2020

Acute appendicitis-can we shorten the length of hospital stay? (2020)

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Type of publication:
Conference abstract

Author(s):
British Journal of Surgery; Jun 2020; vol. 107 ; p. 197

Citation:
*Jones G.; *Bura K.; *Rink J.

Abstract:
Introduction: Appendicectomy is the most commonly performed emergency general surgical operation in the UK. Hospital episode data revealed that our unit had longer than average length of stay (LOS). We designed a study to examine our length of stay and management of acute appendicitis. Method(s): We performed a retrospective study of consecutive patients undergoing appendicectomy from January to March 2019. Cases were identified from theatre logbooks. Data collection included demographics, pre and post-operative LOS, CT imaging and histology. The data was then examined to see what factors were associated with length of stay and where improvements might be realised. Result(s): 71 patients were identified. Mean LOS was 81 hours, mean time to theatre from admission was 22 hours withmean post-operative LOS at 58 hours. There was a difference between females vs males LOS 95 vs 67 hours. CT scan was obtained in 26 patients and the mean time to theatre in these patients was longer at 27 hours compared to 20 hours in the non- CT group. Patients who took longer to get to theatre had increased LOS. Conclusion(s): Rapid access to CT could shorten time to theatre. Getting patients to theatre quicker might shorten post-operative length of stay.

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Regional experiences of endotracheal intubation during the COVID-19 pandemic in The United Kingdom (2020)

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Type of publication:
Conference abstract

Author(s):
Shuker B.; Smith E.; *Checketts P.; Khan Q.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: In the United Kingdom (UK), consensus guidelines for airway management were published early in the COVID-19 pandemic making recommendations to support clinicians during this potentially challenging intervention (1). Adaptions to existing guidance for airway management in critically ill adults from the Difficult Airway Society (2) included: use of personal protective equipment (PPE), preferential use of the best skilled airway manager to maximise chance of first-pass success, avoidance of aerosol-generating procedures (such as noninvasive ventilation, high flow nasal oxygenation), and use of reliable well practiced techniques (including videolaryngoscopy where appropriate). Objective(s): Areas of the West Midlands were some of the worst affected by the COVID-19 pandemic in the UK (3). We aimed to gain insight into the experiences of clinicians involved with airway management during the COVID-19 pandemic in this region. Method(s): An online survey was distributed to multiple centres within the West Midlands region of the UK. Clinicians who had experience of endotracheal intubation in patients with confirmed, suspected, or unknown COVID-19 status were asked to reflect upon their experience of one patient intubation. Result(s): 127 clinicians from 16 hospitals including 3 large university hospitals responded to the online survey, most were consultant grade (56.7%). Clinicians self-reported an average approximate number of pandemic intubations of 7.35 (range 1-30). When asked to reflect on a single intubation, clinicians reflected on intubations in ICU (42.5%), emergency departments (20.5%), wards (8.7%), and theatre (28.3%). Appropriate PPE was available in 96.1%. The most senior clinician available intubated in 65.4%. Clinicians reported first pass success in 93.7% of responses. Most intubators reported use of videolaryngoscopy (74.8%), however 26% reported not using this equipment regularly and 5.5% did not feel confident with their equipment. Despite a high success rate, difficulties were reported in 15.1%. The most common was desaturation. Other common difficulties included equipment or environment unfamiliarity, lack of skilled support. When asked what advice they would give to colleagues, frequently occurring themes included: ensuring familiarity with equipment, use of a checklist, use of videolaryngoscopy, and availability of a second intubator. Desire for simulation and equipment familiarisation was highlighted in multiple responses, and in one example a clinician attributed their success to a simulation session performed in the week prior. Conclusion(s): Experiences from clinicians in this region highlight the specific challenges encountered involved in airway management of patients with COVID-19, in particular highlighting the importance of advance preparation for intubation when faced with unfamiliar circumstances. Simulation sessions, use of checklists and standard operating procedures for emergency intubation may contribute to maintaining preparedness for intubation in this challenging patient group.

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Intensive care unit (ICU) referrals and admissions at a district general hospital (DGH) in light of the COVID-19 pandemic (2020)

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Type of publication:
Conference abstract

Author(s):
*Blair J.; *Naughton E.; *Pradhan N.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: The COVID-19 pandemic has led to an increase in ICU referrals and admissions across the UK during 2020 [1]. Intensive care beds are a limited and expensive resource and decisions on patient admission are often very challenging [2]. Proformas help to standardise documentation and decision logging during patient referrals [3]. They provide easily accessible evidence in case of a future referral and allow audit of decision-making processes. A preliminary survey of doctors working in a DGH ICU was undertaken to assess the current referral and admission process in expectation of an increased volume of work.
Objective(s): As a result of the survey, three main areas for improvement were identified: 1. To maintain a record of all ICU referrals and decision-making processes 2. To reduce the time taken for documentation of referrals and admissions 3. To improve the quality and appropriateness of referrals from parent specialities Methods: A proforma was designed for dual use as a referral and admission document. All referrals were recorded on paper and staff received training on how to apply the proforma. After assessment of each referral, irrespective of admission outcome, a completed copy of the proforma was placed in both the patient's notes and a dedicated referrals folder. After one month, a further survey was designed to assess the response postimplementation of the proforma. All referrals made over a threemonth period between April and June 2020 were audited.
Result(s): The initial survey received 12 responses. Prior to the COVID-19 pandemic, documentation of any referral or admission took on average 10-15 minutes. All survey participants felt that referring teams did not have a good understanding of the role of ICU care and estimated that up to 40% of all referrals received were inappropriate. The follow-up survey received 14 responses. Implementation of the proforma reduced the time taken to document a referral or admission on average by 5-10 minutes. Twelve participants found the proforma a useful aid, helping to provide clear documentation and ease communication between ICU team members. Less than 9% of the referrals made between April and June 2020 were admitted to ICU with over 32% of referrals deemed unsuitable for further escalation. Approximately 50% of referrals were made by registrars, with 13% discussed by consultants. The median age of patients referred was 67.5 and the most common reason was for respiratory deterioration.
Conclusion(s): This quality improvement project successfully reduced the time taken to document ICU referrals and admissions. Use of a proforma has provided many benefits, including standardisation of documentation, decision logging and improvement of intra-and inter-team communication. Only a small proportion of patients referred to ICU have been suitable for admission. A teaching session is being designed so that referral information can be fed-back to parent specialties. Referrals will be reaudited after this. Data analysis of this project has been limited by incomplete proforma documentation from participating users.

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A Tidal volume calculator to improve lung protective ventilation in COVID-19 related Acute Respiratory Distress Syndrome (ARDS) (2020)

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Type of publication:
Conference abstract

Author(s):
*Blair J.; *Hester S.; Baldwin A.; Ali T.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: Routine use of lower tidal volumes (TVs) for the mechanical ventilation of patients with ARDS results in decreased mortality and increases the number of days without ventilator use [1]. Severe COVID-19 pneumonia has been associated with the development of ARDS as characterised by the Berlin definition [2]. A multi-centre preliminary audit was undertaken to identify whether ventilated COVID-19 related ARDS patients were receiving optimal TVs, as recommended by the Faculty of Intensive Care Medicine (FICM) and Intensive Care Society (ICS) ARDS management guidelines [3]. Objective(s): As a result of the audit, three main areas for improvement were identified. 1. To achieve accurate calculations for ideal body weight (IBW) and target TV 2. To improve documentation of IBW and target TV 3. To achieve TVs no greater than 6 ml/kg Methods: A 'tidal volume calculator' tool was developed using Microsoft Excel, which was simple, colour coded and kept on all Intensive Care Unit (ICU) computer desktops. This tool was designed to use height to calculate IBW and, if the patient's height was unavailable, could also be utilised to calculate height from ulna length. IBW was subsequently used to calculate a target TV. Staff received training on how to apply the tool. Two snapshot audits were carried out in April and May 2020 at two ICUs. The first was conducted prior to the tool's introduction with the second two weeks after its implementation. All patients receiving mechanical ventilation, except those spontaneously breathing, were included. Data was extracted from patient notes, charts and ventilator settings. Result(s): The initial audit included 14 patients. Six patients did not have an IBW documented. Three patients had documented IBWs that were 12 kg, 15 kg and 23 kg greater than the weight calculated using the tool, leading to increased tidal volume targets. Only three patients were achieving TVs of 4-6 ml/kg. Eleven patients were achieving a TV greater than 6 ml/kg, with two of these achieving a TV of greater than 8 ml/kg. The follow-up audit included ten patients. This revealed that all patients had an IBW clearly documented. Moreover, nine patients were achieving TVs within 4-6 ml/kg, with only one patient found to be achieving a TV greater than 6 ml/kg. Conclusion(s): This audit cycle revealed that initially adherence to lung protective ventilation and documentation of IBW was poor. In some instances, documented IBW was vastly different to the calculated IBW, suggesting that in these situations actual body weight may have been used. In a time when clinicians were being redeployed to support ICU, this simple tool was shown to support staff by clearly calculating and displaying IBW and target TV for reference. This directly led to improved adherence to lung protective ventilation and optimisation of patient care. Limitations include that no consideration was made for overall patient outcome, and only a snapshot of achieved TVs from ventilators were recorded; daily/weekly trends were not studied.

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'Daycase parathyroidectomy: Time to change the norm?' (2020)

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Type of publication:
Conference abstract

Author(s):
Chang J.; Neophytou C.; Howard E.; Houghton A.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 37

Abstract:
Introduction: The most recent BAETs audit report of 2017 shows a surprisingly low rate of same-day discharge following parathyroidectomy (10%). In our unit we have developed a simple and safe protocol which allows same day discharge for almost all patients (95%). The 2017 BAETS report has 11,463 patients recorded for primary hyperparathyroidism. Following this simple protocol could save over 9,500 inpatient bed days.
Method(s): Demographics, histology, biochemistry and length of stay were identified for all patients undergoing parathyroidectomy for primary hyperparathyroidism between 01/01/2010 and 31/12/2019. Following surgery all patients were discharged on Calcichew D3 one tablet tds, with arrangements for serum calcium analysis and outpatient appointment at 7 and 10 days Results: We performed 264 parathyroid procedures during the study period. The cohort had a median age of 63 (range 15 – 90). Day-case procedures were carried out in 95% (n=249). 10 patients stayed 24 hours, 4 for 48 hours and 1 patient for 4 days (urgent parathyroidectomy following acute medical admission with symptomatic hypercalcaemia). 1 patient was admitted overnight for observation of bleeding wound (no return to theatre). The remainder were admitted for a mixture of social and anaesthetic reasons. 6 patients (2%) had 30 day morbidity: 2with symptoms of relative hypocalcaemia (not admitted), 1 patient with hypocalcaemia requiring intravenous calcium, 1 seroma, 1 patient presented with an exacerbation of COPD and 1 haematoma.
Conclusion(s): We have shown that same-day discharge after parathyroid surgery is safe and ought to become the norm in other units.

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IMPACT. Operating Department Human Factors Training for the whole team (2020)

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Type of publication:
Conference abstract

Author(s):
Allman T.; Schunke N.; Fenton C.; Branfield L.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 14

Abstract:
Aims: We identified a gap in effective staff training and developed a novel truly multidisciplinary training day to capture the whole team and expose them to simulation in their usual environment amongst usual peers. Our aim was to maximise the impact factor of multidisciplinary operating department human factors training and utilise high fidelity simulation to expose unknown unknowns and improve theatre safety.
Method(s): Novel human factors training run onsite. On a rotational basis designated theatre lists are blocked for the mandatory training to ensure all members of the theatre teams can attend ranging from porters to consultants and team leaders. Line managers enforce attendance and feedback is collated. Anaesthesia retained oversight and organisation. 3 main sessions run in parallel by teams of multidisciplinary facilitators.

  1. WHO Steps to Safer Surgery: Trust 'STOP THE LINE' video and discussion.
  2. Raising concerns: discussion lead by consultant surgeon.
  3. Theatre simulation & debrief: High fidelity in the operating theatre.

Result(s): The training received exemplary feedback and review from all staff across specialties.Multiple gaps in knowledge, particularly the location of rarely used emergency equipment and drugs was exposed and this allowed for on the spot, high yield training. Candidate feedback revealed the impact of our training was maximised by the facilitation led by consultant surgeons. Conclusion(s): Human factors training is notoriously variable and limited. We've collaborated surgical, anaesthetic and theatre teams to deliver high impact and resourceful training by addressing the human factors that mould our own learning.

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Laparoscopic ligation of inferior mesenteric artery (IMA) for the management of type II endoleak post endovascular aneurysm repair (EVAR) (2020)

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Type of publication:
Conference abstract

Author(s):
*Mashar R.; *Gangwar A.; *McCloud J.; *Shawish E.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 96-97

Abstract:
Aim: Type II endoleaks following EVAR are caused by patent aortic collaterals causing retrograde blood flow, with the IMA being involved in 45-85% of all cases. Transarterial embolization has been described as a management option, but with a high failure rate. We present laparoscopic ligation as an alternative therapeutic strategy, with both technical success and a favourable outcome.
Method(s): An 80-old hypertensive male was diagnosed with a type II endoleak post-EVAR. Shrinkage of the sac was seen initially from 58mm to 52mm on surveillance-computed tomography (CT) of the aorta at 6 months with apersistent type II endoleak involving the IMA and lumbar arteries. Surveillance at 18 months demonstrated a persistent endoleak with enlargement of the sac to 65 mm. After a failed attempt with arterial embolization, he underwent laparoscopic ligation of the IMA Results: The procedure time was 22 minutes and his length of stay was 2 days, with no signs or symptoms of bowel ischaemia. A CT at 2 weeks demonstrated sac shrinkage to 58 mm. Conclusion(s): There have been reports of persistent endoleaks being associated with adverse outcomes, with their primary management remaining controversial. IMA ligation has been associated with sac shrinkage in 65% of patients, an important prognostic factor, and there have been no reported complications thus far. Therefore, it should be strongly considered as an option for management of type II endoleaks in centres with both vascular and general surgical expertise being available

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The annual usage of anaesthetic gases at the Shrewsbury and Telford Hospitals NHS Trust: the environmental impact and potential solutions (2020)

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Type of publication:
Conference abstract

Author(s):
*Thompson T.; *Passey S.; *Mowatt C.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 74-75

Abstract:
Aims: The NHS is responsible for 5.5% of the UK's net emissions, with anaesthetic gases comprising of 5% of hospital emissions. Shrewsbury and Telford hospitals (SaTH) are DGH's with 18 combined theatres, 9 at each site. The aim of this study was to evaluate the environmental impact of anaesthetic gases used by the trust and suggest possible improvements.
Method(s): Figures from October 2018-2019 supplied by the hospital pharmacy and compared using the RCoA Anaesthetic Impact Calculator. Costs obtained from pharmacy relating to the available anaesthetic gases and drugs.
Result(s): Over the past year SaTH has emitted the equivalent of 4,819,050kg of CO2 through its anaesthetic gases alone (these gases being sevoflurane, isoflurane, desflurane and nitrous oxide). Of these gases, sevoflurane is the greenest, while nitrous oxide is the worst offender. To give this an idea of scale, to offset, this would require the planting of 10915 trees, which would take up an area of 4-10 hectares of land.
Conclusion(s): We are recommending that SaTH stops using Nitrous oxide and Isoflurane, which is currently under consideration by the consultant body. We would discourage the use of desflurane, and where possible sevoflurane. Encourage the use of total intravenous anaesthetic (TIVA). We postulate this would save the trust aminimum of 5000 per year or 15000 per year with a 10% reduction in sevoflurane use. This would reduce our CO2 equivalent production by over 4.6 million kg.

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The benefits of multidisciplinary human factors training in theatre (2020)

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Type of publication:
Conference abstract

Author(s):
*Jones R.; *Branfield L.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 75

Abstract:
Aims: The awareness of Human Factors (HF) and their role in patient safety is vital in the theatre environment.
The aim of this audit was therefore to assess the awareness of human factors within our theatre team during a Human Factors Training Course at a District General Hospital.
Method(s): The Human Factors Training Course started with a questionnaire assessing roles, experience, and awareness of HF. It also looked at staff morale. The course involved a presentation and 2 simulation scenarios in theatre. After completion, there was a post course questionnaire looking at awareness of human factors, effects on staff morale and impact on patient care.
Result(s): Of the respondents, experience varied from 1 to 10+ years. The pre-course awareness of HF averaged 6.1 out of 10. The opinions on morale averaged at 6.7 out of 10, and the effect of HF training on morale averaged 8.4 out of 10. All respondents believed that the course could improve patient care. Post course awareness of HF increased and staff morale also increased as a consequence of the course.
Conclusion(s): From the results we can see that the awareness of human factors within the cohort prior to training was relatively low. Post course, we can see an increase in terms of awareness of human factors. As well as providing a training opportunity, this course had a positive effect on staff morale, and vitally, it was thought that the course would have positive impact on patient care.

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Uterotonic agents for first-line treatment of postpartum haemorrhage: a network meta-analysis (2020)

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Type of publication:
Systematic Review

Author(s):
*Parry Smith, William R; Papadopoulou, Argyro; Thomas, Eleanor; Tobias, Aurelio; Price, Malcolm J; Meher, Shireen; Alfirevic, Zarko; Weeks, Andrew D; Hofmeyr, G Justus; Gülmezoglu, Ahmet Metin; Widmer, Mariana; Oladapo, Olufemi T; Vogel, Joshua P; Althabe, Fernando; Coomarasamy, Arri; Gallos, Ioannis D

Citation:
The Cochrane Database of Systematic Reviews; Nov 2020; vol. 11 ; p. CD012754

Abstract:
BACKGROUND Postpartum haemorrhage (PPH), defined as a blood loss of 500 mL or more after birth, is the leading cause of maternal death worldwide. The World Health Organization (WHO) recommends that all women giving birth should receive a prophylactic uterotonic agent. Despite the routine administration of a uterotonic agent for prevention, PPH remains a common complication causing one-quarter of all maternal deaths globally. When prevention fails and PPH occurs, further administration of uterotonic agents as 'first-line' treatment is recommended. However, there is uncertainty about which uterotonic agent is best for the 'first-line' treatment of PPH. OBJECTIVES To identify the most effective uterotonic agent(s) with the least side-effects for PPH treatment, and generate a meaningful ranking among all available agents according to their relative effectiveness and side-effect profile.SEARCH METHODSWe searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 May 2020), and the reference lists of all retrieved studies. SELECTION CRITERIA All randomised controlled trials or cluster-randomised trials comparing the effectiveness and safety of uterotonic agents with other uterotonic agents for the treatment of PPH were eligible for inclusion.DATA COLLECTION AND ANALYSIS Two review authors independently assessed all trials for inclusion, extracted data and assessed each trial for risk of bias. Our primary outcomes were additional blood loss of 500 mL or more after recruitment to the trial until cessation of active bleeding and the composite outcome of maternal death or severe morbidity. Secondary outcomes included blood loss-related outcomes, morbidity outcomes, and patient-reported outcomes. We performed pairwise meta-analyses and indirect comparisons, where possible, but due to the limited number of included studies, we were unable to conduct the planned network meta-analysis. We used the GRADE approach to assess the certainty of evidence.MAIN RESULTS Seven trials, involving 3738 women in 10 countries, were included in this review. All trials were conducted in hospital settings. Randomised women gave birth vaginally, except in one small trial, where women gave birth either vaginally or by caesarean section. Across the seven trials (14 trial arms) the following agents were used: six trial arms used oxytocin alone; four trial arms used misoprostol plus oxytocin; three trial arms used misoprostol; one trial arm used Syntometrine® (oxytocin and ergometrine fixed-dose combination) plus oxytocin infusion. Pairwise meta-analysis of two trials (1787 participants), suggests that misoprostol, as first-line treatment uterotonic agent, probably increases the risk of blood transfusion (risk ratio (RR) 1.47, 95% confidence interval (CI) 1.02 to 2.14, moderate-certainty) compared with oxytocin. Low-certainty evidence suggests that misoprostol administration may increase the incidence of additional blood loss of 1000 mL or more (RR 2.57, 95% CI 1.00 to 6.64). The data comparing misoprostol with oxytocin is imprecise, with a wide range of treatment effects for the additional blood loss of 500 mL or more (RR 1.66, 95% CI 0.69 to 4.02, low-certainty), maternal death or severe morbidity (RR 1.98, 95% CI 0.36 to 10.72, low-certainty, based on one study n = 809 participants, as the second study had zero events), and the use of additional uterotonics (RR 1.30, 95% CI 0.57 to 2.94, low-certainty). The risk of side-effects may be increased with the use of misoprostol compared with oxytocin: vomiting (2 trials, 1787 participants, RR 2.47, 95% CI 1.37 to 4.47, high-certainty) and fever (2 trials, 1787 participants, RR 3.43, 95% CI 0.65 to 18.18, low-certainty). According to pairwise meta-analysis of four trials (1881 participants) generating high-certainty evidence, misoprostol plus oxytocin makes little or no difference to the use of additional uterotonics (RR 0.99, 95% CI 0.94 to 1.05) and to blood transfusion (RR 0.95, 95% CI 0.77 to 1.17) compared with oxytocin. We cannot rule out an important benefit of using the misoprostol plus oxytocin combination over oxytocin alone, for additional blood loss of 500 mL or more (RR 0.84, 95% CI 0.66 to 1.06, moderate-certainty). We also cannot rule out important benefits or harms for additional blood loss of 1000 mL or more (RR 0.76, 95% CI 0.43 to 1.34, moderate-certainty, 3 trials, 1814 participants, one study reported zero events), and maternal mortality or severe morbidity (RR 1.09, 95% CI 0.35 to 3.39, moderate-certainty). Misoprostol plus oxytocin increases the incidence of fever (4 trials, 1866 participants, RR 3.07, 95% CI 2.62 to 3.61, high-certainty), and vomiting (2 trials, 1482 participants, RR 1.85, 95% CI 1.16 to 2.95, high-certainty) compared with oxytocin alone. For all outcomes of interest, the available evidence on the misoprostol versus Syntometrine® plus oxytocin combination was of very low-certainty and these effects remain unclear. Although network meta-analysis was not performed, we were able to compare the misoprostol plus oxytocin combination with misoprostol alone through the common comparator of oxytocin. This indirect comparison suggests that the misoprostol plus oxytocin combination probably reduces the risk of blood transfusion (RR 0.65, 95% CI 0.42 to 0.99, moderate-certainty) and may reduce the risk of additional blood loss of 1000 mL or more (RR 0.30, 95% CI 0.10 to 0.89, low-certainty) compared with misoprostol alone. The combination makes little or no difference to vomiting (RR 0.75, 95% CI 0.35 to 1.59, high-certainty) compared with misoprostol alone. Misoprostol plus oxytocin compared to misoprostol alone are compatible with a wide range of treatment effects for additional blood loss of 500 mL or more (RR 0.51, 95% CI 0.20 to 1.26, low-certainty), maternal mortality or severe morbidity (RR 0.55, 95% CI 0.07 to 4.24, low-certainty), use of additional uterotonics (RR 0.76, 95% CI 0.33 to 1.73, low-certainty), and fever (RR 0.90, 95% CI 0.17 to 4.77, low-certainty). AUTHORS' CONCLUSIONS The available evidence suggests that oxytocin used as first-line treatment of PPH probably is more effective than misoprostol with less side-effects. Adding misoprostol to the conventional treatment of oxytocin probably makes little or no difference to effectiveness outcomes, and is also associated with more side-effects. The evidence for most uterotonic agents used as first-line treatment of PPH is limited, with no evidence found for commonly used agents, such as injectable prostaglandins, ergometrine, and Syntometrine®.

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