366 An Audit of Electronic Discharge Summaries and the Impact of Dedicated Teaching and Training in an Emergency Surgical Unit

Introduction

Electronic discharge summary forms a vital part of a patient’s journey. As established in GAIN Guidelines 2011 ‘Clear and complete documentation in a patient’s health record is directly linked to the quality of the care they receive’. By improving the quality of E-Discharge summaries this will help to improve patient outcomes.

Method

In the Emergency surgical unit [EMSU] there are over 3500 completed consultant episodes per annum. We audited the quality of E-Discharges using 33 separate parameters included in the Trust’s dedicated discharge proforma. An E-Discharge summary was considered acceptable if >90% of the information was recorded accurately. Discharge failure rate was audited in a randomised sample of 20 discharges in November 2019 and one year later in November 2020 following implementation of specific training and teaching at induction on E-Discharge compilation.

Results

In November 2019 the discharge failure rate was 60%. Common failings were in general omission of data, lack of follow-up planning and inaccurate pharmaceutical arrangements. In November 2020, following dedicated teaching at induction, failure rate was 15%. Where accurate recording of demographic information and pertinent inpatient detail improved, shortcomings remained in inadequate recording of follow-up care and ongoing involvement of the primary healthcare team.

Conclusions

E-Discharge recording is sub-standard. It is often the remit of the least experienced member of the medical team, as is the case in our unit. We have shown that dedicated teaching and training in this area can improve the quality of discharge summaries.

284 Pneumomediastinum in the COVID-19 Era: To Drain or Not to Drain

Introduction

Although quite uncommon in the pre-COVID-19 era, pneumomediastinum has been increasingly reported in COVID-19 cases complicating the management and prognosis of these patients. The aim of this study is to present the current experience on COVID-19 associated pneumomediastinum and to propose a management algorithm based on the existing literature.

Method

A search strategy focused on electronic databases (Medline, Embase, Google Scholar) was performed. Main search keywords were pneumomediastinum and COVID-19-related keywords. Eligible studies were included without strict limitations on type of study, type of publication, language, or date.

Results

Several reports of pneumomediastinum management in the context of COVID-19 infection have been reported. An initial diagnostic approach with computed tomography scan is recommended for all patients with increased oxygen requirements and suspicious chest X ray. In stable, non-intubated patients, pneumomediastinum can be initially monitored, whereas in the event of progressing air accumulation and cardiorespiratory compromise, a subxiphoid drain alone may preserve the cardiopulmonary reserve. In cases with coexisting pneumothorax and pneumomediastinum, a pleural drain should be prioritised and a subxiphoid drain should be reserved for cases not responding to initial treatment. In surgical emphysema cases, conservative management, especially in non-intubated patients, is suggested, while coexisting pneumothorax as described above. For refractory surgical emphysema cases, subcutaneous drain or subxiphoid drain- in presence of pneumomediastinum- might be required.

Conclusions

In air space complications such as pneumomediastinum, surgical emphysema and pneumothorax, a proposed treatment algorithm can be applied aiming to improve the outcomes of these complicated COVID-19 patients.

280 IRT30 [Inadvertent Returns to Theatre Within 30 Days]: Highlighting the Value of This Novel Metric as a Measure of Surgical Performance

Introduction

Unplanned return to theatre is commonly associated with a problem at the original operation. IRT30 is a potentially valuable but underutilised metric. Use of this metric in Governance Meetings allows for standardisation of the selection of patients, objective assessment of morbidity & mortality, and can facilitate an improvement in surgical performance and ultimately outcome.

Method

The complications associated with IRT30 can be graded from Type I to V ranging from Avoidable/Understandable/Major/Serious through to ‘Never events’. We reviewed all emergency procedures prospectively from February to April 2021. Planned returns and returns after 30 days from index operation were excluded. Patients’ notes were individually reviewed, and cases were grouped by subspecialty [Colorectal, Upper Gastrointestinal (UGI) and General] and ‘IRT30 graded’ accordingly.

Results

A total of 486 cases were performed. 20 were unplanned returns to theatre (4.3%). The majority of cases were Colorectal [75% (15/20)] with 20% UGI (4/20)]. There were 3 Type 1, 6 Type 2 and 11 Type 3 IRT30. 4 patients with perianal sepsis required further surgery (Type 2). Bleeding, ischaemia, and anastomotic leak were most commonly associated with IRT30. No ‘serious’ or ‘never’ events were recorded.

Conclusions

IRT30 is an underutilised useful objective metric that can be employed routinely in Governance meetings to improve surgical performance and outcomes. Perianal sepsis requires experienced involvement at the index operation. Bile leaks are more frequent than perhaps we expect following laparoscopic cholecystectomy, but a proactive approach should be encouraged.

457 The Effect of Biochemical Adversity of Primary Hyperparathyroidism on Preoperative Imaging (SPECT-CT and US Parathyroids)

Aim

Primary hyperparathyroidism (PHPT) is a common endocrine disorder, with an estimated incidence of 1/500 women and 1/2000 men older than 40 years. Several factors influence the positivity of preoperative scans including serum calcium, PTH and vitamin D levels, and gland size. The aim of our study is to examine the effect of biochemical adversity of primary hyperparathyroidism on preoperative imaging (SPECT-CT and US parathyroids).

Method

Retrospective study of 176 parathyroidectomies (2017-2020) in a tertiary referral centre with biochemistry, SPECT-CT, US parathyroids and histology outcomes being recorded. Failed parathyroidectomies were excluded.

Results

Patients were divided into 4 groups based on the preoperative calcium levels (normocalcemia <2.6, 3.4%; mild 2.60-2.79, 51.1%; moderate 2.80-2.99, 31.2%; severe >3.0 mmol/l, 14.2% of patients). Age (p-0.0297), preoperative vitamin D (p-0.03) and PTH levels (p-0.0001) were different while SPECT-CT positivity (p-0.29) weight of gland (p-0.015) and US positivity (p-0.09) were similar within the subgroups. Looking at the whole group, patients with positive SPECT-CT have a larger weight (p < 0.0001) while preoperative PTH levels was higher for the positive SPECT-CT patients (p-0.0289). No relation was identified between calcium levels and SPECT-CT positivity (p-0.18). No significance between preoperative vitamin D and positivity of US and SPECT-CT within the study group were noted.

Conclusions

Serum PTH levels and weight of the gland are directly correlated with positivity of preoperative imaging. Preoperative calcium and vitamin D levels correlates indirectly with the severity of the disease but did not influence the preoperative imaging positivity.

1557 Readmission Rates Are Not A Surrogate for Poor Practice – An Audit of Readmissions to An Emergency Surgical Unit [Emsu]- The Devil Lies in The Detail!

Aim

Readmission rates are considered an indicator of poor performance resulting in financial penalty to healthcare trusts. The national peer review figure for monthly readmission varies considerably (1.71%-7.53%). This metric can be misleading and requires detailed analysis. The aim of this audit was to critically review the readmissions to the EMSU.

Method

A 1-month review of all patients presenting to the EMSU via a prospectively maintained electronic database was interrogated. (October 2020). The primary outcome was “true” readmission rate (i.e., inclusion criteria - readmission within 30 days of discharge). Secondary outcomes were to assess the appropriateness of readmission and consequent morbidity.

Results

331 patients were admitted with 39 readmissions (11.8%). 22 patients failed to meet the inclusion criteria. The true readmission rate was 17 (5.1%). 7/17 had a post-operative complication. The remainder had a miscellaneous minor upper and lower gastrointestinal complaints. 6/10 required cross-sectional imaging and blood work. There were no mortalities.

Conclusions

The readmission rate reported by Trust coding was erroneously high due to inaccurate recording of data. The accurate readmission rate was 5.1%. The majority of those readmitted could have been managed successfully in a Surgical Ambulatory Service [SAmS]. These data support the hypothesis that readmission rates can be misleading, and efforts should be directed not just in data recording and analysis but also in the utilization of SAmS.

Correlation between biochemical features and outcomes of preoperative imaging (SPECT-CT and Ultrasound) in primary hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism is the third most common endocrine disorder, diagnosed by elevated parathyroid hormone (PTH) in hypercalcaemia. Several biochemical factors have been described to suggest severity of disease and may be correlated with preoperative imaging.

METHODS

This was a retrospective study of patients who underwent parathyroidectomy over a 3-year period. Preoperative calcium, PTH, vitamin D levels, ALP (alkaline phosphatase), vitamin D, serum phosphate and US and SPECT-CT positivity was noted.

RESULTS

176 patients underwent parathyroidectomy and these were divided into 4 groups based on preoperative calcium. Overall, 61% of patients showed concordance between imaging and operative findings. Severe hypercalcaemia was associated with higher PTH levels, lower vitamin D levels, an increased rate of abnormal ALP levels, lower phosphate, male gender and highest rate of imaging concordance. Imaging positivity was associated with severe hypercalcaemia and elevated PTH levels. Level of PTH >125 pmol/L and hypercalcaemia >2.8 mmol/L are the most accurate cut-off levels for scan positivity.

CONCLUSION

Biochemical factors associated with severity of the disease are directly correlated with positivity of preoperative imaging while ALP and vitamin D did not influence the preoperative imaging positivity but are associated with disease adversity. Serum phosphate level independently predicted results of parathyroid US.