EP.FRI.362 Improving Prescribing and Minimising Delay in Administration of Potassium Replacement Therapies: Surgical Audit on Management of Hypokalaemia in Emergency Surgical Unit at a District General Hospital in UK

Aims Surgical patients are prone to hypokalaemia due to gastrointestinal losses1. Hypokalaemia prolongs ileus2 and thus prompt management is essential. No current guideline on hypokalaemia focuses on surgical patients. We aimed to identify the prevalence of hypokalaemia in emergency surgical patients as well as measure timeliness and appropriateness of replacement. Methods We retrospectively reviewed adult emergency surgical admissions exceeding 48 hours between 05/05/2020 and 15/07/2020. A sub-group analysis assessed the timing of intravenous replacement and duration taken to normalise potassium (3.5 mmol/L). We used another NHS trust’s guideline3 as standard for appropriate potassium replacement. Results Of 110 surgical admissions, 26 cases were hypokalaemic. Of these, 15 had initially normal potassium level. Three cases were likely iatrogenic secondary to inappropriate fluid prescribing. Mean potassium in the hypokalaemic group was 3.2 mmol/L (80.8% mild vs. 19.2% moderate). Mean length of stay was 11.3 days for hypokalaemia versus 6.54 days in normokalaemic cases. Mean duration of hypokalaemia was 2.13±1.45 days. Potassium replacement was prescribed correctly in only 50% of cases (23% not prescribed; 25% insufficient; 2% incorrect) and of these correct prescriptions, 46% were not actually administered. When intravenous replacement was given, there was a mean 3.55-hour delay between lab result and administration. Conclusion The majority of hypokalaemic cases developed during admission. Only 27% of these patients had correct potassium replacement in terms of both prescription and administration. Consequently, we have created a local guideline for hypokalaemia in surgical patients to standardise both prevention and management.

Use of biologicals in dermatology – following the agreed path or going off-piste? A brief report

Introduction: Biological medicines are used to treat a range of conditions according to National Institute for Health and Care Excellence (NICE) technology appraisals. The annual drug treatment cost per patient per year varies depending on various factors, including newer or older biological, and availability of a biosimilar. Our biologicals pathway for dermatology (moderate or severe psoriasis) listed less expensive older biologicals (including biosimilars) early on in the treatment choices and more recently approved (and generally more expensive) choices lower down the pathway. Objective: We aimed to identify which biologicals or selective immunosuppressants were used first line in adult patients with moderate or severe psoriasis, and ascertain if the reasons for use of treatments other than adalimumab were in accordance with the locally agreed pathway. Methods: Medical records were reviewed for a sample of patients prescribed biologicals during late 2019 and early 2020. We identified patients who had commenced any treatment. Contact was made with lead dermatology nurses if needed. Results: There were 33 patients commenced on a biological – 17 had newly started biological therapy and 16 had switched from a prior biological therapy to a new therapy. Of the 17 new patients, two commenced apremilast (biological contraindicated), 10 commenced adalimumab, and five commenced other biologicals. Of these five who commenced other biologicals, two were on guselkumab, two on ustekinumab, and one on certolizumab. In all five instances there was a valid reason for not using adalimumab as first choice though this was not always explicit in the multidisciplinary team (MDT) documentation. Discussion: Though the number of psoriasis patients (17) newly starting a biological medicine was relatively small, it was reassuring that for five of these who commenced a subcutaneous biological other than adalimumab, there was a valid reason for this choice, though not always explicit in the MDT letter, which Dermatology will ensure is clear for future decisions. Hence going ‘off-piste’ was deemed justified. Conclusion: This very small-scale study found that the local guideline was followed with patients commencing treatments other than biosimilar adalimumab for valid reasons.

1251 Risk Stratification in the Management of Post-Tonsillectomy Haemorrhage

Aim Tonsillectomy represents 17% of the elective workload in ENT and post-tonsillectomy haemorrhage is the most significant complication of this procedure. Accordingly, the GIRFT (Getting It Right First Time) report for ENT surgery focusses on the prevention of post-tonsillectomy bleeding. However, there is little guidance on the management of post-tonsillectomy haemorrhage. A local guideline for the management of post-tonsillectomy haemorrhage was introduced in 2020 based on expert consensus. This audit examines the management of patients readmitted with post-tonsillectomy haemorrhage in 2019 and compares this to the management suggested in the new guideline. Method Patients readmitted with post-tonsillectomy haemorrhage within 30 days of a tonsillectomy performed in 2019 were identified. These were retrospectively stratified into risk categories according to both patient and clinical factors. Management was audited against the new guideline including both the initial patient assessment and the treatment suggested for their respective risk category. Results Fifteen patients were identified and stratified into low, medium and high-risk categories. All patients in the “low risk” category were successfully treated conservatively. One patient from the “medium risk” category had a further bleed as an inpatient during the proposed period of observation in the new guideline and was thereafter treated as “high risk”. Within the “high risk” category two patients required return to theatre for arrest of post-tonsillectomy haemorrhage. Conclusions These results show that the risk stratification proposed in these guidelines may be useful in the management of post-tonsillectomy haemorrhage. Amendments to the guideline and a re-audit are in progress.

Serum markers for the early diagnosis of intestinal anastomotic leak after gyne-oncological operations

Objective: To analyze the serum markers for the early diagnosis of intestinal anastomotic leak (AL) after the gyne-oncological operations. Methods: Between September 2017 and March 2021, patients with an intestinal anastomosis performed during the gyne-oncological surgeries were identified from a tertiary center in Turkey. As the local guideline of the clinic, all these patients were followed by measuring serum samples including procalcitonin (PCT) and C-reactive protein (CRP) on postoperative day (POD) 1 through the day of discharge or the day of re-operation for AL. Results: 12.5% (5/40) of the patients suffered an AL and 4 of them were re-operated. The mean albumin values on POD 3-4 and the mean platelet values on POD 1 were lower in the AL group (p<0.05). Although it was not statistically significant (p>0.05), median PCT values (ng/mL) on POD 8-10 were higher in the AL group compared with no leak group. The best cutt-off point for PCT on POD 9 was determined to be 0.11 ng/mL (AUC: 0.917, Sensitivity = %100.0, specifity = %66.7, positive predictive value = %66.7, negative predictive value = %100.0). Conclusion: Serum PCT and CRP concentrations were not found to be helpfull for the early diagnosis of AL in patients operated for gyne-oncological malignancies. Low levels of albumin and platelets in the first days after the operation may be clue for a possible AL.

683 A Quality Improvement Project (QIP) To Increase Compliance with Peri-Operative Antibiotic Guidelines in Colorectal Surgery (CS)

Introduction In CS, the correct use of antibiotics is important in order to reduce the risk of surgical site and intra-abdominal infections, whilst balancing risks from overuse of antibiotics. The Commissioning for Quality and Improvement (CQUIN) of 2019/20 identified that antibiotic prophylaxis guideline compliance could be enhanced in CS. This QIP aimed to improve local CS antibiotic prophylaxis and extension guideline compliance. Method In December 2019, an educational session was held to highlight the details of the local guideline and prescribing discrepancies. A3 posters of the guideline were created for accessible reference in operating theatres. Perioperative antibiotic prescription data from all colorectal elective cases in January 2020 were extracted and analysed using descriptive methods. Results Out of 93 cases in the sample, 70 (75.3%) were compliant with the prophylaxis guideline. However, metronidazole was commonly used in perianal surgery, which is not recommended. 13 cases required extension of the antibiotic course, of which seven were compliant (53.8%). The main issues included: use of agents and course durations which were not indicated; and a lack of antibiotic switch after a pause in therapy. Conclusions To further improve compliance with antibiotic guidelines, targeting historic practice, increasing awareness, and making systemic change is required for the next cycle.

A Proposed Evidence-Based Local Guideline for Definition of Multidrug-Resistant (MDR), Extensively Drug-Resistant (XDR) and Pan Drug-Resistant (PDR) Bacteria by the Microbiology Laboratory

Multi-drug resistant organisms (MDROs) are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. These pathogens are frequently resistant to most available antimicrobial agents and deserve special attention in healthcare facilities. Generally, MDRO infections have clinical manifestations similar to infections caused by susceptible pathogens. Despite of two different classifications by WHO and CDC, still there are debates about update definition of MDROs in medical literature. Here we provide an updated local guideline for definitions of various MDROs by microbiology laboratory.

Base of thumb osteoarthritis (BTOA) in UK interface services—a cohort and survey based study to assess current practice

Aim Base of thumb osteoarthritis (BTOA) is a common age-related disease which has a significant negative impact upon quality of life, while little is known about structure and pathways of interface services. Our aim was to assess disease burden, referral pathways, service structure and management pathways in UK interface services. Patients & Methods A structured questionnaire was carried out with a participating clinician at each centre to detail the local guidelines and management of BTOA. Five patients referred with BTOA were prospectively identified in each of 32 United Kingdom (UK) interface centres. Results Most centres (72%) had a local guideline and a standardised treatment regime consisting of education (100%), joint protection (100%), range of motion exercises (84%), strengthening exercises (88%), splintage (100%) and use of assistive devices (78%). No centre routinely offered a steroid injection at the first appointment and no centre had a specific threshold for offering an injection. Injection delivery was variable. Most patients had not been referred previously (82%). Most patients used analgesia (72%) but a minority of patients had been treated with a splint (46%), therapy (43%) and steroid injection (27%) prior to their latest attendance. Conclusion Most BTOA patients newly referred to interface services have been treated with analgesics and have not received comprehensive multimodal intervention. The management of BTOA at interface services is standardised in terms of education, splintage and therapy. However, there is a lack of standardisation in terms of both the threshold for, timing and mode of delivery of injection therapy.

P01 An evaluation of vancomycin therapy in paediatric patients post guideline change

AimTo evaluate the prescribed dose of vancomycin as per local guideline and review the achieved therapeutic drug levels.MethodRetrospective data was collected from paediatric inpatients that were prescribed vancomycin for more than 24 hours during the audit period. Data was obtained from the Trust’s electronic prescribing system, LastWord. Measured standards included initial vancomycin dose, dose prescribed for renal impairment, time to first trough level and any required dose adjustments as per local guidance. The dose bands for each age group were1; birth - 6 months 15 mg/g 8 hourly; >6 months -12 months 20 mg/kg 8 hourly; >12 months – 12 years 25 mg/kg 8 hourly; >12 years 20 mg/kg 8 hourly. The number of patients achieving therapeutic vancomycin trough levels was recorded. Safety data was collected, including reported adverse effects, infusion related reactions and renal impairment. Renal impairment was defined as an increase in creatinine by 50%. Data was collected from April 2018 for 6 months. Relevant data with regards to patient demographics, dosing and drug levels were collected and analysed using Microsoft Excel.Results12 patients received 15 doses of vancomycin over 6 months. 67% of initial vancomycin doses were prescribed as per local guideline, 60% of therapeutic trough levels were taken at the right time and 71% of patients that were prescribed the correct dose and had levels taken at the right time achieved therapeutic trough levels. 12 patients required dose adjustments. One patient with renal impairment was not prescribed the recommended dose as per local guidance. One patient reported an infusion related reaction, which was overcome by increasing the infusion time. Two patients who received therapy for >7 days accumulated vancomycin and recorded high trough levels, with no adverse events. One patient reported an increase in creatinine by 50% over the treatment period.ConclusionsVancomycin has the potential to induce nephrotoxicity and ototoxicity when consistently at high serum drug levels. Due to its narrow therapeutic index, drug levels should be monitored to ensure the drug does not accumulate. The licensed dose and dose listed in the BNF for Children 2 3 has historically under dosed patients at our trust, leading to the risk of ineffective therapy and bacterial resistance. It is unclear from research what the optimal dose is for paediatric patients.More research is needed to determine the correct paediatric dose of vancomycin. Higher doses than currently recommended as per licence resulted in three quarters of patients achieving therapeutic levels, however 12 patients still required dose adjustment. No patients suffered irreversible adverse effects or toxicity, suggesting that higher doses are safe to use in the paediatric population. Further education is required for those involved in the prescribing, administering and monitoring of Vancomycin in paediatric patients to ensure its safe use. Additional monitoring is required for those receiving higher doses >7 days to prevent drug accumulation, alternatively a loading dose followed by lower maintenance dose may be a more suitable dosing regimen.ReferencesHughes S, Crook J, Ross J. Vancomycin intravenous dosing guideline - paediatrics. Chelsea and Westminster Hospital; 2017.Stockman C, Sammons H, Stakey E, et al. Unanswered Questions Regarding Optimal Pediatric Vancomycin Use. Therapeutic Drug Monitoring 2016; 38:491–420.National Institute for Health and Care Excellence. Vancomycin. Available from https://bnfc.nice.org.uk/drug/vancomycin.html [Accessed 10th Oct 2018]

13 Evaluating Potential Overuse of Intravenous Hydration in Patients Hospitalized with Bronchiolitis

Background Bronchiolitis is the primary cause of hospitalization in children during the first year of life. Respiratory support and hydration are the two pillars of management. Practice guidelines for bronchiolitis (NICE and CPS) recommend nasogastric (NG) hydration before intravenous (IV) fluids if oral hydration cannot be maintained. However, IV hydration remains the primary mode of hydration at our tertiary care pediatric centre. Objectives This is a resource stewardship project aiming to evaluate the baseline use of IV versus NG hydration in children 0-15 months hospitalized for bronchiolitis and requiring supplemental hydration. The secondary objective is to evaluate potential barriers to NG hydration for these children. Design/Methods Data was collected retrospectively for the 2017-2018 bronchiolitis season. A survey was sent to all the pediatric emergency (ED) physicians and nurses, pediatric hospitalists, ED fellows, pediatric residents and ward nurses. Results Among eligible patients (n=95), IV hydration was prescribed 52% of the time, compared to 48% NG hydration. Ninety-six percent (47/49) of IV hydration was initiated in the ED, while only 4% (2/49) was initiated on the ward. Among patients who began receiving hydration in the ED (80/95, or 84%), 41% (33/80) were hydrated via NG and 59% (47/80) by IV. In the survey, while 92% (57/62) of responding physicians claimed to be aware of national guidelines for bronchiolitis, only 67% (42/62) said that NG was the recommended mode of hydration. Among ED practitioners, 56% (19/34) were up-to-date on the recommendation. Two-thirds of all respondents (physicians and nurses) felt that NG hydration would be more acceptable to parents. Among nurses, 84% (38/45) felt that IV installation was a longer procedure to complete. Despite the existence of a local order set indicating NG hydration as the preferred hydration method, only 64% (40/62) of physicians were aware of its existence, and only 23% of these (9/40) actually use the guideline. Main reasons of disuse included forgetting the guideline exists and it not being easily available. In contrast, 93% of nurses were aware of the local guideline. Conclusion Intravenous hydration is overused among patients hospitalized with bronchiolitis at our centre, and the ED is the main setting where this occurs. There is a discrepancy between physicians’ theoretical knowledge of hydration guidelines and the application of these in reality. Barriers to the use of NG hydration can be amenable to a quality improvement (QI) intervention targeting improved knowledge and use of our local guideline, and this will be our focus going forward.

Provision of acute medicine services for pregnant women in UK hospitals: Data from the Society for Acute Medicine Benchmarking Audit 2019

Background Medical problems during pregnancy are the leading cause of maternal mortality in the UK. Pregnant women often present through acute services to the medical team, requiring timely access to appropriate services, physicians trained to manage medical problems in pregnancy, with locally agreed guidance available. Methods Data were collected through the Society for Acute Medicine Benchmarking Audit, a national audit of service delivery and patient care in acute medicine over a 24 hour period. Results One hundred and thirty hospitals participated: 5.5% had an acute medicine consultant trained in obstetric medicine, and 38% of hospitals had a named lead for maternal medicine. This was not related to hospital size (p = 0.313). Sixty-four units had local guidelines for medical problems in pregnancy; 43% had a local guideline for venous thromboembolism in pregnancy. Centres with a named lead had more guidelines (p = 0.019). Conclusion Current provision of services within acute medicine for pregnant women does not meet national recommendations.