EP.TU.270Improving Treatment Escalation Plan (TEP) Completion Rate for General Surgical Patients

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Eric Yuen Ing Yii ◽  
Alison Bradley
Keyword(s):  
Completion Rate ◽  
Surgical Patients ◽  
Filling Rate ◽  
Optimal Care ◽  
Continuous Auditing ◽  
Prospective Data ◽  
Clinical Notes ◽  
Mean Delay ◽  
Audit Cycle ◽  
Treatment Escalation

Abstract Aims Treatment Escalation Plan (TEP) is essential for recognition of patients’ ceiling for care in the event of clinical deterioration. It should be clearly documented to ensure continuity of care, especially during Covid-19 pandemic. This audit aims to evaluate and improve the TEP filling rate for general surgical patients. Methods A prospective data collection was performed for one week in July 2020 in general surgical wards. Data on patients’ gender, age, presence of DNACPR form and date of TEP completion were collected from patients’ clinical notes. Data was analysed using SPSS statistic software. Educational posters were displayed in the ward and presentation was done to emphasise the importance of TEP documentation. Second audit cycle was done in August 2020 to assess for improvement in TEP filling rate. Results In the first cycle, 60 patients were included with a mean age of 60. Only 11.7% patients had TEP form filled in with a mean delay of 2.7 days since admission. In the second cycle, 57 patients were included with a mean age of 66. 28.1% patients had TEP form documented with a mean delay of 1.7 days. This has shown a 140% improvement in completion rate of TEP form and 59% reduction in the delay in TEP documentation. Conclusions TEP is essential to ensure that patients received optimal care when their condition deteriorate. Simple intervention such as educational posters will help to improve the TEP completion rate. However, continuous auditing is required to ensure improvement in TEP documentation for surgical patients.

scholarly journals EP.FRI.849 Quality Improvement Project for Management of Unstable Ankle Fracture in Scunthorpe General Hospital

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Jian Zi Poh
Keyword(s):  
Ankle Fracture ◽  
Ankle Fractures ◽  
Prospective Data ◽  
Improvement Project ◽  
Good Communication ◽  
Clinical Notes ◽  
Root Cause ◽  
Fracture Management ◽  
Skin Integrity ◽  
Change In Practice

Abstract Introduction In SGH, little emphasis is placed on ankle fracture as compared to hip fracture. Hence, an audit was done to compare management of unstable ankle fracture in adherence to BOAST guidelines. It was found out that few aspects of management in A&E were inadequate. Analyzing the root cause of non-adherence to guideline can lead to better care for these patients. Aim Primary aim is to ensure that ankle fractures are treated effectively in line with BOAST guidelines. Secondary aim is to ensure that ankle fractures are treated in a timely manner. Change in practice Discussion was held between Orthopaedic consultant and A&E consultant. Firstly, poster displaying algorithm for ankle fracture management displayed in A&E. Secondly, Orthopaedics doctor would come to A&E to reduce fracture after first failed attempt. Methods Prospective data is collected. Patients with unstable ankle fracture who are admitted in SGH are assessed in regards to BOAST guidelines via WebV, PACS and clinical notes. Results Major improvement is seen in different aspects. The documentation of neurovascular assessment and skin integrity in A&E department is improved by 57%. Additional radiographs of the whole leg when clinical examination suggests a more proximal fracture of the fibula (Maisonneuve injury) was performed in 60% more patients as compared to previously. Adequacy of reduction done in A&E is improved by 25%. Conclusion Small changes can make a big difference. Good communication and teamwork between different departments is the best way to provide better care for patients.

scholarly journals EP.TU.156Frailty in the Emergency General Surgical Cohort, could we being doing more?

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Ross Hunter
Keyword(s):  
Multidisciplinary Approach ◽  
Length Of Hospital Stay ◽  
District General Hospital ◽  
National Standards ◽  
Surgical Patients ◽  
Specialist Care ◽  
Optimal Care ◽  
Clinical Frailty Scale ◽  
Physiological Capacity ◽  
External Stimuli

Abstract Aims Frailty, a state of diminished diminished physiological capacity to deal with external stimuli, is being seen ever increasingly in the aging emergency general surgical cohort. Length of hospital stay, morbidity and mortality are shown in the literature to dramatically increase in the frail population. Outcomes in this cohort are shown to improve significantly with specialist frailty input from geriatricians, physiotherapy and occupational therapy teams. The authors aimed to assess the burden of frailty in emergency surgical admissions in a District General Hospital, and the frailty specialist care these patients received. Methods A snapshot survey of all acute surgical admissions during a single 24 hour period was performed. Frailty was defined as a Rockwood Clinical Frailty Scale score of 5 or above. The management of these patients was then compared to national standards and recommendations made on how the treatment of the clinically frail could be improved upon. Results 73% of patients in the sampled cohort (19/26) were found to be clinically frail. Only 2 (10%) of these patients had been reviewed by the frailty specialist teams within the hospital. Following implementation of recommendations, namely an improved referral system, reminders within initial clerking paperwork and raising departmental awareness, specialist input was shown to increase threefold to 32% (10/31) within the same patient group. Conclusions A significant cohort of emergency general surgical patients are classified as clinically frail. Optimal care for these patients involves a multidisciplinary approach, the uptake of which can be increased significantly with intra-departmental education and increased awareness.

scholarly journals Postoperative urinary retention: risk factors, bladder filling rate and time to catheterization: an observational study as part of a randomized controlled trial

2021 ◽  
Vol 10 (1) ◽  
Author(s):  
Tammo A. Brouwer ◽  
E. N. van Roon ◽  
P. F. W. M. Rosier ◽  
C. J. Kalkman ◽  
N. Veeger
Keyword(s):  
Risk Factors ◽  
Spinal Anesthesia ◽  
Urinary Retention ◽  
Bladder Capacity ◽  
Surgical Patients ◽  
Bladder Volume ◽  
Urinary Catheterization ◽  
Filling Rate ◽  
Postoperative Urinary Retention ◽  
Bladder Filling

Abstract Background Knowledge of risk factors for postoperative urinary retention may guide appropriate and timely urinary catheterization. We aimed to determine independent risk factors for postoperative urinary catheterization in general surgical patients. In addition, we calculated bladder filling rate and assessed the time to spontaneous voiding or catheterization. We used the patients previously determined individual maximum bladder capacity as threshold for urinary catheterization. Methods Risk factors for urinary catheterization were prospectively determined in 936 general surgical patients. Patients were at least 18 years of age and operated under general or spinal anesthesia without the need for an indwelling urinary catheter. Patients measured their maximum bladder capacity preoperatively at home, by voiding in a calibrated bowl after a strong urge that could no longer be ignored. Postoperatively, bladder volumes were assessed hourly with ultrasound. When patients reached their maximum bladder capacity and were unable to void, they were catheterized by the nursing staff. Bladder filling rate and time to catheterization were determined. Results Spinal anesthesia was the main independent modifiable risk factor for urinary catheterization (hyperbaric bupivacaine, relative risk 8.1, articaine RR 3.1). Unmodifiable risk factors were a maximum bladder capacity < 500 mL (RR 6.7), duration of surgery ≥ 60 min (RR 5.5), first scanned bladder volume at the Post Anesthesia Care Unit ≥250mL (RR 2.1), and age ≥ 60 years (RR 2.0). Urine production varied from 100 to 200 mL/h. Catheterization or spontaneous voiding took place approximately 4 h postoperatively. Conclusion Spinal anesthesia, longer surgery time, and older age are the main risk factors for urinary retention catheterization. Awareness of these risk factors, regularly bladder volume scanning (at least every 3 h) and using the individual maximum bladder capacity as volume threshold for urinary catheterization may avoid unnecessary urinary catheterization and will prevent bladder overdistention with the attendant risk of lower urinary tract injury. Trial registration Dutch Central Committee for Human Studies registered trial database: NL 21058.099.07. Current Controlled Trials database: Preventing Bladder Catheterization after an Operation under General or Spinal Anesthesia by Using the Patient’s Own Maximum Bladder Capacity as a Limit for Maximum Bladder Volume. ISRCTN97786497. Registered 18 July 2011 -Retrospectively registered. The original study started 19 May 2008, and ended 30 April 2009, when the last patient was included.

scholarly journals 1405 Improving Documentation of Per Rectal (PR) Exams in An Acute Surgical Unit

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
D Deeny
Keyword(s):  
Data Collection ◽  
General Medical Council ◽  
Surgical Patients ◽  
Medical Council ◽  
Number Of Patients ◽  
Audit Cycle ◽  
Medical Examinations ◽  
Surgical Unit ◽  
Acute Admissions ◽  
Surgical Admission

Abstract Aim A PR exam is routinely performed as part of the complete examination of surgical patients. The General Medical Council (GMC) has provided guidance on the use of chaperone during intimate exams stating that consent should be obtained, and a chaperone offered to all patients and documented accordingly. We aimed to assess and improve our documentation of PR exams. Method Data was collected prospectively from surgical admission documentation. The number of patients with consent and presence of chaperone documented during PR exam was recorded. Following a period of data collection, a proforma was implemented with education on correct documentation as per guidelines. A second audit cycle was performed where formal inclusion of the sticker in the admission booklet was implemented. Results 20 patients were included in the initial data collection, 95% of which had incomplete documentation of PR exam on admission. A sticker was designed to prompt accurate documentation and inserted into the acute admissions booklet. Following this, 50% of PR exams were correctly documented. The remaining 50% without documentation had no sticker in the admission booklet. The second intervention included changing the hardcopy of the admission booklet. Following this, 80% of patients had consent documented and 90% had documented chaperone. Conclusions GMC guidelines state that documentation of consent and the presence of chaperones during intimate medical examinations are crucial. The implementation of a prompt in our admissions booklet has greatly improved our documentation in PR examination.

EP.TU.411Thinking Ahead: Improving Documentation of Treatment Escalation Plans for Surgical Patients

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Laura Tregidgo ◽  
Grace Sutton ◽  
Hasan Mukhtar ◽  
Charlie Cave
Keyword(s):  
Decision Making ◽  
District General Hospital ◽  
Ward Round ◽  
Surgical Patients ◽  
Surgical Team ◽  
Patient Centered ◽  
General Surgeons ◽  
Early Decision ◽  
Treatment Escalation ◽  
Surgical Admission

Abstract Aims The GMC recommends early decision making on CPR status for all acutely unwell patients admitted to hospital. An audit was undertaken of documentation of treatment escalation plans (TEPs) for general surgical patients at a District General Hospital. Method A retrospective study looking at documentation of TEPs in patients (n = 55) admitted under the care of the general surgical team over a one month period. Documentation from the surgical admission clerking and the first consultant ward round were reviewed for evidence of a TEP. Results Of 55 patients admitted only 24% had a TEP documented within 48 hours of admission under the general surgeons. Of those that had a TEP recorded (n = 13), twelve were in the admission surgical clerking and one was completed on the post-take consultant ward round. Conclusions This project highlighted the lack of TEP documentation for surgical patients within 48 hours of admission to hospital. Our recommendation is to develop a specific ‘post-take ward round’ proforma with mandatory TEP, to be filled out within 24 hours of patient admission. This updated process will then be reassessed for improved compliance with TEP documentation. We anticipate this will improve early decision making regarding escalation status and facilitate TEP discussions with patients. Overall this process should help ensure a more patient-centered approach to care planning.

scholarly journals The Diagnostic Utility and Clinical Impact of After-Hours CT Scans of the Abdomen and Pelvis Investigating Abdominal Pain

2017 ◽  
Vol 2017 ◽  
pp. 1-6
Author(s):  
Monil Karia ◽  
Matthew Seager ◽  
Akkib Rafique ◽  
Hemant Sheth
Keyword(s):  
Abdominal Pain ◽  
Clinical Outcomes ◽  
Clinical Management ◽  
Ct Scanning ◽  
Surgical Patients ◽  
Ct Scans ◽  
Diagnostic Utility ◽  
Histopathological Findings ◽  
Clinical Notes ◽  
After Hours

Introduction.The aim of this study was to evaluate the diagnostic utility and impact on clinical management of after-hours CT scans investigating abdominal pain in surgical patients.Methods.After-hours CT A/P reports investigating the acute surgical abdomen were compared with clinical outcomes and histopathological findings to assess sensitivity and specificity of CT reporting. Comparisons between CT reports and clinical notes were made. CT scans were categorised as having direct effects on clinical management, ruling out a serious pathology, ruling out a nonserious pathology, or having no effect. Discrepancies between information in case-notes and information provided to radiologists were also analysed.Results.79 clinical notes were located. After-hours CT demonstrated 91% sensitivity and 82% reporting specificity using clinical outcomes as the standard. In the 26 patients with histopathological findings, CT reports demonstrated 91% sensitivity. In 79.7% of cases, CT scanning had an impact on management. In 35.4% of cases, an indication for scanning was not documented with variation in clinical information in 8.9% of cases.Discussion.This study demonstrates after-hours CT A/P reports result in significant impacts on clinical management of surgical patients with acute abdominal pain. Improvements in providing information when requesting scans are however needed to facilitate accurate reporting.

scholarly journals ClinPhen extracts and prioritizes patient phenotypes directly from medical records to accelerate genetic disease diagnosis

2018 ◽  
Author(s):  
Cole A. Deisseroth ◽  
Johannes Birgmeier ◽  
Ethan E. Bodle ◽  
Jonathan A. Bernstein ◽  
Gill Bejerano
Keyword(s):  
Genetic Disease ◽  
Medical Records ◽  
Genetic Diseases ◽  
Disease Diagnosis ◽  
High Accuracy ◽  
Substantial Contribution ◽  
Optimal Care ◽  
Gene Ranking ◽  
Clinical Notes ◽  
Diagnostic Odyssey

AbstractPurposeSevere genetic diseases affect 7 million births per year, worldwide. Diagnosing these diseases is necessary for optimal care, but it can involve the manual evaluation of hundreds of genetic variants per case, with many variants taking an hour to evaluate. Automatic gene-ranking approaches shorten this process by reporting which of the genes containing variants are most likely to be causing the patient’s symptoms. To use these tools, busy clinicians must manually encode patient phenotypes, which is a cumbersome and imprecise process. With 60 million patients expected to be sequenced in the next 7 years, a fast alternative to manual phenotype extraction from the clinical notes in patients’ medical records will become necessary.MethodsWe introduce ClinPhen: a fast, high-accuracy tool that automatically converts the clinical notes into a prioritized list of patient symptoms using HPO terms.ResultsClinPhen shows superior accuracy to existing phenotype extractors, and when paired with a gene-ranking tool it significantly improve the latter’s performance.ConclusionCompared to manual phenotype extraction, ClinPhen saves more than 5 hours per case in Mendelian diagnosis alone. Summing over millions of forthcoming cases whose medical notes await phenotype encoding, ClinPhen makes a substantial contribution towards ending all patients’ diagnostic odyssey.

scholarly journals 713 Use of A Pre-Operative Investigation Checklist in Plastic Surgery Trauma

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
R Slade ◽  
E Combellack ◽  
A Kaur ◽  
M Eales ◽  
T O'Neill
Keyword(s):  
Plastic Surgery ◽  
Nursing Staff ◽  
Trauma Surgery ◽  
Nice Guidelines ◽  
Clinical Notes ◽  
Complete Cycle ◽  
Regional Centre ◽  
Co Morbidity ◽  
Audit Cycle

Abstract Introduction In a regional centre for plastic surgery, it had been noted that operations were being delayed due to lack of pre-operative investigations. A pre-operative investigation checklist was developed between anaesthetic and surgical staff for semi-elective plastic trauma surgery patients, based on NICE guidelines. The checklist recommends which blood, radiology and cardiopulmonary tests would be appropriate based upon age, ASA grade and co-morbidity. Method A complete cycle audit was used to evaluate the checklist. All patients having GA/block for plastic surgery trauma in a 2-week window were included. Data was collected retrospectively via electronic operative records, anaesthetic assessments, and clinical notes. A minimum of 15 patients was collected per cycle. A single page pre-operative checklist was created for pre-operative investigations were introduced after the first cycle. Results The first audit cycle had 16 patients, ASA1 (5), ASA 2(6) ASA 3 (5). 75% had appropriate pre-op investigations. In the second cycle 22 patients, ASA 1 (8), ASA 2 (9), ASA 3 (3), ASA 4 (1). 100% of patients had appropriate pre-operative investigations. Conclusions There was increased awareness of pre-operative investigations in medical and nursing staff after the introduction of the checklist. It has helped streamline the delivery of semi-elective trauma surgery in our unit.

scholarly journals Postoperative Urinary Retention: Risk Factors, Bladder Filling Rate and Time to Catheterization: An Observational Study as Part of a Randomized Controlled Trial

2020 ◽  
Author(s):  
Tammo Allie Brouwer ◽  
Eric N van Roon ◽  
Peter F.W.M. Rosier ◽  
Cor J Kalkman ◽  
Nic Veeger
Keyword(s):  
Risk Factors ◽  
Spinal Anesthesia ◽  
Urinary Retention ◽  
Bladder Capacity ◽  
Surgical Patients ◽  
Bladder Volume ◽  
Urinary Catheterization ◽  
Filling Rate ◽  
Postoperative Urinary Retention ◽  
Bladder Filling

Abstract BackgroundKnowledge of risk factors for postoperative urinary retention may guide appropriate and timely urinary catheterization. We aimed to determine independent risk factors for postoperative urinary catheterization in general surgical patients. In addition, we calculated bladder filling rate and assessed the time to spontaneous voiding or catheterization. We used the patients previously determined individual maximum bladder capacity as threshold for urinary catheterization.MethodsRisk factors for urinary catheterization were prospectively determined in 936 general surgical patients. Patients were at least 18 years of age and operated under general or spinal anesthesia without the need for an indwelling urinary catheter. Patients measured their maximum bladder capacity preoperatively at home, by voiding in a calibrated bowl after a strong urge that could no longer be ignored. Postoperatively, bladder volumes were assessed hourly with ultrasound. When patients reached their maximum bladder capacity and were unable to void, they were catheterized by the nursing staff. Bladder filling rate and time to catheterization were determined.ResultsSpinal anesthesia was the main independent modifiable risk factor for urinary catheterization (hyperbaric bupivacaine, relative risk 8.1, articaine RR 3.1). Unmodifiable risk factors were a maximum bladder capacity <500mL (RR 6.7), duration of surgery ≥60 minutes (RR 5.5), first scanned bladder volume at the Post Anesthesia Care Unit ≥250mL (RR 2.1), and age ≥60 year (RR 2.0). Urine production varied from 100 to 200mL/hour. Catheterization or spontaneous voiding took place approximately 4 hours postoperatively.ConclusionSpinal anesthesia, longer surgery time and older age are the main risk factors for urinary retention catheterization. Awareness of these risk factors, regularly bladder volume scanning (at least every 3 hours) and using the individual maximum bladder capacity as volume threshold for urinary catheterization may avoid unnecessary urinary catheterization and will prevent bladder overdistention with the attendant risk of lower urinary tract injury.Dutch Central Committee for Human Studies registered trial database: NL 21058.099.07.Current Controlled Trials database: Preventing Bladder Catheterization after an Operation under General or Spinal Anesthesia by Using the Patient’s Own Maximum Bladder Capacity as a Limit for Maximum Bladder Volume. ISRCTN97786497 (https://doi.org/10.1186/ISRCTN97786497). Registered 18 July 2011 -Retrospectively registered. The original study started May 19th, 2008, and ended April30th, 2009, when the last patient was included.

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