Response to winter pressures in acute services: analysis from the Winter Society for Acute Medicine Benchmarking Audit

Background There is increased demand for urgent and acute services during the winter months, placing pressure on acute medicine services caring for emergency medical admissions. Hospital services adopt measures aiming to compensate for the effects of this increased pressure. This study aimed to describe the measures adopted by acute medicine services to address service pressures during winter. Methods A survey of acute hospitals was conducted during the Society for Acute Medicine Benchmarking Audit, a national day-of-care audit, on 30th January 2020. Survey questions were derived from national guidance. Acute medicine services at 93 hospitals in the United Kingdom completed the survey, evaluating service measures implemented to mitigate increased demand, as well as markers of increased pressure on services. Results All acute internal medicine services had undertaken measures to prepare for increased demand, however there was marked variation in the combination of measures adopted. 81.7% of hospitals had expanded the number of medical inpatient beds available. 80.4% had added extra clinical staff. The specialty of the physicians assigned to provide care for extra inpatient beds varied. A quarter of units had reduced beds available for providing Same Day Emergency Care on the day of the survey. Patients had been waiting in corridors within the emergency medicine department in 56.3% of units. Conclusion Winter pressure places considerable demand on acute services, and impacts the delivery of care. Although increased pressure on acute hospital services during winter is widely recognised, there is considerable variation in the approach to planning for these periods of increased demand.

Implementing two-stage consent pathway in neonatal trials

Perinatal trials sometimes require rapid recruitment processes to facilitate inclusion of participants when interventions are time-critical. A two-stage consent pathway has been used in some trials and is supported by national guidance. This pathway includes seeking oral assent for participation during the time-critical period followed by informed written consent later. This approach is being used in the fluids exclusively enteral from day one (FEED1) trial where participants need to be randomised within 3 hours of birth. There is some apprehension about approaching parents for participation via the oral assent pathway. The main reasons for this are consistent with previous research: lack of a written record, lack of standardised information and unfamiliarity with the process. Here, we describe how the pathway has been implemented in the FEED1 trial and the steps the trial team have taken to support sites. We provide recommendations for future trials to consider if they are considering implementing a similar pathway. Trial registration number: ISRCTN89654042.

Factors Associated with Timely Surgery for Semi-elective Distal Radius Fracture Fixation

Background In the United Kingdom, national guidance recommends intra-articular distal radius fractures should undergo surgery within 72 hours and extra-articular fractures within 7 days. Purpose We investigated if hospitals can provide timely surgery and meet national guidelines in patients who are sent home following distal radius fracture (DRF) to return for planned surgery. The influence of patient, hospital, and seasonal factors on wait to surgery are investigated. Patients and Methods We reviewed Hospital Episode Statistics (HES) data between April 2009 and March 2013. Proportion of procedures being performed within 3 and 7 days was calculated. A linear regression model was created to investigate the relationship between wait for surgery and patient and hospital factors. Results A total of 9,318 patients were sent home to return for planned acute DRF surgery during the 4-year study period. Mean time to surgery was 3.04 days (range 1–days, standard deviation [SD] 3.14). A total of 6,538 patients underwent surgery within 3 days (70.2%) and 8,747 within 7 days (93.9%). Patients listed for surgery and sent home to return waited longer if listed toward the end of the week. Less surgery was performed at weekends, and patients were less likely to be listed for semielective trauma surgery. Conclusions Acute semielective DRF fixation is generally performed within targets for extra-articular fractures but there is scope for improvement for intra-articular fractures. Day of presentation and increasing number of comorbidities increase wait for surgery. Hospital trusts should focus on improving pathways for patients with multiple comorbidities and strategies to improve accessibility of these services at weekends.

Exploration of therapists’ views of practice within critical care

IntroductionTherapists are increasing recognised as core members of the critical care multiprofessional team. Each therapy profession provides specialist assessments and interventions, but also work collaboratively across the rehabilitation pathway. Despite inclusion in several national guidance documents, there remains a lack of evidence regarding the perceived role of therapists working within critical care, the unique contributions of each profession and opinion on the day-to-day tasks and responsibilities of each therapy profession.MethodA descriptive qualitative methodology was used involving seven focus groups. Purposeful sampling was used to recruit therapists via professional specialist interest groups. All focus groups were uniprofessional and discussions based on a predesigned framework. Data were analysed thematically.ResultsParticipants (n=65) from across the UK were recruited to seven focus groups with an average of 18.3 years postgraduate clinical experience of which 11.6 years was within critical care. Three core themes were generated from 875 codes and 237 potential subthemes. The final themes were (1) professional characteristics; (2) multidisciplinary team and (3) staffing. An additional theme of ‘COVID-19 pandemic’ was also identified. Findings were similar across all profession groups particularly regarding the need for holistic, patient-centred care. Expected variation was observed for professional characteristics especially regarding specific assessments and interventions.DiscussionTherapy services are an essential component to the delivery of critical care especially regarding recovery and rehabilitation. Through three core themes, this qualitative study has provided new evidence of the perceptions and opinions of the role that therapists undertake within critical care.

OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic

BackgroundEarly in the COVID-19 pandemic, the National Health Service (NHS) recommended that appropriate patients anticoagulated with warfarin should be switched to direct-acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately coprescribed two anticoagulants following a medication change and associated monitoring.ObjectiveTo describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic.MethodsWith the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England.Results20 000 of 164 000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in coprescribing of warfarin and DOACs from typically 50–100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. International normalised ratio (INR) testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420).ConclusionsIncreased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people coprescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.

SP4.2.15 An international multi-centre appraisal of the management and outcomes of acute CHOLEcystitis during the COVID-19 pandemic: The CHOLECOVID Study

Introduction National guidance issued in response to COVID-19 resulted in adoption of non-surgical modes of treatment in emergency surgery, including acute cholecystitis (AC). The CHOLECOVID Study is the definitive global audit of the management and outcomes of AC during COVID19. Methods Patients >18 years admitted to hospital with radiologically confirmed AC, during two predefined 8-week time periods: P1 (pre-pandemic) 12/09/19- 12/11/19; P2 (during the pandemic) 12/03/20-12/05/20, were included. The primary outcome was 30-day all-cause mortality. Secondary outcomes included severity of AC, radiological diagnostic modalities implemented, definitive management and pulmonary complications. Results 9,615 patients were included from 39 countries (P1:5,381; P2:4,234). 30-day mortality was higher in P2 (1.7%vs2.4%; p < 0.015). Higher rates of moderate and severe AC were seen in P2 (30.1%vs35.1%;3.7%vs4.1%). First-line CT imaging was more common in P2 (36.3%vs46.3%; p < 0.001). There were higher failure rates of conservative management in P2 (37.4% vs 44.4%; P < 0.001). Cholecystostomy rates were higher in P2 (5.8%vs8.8%; P < 0.001). Overall 4.6% (n = 193) of P2 patients were COVID-19 positive, with overall mortality of 0.7% (n = 30). There was no significant difference in pulmonary complications between COVID-19 positive or negative patients. Conclusion During the COVID-19 pandemic, a small increase in mortality among AC patients was noted, when compared to the pre-pandemic cohort. Patients during the COVID-19 pandemic presented with more severe AC, resulting in altered trends in diagnosis and management. New guidance and clear pathways are required to safely manage AC moving forward, in the face of further waves of COVID-19.

EP.WE.93An Overview of the Effect of COVID-19 on the General Surgical Take: Before, During and After the First UK National Lockdown

Aims Emergency general surgical (EGS) services have faced new challenges during the coronavirus pandemic. This study compared all EGS presentations before, during and after the first UK national lockdown between March and May 2020. Methods All EGS patients presenting to our centre in four separate weeks were included. These weeks represented ‘pre-lockdown’, ‘early lockdown’, ‘established lockdown’ and ‘post lockdown’ groups. Demographic data, treatment, admission and outcomes were collected for all patients and compared between groups. Results 178 patients accounted for 214 EGS attendances over four weeks. Attendances decreased from 74 pre-lockdown, to 43 in early lockdown, 32 in late lockdown and rose to 65 in the post lockdown group. Significantly more patients received repeat outpatient reviews in the lockdown groups (p = 0.002). Length of stay was significantly reduced in established lockdown (0.5 days vs. 2 days pre-lockdown, p = 0.042). There was a trend towards conservative management of surgical pathology in the lockdown groups (65% vs 47% pre and post-lockdown, p = 0.10). No very elderly or frail EGS patients presented during the lockdown study period. There was no evidence of delay to presentation. Conclusions The COVID-19 pandemic and UK Coronavirus lockdown resulted in a large decrease in EGS admissions and alteration in characteristics of these admissions. New national guidance during the pandemic advocated ambulatory and conservative management of surgical conditions where possible and is reflected in our cohort. These changes reverted almost back to pre-lockdown state the week following the easing of the first UK national lockdown.

SP4.2.7 Outcomes following reorganisation of colorectal cancer pathway using FIT testing and a locally developed risk stratification score in a busy District General Hospital in United Kingdom during the COVID-19 pandemic

Aims/Introduction Limited availability of endoscopy and CT colonography led to significant pressures on the colorectal cancer pathway during the COVID-19 pandemic. Risk stratification was necessary to determine the order in which patients on the tracking list could access diagnostics. Based on national guidance, patient symptoms and FIT test results, we used a locally developed risk stratification score (RSS). The aim of this study was to evaluate the impact the RSS had on patient diagnoses over a period of 8 months Methodology A prospectively maintained database was used to assess the outcomes. Based on their symptoms, patients on the colorectal 2ww pathway were invited to provide FIT samples if eligible. Diagnostics were prioritised using RSS. Results were analysed to assess how the cancer diagnostic yield during the pandemic compared to a similar period the year before. Results There were 1133 patients referred on the colorectal 2ww pathway between May - December 2020. 884 of these patients had FIT testing and 249 were not eligible. Of the 69 colorectal cancers diagnosed, 25 were in the FIT group and 44 in those not eligible. The RSS stratified to high or indeterminate risk in the non-FIT group was 31 and 23 in the FIT group. Compared to the previous year’s number of 59 patients diagnosed between May - December 2019, no statistical difference was found. Conclusion Our study shows that FIT testing and RSS led to an equivalent pick up rate of colorectal cancer and can be utilised in clinical settings with limited resources.