Is it feasible to learn research skills in addition to audit skills through clinical audit? A mixed methods study in general practice

Background Involving medical students in research in their undergraduate careers may increase the likelihood that they will be research active after graduation. To date, there has been a paucity of published research of students doing research in general practice. Aim The study aims to evaluate the impact of general practice clinical audits on early-stage graduate entry students’ audit and research self-efficacy and explore feasibility issues from the student and GP perspective. Methods Two student questionnaires (pre- and post-intervention), a qualitative GP survey of the 25 participating GPs and semi-structured interviews of a purposeful sample of GPs were conducted. Results Participating students who completed the follow-up survey found that it had a positive educational impact (55%), increased their understanding of the audit cycle (72%) and real-world prescribing (77%). Research confidence wise, there was a statistically significant difference in the student group who completed the audit project compared to those students who did not in knowledge of the audit cycle and the difference between research and audit (p = 0.001) but not in other research skills. Ninety-six percent of responding GPs would be happy for students to do future audits in their practice but some feasibility issues similar to other research initiatives in general practice were identified. Conclusion We found this audit initiative feasible and useful in helping students learn about audit skills, patient safety and real-world prescribing. GPs and students would benefit more if it were linked to a substantial clinical placement, focussed on a topic of interest and given protected time. Separate research projects may be needed to develop research skills confidence.

EP.FRI.96 Negative appendectomy rate in young females, between theory and practice. Full audit cycle

Aims Females of child bearing age are at higher risk of negative appendectomy rate, the accepted overall NAR is up to (20-25%). Presented is our study to examine the real NAR in the female’s cohort aged (15-45 years) in the form of quality improvement project to improve patient’s outcome. Methodology Retrospective study in the form of Full audit cycle over 18 months, the first cycle was conducted over 12 months period, followed by the action plan and reassessment over 6 months. Preoperative clinical, laboratory, radiographic and histopathological data were collected. Results Over the whole audit period 632 cases were analysed, 238 cases were females in the child bearing age included in our cohort. Over the first phase 419 appendectomy cases were performed, among those 156(37%) were females in child bearing age. Overall NAR was 29% and in our females cohort was 43.5%. Over the second cycle, 213 cases performed, out of which 82(38%) cases included in our cohort. Overall NAR reduced to 25% and in our cohort was 37% Conclusions Despite the advances in diagnostic modalities, Females are at significantly higher risk of NAR 37%. Our overall NAR reduced from 29% to 25% compared to the young females cohort, the rate dropped from 43% to 37%. specific consideration and regular auditing of results regards this cohort are highly recommended. Validation of appendicitis scores for risk stratification, Serial examinations and radiological adjuncts are possible solutions to reduce the NAR among this group.

EP.TU.673Optimising the referral process to the Surgical Emergency Clinic through mutual education of primary and secondary care teams: an audit cycle

Aims The Surgical Emergency Clinic (SEC) in our Hospital facilitates access to General Surgical consultant-led emergency assessment. Anecdotally, referrals are often (likely inadvertently) inappropriate and / or incomplete, which may delay assessment by the correct specialist. We audited the quality of GP referrals to the SEC against four standards: Methods Retrospective analysis of 50 GP referrals to the SEC between November - December 2017, after recording data pertinent to the above standards in a spreadsheet. Results were presented at a local GP development day, a re-designed referral form incorporating GP feedback received was uploaded onto the Trust’s intranet and an email inbox created for e-referrals. 50 further referrals between September - November 2018 were analysed. Results Full completion of the referral form increased from 0% (initial audit) to 29% (re-audit), and appropriateness of referrals from 62% to 90%. The proportion of patients having had specified blood and urine tests in advance improved overall also. Conclusions Our experience demonstrates that primary and secondary care teams actively communicating and working closely together can improve the referral process for both parties, and most importantly enhance patient access to timely, appropriate specialist care.

EP.FRI.821 Operative Treatment of Abscesses – Optimising A Timely Route to Theatre

Aim 1st audit cycle to assess whether patients presenting to the acute surgical service had their abscesses incised and drained in a prompt and timely manner. To develop a pathway for improving efficiency Methods All general surgical patients admitted to the surgical admissions unit between 1st September and 31st October 2020 by reviewing clinical and operative notes. Only those patients that had abscesses drained under general anaesthesia. Other specialties abscesses were excluded. Guidelines from the American Society of Colon and Rectal surgeons for draining abscesses acutely were used. Data was collected on various parameters. Results A total of 62 patients had abscesses drained. The mean age of patients was 32 years. The average waiting time between decision to operate and surgery was 14 hours and 54 minutes. 19% of the patients were sent home after decision was made to operate and brought back in the morning. Conclusion This 1st audit cycle concludes long waiting times and unnecessary overnight stay. A re-audit will be carried out using the same parameters in March 2021. Implementing a dedicated general surgical abscess pathway for patients without significant co-morbidities will improve efficiency and patient satisfaction. References 1. Kumar C, Page R, Smith I, Stocker M, Tickner C, Williams S, et al. Day case and short stay surgery: 2. Anaesthesia. 2011;66(5):417–34. 2. Balakumar R, Samuel N, Jackson A, Butterworth J, Shiwani MH. Day-surgery approach for incision and drainage of an abscess. Surg Pract. 2016;20(4):157–60.

EP.FRI.461 Management of acutely ill surgical patients NICE guidance CG50: a complete audit cycle

Aim NICE CG50 guidelines are a response to evidence suggesting patients who are, or become, acutely unwell may receive suboptimal care. The guidelines suggest: After previously unsuccessful audits a fourth re-audit was designed to re-assess compliance with the CG 50 guidelines. Method After implementing previous recommendations like, keeping a poster of recommendations in the handover room and making these guidelines as part of surgical induction, a re-audit was planned. A prospective random sample of 40 patients admitted during the general surgery was taken. Using the audit tool the following parameters were recorded for each patient in the sample: Results The compliance was 100% for patients who have had their physiological observations recorded at the time of admission or initial assessment, the percentage of patients monitored using a physiological track and trigger system, and the percentage whose physiological observations were monitored at least every 12 hours. The compliance was 95% for the percentage of patients with a clear written monitoring plan. Conclusions Following the interventions detailed above, there is now 95 to 100% compliance with NICE guidelines in the documentation.

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

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.

EP.FRI.60 A complete audit cycle into the paediatric negative appendicectomy rate for children presenting to A&E with suspected appendicitis at a District General Hospital

Aim Determine compliance rate with a local policy implemented in 2017, and whether interventions from audit cycle 1 were successful. The policy stated that all children aged 6-18 with acute abdominal pain must initially be reviewed by the ED registrar/consultant and have a documented Alvarado score. Method A closed loop audit on adherence to the 2017 policy and negative appendicectomy rate in children aged 6 to 18, with suspected appendicitis. The data were collected and analysed. Areas for improvement were discussed at the M&M meeting, alongside methods to achieve these improvements. Results The study included 67 patients aged 6-18 who underwent an appendicectomy in 2019. The study found that the Alvarado score had only 14.29% specificity. There was poor adherence to the 2017 protocol as only 36% had a documented Alvarado score and 55% had a senior ED review. Audit cycle 1 recommended improvement of ultrasound quality and increased use of CT scanning to reduce the negative appendicectomy rate. We found that only 2 patients had a CT. The negative appendicectomy rate in patients with and without an ultrasound remained at 8%, indicating no quality improvement. Nevertheless, our primary outcome showed that negative appendicectomy rates reduced from 28% to 11%. Conclusion These results demonstrate negligible impact of ultrasound and Alvarado scores. Good history-taking and clinical examination skills are key in reducing the negative appendicectomy rate. A specific ambulatory care pathway for children with suspected appendicitis has been implemented to lower inpatient stays and cost impact of unnecessary laparoscopies.

EP.TU.371The introduction of standardised ward round notes in the Acute Surgical Unit

Introduction A standardised approach to note-keeping has been shown to improve patient care and experience. Aims This repeated audit cycle assesses the compliance with the introduction of a standardised proforma. Method Data collection was prospective. Round 1 (n = 83) after introduction of a ward round proforma, Round 2 (n = 94) following result analysis / education, Round 3 (n = 62) following proforma changes. Results (% Compliance with proforma) Conclusions Some improvements were seen in Round 2. A notable improvement was observed in EDD and CFD when a tick box option was implemented in Round 3. Successful implementation of a standardised note-keeping requires repeated analysis, education and modification of the proforma.

TP6.2.2 Multi-disciplinary interventions to increase utilisation of NELA scores and critical care involvement following emergency colorectal surgery

Aims This audit aimed to assess pre-operative NELA risk score documentation and subsequent specialist peri-operative critical care involvement. Methods This complete audit cycle retrospectively reviewed notes (electronic patient records, anaesthetic charts and CEPOD booking forms) of all patients undergoing emergency laparotomy between March and May 2019. The NELA score was calculated retrospectively if not documented. Following the initial audit, the following multi-disciplinary interventions were instituted: alteration of the physical CEPOD booking form to include NELA score (Surgical); a sticker added to anaesthetic charts to prompt NELA calculation (Anaesthetic), formal recording of NELA score during theatre brief (Theatre staff); and by increasing awareness of NELA via departmental education (All). The audit cycle was completed by reassessment between October and November 2020. Results The initial cycle included 34 patients, with only 2 (6%) having a NELA documented. The repeat cycle included 35 patients, with 29 (83%) having a NELA documented. Regarding post-operative critical care admissions, both cycles found that 100% of patients with a NELA of ≥ 5%, were admitted to either surgical HDU or ICU (n = 17 in first cycle, n = 17 in second cycle). For those with a high-risk NELA of ≥ 10% (n = 11 in first cycle, n = 7 in second cycle), only 2 (18%) were admitted to ICU in the first cycle vs 7 (100%) in the second cycle. Conclusions This complete audit cycle demonstrates improved NELA score calculation following institution of several multidisciplinary interventions. The improved NELA score uptake was associated with increased critical care review and admission to ITU in high-risk cases.