Barriers to completing the 4AT for delirium and its clinical implementation in two hospitals: a mixed-methods study

Purpose To assess the clinical implementation and barriers to completing the 4AT for delirium in general medical and geriatric patients over 75 years upon admission to Wellington and Kenepuru Hospitals during the first eight months of 2017, 2018 and 2019. Methods Retrospective data from electronic health records were analysed using an explanatory-sequential mixed-methods approach. The initial quantitative phase measured doctors’ adherence to the 4AT and the rate of positive 4ATs (≥ 4). The subsequent qualitative phase identified doctors’ main reasons for omitting the 4AT through conventional content analysis. Results The quantitative population included 7799 acute admissions (mean age 84, 58.2% female). There was good clinical implementation of the 4AT, evidenced by an overall adherence rate of 83.2% and a rate of positive 4ATs of 14.8% that is in keeping with expected delirium rates in similar settings. The qualitative sample consisted of 875 acute admissions (mean age 84, 56.3% female) with documented reasons for omitting the 4AT. The main barriers to completing the 4AT were: reduced patient alertness, communication barriers (language, deafness, aphasia and dysarthria), prioritising patients’ wellness and comfort (addressing critical illnesses, symptoms, end-of-life issues and promoting sleep), pre-existing cognitive disorders, and unstructured delirium assessments. Conclusion Adherence to the 4AT was high and sustainable in both hospitals. Most barriers to completing the 4AT were potentially avoidable. Education about the 4AT in relation to these barriers may improve its implementation.

Impact of COVID-19 lockdowns on hospital presentations and admissions in the context of low community transmission: evidence from time series analysis in Melbourne, Australia

BackgroundMelbourne, Australia, successfully halted exponential transmission of COVID-19 via two strict lockdowns during 2020. The impact of such restrictions on healthcare-seeking behaviour is not comprehensively understood, but is of global importance. We explore the impact of the COVID-19 pandemic on acute, subacute and emergency department (ED) presentations/admissions within a tertiary, metropolitan health service in Melbourne, Australia, over two waves of community transmission (1 March to 20 September 2020).MethodsWe used 4 years of historical data and novel forecasting methods to predict counterfactual hospital activity for 2020, assuming absence of COVID-19. Observed activity was compared with forecasts overall, by age, triage category and for myocardial infarction and stroke. Data were analysed for all patients residing in the health service catchment area presenting between 4 January 2016 and 20 September 2020.ResultsED presentations (n=401 805), acute admissions (n=371 723) and subacute admissions (n=15 676) were analysed. Substantial departures from forecasted presentation levels were observed during both waves in the ED and acute settings, and during the second wave in subacute. Reductions were most marked among those aged >80 and <18 years. Presentations persisted at expected levels for urgent conditions, and ED triage categories 1 and 5, with clear reductions in categories 2–4.ConclusionsOur analyses suggest citizens were willing and able to present with life-threatening conditions during Melbourne’s lockdowns, and that switching to telemedicine did not cause widespread spill-over from primary care into ED. During a pandemic, lockdowns may not inhibit appropriate hospital attendance where rates of infectious disease are low.

EP.FRI.1036 Provision of 7 Day Radiology Service: Are we compliant against standards

Aim The audit aimed to retrospectively look into reporting times for investigations for acute surgical inpatients and determine if we were able to meet standards as set in NHS 7 day service provision standards which aims to provide 7day radiological service for hospital inpatients from commission to reporting. Method A prospective audit is undertaken to collect waiting times for investigations for all acute admissions requiring radiological investigations over one month. Investigations were categorized into ‘critical’, ‘urgent’ and ‘non-urgent’ according to guidelines set by Royal College of Surgeons. The results were tabulated in Excel and analyzed to determine level of compliance. Results Collected data shows that off the total 119 investigations performed, 34% were USG, 63% were CT scans and 2.5% were MRI. Standards were met for a total of 67% of the investigations. Only 20% of critical, 67% of urgent and 76% of non-urgent scans were done within the standard time while by modality, CT scans had the highest rate of compliance. 60% of investigations requested over weekends met standards with highest compliance for USG and for non-urgent scans. Average reporting time was approximately 50 minutes. Conclusion The audit outcome highlighted that 1 out of 3 investigations did not meet standards. Within its limitations of no numerical parameters to guide urgency, the audit was able give an idea of the radiology service offered by the hospital and highlighted clear areas for improvements which can be suggested to improve compliance such as documenting ‘operative catergory’ of requested investigations on request forms.

EP.FRI.4 Cholecystostomy presents as a viable option in acute biliary sepsis during the COVID-19 pandemic

Aim To audit and evaluate gallstone related admissions during the COVID-19 pandemic and assess cholecystostomy as an interim and potentially life-saving measure in acute biliary sepsis Methods Patients attending with gallstone disease related complaints from January to September 2020 were assessed, along with data collection on ‘hot’ gallbladder operations, elective cholecystectomies and cholecystostomies performed. Data was assessed on a month by month basis Results There were 306 gallstone related acute admissions in this audit time period. August had the highest number of admissions with 42 (14%) and March the lowest with 21 (7%). Despite 15 hot cholecystectomies (94%) being performed from January to March, only 1 was performed from April to September (6%). 116 elective cholecystectomies were performed during the time period, with 94 (81%) occurring from January to March. 15 cholecystostomies (9 radiologically, 6 surgically) were performed in the period, with 12 (80%) occurring from March onwards. All cholecystostomy patients have been subsequently listed for laparoscopic cholecystectomy. Conclusions This study demonstrates a drop in elective surgery from March 2020 onwards consistent with the COVID-19 pandemic peak. Furthermore, acute admissions related to gallstones decreased over a similar timeframe. Cholecystostomy proved itself to be a viable and potentially life-saving option in dealing with acute biliary sepsis during the COVID-19 pandemic

SP1.2.3General Surgical Registrar in the Emergency Department: Developing and Evaluating a New Surgical Role

Intro NHS Departments are experiencing unprecedented pressures with exponentially growing patient numbers and severe delays in waiting time. This directly influences bed pressures leading to cancellation of elective surgical lists to aid acute admissions. We introduce the role of a surgical registrar in emergency departments (ED) to review general surgical patients to (i) help reduce ED waiting times (ii) prevent unnecessary admissions and (iii) accelerate management plans. Methods This unique role was introduced in our local ED department for 3 months (Nov 2019 - Jan 2020). The shift was trialled Mon-Fri from midday to 8pm. Patient length of stay (LOS), referral times, admissions, discharges and breaches (&gt; 4hrs) were recorded. Results The admission rate was 24% (n 681), with a 10% reduction compared with preceding months. 75% patients were discharged following review from which 20% had outpatient investigations arranged. Average LOS at time of referral was 1hr37mins. Peak referral activity was observed on Mondays, Fridays and between 2-5pm. 98% underwent investigations and 79% received active treatments. Feedback from stakeholders, including surgical colleagues was favourable as it allowed more time spent on operative activities. Conclusion The NHS has some of the most challenging performance standards in the world. We introduce an innovative solution to help reduce rising clinical and financial pressures. The role of the surgical ED registrar helps reduce waiting times, escalate management and prevent unnecessary surgical admissions. Further studies are being conducted to further evaluate the sustainability of this service and extending it to neighbouring trust hospitals.

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

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.

441 Management of Intracapsular Hip Fractures During Unprecedented COVID Times In A DGH

Aim NICE published eligibility criteria for Total Hip Replacement (THR) vs Hemiarthroplasty for intracapsular hip fractures. COVID-19 resulted in the BOA publishing emergency guidelines regarding management of patients eligible for THR. If the available surgeon does not routinely perform hip arthroplasty, the patient should undergo a hemiarthroplasty to maximise theatre efficiency and minimise hospital stay. This project will compare Kings Mill Hospitals compliance with these new guidelines. Method Retrospective data was collected over a two-month period (24/03/20 – 22/05/20) from patients with intracapsular hip fractures. Notes and records allowed us to determine suitability for THR using NICE guidelines. National statistics were taken from the National Hip Fracture Database. The standards for this project consist of the NICE guidelines for Hip Fracture management and the BOA standards for Trauma and Orthopaedics - Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic’. Results 51 patients were included in this audit. THR compliance dropped during the peak months of COVID 35% to 21.4%. Length of acute admissions stay decreased from 10 days to 8 days. Compared to the national averages, Kings Mills THR compliance rate was 27.3% vs 18.3%. 54.5% of eligible patients were operated on by THR performing consultants but received Hemiarthroplasty's Conclusions Some patients were eligible for THR according to the BOA guidelines (1) however received Hemiarthroplasty’s. Better identification may increase guideline compliance. Introduction of a new table in the clerking booklet will be implemented and Re-audited to evaluate effectiveness.