TP9.2.25No beds! Developing ambulatory surgical care in a District General Hospital

Aims Referrals to acute surgery are increasing by 10% a year with no increase in inpatient bed numbers. Our aims are to improve the patient experience with early review and provide early decision making preventing admission to hospital. In August 2019 we launched our ambulatory surgical service, in order to measure the impact we have reviewed every patient that has come through the service from its inception. Methods The service is manned by two dedicated surgical fellows based in an ambulatory unit with dedicated early morning USS slots available. To compare old with new we collated presentations into categories, for example ‘Right upper quadrant pain’ and compared the number of patients ‘ambulated’ to the average length of stay for patients with these presentations before ambulatory care. Results From August to October a total of 180 patients were ambulated via the new service. Using the comparison described this equated to approximately 423.05 ‘bed days’ saved the three-month initial period. Discharge times were spread throughout the day rather than ‘peaking’ with emergency team handover indicating an improved experience this has been backed up by qualitative reports from patients and families. Conclusion The introduction of the ambulatory service has improved the general surgical on-call experience at our hospital both for patients and clinicians alike, whilst decreasing surgical bed occupation. Utilising existing resources we have improved the patient experience, enabled quicker decision making and taken pressure away from the on-call.

SP3.1.9 Building the ‘LIEGS’ way – The development and delivery of ambulatory surgical services in the busiest acute surgical unit in the UK

Background Managing unplanned surgical care presents enormous challenges to trusts and continues to be resource intensive. Significant patient numbers can be managed in novel ways preventing admission with effective triage to alternative flow streams using outpatient/ambulatory models. Leeds Institute of Emergency General Surgery (LIEGS) reports its early experience. Methods Patients requiring assessment or admission from primary care are triaged directly by a consultant. GP’s are offered advice or patients are directed to appropriate assessment/triage pathways. A number of alternative pathways exist depending on pathology and patient demographics. Prospective data for all patients referred are captured and retrospective analysis of outcomes collected. We report our experience from October-November 2020. Results Consultant triage and early senior decision-making has streamlined patient pathways and flow. 51%(237) of all GP referrals(465) were assessed primarily in ASC, 8%(36) required advice only and 10%(44) were directed to other specialities. 30%(139) were seen on the Surgical Assessment Unit ward representing a reduction of 70% compared to the previous year. Outcomes from those patients seen in ASC were discharge after imaging (87,18.7%), discharge without imaging (74,15.9%), hospital admission (65,14%), acute operation (63,13.5%), referral to other specialty (64,13.8%) and Rapid Access Theatre for day case operation (32,6.9%). Conclusion 71.7% of all acute surgery primary care referrals were managed on in an ambulatory fashion providing an invaluable resource. Early senior decision making, a one-stop clinic for investigations and day case Rapid Access Theatre (RAT) lists can significantly improve the patient pathways and experience.

Risk factors and treatment of oxygenator high-pressure excursions during cardiopulmonary bypass

Introduction: A high-pressure excursion (HPE) is a sudden increase in oxygenator inlet pressure during cardiopulmonary bypass (CPB). The aims of this study were to identify factors associated with HPE, to describe a treatment protocol utilizing epoprostenol in severe cases, and to assess early outcome in HPE patients. Methods: Patients who underwent cardiac surgery with cardiopulmonary bypass at Sahlgrenska University Hospital 2016–2018 were included in a retrospective observational study. Pre- and post-operative data collected from electronic health records, local databases, and registries were compared between HPE and non-HPE patients. Factors associated with HPE were identified with logistic regression models. Results: In total, 2024 patients were analyzed, and 37 (1.8%) developed HPE. Large body surface area (adjusted Odds Ratio (aOR): 1.43 per 0.1 m2; 95% confidence interval (CI): 1.16–1.76, p < 0.001), higher hematocrit during CPB (aOR: 1.20 per 1%; (1.09–1.33), p < 0.001), acute surgery (aOR: 2.98; (1.26–6.62), p = 0.018), and previous stroke (aOR: 2.93; (1.03–7.20), p = 0.027) were independently associated with HPE. HPE was treated with hemodilution ( n = 29, 78.4%), and/or extra heparin ( n = 23, 62.2%), and/or epoprostenol ( n = 12, 32.4%). No oxygenator change-out was necessary. While there was no significant difference in 30-day mortality (2.7% vs 3.2%, p = 1.0), HPE was associated with a higher perioperative stroke rate (8.1% vs 1.8%, aOR 5.09 (1.17–15.57), p = 0.011). Conclusions: Large body surface area, high hematocrit during CPB, previous stroke and acute surgery were independently associated with HPE. A treatment protocol including epoprostenol appears to be a safe option. Perioperative stroke rate was increased in HPE patients.

1161 Streamlining the Patient Journey for Operative Management During COVID 19

Aim Leeds, UK is a high-volume acute surgery unit. Emergency operating was drastically affected by the pandemic and time from admission to definitive procedure significantly increased. This intervention aimed to streamline the patient journey from acute admission to the operating theatre. Method An audit considering delays to transfer, theatre access and recovery discharge, along with the criteria used for ‘Hot’ theatre was undertaken. Data was collected prospectively between 02/06/2020-06/07/2020 via a standardised proforma. Preliminary results suggested a geographically remote ‘hot’ theatre was associated with multi-factorial delays so was relocated to more familiar surroundings. This was re-audited between 06/07/2020-06/08/2020 aiming to characterise factors contributing to delay. A dedicated in-hours acute theatres porter was introduced for a trial period. Data was collected retrospectively between 24/08/2020-14/09/2020 and prospectively between 14/09-05/10/2020 via hospital electronic systems. Results Initially the average time from patient transfer to leaving theatre recovery was 4h6m55s (N = 52). Relocating theatres reduced this to 2h48m04s (N = 74)- an average reduction of 1h18m51s. The greatest reduction was seen in anaesthetic time between 1h17m54s to 41m29s. The introduction of a dedicated porter reduced the average transfer time to theatre from 36 minutes (N = 53) to 21 minutes (N = 68) (p &lt; 0.05). Conclusions Delay to theatre has a high cost financially and in its effect on patient outcomes. Delays are often multifactorial and robust systems are essential to minimise delays. Patients are best served by well-trained, dedicated ‘Acute’ team in familiar surroundings. Long-term implementation of dedicated portering service will save time, money and improve patient care.

Letter to Editor Didactic and Certified Trauma and Acute Care Surgery Fellowship is Inevitable Demand of Pakistan

Discussions about the content and competencies of any postgraduate training program mainly focus onwhat the graduates need in long run after completion of training1. However, from the prospect of any progressive country, a post-graduate training program should also liaise with the demands of the country. Overthe past decade, the acute care surgery practice paradigm has become a defined entity in the developed world and didactic fellowship training programs in trauma and acute surgery have been implemented. In recent years, the American Association for Surgery has matured to 20 different disciplines of trauma and acute care2.

APOE4 genotype increases neuronal calcium signals and decreases pial arteriole responsivity and vasomotion in visual cortex of awake mice

Vascular dysfunction is an early feature of late onset Alzheimer's disease (AD), preceding classic AD pathology such as beta amyloid accumulation and formation of hyperphosphorylated tau. Such vascular dysfunction may promote classic AD pathology by decreasing blood flow, impairing brain oxygenation and clearance of molecules such as beta amyloid. The main genetic risk factor for AD is the ϵ4 allele of APOE, which has been found to increase blood brain barrier permeability and decrease vascular density, as well as decrease blood flow and functional hyperaemia in anaesthetised mice undergoing acute surgery. These results suggest that APOE4 may confer AD risk via its effects on the vasculature. However, the responses of neurons and individual vessels have not been studied, so neurovascular relationships are unknown, and no previous studies have looked at awake mice. We therefore measured neurovascular responses at rest and in response to visual stimulation using 2 photon imaging of awake APOE3 and APOE4 targeted-replacement (APOE TR) mice that expressed the calcium indicator GCaMP6f in excitatory neurons, while labelling the vascular lumen with Texas Red dextran. In parallel, we measured cerebral blood flow, blood oxygenation and cerebral blood volume using combined laser Doppler flowmetry and haemoglobin spectrometry. Measurements were performed in mice aged between 3-4 months to 12-13 months. We found a milder vascular deficit in awake mice than previous studies that used an acute surgical preparation: capillary responses to visual stimulation were the same in APOE3 and APOE4 TR mice, leading to unimpaired functional hyperaemia. However, neuronal calcium signals during visual stimulation were significantly enhanced in APOE4 mice, while there was a marked decrease in pial arteriole responsiveness and vasomotion. This pattern of results was unaffected by age, suggesting that APOE4 expression creates a stable, but mildly altered neurovascular state that does not itself cause degeneration. However, these changes likely make the system more sensitive to subsequent insults; for example, weaker vasomotion could impair clearance of beta amyloid as it starts to accumulate, and therefore may help explain how APOE4 expression increases risk of developing AD.

Severe deep neck space infection caused by Eggerthia catenaformis

A 64-year-old woman was acutely referred to the Department of Otorhinolaryngology, Head and Neck Surgery, Aalborg University Hospital due to rapidly progressing neck swelling, fever and dysphagia. Clinical examination revealed submental swelling, trismus and laryngeal inflammation. A contrast-enhanced CT scan showed infection in the deep neck spaces with multiple abscesses. The patient underwent acute surgery and antimicrobial therapy was initiated and she was transferred to an intensive care unit. Three additional surgical procedures were needed before sufficient drainage was achieved. There was growth of different oral commensals from four separate pus aspirates, while Eggerthia catenaformis was cultured in all samples. Due to the extent of the infection, the patient stayed in the intensive care unit for 16 days, but recovered completely due to adequate surgery and antimicrobial therapy for 4 weeks. Here we present the third reported case of a severe deep neck space infection with multiple abscesses due to E. catenaformis.