402 Assessed and Discharged - An Audit of Discharge Summaries Completion During On-Calls

Aim

Effective health care provision is heavily dependent on timely, reliable transfer of patient information. Failure of this communication between professionals could result in redundancy of tests, delay in treatment, which may in turn endanger patient safety. The NHS Standard Contract requirements state discharge summaries should be completed within 24 hours of hospital assessment and discharge. Discharge summaries for patients who were reviewed but not admitted have been observed to be poorly completed and this audit aims to clarify this.

Method

On-Call Patient Lists between 1 December to 14 December 2020 were studied retrospectively. Patients who were assessed by the on-call surgical team but not admitted were included in the audit. Patients referred to other specialties were excluded. Hospital electronic system was reviewed for electronic records frim the encounter including clinical note or discharge summary.

Results

In total, 47 patients were identified during the 2 week- period. 40/47 patients were referred from AE and 9 of these patients were discharged from AE directly. 3 of the patients had a clinical note or discharge summary completed on the hospital electronic system. Overall, 18 of the 47 (38.3%) patients had a clinical note or discharge summary on the electronic system, with 6 (12.8%) of them being recorded as discharge summaries.

Conclusions

The overall completion of discharge summaries for this group of patients was poor. Awareness of this failing and the importance of professional communication should be highlighted with the juniors during surgical meeting to improve compliance before re-audit.

1135 Improving Surgical Discharge Summaries

Introduction

Discharge summaries are a means of communication to the patient, the GP and for medical records. An initial audit showed surgical discharge summaries contained misleading information and sometimes omitted relevant information. Changes were implemented to improve the accuracy of surgical discharge summaries.

Method

The initial audit assessed the accuracy of discharge summaries over a two-week period and the re-audit was conducted after implementation of change over a similar time period. Data was extracted from electronic patient records (EPR). Change implementation included educating the surgical team on the need for accurate discharge summaries. The EPR team was notified of the intrinsic error in the PowerChart system which is widely used in various NHS Trust.

Results

Incidence of misdiagnosis or misleading diagnosis in discharge summaries reduced from 42% to zero, lack of relevant investigations decreased from 7% to 1%, No follow up status reduced from 23% to 10% (usually post appendicectomy patients which are not routinely followed up but this needs to be stated in the discharge summary for clarity), at both initial audit and re-audit all patients had relevant surgery or procedures done included in their discharge summaries while the rate at which relevant medications were not stated in the discharge summary decreased from 4% to zero.

Conclusions

Discharge summaries are vital for record keeping and are usually the only written information a patient receives regarding their hospital stay. It is important that errors in EPR systems be flagged up for review.

282 Cholecystoappendicular Fistula- 1st Ever Reported Case

A 30-year-old male presented with a history of recurrent episodes of acute cholecystitis; first acute attack associated with fever and nausea was 18 months prior to this presentation, for which he was managed conservatively for acute cholecystitis with antibiotics and analgesia following an ultrasound that showed features of acute cholecystitis with no obvious gallstones.

The patient had further episodes of acute cholecystitis with no signs of obstructive jaundice and subsequent ultrasound showed multiple small gallstones. Due to the severity of his symptoms, he was scheduled for a planned cholecystectomy.

During surgery (right subcostal incision)- findings were that of a contracted gall bladder with dense adhesions, after careful dissection a fistulous tract between the appendix and gallbladder was identified along with a cholecystoduodenal fistula.

An en-bloc cholecystectomy plus appendicectomy was performed with the duodenotomy repaired. On the first day post op there was approximately 300 ml of bilious effluent in drain, a white cell count-8.1 x 109 and hemoglobin -12.1 g/dL, Serum bilirubin-1.4mg/dL, ALP-104mg/dL. The second and third post-operative days were uneventful with minimal bile mixed serous fluid in drain respectively with no other complains, following which the drains were removed and patient discharged home.

Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is a cholecystoduodenal (70%), followed by cholecystocolic (10–20%), and the least common is the cholecystogastric fistula accounting for the remainder of cases.

No case of cholecystoappendicular fistula has been reported so far.

1222 Improving Consenting for Emergency General Surgery During The COVID-19 Pandemic

Aim

Patients undergoing surgery during the Covid pandemic are exposed to increased risks of pulmonary complications and mortality. These novel risks need to be documented on the consent form. We carried out various interventions to ensure appropriate consenting and documentation following an initial audit that revealed poor compliance with published guidelines.

Method

The initial audit reviewed consent forms of patients undergoing emergency surgery over two-weeks in May 2020 while the re-audit was over a two-week period in June 2020 following implementation of interventions. Inclusion Criteria: Age >18-years, urgent or emergency laparoscopic surgery Exclusion criteria: Age <18-years, Open surgery, ‘Covid-light’ areas, NELA.

Results

57 consent forms were assessed during the audit loop: 22 laparoscopic appendicectomies and diagnostic laparoscopies, 14 incision and drainage, 8 laparoscopic cholecystectomies, 4 hernia repairs, and 9 other procedures. Consenting for covid pneumonia increased from 70% to 89%, potential ITU admission 56% from 25% and the risk of death 63% from 21%

Conclusions

The covid pandemic changed our surgical practice. There are many unknowns regarding the risks to surgical patients, however, evidence shows increased risks of covid pneumonia, ITU admission and death in the perioperative period. Our consenting and the documentation of such conversations with patients must reflect our new reality.

719 Colovaginal Fistula from Neglected Vaginal Pessary; Fallouts from the COVID-19 Pandemic

An 86-year-old lady was admitted with a one-week history of feeling unwell, polyuria, dysuria, urinary and faecal incontinence. She had previously been treated for recurrent UTIs by her GP. On examination she had suprapubic tenderness but no peritonism. Observations revealed tachycardia of 122bpm with a temperature of 36.3*C. Inflammatory markers were raised with a white cell count of 22.0x106 /L and CRP 129 mg/L. Urine cultures grew Pseudomonas aeruginosa. She was managed for urosepsis with intravenous antibiotics.

Past medical history included vaginal pessary for uterine prolapse, congestive cardiac failure, hypertension, polymyalgia and osteoporosis She lived alone with no package of care.

On admission she improved with intravenous antibiotics however she had a perineal examination due to ongoing faecal and urinary incontinence and was noticed to be passing faeces per vaginam. A colo-vaginal fistula was suspected, and she was reviewed by the gynaecologist who noted her pessary had been in-situ for up to a year and her routine appointment to have it changed was cancelled due to the COVID-19 pandemic.

An MRI Pelvic scan confirmed a 3x2cm rectovaginal fistula.

She was reviewed by the general surgery team and the decision was made for her to be defunctioned to prevent her episodes of recurrent UTIs and improve her quality of life. She successfully had a laparoscopic end colostomy with an uneventful post-operative period.

This case highlights the harms caused from the cancellation of appointments and demonstrates a rare cause of rectovaginal fistula.

1129 UK Based Experience of The Elipsetm Intragastric Balloon; Short Term Safety and Effectiveness

Aim

Intra Gastric Balloons (IGB) have been used over the last three decades as a minimally invasive, non-surgical weight-loss option. The ElipseTM gastric balloon (EIGB) is a ‘procedure-less’ gastric balloon which can be placed in an average of 20 minutes without the need of endoscopy or sedation. The aim of our study is to investigate the first cohort of patients in uk who underwent IGB capsule and short term follow up.

Method

Single centre retrospective study of the first consecutive 202 patients that had the Eclipse IGB inserted between May 2018 and November 2020. Patients swallow the ElipseTM capsule and pre-inflation x-ray is taken to confirm correct positioning after which the gastric balloon is inflated with 550mls of sterile water and a post-inflation x-ray is taken. The balloon is designed to be in-situ for 4 months and then automatically deflates.

Results

Out of 202 patients 24 were lost to follow-up, 146 patients followed up to an average of 15 weeks, while 26 patients followed up to 4 weeks. Average weight loss at 4 weeks was 6% Total Weight Loss (%TWL) while at last follow up 9.63% TWL. Majority of patients experienced post procedural reflux, abdominal pain, bloating and vomiting. 6 patients had early removal of the balloon due to severe symptoms (4), pancreatitis (1) and hyperinflation (1). 1 had early expulsion at 2 months.

Conclusions

Eclipse IGB is safe and effective in selective patients, however long-term follow is needed to compare it with the other balloons in terms of significant and sustained weight loss.

78 A Lockdown Dilemma; Ingestion of Magnetic Beads Presenting as Right Iliac Fossa Pain and Sub-Acute Small Bowel Obstruction

A 13-year-old girl presented with a three-day history of migratory right iliac fossa pain. Observations and inflammatory markers were normal, and an ultrasound scan was inconclusive. A provisional diagnosis of non-specific abdominal pain or early appendicitis was made, and she was discharged with safety netting advice.

She represented six days later with ongoing abdominal pain now associated with multiple episodes of vomiting; hence, the decision was made to proceed to diagnostic laparoscopy rather than a magnetic resonance scan for further assessment as recommended by the radiology department.

Intra-operative findings revealed 200mls of serous fluid in the pelvis, normal-looking appendix, dilated stomach, and a tangle of small bowel loops. Blunt and careful dissection revealed fistulous tracts that magnetized the laparoscopic instruments.

A mini-laparotomy was performed with the extraction of fourteen magnetic beads and the repair of nine enterotomies.

Foreign body ingestion is a known cause of abdominal pain, which in some cases might mimic or even be the cause of acute appendicitis.

This case highlights the importance of careful history taking in children presenting with acute abdominal pain of doubtful aetiology.