EP.TU.601Improving extended venous thromboembolism prophylaxis prescription compliance at discharge for colorectal cancer resection patients

Aims Extended venous thromboembolism prophylaxis (exVTEp) is used to reduce venous thromboembolism (VTE) incidence following colorectal cancer (CRC) resection. Within our tertiary care centre patients undergoing CRC resection should receive an electronic VTE risk assessment (eVTE) within 24 hours and exVTEp at discharge, compliance targets set at 95%. Our aim was to improve absolute compliance rates of exVTEp prescription at discharge following CRC surgery. Methods Data were collected prospectively on CRC resection patients pre and post an educational intervention for doctors during surgical induction, with posters placed in key areas highlighting discharge exVTEp importance. Patients discharged between August-December 2019 served as pre-intervention and those between December 2019-March 2020 as post-intervention cohorts. Time periods reflected junior doctor rotating periods within the country’s healthcare system thus providing more comparable data sets. The service evaluation was registered within the Trust (19-562Q) Results Of 80 pre-intervention and 40 post-intervention eligible patients: 81.25% vs. 92.68% received exVTEp at discharge, 70.19% vs. 72.34% had a valid eVTE and 32.50% vs. 36.59% had exVTEp recorded in the post-operative note. Those missing exVTEp documentation in the post-operative plan were significantly less likely to receive exVTEp at discharge with an 80% decrease in exVTEp prescription compared to patients with exVTEp documented within the post-operative note (unadjusted-OR 0.2051, 95%CI 0.0431-0.9773; p = 0.0276). Conclusions Educational and visual interventions have shown improvement in exVTEp prescription at discharge. Despite suboptimal eVTE scores true service quality in delivering exVTEp is high. The relationship between exVTEp post-operative instruction and exVTEp prescription needs further investigation.

1631 The Pen is Mightier than the Sword; but the Keyboard may be Better

Introduction Operation notes ensure patient safety through continuity of care, and act as reliable treatment records. Notes must be legible, accessible, and contain all relevant information. Specific standards are outlined in the Good Surgical Practice Guidelines (2014) by the Royal College of Surgeons of England. Audits in the UK show poor adherence to these standards. Online operative note systems are becoming more common, but variety still exists in operations notes. This work assessed operative note standards in an orthopaedic department and assessed the utility of electronic operative note systems. Method This was a prospective quality improvement project. Operation notes for all emergency orthopaedic operations were audited against national standards. An online operation note system was introduced and re-audit carried out following implementation. Results Initial audit noted poor adherence to standards. An online operative note system was introduced. A second audit with 96 patients was undertaken. Uptake of the software was low, with 10% of notes being online. 19 of 21 information points showed improved standards adherence with the online system versus other methods. In the remaining 2 areas 100% of notes adhered to standards in both methods. The online system had 100% adherence in 19 data points, and 90% in the remaining 2. Conclusions Online note softwares have various benefits, including improved adherence to standards. Other benefits exist, such as databasing of operations for review and audit. These systems appear reliable and beneficial for operative documentation and are easily implemented; however, some work is still required to change old habits and improve uptake.

483 A Quality Improvement Project: Novel Electronic Operative Note Templates to Improve the Continuity of Post-Operative Patient Care

Introduction Good Surgical Practice from RCS England encourages the use of e-health records and detailed typed operative notes. The Covid-19 pandemic has led to multi-site operating. ENT operations in our trust were split over three sites including the private sector leading to potential disruption in continuity of patient care. Physical operation notes are difficult to access in emergencies, telephonic clinics or for audit purposes. We aim to have operative notes available on patients’ e-records which adhere to RCSEng guidelines. Method In this QIP, we reviewed all ENT operations over a retrospective one-month period recording percentage of notes uploaded to patient e-record and the number of surgeons in theatre. We created two novel RCSEng compliant e-operative notes with a user guide, generic and tonsillectomy-specific, and prospectively collected data to complete the cycle. Results 261 patients were included in both study periods. Only 36/134(27%) had e-operative pre-intervention improving to 71/127(56%) post-intervention. In the latter period, 76% of operations included a registrar and were more likely to have e-operative notes(72%) compared to when a consultant was operating alone(6%). There was low uptake of our tonsillectomy e-proforma(33%). Conclusions Our QIP has already proved effective with our templates increasing operative documentation on e-records. Increased use of e-template was more likely with the presence of a registrar in theatre. Room for improvement remains and we will re-audit after the introduction of further user-friendly operative templates and IT training. This QIP has also revealed additional operative training opportunities of which registrars can take advantage.

1632 Improving Excision Margins in Skin Oncology

Aim There are 152,000 new non-melanoma skin cancer (NMSC) cases in the UK every year, and excision and reconstruction of basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) form a significant part of the clinical workload in plastic surgery. In this quality improvement project, we aimed to identify and improve our unit’s compliance of guidelines for excision margins for NMSCs. Method A retrospective audit was undertaken in June 2020 to determine compliance with British Association of Dermatology and local guidelines on excision margins for NMSCs. A repeat audit was undertaken in October 2020 following quality improvement interventions. Results The first audit cycle examined 66 lesions in total. Guidelines were met in 53% (BCCs) and 50% (SCCs) of lesions. 12% of lesions had unclear documentation of margins. 16 lesions had margins that were too small as according to the risk factors present. These findings were presented to the department, and a new operative note template specifically designed for skin oncology was launched. Key audit findings were displayed along with the guidelines on posters. A repeat cycle was undertaken in October 2020, which examined 52 lesions. Significant improvement was seen with 100% documentation, and excision margin guideline compliance rate of 71% (BCCs) and 79% (SCCs). Conclusions Adequate excision margins in skin oncology is vital to ensure complete excision and to minimise the risk of recurrence. Our project demonstrates significant improvement in excision margin compliance through the launch of a specific operative note template and information posters.

683 Minimum Data Set in Documentation of Operative Findings in Diagnostic Laparoscopy

Aim Legible, accurate and clear documentation of operative findings is an integral part of patient safety, with guidelines from the Royal College of Surgeons and General Medical Council having clear standards of operative note-keeping. However, a substantial variation in the quality and accuracy of these notes can still be observed in everyday practice. We recognised the significance of a minimum set of data in operative record keeping for diagnostic laparoscopies as a standard, to improve quality and uniformity. Method We retrospectively examined 50 diagnostic laparoscopies over 6 months and assessed their operative notes against the guidelines described above. We found that there was no clear uniformity in reporting, subjective descriptions used and a significant amount of under-reporting of operative findings. We developed a proforma as a substitute for the documentation of operative findings which was implemented in the second phase of the audit and the compliance was assessed over a 3-month period. Results We found that usage of the proforma was limited (9/22), however those notes using the proforma were compliant with the guidelines for operative note keeping, to a much higher degree than those without. All the operative findings were documented for 100% of those notes which used the proforma; for those using freehand notes, only the appendix was identified to the same standard, which is explained by all diagnostic laparoscopies proceeding to appendicectomies. Conclusions Using a proforma as standard record keeping can improve the quality and accuracy of operative notes and thereby help improve safety and quality of patient care.

September 2021 Pulmonary Case of the Month: A 45­-Year-Old Woman with Multiple Lung Cysts

No abstract available. Article truncated after the first 150 words. History of Present Illness A 45-year-old woman presented with increasing dyspnea on exertion and a history of recurrent pneumothoraces. In March 2018 she had laparoscopic ovarian cyst removal and noted some subsequent shortness of breath. In August 2018 she developed a right pneumothorax requiring chest tube placement. In September 2018 she had recurrent right pneumothorax and had video-assisted thoracoscopic surgery (VATS) with a right pleurodesis. The operative note from the outside VATS indicates a RUL bleb was removed and a wedge biopsy was done from posterior segment of the RUL. Pathology from the wedge biopsy reported “minimal emphysematous disease without other diagnostic abnormality”. She continued to be short of breath after the operation. PMH, SH, and FH • In 1975 she reportedly had pulmonary tuberculosis. • In 2018 the pneumothoraces, pleurodesis and the right ovarian cyst resection noted above. She is a never smoker and has no family history…

Surgeon involvement in clinical coding to improve data accuracy and remuneration in a shoulder and elbow unit

Background Clinical coders are dependent on clear data regarding diagnoses and procedures to generate an accurate representation of clinical activity and ensure appropriate remuneration is received. The accuracy of this process may potentially be improved by collaboration with the surgical team. Methods Between November 2017 and November 2019, 19 meetings took place between the Senior Clinical Fellow of our tertiary Shoulder & Elbow Unit and the coding validation lead of our Trust. At each meeting, the Clinical Fellow assessed the operative note of cases in which uncertainty existed as to the most suitable clinical codes to apply and selected the codes which most accurately represented the operative intervention performed. Results Over a 24-month period, clinical coding was reviewed in 153 cases (range 3–14 per meeting, mean 8). Following review, the clinical coding was amended in 102 (67%) of these cases. A total of £115,160 additional income was generated as a result of this process (range £1677–£15,796 per meeting, mean £6061). Only 6 out of 28 (21%) cases initially coded as arthroscopic sub-acromial decompressions were correctly coded as such. Discussion Surgeon input into clinical coding greatly improves data quality and increases remuneration received for operative interventions performed.