesterfield, United Kingdom. ⁴The Rotherham NHS Foundation Trust, Rotherham, United Kingdom

Abstract

Introduction: Many day case procedures are performed under general anaesthesia despite their suitability for spinal anaesthesia. The Royal College of Anaesthetist’s recognises that there is the opportunity for increasing day case spinal anaesthesia rates¹. We surveyed anaesthetist’s familiarity with day case spinal anaesthesia and reasons for not using this technique.

Methods: Anaesthetists from The Rotherham Foundation Trust, Barnsley Hospital and Chesterfield Royal Hospital were surveyed between January and August 2020.

Questions asked included which drugs were used; what dose; whether an opiate was added; likelihood of performing  a day case spinal anaesthetic in the next month and any reservations about day case spinal anaesthesia.

Results: 81% of the 94 anaesthetists surveyed had performed a day case spinal in the past year. Drugs used were: 2%hyperbaric prilocaine (59%), 0.5%heavy bupivacaine (27%), 1%chloroprocaine (10%) and 2.5/5% levobupivacaine (4%). 41% never added an opiate, 59% sometimes or always did. Fentanyl was the most commonly added opiate  (52%).

32% of anaesthetists had reservations regarding day case spinals which included the variation in the time taken for the same procedure by different surgeons and lack of confidence in using the newer drugs.

Conclusion: Day case spinal anaesthesia is being used despite reservations. 2%heavy prilocaine is the most popular drug to use and opiates were commonly added.

Increased familiarity drug usage and availability of suggested dosing regimes may increase confidence and rates of day case spinal anaesthesia.

Reference:

1. Russon, Hormis. How effective is your daycase spinal service? Chapter 5 RCoA QIP https://rcoa.ac.uk/safety-standards-quality/support-anaesthetic-departments/raising-standards-rcoa-quality-improvement

68  Maintaining head and neck skin cancer surgery via the designation of a 'clean' hospital site and utilisation of mobile theatres

Lakshana Kanagalingam, Nicholas Hampton

University Hospitals of Morecambe Bay NHS Trust, Lancaster, United Kingdom

Abstract

Introduction: In response to the Coronavirus (Covid-19) pandemic the Oral and Maxillofacial (OMFS) Unit at University Hospitals of Morecambe Bay NHS Trust (UHMBT) has taken advantage of its multiple hospital sites in an effort to maintain the non-melanoma skin cancer service.

Methods: Prior to Covid-19, the OMFS team at UHMBT utilised theatres and clinics across three hospital sites providing surgery to the widespread population of South Cumbria and North Lancashire. In order to maintain a service throughout the pandemic, Westmoreland General Hospital (WGH) was designated a 'clean' site. Patients isolated for 14 days and were swabbed within 72 hours of surgery.¹ Surgeons were isolated and swabbed prior to a week of operating and rotated to allow for sickness and isolation.²

Also, mobile "Vanguard" theatres were built at WGH, allowing for more elective surgery.

Surgery was undertaken within one to three months as recommended by the Federation of Surgical Specialty Association's (FSSA) Covid-19 guidelines.³

Results: These protocols demanded sacrifices, with some patients having to travel further to be treated. However, these measures have allowed skin cancer surgery to continue among likely non-infected patients and surgeons. 

Conclusions: Directing all skin surgery to one hospital site, utilisation of mobile theatres and instigation of an isolation protocol, mitigate the risk of infection, allow for service continuity and put into place processes that may continue beyond the current pandemic. 

69  Managing the Impact of COVID-19 on Paediatric GA Dental Extractions

Lauren Smith, Matthew Heming, Aubrey Dickason, Tasneem Ali, Theresa Hinde

Torbay and South Devon Foundation Trust, Torbay, United Kingdom

Abstract

Introduction: Nationally, COVID-19 has resulted in increased health inequality in children following loss of elective paediatric general anaesthetic (GA) dental extractions. Complete cessation of day surgery and outpatient activity at our trust for 4 months left children with untreated decay in pain and sometimes requiring multiple courses of antibiotics.  On reopening of limited day surgery facilities, we worked to decrease waiting times to 2 weeks from consultation to treatment. Now under a 3^rd lockdown and repeated day surgery closure, we proposed a further pathway to limit the continued impact of COVID-19.

Method: Data was collected from hospital records between February 2020 and January 2021.   

Results: Pre COVID-19, the average waiting time from consultation to treatment was 6 weeks, rising to 6 months during unit closure between March and July; a 140% increase in waiting list numbers. Day surgery initially reopened allocating 3 all day lists per week from the end of July through August, decreasing waiting times to 2 weeks. Waiting time was maintained on 1-2 weekly lists until January 2021 when the unit was again forced to close. From 3^rd February, the day surgery and maxillofacial teams aim to combat any rise in waiting lists by opening an ambulatory paediatric dental GA pathway via main theatres. 

Conclusion:  We have reduced the backlog of children awaiting surgery from the initial lockdown. Through the implementation of new pathways, we continue to strive for a reduction in health inequalities faced by our paediatric population, ensuring no pathway is closed to any patient.

 

71  Quality of Post-Operative Information Given to Patients Following Surgical Management of Orofacial Trauma: A Clinical Audit

Tulsi Patel, Khari Lewis, Kemal Tekeli, David Tighe

East Kent Hospitals University NHS Foundation Trust, Kent, United Kingdom

Abstract

Introduction:  Effective provision of post-operative information (POI) can improve outcomes following surgery. At East Kent Hospitals University NHS Foundation Trust, numerous patients are surgically managed for facial fractures predominantly sustained from trauma. Electronic Discharge Notification (eDN) are a modality that patients refer to for POI. Therefore, the aim of this audit was to assess the quality of POI provided on eDNs following surgical management of orofacial trauma. 

Methods: Surgical management of facial fractures was divided into the following anatomical regions: Nasal, Zygoma, Maxillary, Mandibular and Orbital. Operating procedure codes were used to construct a list of patients who underwent surgery of each anatomical region over a 12-month period. Standards were derived from British Association of Oral and Maxillofacial Surgeons post-operative leaflets where information was tabulated as mandatory or optional following agreement from several Maxillofacial Surgeons. The eDN of each patient was checked against these standards where a goal of 100% and 50% was set for mandatory and optional POIs respectively.  

Results: Following assessment of 63 cases, significant areas of improvement was required as mandatory POIs were 55%, 44%, 58%, 54% and 60% for Nasal, Zygoma, Maxilla, Mandible and Orbital fracture reduction respectively. Consequentially, the department has raised awareness to all team-members regarding the importance of high-quality POIs and adopted the use of E-templates which can be personalised to meet individual patient needs.

Conclusion: POI in eDNs play a role in the post-operative recovery of patients, therefore the information recorded should be improved to achieve optimal outcomes.

 

73 Auditing a day case appendicectomy pathway in a London District General Hospital; a single centre experience

Caoimhe Walsh, Lavanya Varatharajan, Awais Ahmad, Beatrix Cardus, Karim Jamal

Epsom and St Helier University Hospitals NHS Trust, London, United Kingdom

Abstract

Introduction: Over 300 laparoscopic appendicectomies are performed annually at our Trust, the majority of whom remain in hospital for ≥1 night. Evidence suggests that with careful patient selection, same-day discharge is safe and feasible. We sought to (1) identify factors associated with same day discharge, (2) establish a day case appendicectomy pathway and (3) audit the success of our pathway.

Methods: Adult patients undergoing emergency laparoscopic appendicectomy between January – April 2018 were identified. Anonymised patient data related to patient demographics, ASA grade, intra-operative findings, operation end-time, length of stay (LOS) and complications were collected. Exclusion criteria included age ≤16 years and an operating theatre finish time after 5pm. A day case appendicectomy pathway was implemented (March 2019) and outcomes were audited (April – July 2019).

Results: 43 patients were operated between January – April 2018, of which 9.3% were discharged on the same day (mean LOS post-operatively 1.72 days, range 0 – 5 days). Factors contributing to delayed discharge included (1) presence of an abdominal drain, (2) ongoing intravenous antibiotics, (3) lack of a timely senior review post-operatively, (4) four-quadrant peritonitis and (5) patient age ≥80 years. Following the adoption of a local day case appendicectomy pathway in March 2019, we noted that 19.0% of eligible patients (42 patients from April – July 2019) were discharged on the same day (mean LOS post-operatively 1.40 days, range 0 – 5 days).

Conclusions: Our day case appendicectomy pathway prompted timely discharges. This encourages early recovery, minimises disruption to the patient’s life and is financially beneficial for hospitals.

74  Single Centre Experience of Day Case Elective General Surgery with a dedicated ‘Green Zone’ after the first wave of COVID-19

Muhammad Rafaih Iqbal, Subiksha Subramonian, Kabir Matwala, Catherine Morrison, Aaliya Uddin, Bryony Lovett

Basildon and Thurrock University Hospital NHS Foundation Trust, Basildon, United Kingdom

Abstract

Introduction: COVID-19 pandemic resulted in the cessation of the elective surgery. After the first wave, resumption of elective surgical activity has been a major challenge with significant changes to the patient pathways. The aim of this study was to look into the outcomes of Day case elective general surgery with a dedicated pathway after the first wave of COVID-19.

Methods: A dedicated ‘Green Zone’ elective pathway was created. Data was collected prospectively on consecutive patients who underwent Day case elective general surgical procedure at a single centre over a 10-week period (1^st Sept 2020 – 10^th Nov 2020). The primary outcome was 30-day COVID-19 mortality. Secondary outcomes included 30-day nonCOVID-19 mortality, readmissions and complications.

Results: A total of 131 day case elective general surgical procedures were performed over the study period. Mean age was 51 years (IQR = 39-63) with 66(50.3%) female patients. Majority of the patients were ASA 2 (n=73, 55.7%) and ASA 1 (n=36, 27.4%). Most of the patients (98%) underwent General Anaesthetic. There was no 30-day COVID-19 or nonCOVID-19 related mortality. 30-day readmission and complication rate were 2.2% (n=3) and 7.6% (n=10). One patient developed COVID-19 3 weeks after the index operation.

Conclusion: A dedicated ‘Green Zone’ pathway appears to be safe with minimal risk of COVID-19. Such pathways may help to reduce the pressure on NHS elective waiting lists. With our increased awareness and knowledge of the COVID-19 virus strains, along with the rollout of the vaccine, may help further to make such pathways even safer. 

 

75  Keeping Day Surgery going in a district general hospital during the COVID-19 pandemic

Paula Vine, Julie Cunliffe, Kim Russon

The Rotherham NHS Foundation Trust, Rotherham, United Kingdom

Abstract

Introduction: Usually admissions for elective surgery to The Rotherham NHS Foundation Trust (TRFT) are via the Day Surgery Unit (DSU) or Theatre Admission Unit (TAU). Theatres is between theses 2 areas. Pre-covid approximately 6000 day surgery patients per year were discharged via our 19 trolley day surgery ward.

In March 2020, the majority of elective surgery at TRFT was cancelled to enable the Trust to manage the rising number of patients admitted with COVID-19 and some staff were deployed to other wards.

On the 3^rd April 2020 TRFT intensive care unit (ICU) reached maximum capacity and our DSU became non-covid ICU and was closed to day surgery patients.

Methods: On 3^rd April 2020 we converted 2 of the 13 rooms in TAU to post-op rooms with 2 day surgery trolleys in each room and the area outside of these rooms was converted to a nurses’ station. Patients were admitted and waited in individual consulting rooms pre-operatively  rather than a waiting area, to maintain social distancing. Post surgery day cases returned to the “new” TAU post-op rooms and were discharged from TAU.

Results: Between 3^rd April and 7^th June 2020 131 day cases were successfully discharged via this pathway. An additional 14 elective inpatients were admitted for their surgery via TAU.  

Conclusion: By thinking quickly and re-utilising our space, we enabled patients to continue to be treated as day cases with benefits to patients and the Trust by avoiding admission to inpatient wards until our DSU reopened on 8th June 2020.

 

77 The Effect Of Centralisation of Preoperative Assessment on Day Surgery List Efficiency

Rachel Tibble

Royal Derby Hospital, Derby, United Kingdom

Abstract

Introduction: Day surgery list efficiency is important to maintain throughput, use theatre time well and offer as many patients as possible the chance for successful same day surgery. Post covid 19, efficiency will be essential in addressing the backlog of elective surgery patients the have been postponed.   Effective pre operative assessment (POA) is essential for the lists to work. Moving from a daycase specific POA to a centralised POA has occurred in our hospital and we have compared list efficiency before and after this change.

Methods: 2 months of Day Surgery Lists were compared before and after the centralisation occurred. The number and reasons for patient cancellation on the day of surgery, the number of underfilled lists and the overall number of patients on those lists were recorded

Results: In 2019 when POA was daycase specific and located in the Day Surgery unit 482 patients were done in Day Surgery No lists were underfilled due to patients being cancelled before the list occurred and 6 patients were cancelled on the day as not being fit for surgery. This compared to 326 operations in 2 months from September 2020, 20 lists were underfilled and 15 patients deemed not suitable and cancelled on the day

Conclusion: Moving to a centralised POA has reduced list efficiency in day case and increased the number of cancellations on the day of surgery.

 

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