P-O09 Development of a non face-to-face pre-operative assessment pathway for laparoscopic cholecystectomy

Background The Covid-19 pandemic has led to markedly reduced capacity in almost all areas of normal face-to-face activity in our hospitals. Prior to the pandemic, the standard pre-operative pathway for all patients included an initial appointment in the outpatients clinic and formal examination before recommending surgery. With the reality of limited clinic capacity, our unit developed a non face-to-face assessment pathway alongside a parallel green operating area in our local Independent Sector (IS) hospitals for laparoscopic cholecystectomy. This study describes and methodology and outcomes of this approach Methods A non face-to-face (telephone) proforma for all new referrals for consideration of laparoscopic cholecystectomy was prepared in April 2020 with the first operations carried out in June 2020. All consultations were carried out by consultant surgeons and included thorough history, careful documentation of previous surgery and duration of symptoms and, where appropriate, patients were told to send images of their abdominal wall if they were unable to describe their scars. The first stage of the consent process was completed at initial appointment and all patients were sent written information about surgery. Patients who had BMI<40, uncomplicated biliary disease (biliary colic, mild cholecystitis, ERCP for CBD stones) and ASA of 1/2 were deemed suitable for surgery in the IS and sent across accordingly. A telephone pre-assessment was completed by the hospital and patients were sent blood tests forms in the post, as well as a Covid test to be completed at home followed by a period of self isolation before surgery. All patients were examined on the day of surgery by the operating surgeon and formal consent taken on the day. Primary outcomes that were recorded were cancellation on the day, transfer to the NHS hospital after surgery and complications. Results From June 2020 to December 2020, when the contract with the IS changed, 218 patients attended the IS hospitals for planned elective laparoscopic cholecystectomy. Four patients (2%) did not have surgery (one cancelled as inappropriate for the Independent Sector, two patients whose Covid swab result was not complete and one patient who no longer wished to have surgery). Three patients required transfer to the NHS hospital for post-operative care (drains inserted after unanticipated difficult surgery). All patients were given details of the surgical SDEC unit at the NHS hospital to allow ease of admission in the event of any problems or complications. 28 patients (13%) attended SDEC within 30 days after surgery; most had blood tests and clinical assessment alone. One patient (<1%) required re-laparoscopy for abdominal pain three days after their initial surgery (washout alone) and 5 patients developed umbilical wound infections after surgery (antibiotics alone). Two patients were found to have CBD stones on MRCP. The waiting time from initial assessment to surgery for patients on this pathway was less than 18 weeks for 168 patients though patients who were not suitable for the Independent Sector have had waiting times that are considerably longer. Conclusions These results demonstrate that it is possible to plan surgery for laparoscopic cholecystectomy without a face-to-face appointment at all which has considerable implications for resource allocation in the future; indeed, this approach has been continued within our unit even as clinic capacity has increased and been rolled out to patients with inguinal or para-umbilical hernia. Use of a green site away from the acute NHS hospital allowed elective surgery for non-urgent pathology to continue with acceptable waiting times even during the worst of the Covid-19 pandemic though patients who were not suitable have had markedly worse experiences and waiting times.

SP2.2.18UK Surgical Training in the Independent Sector During COVID-19 – A Snapshot Survey

Aims In response to the COVID-19 pandemic and the cancellation of elective surgery, the Independent sector (IS) has been utilised to provide COVID-light sites. On average operative log book numbers have been reduced by 50% due to a reduction in operative exposure. The Four Educational Bodies continue to support training within the independent sector. This study aimed to qualitatively assess access and barriers to UK surgical training in the Independent Sector. Methods A snap-shot online survey was distributed to ASIT members of all training specialities and grades between 21/10/2020-11/11/2020 . Data measures included participant demographics, frequency of access, participation in training opportunities including outpatient clinic, theatre lists and endoscopy and any barriers encountered. A mixture of Likert scale and short answer questions were utilised. Results 249 complete responses representing all grades and specialities were included in the final analysis (34.29% CST and 56.3% HST). 35.7% of trainees reported access to the IS. 22.9% had access to at least one operating list whilst 70.3% had none. Access to outpatient clinics and endoscopy was negligible. 75% of trainees ‘strongly agreed’ that when access was achievable, it was beneficial to their training. Multiple barriers were identified including Human Resource requirements and local service provision. Conclusions Within the sample, access to the IS has been poor. There is wide variation in barriers to access across the 4 nations and IS providers. Trainees and Trainers should maximise training opportunities in the IS. Where barriers exist, they should be reported to local Training Programme Directors.

EP.WE.555Impact of COVID 19 on Renal access surgery

Aims To assess the impact of COVID -19 on renal access surgery. Methods Electronic patient records and renal ware were accessed to obtain data of all renal access activity during the COVID period. Results There as a shutdown of all elective activity which affected the renal access surgery as well. No new Arterio venous fistulas (AVFs) were created in the time period 14 March to 05th May 2020. No pre-fistula mapping scans were performed. All new starters started with a tunneled dialysis line. In the recovery phase special theatre sessions were asked for and procedures carried out in Day surgery and in independent sector (n-18). A total of 203 new AVF’s were created compared to 272 the year before a fall of 25%. There were 48 patients admitted with blocked access, 70% of whom underwent radiological intervention compared to 52% in 2019. Surgical intervention was offered to just 4% compared to 25% in 2019. The number of access abandoned was 27% in 2020 vs 19% in 2019. Conclusion COVID-19 adversely affected the renal access population and none of the British Renal access surgery targets were met for 2020.

Building independent media: Sustaining democratic freedoms

This article examines trends in new media journalism, identifying an independent sector which began to emerge with the internet circa 2000. It finds that publications from initially single-person start-ups like Crikey, to the large circulation New Daily, have proved viable and durable, providing alternatives to mainstream print and broadcast media. They have specialised in politics while publishing also in many other fields, characteristically emphasising user participation in both production and funding and exploiting possibilities of new digital models. This article has case studies of the publications Independent Australia, and the New Zealand-based Asia Pacific Report, to further explain the independents’ motivation and mode of operation. It reviews the media environment in two parts: a first phase from 2000 to 2010 and a second major change after 2010 with smart phones and social media. Conclusions are made that the independent sector stands to play a central role in sustaining democracy.

793 Orthopaedic Surgical Training in The Independent Sector During the COVID 19 Pandemic

Introduction The COVID pandemic had led to the cancellation of elective Orthopaedics in the NHS. The aim of this study was to investigate the effect of the independent sector on orthopaedic training and the effect of the COVID pandemic on training locally. Method A retrospective review of trauma and elective operations was made between April and September of 2019 and 2020 to compare the effects of COVID on training opportunities and the additional capacity provided by the private sector. Results The impact of COVID on Surgical training at GWH has been no decrease in trauma operating experience, but a 53% decrease in elective operating experience and a 74% decrease in joint replacement operative experience during an equivalent six-month period. Use of the independent hospital has enabled 6% of the total elective surgery experience, and 11% of the joint replacement surgery experience. Discussion The private sector has provided additional capacity but a productivity of 66 cases from 48 half day lists is low (1.4 cases per list) has proved disappointing. There has been a low impact on elective training. The challenges have been faced on the elective side as trauma cases have remained consistent during the pandemic. Conclusions Use of the alliance between the private sector and NHS as a resource to provide additional training opportunities needs to be developed further in the future with incentivised guidance. Orthopaedic training will inevitably adapt to the challenges presented for the next generations of surgeons.

423 Patient Perspective on the Use of the Independent Sector to Maintain Elective NHS Services During the COVID-19 Pandemic

Introduction COVID-19 resulted in the suspension of planned treatments for patients worldwide leaving millions suffering the physical and mental effects of delay. Reports indicate that when services have been re-established, patients have been afraid to take up appointments. Hospitals put processes in place to counter this, notably separating emergency and elective patient cohorts. Most notably seen by the co-operation between the NHS and independent private healthcare providers in March 2020 at the height of the pandemic. We undertook a study to ascertain the perceptions of NHS patients who underwent elective treatment at independent ‘cold’ sites during the COVID-19 pandemic. Method A cross-sectional study with structured telephone interviews of patients who had planned elective treatments at ‘cold’ independent hospitals between March and September 2020. 1150 patients were identified, and a 20% sample formed a 230 patient study group, with 158 (70%) agreeing to participate. Results 30% of patients delayed their treatment due to COVID related concerns, with 76% of these only accepting treatment because this was at a ‘cold’ site. 46% of patients perceived treatment at a ‘cold’ site as the most important factor contributing to their safety. 153 patients (97%) supported the paid arrangement between the NHS and the independent sector to provide separate ‘cold’ sites for elective treatments. Discussion Safely restarting elective services to allow important planned treatments to take place, as was the pandemic continues, is a priority. Our study indicates that physical separation of patient pathways impacted most on patient confidence, and that the use of ‘cold’ sites is a viable option.

Planned surgery in the COVID-19 pandemic: a prospective cohort study from Nottingham

Purpose Globally planned surgical procedures have been deferred during the current COVID-19 pandemic. The study aimed to report the outcomes of planned urgent and cancer cases during the current pandemic using a multi-disciplinary prioritisation group. Methods A prospective cohort study of patients having urgent or cancer surgery at a NHS Trust from 1st March to 30th April 2020 who had been prioritised by a multi-disciplinary COVID Surgery group. Rates of post-operative PCR positive and suspected COVID-19 infections within 30 days, 30-day mortality and any death related to COVID-19 are reported. Results Overall 597 patients underwent surgery with a median age of 65 years (interquartile range (IQR) 54–74 years). Of these, 86.1% (514/597) had a current cancer diagnosis. During the period, 60.8% (363/597) of patients had surgery at the NHS Trust whilst 39.2% (234/597) had surgery at Independent Sector hospitals. The incidence of COVID-19 in the East Midlands was 193.7 per 100,000 population during the study period. In the 30 days following surgery, 1.3% (8/597) of patients tested positive for COVID-19 with all cases at the NHS site. Overall 30-day mortality was 0.7% (4/597). Following a PCR positive COVID-19 diagnosis, mortality was 25.0% (2/8). Including both PCR positive and suspected cases, 3.0% (18/597) developed COVID-19 infection with 1.3% at the independent site compared to 4.1% at the NHS Trust (p=0.047). Conclusions Rates of COVID-19 infection in the post-operative period were low especially in the Independent Sector site. Mortality following a post-operative diagnosis of COVID-19 was high.

998 Utilisation of A “COVID-Free” Hospital in The Independent Sector - Endourology Service Provision and Outcomes During The COVID-19 Pandemic

Introduction COVID-19 may negatively affect peri-operative outcomes, requiring strategies to allow operating whilst minimising risk. We present our endourology service provision throughout the “lockdown” period. Method Endourological operations 23rd March to 11th May 2020 were designated to the base hospital or independent “green” site by urgency and comorbidity status. Base hospital emergencies underwent surgery in main theatres, whilst elective patients had dedicated “COVID-free” theatres and wards. A portable Holmium laser enabled lasertripsy at the independent site. After 27th April, elective cases required a negative swab and 2-week self-isolation pre-operatively. Results 70 operations were performed: 42 ureteroscopies, 20 stent procedures, 8 PCNLs. Mean age was 57 and 58 at base and independent sites respectively, mean ASA 2.1 and 1.9. 37 operations (53%) occurred at the base hospital, including 14 emergencies (38%). 19 patients received post-operative COVID-19 swabs: 3 positives (8%), all emergencies. 2 patients (5%) died of COVID-19 pneumonia within 35 days; both had negative pre-operative swabs. Of 33 patients at the independent site, 3 (9%) received post-operative swabs, all negative. None had COVID-19 symptoms post-operatively. Conclusions “COVID-free” hospitals, wards and theatres enable elective operating whilst minimising peri-operative virus risk. Further utilisation of independent hospitals would more safely allow operating throughout the pandemic.