National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

229 A Systematic Review Protocol Examining the Role of Immobilisation in Hand Infections

Aim

Hand infections are common and varied, leading to long-term complications when managed poorly. Splinting of the hand in a position of safe immobilisation (POSI) is frequently used to avoid complications including pain and stiffness, however it is not a universally accepted technique because the effects of splinting in hand infections remain unestablished.

This systematic review will compare outcomes in adult hand infections between those treated using hand immobilisation and those not immobilised. The primary aim is to compare patient reported outcomes, for example pain, and the secondary aim is to compare functional active range of motion, complications, and resource use.

Method

A systematic review protocol has been developed. The search strategy was developed following background reading, expert opinion, and review by an academic librarian, and will be used to search MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Central Register of Controlled Trials, to identify publications on management of hand infections including use of hand immobilisation. Title, and full-text screening will be carried out by two independent investigators to identify studies for inclusion. Editorials, letters, and literature reviews will be excluded.

Results

This systematic review has been successfully registered on the PROSPERO International prospective register of systematic reviews (CRD42021232880)

Conclusions

This systematic review will summarise the available evidence to establish the effect of hand immobilisation in hand infections, including whether hand immobilisation leads to improved outcomes in hand infections, which could guide health care professionals in their practice and influence future clinical guidelines.

64 An Audit of Same Day Theatre List Cancellations

Introduction

Given the reduction in elective operating during the Covid pandemic, efficient use of theatre time is paramount to reduce elective waiting list times. The aims of this audit were to identify the proportion of patients who were cancelled from theatre lists on the day, reasons for cancellation, and the proportion of patients who were cancelled due to non-adherence to pre-operative fasting rules.

Method

The previous 30 patients on a single surgeon’s elective operating list were reviewed using electronic patient records, admissions teams list, and surgeon recall to identify numbers of and reasons for on the day cancellations.

The standards used were the perioperative fasting in adults and children guideline from the European Society of Anaesthesiology, and a local trust guideline on pre-operative fasting.

Results

30 patients had been scheduled for elective surgery on a single surgeon’s paediatric plastic surgery list between April and May 2021. 3 patients (10%) cancelled on the day of their planned procedures. Of these patients cancelling on the day, 2 (66%) cancelled due to non-adherence to pre-operative fasting rules, 1 (33%) cancelled due to parents choosing to defer the operation.

Conclusions

Non-adherence to pre-operative fasting rules was an important reason for on the day cancellations on this elective operating list. A pre-operative fasting information sheet was developed for patients and parents to explain the fasting rules and timings. Once sufficient patients and parents receive the information sheet, the audit will be repeated. If successful, it may be sent to patients and parents for all elective operating lists.

1249 A 3D Morphable Model of the Apert Mandible

Aim

Assess the three-dimensional Morphable Model (3DMM) of the Apert mandible, investigate differences between sex and age, and characterise growth by age. Additionally, compare with a healthy mandible 3DMM.

Method

High-quality CT scans of children with Apert’s Syndrome (without previous mandibular surgery) between November1987-January2020 were sourced from Great Ormond Street (GOSH) and Necker Hospitals. DICOM files were constructed to 3D meshes through isolation of mandibles and artifact removal (MeshMixer, Mimics) and annotation using standardized landmarks (Wrapped). A 3DMM was constructed using an existing pipeline, and experiments performed to compare with the healthy mandible 3DMM, investigating differences between sex and age, and to characterise growth by age. A healthy mandible 3DMM has been created by our team using healthy mandible CT scans sourced from a GOSH database.

Results

A 3DMM of the unoperated Apert mandible was successfully constructed from 276 Apert CT scans, male=137 (aged0-20), female=139 (aged0-23), and the first components of the morphable model identified.

Conclusions

Apert’s Syndrome is a rare genetic condition, with characteristic extremity (syndactyly) and craniofacial features (craniosynostosis), however breathing problems, sleep apnoea, relative prognathism and Angle class III malocclusion have been reported. Few studies have analysed the potential role of the Apert mandible. 3DMMs are statistical tools used to represent 3D shapes and have been used to create shape and texture parameters for anatomical areas. The 3DMM of the unoperated Apert mandible has potential applications for further understanding of Apert’s Syndrome, diagnostic purposes and may be used to develop further management of these patients, such as surgical planning.

1173 Airway and Breathing Problems in Pierre Robin Sequence: A Systematic Review Protocol

Aim

The primary aim is to systematically review the specific airway and/or breathing problems which have been reported in Pierre Robin Sequence (PRS). Secondary aims are to understand the prevalence and severity of these airway and breathing problems, and options for screening, assessment, and monitoring.

Method

A search strategy will be designed to search the following databases: MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials(CENTRAL) including a grey literature search, to identify publications on airway and/or breathing problems in Pierre Robin Sequence patients. Airway or breathing problems to be included are defined upper airway conditions (e.g., sleep apnoea) or clinically or objectively defined airway/breathing problems (e.g., increased respiratory rate, polysomnography). Screening will exclude non-English articles, abstracts, letters, editorials, expert opinions and breathing problems not anatomically related to craniofacial underdevelopment.

Results

This systematic review has been successfully registered on the PROSPERO International Prospective Register of Systematic Reviews (CRD42020210572)

Conclusions

PRS is a rare craniofacial condition which presents at birth, consisting of micrognathia, glossoptosis and airway problems, and is usually, but not always, associated with a cleft palate. There is no consensus on the type of airway problems that affect patients with PRS. The findings of this systematic review will help to develop a consensus on the airway and breathing problems in PRS and options for assessment and monitoring of the airway and breathing problem. This data may also contribute to development of a standardized guideline for management of airway and breathing problems in PRS.

1004 Student Perspectives on Surgical Careers

Aim

To investigate medical students’ understanding of skills needed as surgeons and how prepared they feel to pursue surgical careers, and to identify methods to support and prepare medical students who want to pursue surgical careers.

Method

A student-led National Surgical Conference (Cardiff, 2018) ran a consensus and debate session entitled ‘Are students adequately prepared for a career in surgery at medical school?’, including a questionnaire addressing elements of medical school curriculums relevant to surgery and the importance of developing technical skills and non-technical skills (NTS).

Results

60 delegates completed the questionnaire: Year1-3 (n = 38), Year4-6 (n = 15), intercalating (n = 4), foundation doctors (n = 3). Delegates most frequently stated specific surgical skills (20.1%), broader surgical skills (20.1%) and interpersonal skills (17.2%) as the most important skills to be a surgeon. 75% rated technical skills and NTS as equally important, 25% rated technical skills as more important. 12.5% felt unconfident in their NTS to be an efficient surgical team-member, 37.5% felt between confident and unconfident, and 50% were confident. 26.3% felt unprepared to pursue surgical careers following medical school, 70.2% felt between prepared and unprepared, and 3.5% felt prepared. More practical surgical skills sessions (35%), career pathway sessions (15%), surgically relevant teaching (16%) and theatre or surgical placements (19%) were the most frequently wanted improvements.

Conclusions

Prospective surgeons highly valued developing surgical skills and overall do not feel prepared to pursue surgery. Medical students would benefit from education on the surgical career pathway and the importance of the non-practical components of surgery, including patient safety and NTS.

989 Sustained and Further Improvements in Management of Open Fractures at a UK Major Trauma Centre

Aim

To re-audit pre-operative hospital management of open fractures following further interventions (junior doctor education and awareness, editing of trauma clerking form), after the initial audit and interventions led to improvements in all parameters.

Method

Pre-operative hospital management of open fractures was audited by reviewing patient notes using standards from the NICE (NG37) and BOAST/BAPRAS open fracture management guidelines. Patients included were treated by doctors with full exposure to the further interventions (due to junior doctor changeover the third cycle included fewer patients).

Results

All parameters remained improved in the third audit cycle compared to the first (before interventions were implemented). The following results compare the second (n = 30) and third audit (n = 14) cycles. Patients receiving correct antibiotics (96%vs100%) and in a timely manner (<2 hours) where not given pre-hospital (46%vs60%) improved. Initial neurovascular assessment (93%vs100%), specifying nerves assessed (60%vs71%), assessing all relevant arteries (60%vs71%) and nerves (63%vs71%) and using Medical Research Council (MRC) grading in nerve assessment (3%vs71%) improved, while specifying arteries assessed was similar (87%vs86%). Post-manipulation, neurovascular assessment (93%vs75%) and appropriate nerve examination (90%vs50%) deteriorated, however appropriate vascular assessment (60%vs75%) and use of MRC grading in nerve assessment (0%vs50%) improved. Documentation where neurovascular assessment was not possible, initially (50%vs93%) and post-manipulation (40%vs50%) improved. Photo availability deteriorated (70%vs64%). Tetanus cover (87%vs100%) and appropriate dressing use (47%vs71%) improved.

Conclusions

Most parameters showed sustained and further improvements. The haemodynamic stability variation of these patients may create difficulties in fully adhering to the management standard; in some cases, other acute concerns may take priority.

180 Management of Open Fractures at Oxford University Hospitals NHS Trust Major Trauma Centre

Introduction

This audit was developed after noticing patients with open fractures had poor neurovascular assessment documentation (non-specific, none post-manipulation), and to check these patients received appropriate antibiotics. Review of open fracture management guidelines identified areas to be improved.

Method

Pre-operative hospital management of open fractures was audited using the NICE (NG37) and joint BOAST/BAPRAS guidelines on open fracture management. Interventions were awareness and education of junior doctors and editing the Trauma Clerking Form to prompt appropriate management and documentation, followed by re-audit.

Results

30 patients were assessed pre- and post-intervention. Correct antibiotic administration rate (93%vs97%) and speed (50% <2 hours where not given pre-hospital - in both groups) were similar. The initial neurovascular assessment frequency was identical (93%), however documentation of assessment of specific arteries (86%vs30%) and nerves (60%vs23%) and assessing all appropriate arteries (60%vs13%) and nerves (60%vs20%) improved. There were increased frequencies of documenting manipulation in A&E (90%vs47%) and neurovascular assessment post-manipulation (90%vs16%). Tetanus cover (87%vs77%), photo availability (70%vs40%), and appropriate dressing use (47%vs27%) improved.

Conclusions

Antibiotic management was consistent and appropriate. There were improvements in frequency and quality of neurovascular assessment, tetanus cover, availability of photographs of injuries and appropriate dressings used. Overall, pre-operative hospital management of open fractures improved.