COVID-19 patient cohort identification during the SARS-CoV-2 outbreak through a tertiary hospital Electronic Health Record alert system (Preprint)

BACKGROUND On 11th March 2020, the World Health Organization declared a pandemic caused by the coronavirus with 118.629 identified cases and 4.292 confirmed deaths. Up to date, 252 million cases and 5 million deaths have been identified as caused by COVID-19. An epidemic situation is characterized by an overload of patients suffering a particular clinical condition and needing acute medical attention in a short period. Usually, the pathogen n causing the epidemic is either new or emergent, and the knowledge a priori is limited. Information is crucial for public health authorities to establish policies to prevent transmission. Thus, the cycle of knowledge acquisition must be efficient and as short as possible. An interdisciplinary team adapted the electronic health record alert systems for real-time data tool collection for clinical characterization and epidemiological surveillance. This system has been working from the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) first outbreak up to date OBJECTIVE To share the experience of handling COVID-19 and non-COVID-19 patients' circuits through an Electronic Health Record (EHR) alert system during the pandemic. This system allowed the creation of a COVID-19 hospitalized patient cohort, with implications in the hospital circuit management, patients risk stratification and secondary use for research projects in a period of high uncertainty. Additionally, its integration as an epidemiological surveillance tool favored the submission of updated information to public health authorities. METHODS Almost 30,000 alerts related to COVID-19 were activated in the EHR. Overall, the most frequent were “COVID-19 ruled out” (N = 12,438) followed by “COVID-19 Confirmed Case” (N = 8,999). Up to 13,106 patients (65.7%) were labeled with just one alert during their in-patient stay, while 6,857 (34.3%) received two or more labels. For the alert sequences, 96% were considered logical sequences, 3,1% as low-quality logic sequences, and less than 1% aberrant sequences. Although some temporal variations, all periods had a high rate of logical sequences achieving more than 95%. Preventive medicine professionals activated most COVID-19 alerts and acted as auditors for data quality. When possible, automatic alerts were in place, which became the most frequent. RESULTS Almost 30,000 alerts related to COVID-19 were activated in the EHR. Overall, the most frequent were “COVID-19 ruled out” (N = 12,438) followed by “COVID-19 Confirmed Case” (N = 8,999). Up to 13,106 patients (65.7%) were labeled with just one alert during their in-patient stay, while 6,857 (34.3%) received two or more labels. For the alert sequences, 96% were considered logical sequences, 3,1% as low-quality logic sequences, and less than 1% aberrant sequences. Although some temporal variations, all periods had a high rate of logical sequences achieving more than 95%. Preventive medicine professionals activated most COVID-19 alerts and acted as auditors for data quality. When possible, automatic alerts were in place, which became the most frequent. CONCLUSIONS The EHR integrated system favored in-hospital management of patients during the COVID-19 pandemic. It was helpful for both the institution and the health system, representing an example of interlevel integration. The performance was adequate and robust, with insights at different levels: infection control, patient safety, research, and pandemic response. Preventive Medicine teams should maximize EHR solutions for epidemiological surveillance. CLINICALTRIAL Not required.

A rare case: Penetrating craneoencefalic trauma by knife

Background: Cranioencephalic penetrating trauma (CPT) is caused by a sharp or short- pointed object that passes through the bone, dura mater, brain and other structures. Its incidence is unknown and few cases are described; penetrating injuries represent 0.4%, therefore there is no protocolized management. Case report: A 24-year-old male patient suffered penetrating trauma at left parietal region with a "knife"; he was sutured and sent home with analgesics. Five days after the trauma, he was admitted for headache, disorientation and decreased visual acuity. X-ray (XR) of Cranium evidencing a foreign body, therefore it is sent to a reference hospital. Evolution: The diagnosis is confirmed by a computerized tomography (CT) scan of the skull with 3-dimensional reconstruction (3D) plus CT angiography (angio CT), which shows "knife" in the left parietal region without vascular compromise. Neurosurgeons perform removal of the foreign body plus a dura mater plasty. Patient stay 12 days hospitalized with a favorable evolution and improvement of neurological symptomatology. Conclusion: CPT due to a knife is an emergency and there is no protocolized management. The removal of the foreign body must be done in a hospital for the risk of lesions of large vessels.

To triage or not to triage? The history and evidence for this model of care in psychiatry

SUMMARY Triage wards were introduced as a new model of psychiatric in-patient care in 2004. However, there is limited evidence comparing them with the traditional in-patient models of care. This article reviews the history of triage wards, their principles, the evidence for this model (e.g. length of in-patient stay, readmission rates, staff and patient satisfaction) and the development of assessment wards based on the triage model of care. The evidence shows that the triage model has higher rates of rapid discharge, with a greater proportion of ‘acute care’ performed in the community with the support of home treatment teams. This leads to lower bed occupancy in the triage wards without increased rates of readmission or a worse patient experience of in-patient care. However, overall staff experience was better in the traditional model, given that staff satisfaction rates were lower on locality wards in settings with triage systems in place. Future research should explore the potential impact on home treatment teams, and the rates of serious incidents due to the high number of acutely unwell patients on triage wards.

TP6.2.8 Impact of patients’ characteristics on operative difficulty and clinical outcomes of laparoscopic cholecystectomy

Background Laparoscopic cholecystectomy (LC) is a common surgical procedure. Intraoperative findings are highly unpredictable and the operative difficulty varies from straightforward to very challenging procedures. Several studies described predictors of technical difficulty and graded intraoperative findings of LC, however none specifically reported on the effect of such factors on clinical outcomes. This study aims to evaluate the impact of patients’ preoperative characteristics on operative difficulty of LC and clinical outcomes. Methods Data of patients who underwent LC from 2015 to 2017 retrospectively analysed. Subjects were divided into four groups, according to Nassar’s classification of intraoperative difficulty. Differences in frequencies were evaluated with the Fisher’s exact test; logistic regression analysis was used to identify independent variables that were predictors of postoperative morbidity and length of stay. Results A total of 1069 patient were included. Male to female ratio of 1:2.5. Older age, male gender and comorbidities were associated with higher Nassar score (p < 0.0001); Nassar 3 and 4 were predictors of postoperative morbidity(P£0.01). The day case rate was 88.8% (Nassar 1), 86.1% (Nassar 2), 69.6% (Nassar 3), 62.3% (Nassar 4), respectively. Age of 60 and above(P£0.018), ASA 2 or 3(P£0.04) and Nassar 3, 4 (P£0.012), were predictors of increased conversion from day case to in-patient stay. Conclusion LC can be performed on a day case basis even when surgery is technically challenging. However, the need of in-patient stay can be predicted in comorbid old adult men with anticipated higher Nassar’s score.

Spring-assisted posterior vault expansion—a single-centre experience of 200 cases

Purpose Children affected by premature fusion of the cranial sutures due to craniosynostosis can present with raised intracranial pressure and (turri)brachycephalic head shapes that require surgical treatment. Spring-assisted posterior vault expansion (SA-PVE) is the surgical technique of choice at Great Ormond Street Hospital for Children (GOSH), London, UK. This study aims to report the SA-PVE clinical experience of GOSH to date. Methods A retrospective review was carried out including all SA-PVE cases performed at GOSH between 2008 and 2020. Demographic and clinical data were recorded including genetic diagnosis, craniofacial surgical history, surgical indication and assessment, age at time of surgery (spring insertion and removal), operative time, in-patient stay, blood transfusion requirements, additional/secondary (cranio)facial procedures, and complications. Results Between 2008 and 2020, 200 SA-PVEs were undertaken in 184 patients (61% male). The study population consisted of patients affected by syndromic (65%) and non-syndromic disorders. Concerns regarding raised intracranial pressure were the surgical driver in 75% of the cases, with the remainder operated for shape correction. Median age for SA-PVE was 19 months (range, 2–131). Average operative time for first SA-PVE was 150 min and 87 for spring removal. Median in-patient stay was 3 nights, and 88 patients received a mean of 204.4 ml of blood transfusion at time of spring insertion. A single SA-PVE sufficed in 156 patients (85%) to date (26 springs still in situ at time of this analysis); 16 patients underwent repeat SA-PVE, whilst 12 underwent rigid redo. A second SA-PVE was needed in significantly more cases when the first SA-PVE was performed before age 1 year. Complications occurred in 26 patients with a total of 32 events, including one death. Forty-one patients underwent fronto-orbital remodelling at spring removal and 22 required additional cranio(maxillo)facial procedures. Conclusions Spring-assisted posterior vault expansion is a safe, efficient, and effective procedure based on our 12-year experience. Those that are treated early in life might require a repeat SA-PVE. Long-term follow-up is recommended as some would require additional craniomaxillofacial correction later in life.

Information Technology in Hospitalization Management in a Federal Medical Organization

The article presents the experience of organizing the management process of planned hospitalization at the Federal Center for Traumatology, Orthopedics and Arthroplasty (Cheboksary). Automation of the process of hospital admission planning, including monitoring of hospital admissions failures and the length of patient stay in the PA, organization of information support for the staff of the Center's admission department based on the developed MIS "Medialog" module, related to patient registration and registration of documents specific to the federal medical center in the PA, allowed for ongoing monitoring of hospitalization, reducing the proportion of patients waiting in the emergency department for more than 3 hours, improving the quality of patient flow planning and management.

749 Unexpected benefits of pandemic guidelines for the management of epistaxis

Aim The Royal Victoria Hospital adopted ENT UK’s pandemic guidelines for the management of epistaxis. We aimed to reduce ENT referrals, in-patient admissions and staff exposure to COVID-19 whilst maintaining patient safety. This involved collaboration with ED to promote the use of absorbable packs and pharmacological alternatives over rhinoscopy & rigid endoscopy with cautery +/- non-absorbable packs. Method Data was collected on patients presenting with epistaxis over a six-week period beginning March 2020 and the same period in 2019. Key factors recorded were number of presentations, ENT referrals, admissions, and their durations, along with management and outcomes. ENT provided training to ED staff and produced video resources for the "My ED" app. Feedback from ED and patient data was gathered to improve training and assess effectiveness. Results Pre-pandemic, 48% of ED epistaxis presentations were referred to ENT vs. 28% following the guidelines introduction. In 2019 49% of referrals were admitted vs. 42% in 2020. The average in-patient stay was reduced from four nights to one. Re-admission rate remained similar from 22% in 2019 to 20% in 2020. These results were achieved following repeated improvements to the training sessions. Conclusions The ENT UK guidelines, when supplemented with ED collaboration, are effective at reducing ENT referrals and admissions. In addition to reducing COVID-19 exposure, the guidelines offered an improved patient experience (less invasive intervention, reduced/removed in-patient stay) with no loss of efficacy. This, combined with a reduced treatment cost of ∼£2,000 per in-patient, suggests the guidelines have long-term value out-with a pandemic setting.

573 What's in A Name? An Audit of Correct Identification of Patients During Ward-Rounds in A Surgical and Urology Receiving Ward

Aim Clinical governance states that patients should have a named Consultant during their in-patient stay. In our institution, every bed has a whiteboard above it, which mentions the name of the patient and the responsible Consultant. This should correspond with the electronic system, TrakCare. Ouraim was to audit and look into the accuracy of this practice, in order to improve the efficacy of ward-rounds and hence improve patient care and safety. Method Data was collected for general surgery and urology receiving wards over 3 consecutive days and was matched to the data available on the electronic system, TrakCare. Intervention was made in the form of verbal and written communication with the nursing staff and junior doctors. Effect of intervention was assessed 2 weeks later. Results n = 38 bed-boards were assessed. The first cycle of the audit demonstrated that 7 (18.4%) had either incorrect or no entries. The detailed analysis revealed that of these, 2 had no consultant names whereas 5 were incorrect. The second cycle demonstrated a good improvement with only 1(2.6%) bed-boards having incorrect or no names. The third cycle demonstrated sustainable impact with only 1 (2.6%) missing consultant’s name. Conclusions Ward-rounds have been an age-old practice to review patients and are vital to formulate a care plan for patients, particularly in acute settings. It is also important for the patient to know who is providing their care. Wrong or missing entries could compromise patient care and has implications in patient follow up and chasing results. A simple intervention by the nursing and medical staff can improve the quality of care.

927 Epistaxis Management in COVID-19

Aim Traditional management of epistaxis include endoscopic examination of the nasal cavity and/or cautery requiring close contact between doctor and patient. We aimed to reduce the length of in-patient stay for patients with epistaxis whilst maintaining patient safety during the COVID-19 pandemic. Method A retrospective and prospective audit was performed to assess the management of patients and their outcomes prior to and after new COVID-19 epistaxis guidelines were introduced in our unit. A PDSA cycle was undertaken. Results 27 patients presented to our ENT department in each 3-month audit cycle. 20 patients in each group were packed. More patients were packed bilaterally in group 2. The admission rate reduced from 100% to 25%. Packing duration increased from 1.8 (in group 1) to 3 days in group 2. 1 patient in each group required surgical management. The 30-day re-bleed rate increased from 11% to 30% All re-bleeds in group 1 were admitted. Only 1 patient (3.7%) with a re-bleed in group 2 required admission. The mortality rate was unchanged. The length of time during the initial visit decreased. Hospital visits per patient (for removal of pack, pain, and re-bleeding) increased from 1.1 in group 1 to 2.7 in group 2. Conclusions Our COVID-19 epistaxis guidelines reduced close contact, in-patient admissions, and length of stay. However, there is an increase number of visits per patient and increase re-bleed rate (suggesting that cautery plays an important role). The next cycle plans to introduce a patient leaflet and a virtual clinic.

An unusual cause of free air in the abdomen: emphysematous cystitis with bladder diverticulum perforation

A 64-year-old male, with a history of chronic urinary outflow obstruction secondary to benign prostatic hyperplasia, presented with haematuria and urinary retention following spontaneous removal of his long-term catheter. The patient was septic on admission and a CT examination of the abdomen and pelvis showed an acutely inflamed urinary bladder diverticulum and extensive intra-abdominal free air. The patient was treated medically for emphysematous cystitis centred on a perforated bladder diverticulum, which was thought to be caused by the underlying infectious/inflammatory process. Alternative aetiologies for free air in the abdomen such a traumatic bladder perforation and gastrointestinal perforation were considered and excluded. The patient responded well to medical management and was discharged after an 11 day in-patient stay.