393 Reducing plastic waste in Paeds ED

Aims/Objectives/BackgroundVenepuncture and PVC insertion are common procedures in Children’s ED and often include blood cultures. Opening a universal dressing pack (udp) including a plastic tray, sterile swabs, gloves and 2 plastic sterile field drapes (sfd) is common practice. Our department was making a huge spend on udp’s. We aimed to determine if this was necessary and if we could reduce our plastic waste.Methods/DesignA sample of 8 doctors across all grades demonstrated their set up for both procedures. We replaced udp in the IV trollies with x2 sfd pack (sfdp). Information was disseminated via weekly staff brief. Trollies are restocked each night using attached flashcards which were updated appropriately. The use and costs of dressing packs in ED was determined for April-June 2019. We planned to compare this for April-June 2020.Results/ConclusionsAll clinicians were opening a dressing pack for procedures but 87.5% only used the sfd and swabs. 100% discarded gloves due to inappropriate size and 100% discarded the tray. All staff adopted the new equipment with no problems identified. 3500 udps were being used in dept in 3 months. Udp v sfdp per item costs 32p v 8p, weight 65 g v 30 g. Due to CoVID-19 pandemic the number of ED attendances significantly reduced therefore costs were based on 2019 usage. In 3 months switching from udp to sfd would save £840 and 122.5 kg of refuse weight. Volumes of stocks were reduced from 0.05 m2 to 0.01 m2 for 50 udp v 50 sfdp which aids storage and restocking of IV trollies releasing staff time.We demonstrated a significant reduction in unnecessary plastic waste while also reducing costs and need for storage and restocking whilst maintaining safe practice. This has been rolled out in the neighbouring Clinical Decision Unit with anticipation of being a permanent change in both areas.

Use of a Mandatory Clinical Decision Unit Reduces Readmission Rates following Total Joint Arthroplasty

Readmission penalties have encouraged the implementation of protocols to reduce readmission rates. We hypothesized that by keeping postoperative patients, who return to the emergency department (ED) in a clinical decision unit (CDU) until being evaluated by the orthopaedic team, there would be a reduction in the readmission rate after total joint arthroplasty (TJA) at our institution. Our institution mandated the use of the CDU for all potential orthopaedic TJA readmissions. A retrospective review of prospectively collected data was performed on 365 patients who presented to the ED after either total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients presenting in the year prior to the implementation of the CDU program were compared with patients presenting in the year after implementation. Demographics, length of stay, comorbidities, and 30-day readmission rates were recorded. Additionally, a financial analysis was performed. Overall, for THA and TKA, there were a combined 141 ED visits prior to the implementation of the CDU program and 224 afterward; of these, 40 were readmitted before the CDU program and only 13 were readmitted afterward (p < 0.01). The financial analysis found that the overall 90-day cost for patients in the postoperative period was nearly $800 lower on average (p = 0.027) post-CDU implementation.During the first year of the CDU project at our institution, we significantly reduced the readmission rates following TJA and demonstrated significant cost saving. This is a Level III, prognostic study.

152 Implementation of Older Persons Rapid Assessment Hub (OPRAH) in the Emergency Department (ED)

Background The Emergency Department (ED) is where most people, including older adults in crises, seek care. OPRAH was introduced in order to meet the needs of our changing population. The unit was developed out of existing resources within the ED and cohorts both older patients and staff to an area more suitable to carry out assessments. Methods We used a quality improvement framework to develop our service. OPRAH is led by an ED GEM (Geriatric Emergency Medicine) consultant, staffed using the existing ED team, housed within footprint of the ED as part of the Clinical Decision Unit (CDU) with the addition of an HCA (healthcare assistant) as required. To determine the impact of the service on admissions of older adults, we collated patient records prospectively. These were reviewed and coded by senior ED professionals blinded to outcomes, to determine medical-referral rate for admission in these cohort. Results In the first 3 weeks of implementation, 76 patients were assessed. Four were admitted and 2 transferred to other hospitals. Mean age was 83 years ranging 66-103 years with an average of 262 minutes in the ED prior to OPRAH admission. Blinded coders review determined 53 (76%) of these patients would have been referred for admission. The majority of the remainder would have completed their care in the ED, as they were not eligible for admission to CDU. Conclusion Introduction of OPRAH to the ED has improved access for older people to short-stay ED led care and reduced admission rates. We have identified a trend towards fewer episodes where care by in-house teams is completed within the ED. We are in an early phase of this project. Nonetheless, it is evident that by redesigning how we assess older people in the ED and using available outpatient resources, we could impact on admission rate and length of stay in the ED without compromising patient care. Implementation has increased the use of the integrated care team, hospital and community MDT (multidisciplinary team).

Symptom-triggered therapy for assessment and management of alcohol withdrawal syndrome in the emergency department short-stay clinical decision unit

IntroductionWe previously reported that benzodiazepine detoxification for alcohol withdrawal using symptom-triggered therapy (STT) with oral diazepam reduced length of stay (LOS) and cumulative benzodiazepine dose by comparison with standard fixed-dose regimen. In this study, we aim to describe the feasibility of STT in an emergency department (ED) short-stay clinical decision unit (CDU) setting.MethodsIn this retrospective cohort study, we describe our experience with STT over a full calendar year (2014) in the CDU. A retrospective chart review was conducted and data collection included demographics, clinical details, total cumulative dose of diazepam, receipt of parenteral thiamine, LOS and disposition.Results5% (n=174) of 3222 admissions to CDU required STT. Collapse or seizure (41%, n=71) and alcohol withdrawal (21%, n=37) were the most common reasons recorded for admission to CDU in those who required STT. Median Alcohol Use Disorders Identification Test score was 25 and 112 patients (64%) had at least one Clinical Institute Withdrawal Assessment for Alcohol revised measurement ≥10, triggering a dose of diazepam (20 mg). The median cumulative oral diazepam dose was 20 mg while 24 (15%) patients received a cumulative dose of 100 mg or more. Median time for STT was 12 hours (IQR=12, R=1–48). 3% (n=5) of patients required further general hospital admission and median LOS in CDU, was 22 hours (IQR=20, R=1–168).ConclusionSTT is potentially feasible as a rapid and effective approach to managing alcohol withdrawal syndrome in the ED/CDU short-stay inpatient setting where patient LOS is generally less than 24 hours.