P-EGS09 The Introduction of an Ambulatory Surgical Pathway

Background Since the publication of the Emergency General Surgery Commissioning Guide by ASGBI in 2014, there has been a drive to develop ambulatory pathways for acute surgical patients, saving inpatient stays and reducing the risk of hospital-acquired infections. Many units, like ours, had a large workload increased by seeing next day returns as well as acute presentations. In October 2020 an Institute of Emergency General Surgery was formed who developed an ambulatory pathway to ameliorate some of these issues and provide a point of contact for primary care referrals, for one the busiest emergency general surgical takes in the UK. Methods A retrospective analysis was undertaken to identify all acute referrals to general surgery over a 14-day period in February 2019 prior to (Pre-ASC) and 2021 after (Post-ASC) the introduction of an Ambulatory Surgical Clinic (ASC). All patient episodes were reviewed, and descriptive statistics on overall attendance to the surgical assessment unit (SAU), admissions to inpatient wards and referrals to ASC were analysed. Patients presenting to the acute urology take were used as a control to compare the number patients attending the surgical assessment unit both before and during the COVID-19 pandemic. Results 830 patients presented over the 28-day study period (426 pre-ACS vs 404 post-ACS; 5% reduction), totalling 992 patient encounters including planned returns (525 vs 467; 11% reduction). After the introduction of the ASC total attendance to SAU was reduced by 42% (525 vs 306); next day return attendances were reduced by 87% (99 vs 13) and attendances from primary care were reduced by 68% (208 vs 67). The proportion of patients admitted was similar (46% vs 50%). 146 patients attended the ASC, and 15 patients received telephone advice alone. The control group saw attendance increase by 25% (178 vs 223). Conclusions The results clearly show that the introduction of the ASC has decreased attendance to SAU, freeing clinicians to dedicate more time to those acutely unwell. The similar proportion of admissions after the introduction of the ASC suggests that the ambulatory pathway correctly identifies those who are well enough to be managed as outpatients. The increased attendance in the control group suggests that the data were not the results of a decrease in referrals due to COVID-19. The results shared here should encourage other large units to consider developing ambulatory pathways.

TP10.2.3Restarting Elective Orthopaedic Surgery during the COVID-19 Pandemic: Experiences and Patient Outcomes

Aim The novel coronavirus disease 2019 (COVID-19) resulted in postponing all non- emergency elective surgeries from April 2020. Restarting elective orthopaedic surgery is important to help people with chronic disabilities. Our hospital successfully restarted elective orthopaedic surgery during the pandemic to help improve the quality of life of patients. This study describes the development of local protocols and pathways to allow for a safe restart of elective orthopaedic surgery in a COVID-19 free ‘green’ site. It also includes the morbidity and mortality outcomes of those patients who underwent non-emergency orthopaedic operations during this time. Methods A prospective cohort study evaluating patients undergoing non- emergency orthopaedic procedures through a COVID-19 free surgical pathway in a National Health Service acute general hospital in the United Kingdom from 18th May 2020- 10th July 2020. 104 patients were identified and their outcomes during the 2 week post-operative period was recorded. Results No patients developed COVID-19 infection in the two-week post-operative period. There were no intensive care unit admissions or in- hospital deaths during our study time frame. There was no statistical difference found in the development of complications for age (< 70 or >70), gender, body mass index or ASA physical status classification system grades. Conclusions This study describes a roadmap to setting up a protocolised elective operating service for orthopaedic surgery. It has shown that standardised protocols in a COVID-19 free ‘green’ site, pre-operative COVID-19 testing and adherence to national guidelines on self-isolation can help prevent developing COVID-19 infection post-operatively.

TP10.2.4Access surgery for dialysis patients during COVID-19

Aims To describe the organisation of a triage system and COVID-19-free surgical pathway, and to assess the outcomes after its implementation for planned dialysis access surgery for patients during the first wave of the COVID-19 pandemic in the UK. Methods In response to the suspension of elective operations due to SARS-CoV-2 outbreak, we devised a COVID-19 free surgical pathway performed in NHS and an independent hospital. We audited the outcomes of its application in patients requiring access surgery between 17 April and 15 September 2020. The data was collated, analysed, and presented at clinical governess. We are looking to re-audit for the second wave in the coming months. Results A total of 235 cases were listed, and 203 procedures were performed. Thirty-two cases were cancelled and the top reason for cancellation was patient refusal. Of the procedures carried out, 47% (n = 96) were arteriovenous fistula formation, 42% (n = 84) were peritoneal catheter procedures, and 11% (n = 23) were arteriovenous grafts. The postoperative complication rate by day 7 was 13.3% (n = 27), by day 30 was 6.9% (n = 14) and they are similar to pre-COVID outcomes. By performing a definitive dialysis access, we avoided the significant morbidity and mortality associated with tunnel-line based dialysis. No patients acquired COVID-19 or died from its related illnesses in 30 days. Conclusion Our results confirmed that our pathway was effective in delivering dialysis access in a timely manner and COVID safe. Our model is safe, easy to replicate COVID-19-free pathway and can be used during similar challenges in the future.

SP4.1.11 Acute general surgical emergency and COVID-19 is a pandemic challenge for surgeons: a UK based practical experience

Background Transmission of COVID-19 is a considerable risk during the perioperative period of emergency surgery. We aimed to provide a practical experienced adaptation to reorganize the emergency surgical pathways during the COVID-19 pandemic. Methods A prospective observational study was performed between 30th March 2020 to 30th June 2020 at a large DGH in England. The primary outcome was perioperative COVID-19 related complications and secondary outcome measures included incidence of COVID-19 infections among the surgical doctors and healthcare workers. Data was collected on the number of acute surgical admissions and operations performed. The perioperative COVID-19 status of the patients, doctors and the healthcare workers were recorded. Results 584 patients admitted through the emergency surgical pathway and 43% (n = 253) underwent surgical intervention. Approximately 5% (n = 30) patients contracted with COVID-19 during the perioperative period and 6 of them died. Eight surgical doctors, 11 nurses and theatre staff were confirmed for COVID-19 by swab test. Acute cholecystitis and early appendicitis were managed conservatively. Conclusion High mortality (20%) observed among the patients who contracted COVID-19 perioperatively. Acute surgical emergencies and perioperative management of the urgent surgical patients during the COVID-19 pandemic is a global challenge but adequate preparedness and strategic plan to adjust the surgical services can reduce the exposures to this highly contagious virus.

131 PRACTICES IN PERIOPERATIVE NUTRITION PRECEDING OR FOLLOWING OESOPHAGECTOMY: RESULTS OF A EUROPEAN SURVEY

The route and type of peri-operative feeding after oesophagectomy varies widely across centres, usually based on local experiences and standing orders. The aim of this survey on perioperative nutrition after oesophagectomy (PONOS) was to create a snapshot the way perioperative nutrition preceding or following oesophagectomy is established across reference centres in Europe, and what the reasons are for preferring one method over another. Methods A survey consisting of four parts was distributed to the membership of 3 European, mainly surgical oriented scientific societies between October 2019 and January 2020. The first part contained some general questions regarding demographics of the participants and type of performed surgery. In the second section, centres were asked about practices in preoperative nutrition. The third section questioned participants about their practices in postoperative nutrition; in the last part the daily practice was reflected against the current available ESPEN guidelines. Results Fifty-one surgeons from 49 centres in 16 countries participated. The majority had a structured nutrition team in their institution. An Enhanced Recovery Pathway was implemented in 2/3 of centres. ESPEN guidelines were followed in 50% of centers. Routine preoperative nutritional assessment was performed in 84%. Preoperative nutritional support consisted mainly of enteral and oral support; immediate postoperatively mostly a combination of oral and enteral or enteral only; at discharge mostly a combination of oral and enteral or only oral nutritional supplementation were used. Timing, definition and means of postoperative oral intake also seemed to differ widely across centres. Conclusion The PONOS survey confirmed our assumption that perioperative feeding after oesophagectomy exists in a wide variety across European centres performing oesophageal resections for cancer. Survey based feedback to the surgical community draws attention to this often underexposed part of the surgical pathway of a patient. As such, this might further enhance the exchange of experiences in order to try to harmonise peri-operative feeding regimen.

1357 Ankle Blocks: Improving Day Case Efficiency

Introduction The COVID pandemic has exerted unprecedented pressure on hospital resources. Resulting in cancellation of elective operative services, increased patient waiting lists, limited surgical training opportunities along with reduced availability of staff, theatre, and in-patient bed capacity. A novel approach for day case forefoot surgery under ankle block, to mitigate the pandemic service limitations without compromising care, was developed. Method This is a 3-month, multi-centre, prospective cohort study evaluating the novel ankle block day case forefoot surgery pathway. Patients had a minimum of three months clinical follow up with outcome scores. They were matched to a cohort undergoing similar surgery prior to the COVID pandemic. Results The utilisation of an ankle block pathway resulted in an average reduction of inpatient stay by 2 days per patient. Over the study period conservative savings of £26,659 were calculated. Anecdotally we observed a reduction in morbidity (wound complications, SSI’s) although not statistically significant. Conclusions Our novel surgical pathway has enabled continued elective operating for procedures that previously required hospital admission during a period of severe restrictions within the NHS. We observed significant reductions in cost, surgical inpatient bed utilisation and total operative time with staff, resource, and time savings. We hypothesise that prehabilitation with physiotherapy, ankle instead of thigh tourniquets and early mobilisation may have contributed to improved morbidity scores. The findings of this project have implications for training, upper limb services and are transferrable as a template to improve service efficiency while maintaining high quality care.

Delays In the Surgical Pathway In Breast Cancer Patients In Tunisia: A Descriptive Prospective Study

Objectives Describe the surgical pathway and identify the different waiting times to surgery of women with a breast cancer in the Gynecology Department of the University Hospital of Sousse in Tunisia.Methods:It is a descriptive prospective study based on an assessment of professional practices using the process approach method. The study focused on the surgical management of women with breast cancer followed and scheduled for surgical management.The data were collected using a data collection sheet, developed according to a literature review.Results:The sample consisted of 77 women. Ten waiting times have been calculated. Global time to first treatment (surgical treatment) was 78.5 days with an interquartile range (IIQ) of [55.5-113.25 days]. The information period was 10 days with an IIQ of [3-19 days]. The global time of access to surgery was 43.5 days with an IIQ of [40-54.75].Conclusion:Delays in access to care appear to be a potential marker of inequalities in access to care and an indicator of the performance of the health care system and can influence patient prognosis. The reduction of these delays must be integrated into a continuous quality improvement approach.

308 A Qualitative Study Evaluating the Uses, Benefits and Barriers of Tele-Consultations in The Pre-Operative Pathway for Elective Orthopaedic Surgery at A Major London Teaching Hospital

Introduction Digital healthcare technology is becoming a prodigious tool in healthcare management, supporting efforts for effective demand management and personalised, user-centred care. One example is tele-consultations, clinical consultations conducted remotely using technology such as telephones or videos. However, there is slow adoption of such technology and lack of literature supporting its use, particularly within the pre-operative surgical pathway, where communication, patient education and planning is vital to post-surgical outcomes. This study aimed to evaluate the uses, benefits and barriers of tele-consultations in the pre-operative pathway for elective hip and knee arthroplasty, at Imperial College Healthcare NHS Trust, from the perspective of key clinical stakeholders. Method 16 Semi Structured Interviews were conducted with Healthcare professionals (HCPs) along the preoperative pathway before conducting a thematic analysis. Ethical approval was received from Imperial College Research Ethics Committee on 05/02/2019. Results HCPs suggested use-cases for tele-consultation use in pre-assessment consultations with lower risk patients, information delivery, physiotherapy, and occupational therapy pre-assessment. Benefits cited were reduced overall costs and time, increased workflow efficiency with barriers noted as accessibility challenges, lack of holistic examination of patient and digital illiteracy. Conclusions Future studies should be conducted in other NHS trusts to identify greater uses within the entire surgical pathway.

Designing digital health technology to support patients before and after bariatric surgery: a qualitative study exploring patient desires, suggestions and reflections to support lifestyle behaviour change. (Preprint)

BACKGROUND A patient’s capability, motivation, and opportunity to change their lifestyle are significant determinants of successful outcomes following bariatric surgery. Healthier lifestyle changes before and after surgery, including improved dietary intake and physical activity levels, have been shown to contribute to greater post-surgical weight loss and improved long-term health. Integrating patient-centered digital technologies within the bariatric surgical pathway could form part of an innovative strategy to promote and sustain healthier behaviours and provide holistic patient support, to improve surgical success. Research has focused on implementing digital technologies and measuring their effectiveness in various surgical cohorts, yet there is limited work concerning the desires, suggestions and reflections of patients undergoing bariatric surgery. This qualitative investigation explores patient perspectives on technology features that would support them to change their lifestyle behaviours during the pre- and post-operative periods, to potentially maintain long-term healthy lifestyles following surgery. OBJECTIVE To understand how digital technologies could be used to better support patients across the perioperative pathway to improve weight-loss outcomes and surgical success. Specifically, the objectives concerned: 1) what do patients want from digital technologies, 2) how do they want to use them, and 3) when would they be of most benefit during their surgical journey? METHODS Patients attending bariatric surgery clinics within one hospital in the North of England were invited to take part. Semi-structured interviews were conducted with purposively sampled pre- and post-operative bariatric surgical patients to discuss lifestyle behaviour change and the use of digital technologies to complement their care. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data. Ethical approval was obtained from the NHS Health Research Authority. RESULTS Twenty patients were interviewed. Four overarching themes were developed from the data relating to perspectives of optimised technology functionality. These centered on providing tailored content and support; facilitating self-monitoring and goal-setting; delivering information in an accessible, trusted, and usable manner; and meeting patient information-seeking and engagement needs. Interventions that supported the delivery of personalized feedback and post-operative follow-up were perceived as beneficial. Individualized goal- and target-setting could further support a generation of digitally engaged patients with bariatric conditions. Working towards achievable targets was deemed an effective strategy to successfully motivate behaviour change. The creation of digital ‘package of care’ checklists between patients and clinicians was a novel finding from this research. CONCLUSIONS Perceptions of patients undergoing bariatric surgery validated the integration of digital technologies within the surgical pathway, offering enhanced connectedness and support. Recommendations are made that relate to the design, content and functionality of digital interventions to best address the needs of this patient cohort. These findings have the potential to influence future co-design and integration of person-centered, perioperative technologies within surgical pathways. CLINICALTRIAL N/A