SP10.1.2 Increased Access to Computed Tomography Reduces Acute Surgical Admissions: Lessons Learnt During the COVID-19 Pandemic

Aim With increased bed pressures due to COVID-19, keeping patients out of hospital became critical. Computed Tomography (CT) utilisation was increased to aid in the assessment of acute surgical patients. The aim of this study was to assess if increased access to CT reduced inpatient admissions. Methods A Retrospective audit of patients presenting to the Emergency Department (ED) between 12th July – 23rd August 2020 who required a CT scan. Data collected from Electronic Care Records and NIPACS, including patient destination at time of CT and decision following CT. For comparison, the same time-period in 2019 was assessed. Results In 2020, 301 patients required a CT compared to 207 in 2019. 84.7% (255/301) had a CT direct from ED in 2020 vs. 56.5% (117/207) in 2019 (p < 0.001). Of those who had CT direct from ED in 2020 18.4% (47/255) were discharged, compared to 1.7% (2/117) in 2019 (p < 0.001). 9.8% (25/255) were directed to an alternative specialty in 2020 vs. 2.6% (3/117) in 2019 (p = 0.014). 2.7% (8/301) were discharged for an ambulatory CT in 2020, an increase from 0.5% (1/207) in 2019 (p = 0.07). Overall, there was a 24% reduction in the number of patients requiring acute surgical admission in 2020 vs. 2019. Conclusions There was a significant increase in the number of CT’s carried out directly from ED. This enabled a significant number of patients to be discharged or transferred to a more appropriate specialty. These results demonstrate that increased access to CT can reduce the need for acute surgical admission.

EP.FRI.997 Recognising frailty: the scale of the problem

Aim To assess compliance with frailty scoring in acute surgical admissions. Method Data including age, admitting speciality, whether the frailty score was completed and the recorded score if completed, were collected for all admissions to an acute surgical unit over a 7 day period in November 2019. Results The average age of the 139 patients was 56.25 years (range 16-89). Frailty scoring was completed in 53 patients (38.1%); 8 patients (15%) met the criteria for frailty. Sixty-four patients (46%) were aged over 65 years, 26 (40.6%) had the score completed and 7 (27%) met the frailty criteria. Of 36 patients (26%) aged 75 or over, 16 (44.4%) were scored and 6 (37.5%) met the frailty criteria. Scoring was most frequently completed in patients admitted under the Vascular Surgery team (52.9% compliance) with a mean score 3.8. Conclusion Worsening frailty is associated with increased morbidity and mortality in acute surgical admissions. The 7-point Clinical Frailty Scale has been added our acute surgical admission document and should be completed for every patient. Our compliance with scoring is a long way from our recommended 100%, with compliance with assessing frailty across age groups similar, despite the increased rates of frailty seen in older age groups. Poor compliance with frailty assessment may hamper future progress with the management of the frail, older surgical patient. We are planning documentation changes, staff education sessions and to appoint frailty ‘champions’ with a repeat audit of compliance to assess the effects of these changes.

EP.TU.411Thinking Ahead: Improving Documentation of Treatment Escalation Plans for Surgical Patients

Aims The GMC recommends early decision making on CPR status for all acutely unwell patients admitted to hospital. An audit was undertaken of documentation of treatment escalation plans (TEPs) for general surgical patients at a District General Hospital. Method A retrospective study looking at documentation of TEPs in patients (n = 55) admitted under the care of the general surgical team over a one month period. Documentation from the surgical admission clerking and the first consultant ward round were reviewed for evidence of a TEP. Results Of 55 patients admitted only 24% had a TEP documented within 48 hours of admission under the general surgeons. Of those that had a TEP recorded (n = 13), twelve were in the admission surgical clerking and one was completed on the post-take consultant ward round. Conclusions This project highlighted the lack of TEP documentation for surgical patients within 48 hours of admission to hospital. Our recommendation is to develop a specific ‘post-take ward round’ proforma with mandatory TEP, to be filled out within 24 hours of patient admission. This updated process will then be reassessed for improved compliance with TEP documentation. We anticipate this will improve early decision making regarding escalation status and facilitate TEP discussions with patients. Overall this process should help ensure a more patient-centered approach to care planning.

1405 Improving Documentation of Per Rectal (PR) Exams in An Acute Surgical Unit

Aim A PR exam is routinely performed as part of the complete examination of surgical patients. The General Medical Council (GMC) has provided guidance on the use of chaperone during intimate exams stating that consent should be obtained, and a chaperone offered to all patients and documented accordingly. We aimed to assess and improve our documentation of PR exams. Method Data was collected prospectively from surgical admission documentation. The number of patients with consent and presence of chaperone documented during PR exam was recorded. Following a period of data collection, a proforma was implemented with education on correct documentation as per guidelines. A second audit cycle was performed where formal inclusion of the sticker in the admission booklet was implemented. Results 20 patients were included in the initial data collection, 95% of which had incomplete documentation of PR exam on admission. A sticker was designed to prompt accurate documentation and inserted into the acute admissions booklet. Following this, 50% of PR exams were correctly documented. The remaining 50% without documentation had no sticker in the admission booklet. The second intervention included changing the hardcopy of the admission booklet. Following this, 80% of patients had consent documented and 90% had documented chaperone. Conclusions GMC guidelines state that documentation of consent and the presence of chaperones during intimate medical examinations are crucial. The implementation of a prompt in our admissions booklet has greatly improved our documentation in PR examination.

1118 The Role of Emergency Surgery in Diverticular Strictures of Those Who Were Initially Managed Conservatively

Aim The presence of diverticulosis can lead to several different complications including formation of strictures. However, the literature concerning management of diverticular strictures is poor. The purpose of this study is to evaluate the patients who were initially treated non surgically and had to undergo emergency surgery. Method A retrospective study was performed using a cohort of patients between 2016 and 2020 where 84 patients with diverticular strictures were identified and followed up. Data on the management of diverticular stricture was captured using the hospital’s electronic medical records. Results Out of 84 patients with diverticular strictures, 9 had elective surgery without any medical treatment while 75 had medical treatment first. Out of the 75 patients who were medically treated, 12 underwent emergency surgery while 2/75 underwent elective surgery after receiving medical treatment due to ongoing symptoms. Out of the 12 patients that underwent emergency surgery, 9 patients presented with obstruction while 3 had a bowel perforation. 6 patients had Hartmann’s procedure, 5 had defunctioning colostomy and 1 patient had adhesiolysis. No patient deaths were recorded at 12 months. Conclusions Although medical management remains the preferred method of managing diverticular strictures in the UK, it is not without its complications. 1 in 5 patients had an acute surgical admission requiring emergency surgery. This raises the importance of a good ‘safety net’ in those managed non-surgically, to reduce delays associated with seeking medical advice. We also appreciate the importance of carrying out more extensive studies to establish the best way to manage diverticular strictures.

Trends in medical and surgical admission length of stay by race/ethnicity and socioeconomic status: a time series analysis

Length of stay, a metric of hospital efficiency, differs by race/ethnicity and socioeconomic status (SES). Longer LOS is associated with adverse health outcomes. We assessed differences in average adjusted length of stay (aALOS) over time by race/ethnicity, and SES stratified by discharge destination (home or non-home). Using the 2009-2014 State Inpatient Datasets from three states, we examined trends in aALOS differences by race/ethnicity, and SES (defined first vs fourth quartile of median income by zip code) controlling for patient, disease and hospital characteristics. For those discharged home, racial/ethnic and SES aALOS differences remained stable. Notably, for those discharged to non-home destinations, Black vs White, and low vs high SES aALOS differences increased significantly from 2009 to 2013, more sharply after Q3 2011, the introduction of the Affordable Care Act (ACA). Further research to understand the impact of the ACA on hospital efficiencies, and relationship to racial/ethnic and SES differences in LOS is warranted.

High volumes of recent surgical admissions, time to surgery, and 60-day mortality

Aims Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients. Methods This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions. Results Among 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75th percentile) proportion of recent surgical admission compared to a low (25th percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4). Conclusion A high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality. Cite this article: Bone Joint J 2021;103-B(2):264–270.

Trends in Medical and Surgical Admission Length of Stay by Race/Ethnicity and Socioeconomic Status: A Time Series Analysis

Background: Length of stay (LOS), a metric of hospital efficiency, differs by race/ethnicity and socioeconomic status (SES) and longer LOS is associated with adverse health outcomes. Historically, projects to improve LOS efficiency have yielded LOS reductions by 0.3 to 0.7 days per admission. Objective: To assess differences in average adjusted length of stay (aALOS) over time by race/ethnicity, and SES stratified by discharge destination (home or non-home). Method: Data were obtained from 2009-2014 Healthcare Cost and Utilization Project State Inpatient Datasets for New York, New Jersey, and Florida. Multivariate generalized linear models were used to examine trends in aALOS differences by race/ethnicity, and by high vs low SES patients (defined first vs fourth quartile of median income by zip code) controlling for patient, disease and hospital characteristics. Results: For those discharged home, racial/ethnic and SES aALOS differences remained stable from 2009 to 2014. However, among those discharged to non-home destinations, Black vs White aALOS differences increased from 0.21 days in Q1 2009, (95% confidence interval (CI): 0.13 to 0.30) to 0.32 days in Q3 2013, (95% CI: 0.23 to 0.40), and for low vs high SES patients from 0.03 days in Q1 2009 (95% CI: -0.04 to 0.1) to 0.26 days, (95% CI: 0.19 to 0.34). Notably, for patients not discharged home, racial/ethnic and SES aALOS differences increased and persisted after Q3 2011, coinciding with the introduction of the Affordable Care Act (ACA). Conclusion: Further research to understand the ACA’s policy impact on hospital efficiencies, and relationship to racial/ethnic and SES differences in LOS is warranted.