Poster Group O - Patient Safety Audit- BPSC2023

INTRODUCTION

Information dissemination regarding analgesia options for labour is a vital component to ensure not only informed consent but also increase maternal safety and satisfaction [1].

Consent prior to regional anaesthesia is a legal obligation and a fundamental principal of good clinical practice. However, decision-making in labour is heavily influenced by external and emotional factors. Providing analgesia information and consent in a structured manner throughout the antenatal period improves patient satisfaction [2].

AIMS

v To evaluate satisfaction of parturients with the information received about analgesia options available during delivery.

v To identify factors which can be optimised in order to increase parturients’ satisfaction

v To improve information delivery and consent prior to regional anaesthesia

METHODOLOGY

- 100 post-partum patients included via convenience sampling were interviewed using a standardized questionnaire.

RESULTS

- 17.3% of Normal Vaginal Delivery (NVD) mothers and 15.56% of elective CaesareanSection (CS) mothers did not receive any information about analgesia options available during labour.

- 32.7% of NVD mothers and 18.2% of elective CS mothers were not satisfied with information received.

- All 15 emergency CS mothers interviewed received information and were satisfied with information received.

Process of Obtaining Informed Consent prior to Epidural

Reasons for poor maternal satisfaction with information

Lack of awareness about different analgesia options

Maternal Suggestions for Optimal Information

Dissemination

Preferred Professionals: Midwives; Anaesthetists & Obstetricians

Commonest source, medium and timing for delivery of information

Commonest source

Commonest medium

Lack of guidance to reliable sources of information

Contradictory information received about different analgesia options

• Anaesthetists among CS mothers

• Midwives amongst NVD mothers

• Face-to-face delivery of information

Commonest timing

Preferred Media : Face-to-face; leaflets and links to online websites

Preferred Timing: Third trimester

• Third trimester amongst NVD mothers

• Prior to theatre amongst CS mothers

RECOMMENDATIONS

- Incoorporation of informative programmes about perinatal analgesia in the local antenatal care pathway. Informed consent for epidural insertion can be discussed in such sessions.

ACTIONS BEING TAKEN

- Antenatal information sessions regarding epidural analgesia have started being offered by a consultant obstetric anaesthetist.

- A re-audit is planned.

DIGITAL REPLANTATION: A PATH TOWARDS STANDARDISATION OF CARE

1. Background

• BSSH Guidelines: Replantation should be done in normal working hours even if this incurs a delay of up to 24 hours to reattachment

3. Methodology

• Retrospective cohort analysis over two year period

2. Aims

• To assess the timing of replantation at Salisbury NHS Foundation Trust and compare this against the BSSH guidelines and gain an understanding of factors associated with successful replantation.

• Patients attending theatre between 5:30am and 5:30pm were considered normal working hours

• Assessed difference in outcomes for patients operated on during working hours, to operations outside of working hours.

• Factors considered were time and mechanism of injury, level of injury, time to theatre, length of operation, overall success of replantations, whether patients were returned to theatre and, intra-operative techniques.

4. Results

12 operations during working hours

57.1% compliant

5. Discussion

• Limited by the nature of record keeping

• Case number (n=21) does not allow for significant data

• Multiple factors difficult to account for

Ø Theatre availability

Ø Patient factors

• What is meant as Normal Working Hours?

• Should we standardize the care being given to patients with these presentations?

Student)

6. Conclusion

• Digital replantation during normal working hours is associated with a shorter operating time, a higher success rate, increased return to theatre and increased use of vein graft.

• A national audit of digital replantation is encouraged to understand the varying standards of replantation care and subsequent outcomes, to optimise the care being delivered to patients, thus improving resource efficiency.

Author: Malin White (Medical

Getting the most out of ReSPECT - Improving care planning conversations and documentation in one Hospital Trust

Introduction

The national DNACPR document ‘Recommended Summary Plan for Emergency Care and Treatment’ (ReSPECT) by the Resuscitation Council UK was adopted by BaNES, Swindon and Wiltshire in October 2021 to improve end of life and care planning discussions.

Its success in the Royal United Hospital, Bath (RUH) is measured on a trust wide scale through auditing of the forms against Resus Council quality standards (1). An audit in June 2022 revealed multiple domains requiring improvement.

Aims

The aim of this quality improvement project was to improve care planning discussion and documentation in the Trust by implementation of Trust wide training sessions that would increase clinicians’ knowledge of the ReSPECT process and confidence using ReSPECT plans.

Methods

Data collection: Data collection drives were completed in June 2022 and November 2022. 10 wards were identified which covered a variety of medical, surgical and acute patients. On each ward, 10 patients were identified who were at risk of deterioration. The patient notes were searched for evidence of either a TEP or ReSPECT form. Forms were then audited against the resus council quality markers for ReSPECT.

Intervention: Between June 2022 and November 2022 a series of training and Q&A sessions were given to 11 hospital departments and clinical cohorts across the Trust. Teaching was given face to face and covered all aspects of ReSPECT planning, specifically targeting areas that had been identified for requiring improvement.

November 2022

Results and Conclusions

The overall proportion of ReSPECT forms in use at RUH increased by 87% between July and November 2022. Following Trust-wide training, there was a marked improvement in several domains including form location (in the front of the patients notes) and documentation of the following: resuscitation decisions, patient wishes, patient health information, whether the patient has capacity or not and who has been involved in the ReSPECT discussion. Documentation of a reason for lack of capacity remained poor (35% of plans met this criteria both before and after training). Documentation of patient demographics decreased by 7%.

November 2022 July 2022

Limitations: Although this project compares ReSPECT plans before and after intervention with training, it is possible that improvement in the use of ReSPECT can in some part be put down to clinicians becoming more comfortable using it over time. This project only reviews the impact of training in secondary care. Clinician time was recognised as a significant barrier to primary care training.

Conclusions: Providing formal ReSPECT training sessions to clinicians in secondary care has a significant effect on the quality of ReSPECT forms completed across the hospital where quality is measured by concordance with the resus council quality markers. More research should be done to understand the impact of this from the patient perspective

Atkinson-Seed T

Figure 1. Distribution of advanced care planning documents in November 2022 compared to June 2022

Improving the Weekend Handover in a Tertiary

Oncology Hospital: A Closed -Loop Five-Cycle Audit

Sirat Lodhi, Academic Foundation Doctor The Christie NHS Foundation Trust, Manchester

Introduction

• The handover process is recognised as being a high-risk process. Poor handover practice increases the likelihood of adverse events occurring during on-call working.(1)

• This is concerning as mortality has been noted to be higher over the weekend.(2) In line with this, we have identified poor handover practice and adverse events occurring out-of-hours at the Christie hospital.

Aims

1. Assess weekly completion of the weekend medical handover proforma (July – October 2022), in line with the Royal College of Physicians (RCP) handover guidelines.(3)

2. Develop a standardised handover template, in line with the RCP handover template guidance.(3)

3. Improve completion of the handover proforma to over 80%.

Methodology

• Standard: Baseline (4-week mean) structure and completion of the electronic medical weekend handover proforma was assessed for adherence to out-of-hours RCP handover guidance (Figures 1 & 2).(3)

• Outcome measure: The percentage of proforma sections completed (3-weekly mean calculated).

• Interventions: Amendment of the handover proforma structure (Figure 2), and handover teaching delivery. Feedback used to guide audit process.

• Stakeholder support (consultants, audit & IT team): Audit importance emphasised by presenting local adverse events occurring secondary to handover errors.

• Audit cycles: Preceding 3-week proforma completion mean calculated at 3, 6, 9, and 12-weeks post-intervention (Figure 1).

Cycle 2

Cycle 4

Results

• Mean proforma completion increased from 58% at baseline (weeks 1 to 4), to 83% by weeks 10 to 12 post-intervention (Figure 3).

• Proforma amendment to include missing sections (e.g. date of birth), and email reminders for proforma completion resulted in improved completion (72% weeks 5 to 7 mean). Newly-added sections were deleted by doctors by week 7 (Figure 4).

• Teaching was delivered, and the proforma settings were amended to create a fixed template structure, to prevent section deletion. This was based on feedback:

“Completing three patient identifiers is time consuming, thus, doctors have resorted to deleting sections. The importance of identifiers should be highlighted” – proforma user feedback

Patient identifier section completion over time

Cycle 3

Cycle 5

Discussion & Conclusion

• We have demonstrated that teaching, proforma improvement, and creating a fixed-format electronic proforma can improve proforma completion.

• Future work focuses on using auto-fill function to reduce the number of sections requiring manual completion. Proforma completion longevity is yet to be assessed.

• Limitations: Proforma completion is not yet at 100%. Doctors require education regarding treatment aims/escalation status decisions to support with completion.

• Electronic software can be used to improve patient safety. Interventions must be designed in line with feedback as this could improve proforma completion.

Figure 1. Audit cycles completed

Figure 2. Handover proforma items for completion

Figure 3. Completion of proforma sections over time (mean completion displayed)

Figure 4. Completion of patient identifier sections over time

#76 Re-audit of guideline on the investigation and management of patients with gallstones

D Limnatitou1, O Brewster2, M Quinn3, P Ireland2, J Thornton1, A Osborne1

1. North Bristol NHS Trust

2. Gloucester Royal Hospitals NHS Foundation Trust

3. Musgrove Park Hospital

Introduction & Background

The management of patients with gallstone disease and low risk of common bile duct (CBD) stones has been a subject of ongoing research

Following questions in the management of a clinical case, that led to an investigation conducted by Parliamentary and Health Service Ombudsman, the Upper Gastrointestinal Surgery Department at North Bristol NHS Trust (NBT) had devised a local guideline to address the matter1 A table summarising the guideline is seen below:

1 Risk of Common Bile Duct (CBD) stone documentation

2 Sunflower Study2 enrolment

3 Biliary imaging for patients with low/moderate risk of CBD stones

4 Biliary imaging for patients with high risk of CBD stones

Patient categorized into low/moderate or high risk for presence of CBD stones according to the Sunflower Study criteria2

All eligible patients to be offered to enroll in the Sunflower Study2

Patients who did not meet the Sunflower Study2 criteria or refused to participate in the study may require biliary imaging (preoperative Magnetic Resonance Cholangiopancreatography (MRCP) or endoscopic ultrasound or intraoperative cholangiogram)

All high CBD stone risk patients will require biliary imaging (preoperative Magnetic Resonance Cholangiopancreatography (MRCP) or endoscopic ultrasound or intraoperative cholangiogram)

Table 1 Summary of ‘Guideline on the Investigation and Management of Patients with Gallstones.’1

As part of the action plan that was developed in response to the PHSO investigation, the guideline above was first audited in May 2021 As a result, following the outcomes of the first cycle, interventions were introduced to improve adherence These included the addition of two mandatory questions to the laparoscopic cholecystectomy booking card on the electronic system used by the trust The first question was for documenting the risk of CBD stones and the other for determining whether the patient was recruited to the Sunflower Study2 Hence, those questions were answered for every patient that had an outpatient laparoscopic cholecystectomy requested

Aim

The main aim of this project was to re-audit our adherence to the local guidelines following the implementation of the interventions from first cycle More specifically, to evaluate our adherence against the audit criteria and determine whether improvement was achieved, as well as identify any areas of improvement and generate recommendations and interventions to further improve our practice

Methods

Data was collected retrospectively from the electronic system used by the trust for laparoscopic cholecystectomy requests Any discrepancies were investigated through a combination of reviewing results on the electronic system and the documentation in clinic letters As the inclusion criteria were any patients who had a laparoscopic cholecystectomy requested for gallstone disease in September 2022 at NBT, all laparoscopic cholecystectomy requests made on the electronic system used by the trust, between the 1st of September and the 30th of September 2022, were eligible and included in the study It is noted that this process was different from the first cycle in May 2021, where patients were identified from clinic letters, and hence, any requests made outside of an outpatient clinic setting, for example during the surgical take, were not included The collected data was anonymized to maintain confidentiality and was analysed using simple percentages This project had received approval and was assigned an audit identification (ID) number from the local audit department at NBT

Results

A total of thirty laparoscopic cholecystectomy requests were made on the electronic system at NBT in September 2022 This was similar to the number from the first cycle in May 2021, which was twenty-eight The results on compliance are summarized in the table below:

27%

close to 100% overall as intraoperative laparoscopic ultrasound standard practice at NBT)

Table 2 Summary of results

Adherence against criteria and comparison between May 2021 and September 2022

During the results analysis, it was noted that although four patients were recorded as high risk for CBD stones, only three were categorized as ineligible for the Sunflower Study2 This discrepancy was further investigated and based on the blood results and radiological findings, it was concluded that one patient was recorded as high-risk by error This correction is reflected on the results above Additionally, it was noted that during the data collection of the first audit cycle in May 2021, recruitment to Sunflower Study had paused due to the COVID pandemic, and therefore Criterion 2 was non-applicable

Conclusions

Significant improvements in adherence were noted following the implementation of the interventions from the first audit cycle However, recruitment to Sunflower Study2 was identified as the area of improvement Recommendations included raising awareness locally and encouraging individuals to get involved in the study In addition, clinicians creating the laparoscopic cholecystectomy requests on the electronic system could inform the local Sunflower Study2 team of any eligible participants

References

1. Hewes J. Guideline on the Investigation and Management of Patients with Gallstones. North Bristol NHS Trust. 2021; [Available on North Bristol Trust Intranet]

2. Clout M, Blazeby J, Rogers C, Reeves B, Lazaroo M, Avery K, et al. Randomised controlled trial to establish the clinical and cost-effectiveness of expectant management versus preoperative imaging with magnetic resonance cholangiopancreatography in patients with symptomatic gallbladder disease undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones (the Sunflower Study): A study protocol. BMJ Open. 2021;11(6).

Impact of Covid-19 pandemic on adherence to immunisation guidelines in patients undergoing splenectomy in a UK teaching hospital

Authors: Florentina Penciu Vaccine Research Fellow, Rajeka Lazarus Consultant Microbiology and Infectious Diseases, Alexander Middleditch Consultant Anaesthetist UHBW, Bristol

Background

Post-splenectomy patients are at higher risk (10 to 50 fold) than the general population of developing an overwhelming post-splenectomy infection (OPSI), especially with encapsulated bacteria like Streptococcus pneumonia, Haemophilus influenza B and Neisseria meningitides.

To prevent this, national guidelines Green Book (Chapter 7) and the British Committee for Standards in Haematology (BCSH 2011) advise these patients should receive a dose of pneumococcal polysaccharide vaccine (PPV23), meningococcal B (MenB), meningococcal ACWY conjugate vaccine (MenACWY) prior to surgery or after surgery. Also, a Men B booster dose 4 weeks after the first dose, an annual flu vaccine and a PPV23 booster every 5 years. National Guidelines recommend also antibiotic prophylaxis after surgery for this group.(1)

A systemic review and meta-analysis showed PPV23 vaccine coverage (VC) 55.1%, anti-meningococcal B 13.3%, anti-meningococcal ACWY 33.7%, for MenC/Hib 48.3% and antiinfluenza 53.2% in patients undergoing splenectomy(3). There is limited data from the UK therefore we undertook an audit of practice in a teaching hospital. The aim of this audit was to establish adherence to vaccination and antibiotic prophylaxis according to national and local guidelines during the first two years of the pandemic.

Method

A retrospective audit of 35 patients who underwent splenectomy in one teaching hospital was undertaken between 1st January 2020 and 30th of December 2021. Demographic data, clinical details and immunisation history were obtained from Surgical, Pre-Op Clinic( via Evolve) and GP (Connecting Care Flow) records. Using the Excel spreadsheet, the analysis was performed on objective measurements. The local Trust has a standardised letter to GP’s with specific details for vaccination and antibiotic prescriptions.

Standards

100 % of patients with elective or emergency operations should receive the PPV23, Men B and Men ACWY conjugate vaccine prior or after surgery.

100 % of the patients should receive the MenC/Hib vaccine per Trust guidelines advice.

100 % of the patients should receive a Men B booster dose 4 weeks after the first dose, a PPV23 booster at 5 years and an annual flu vaccine.

100 % of the patient should receive prophylactic antibiotic post surgery

This audit looked at operations done during the pandemic period and there have been multiple cancellations which explained the long time interval pre or post-operation when vaccines were given.

Documentation of vaccine records was poor therefore making it difficult for a provider to confirm vaccine records

There were no educational materials for asplenic patients in the Pre-Op Clinic or other evidence that these patients were informed about the increased risk of developing severe sepsis post-splenectomy.

These results demonstrate suboptimal uptake for all vaccines.

However, uptake of PPV23, anti-meningococcal B and C/Hib was higher than recently reported results in the 2020 systemic review.

It is not clear why there is variation between vaccine uptake and types

The audit revealed that ways to improve the system are needed.

Among its findings was that the hospital is the most important setting for vaccine administration, especially because the patients undergoing elective surgery and patients in the immediate pre and post-operative period can be readily targeted.

Results

35 patients had splenectomy operations between January 2020 and 30th December 2021.

8 out of 35 (22.8 %) patients have had emergency operations and the rest of the 27 had elective operations.

Ten out of 35 (28.5 %) had incomplete or inadequate records of their immunization status and they were removed from the final analyses.

Pneumococcal vaccine intake was 64 % which is slightly better compared with other NHS trusts and definitely higher compared with international uptakes (2).

There was a good uptake of MenC/Hib and the first dose of MenB up to 84 %.

There was a fall in vaccination of these patients with Men ACYW to 40 % and Men B booster to 48 %.

24 out of 25 (96 %) patients with immunisation records had Influenza vaccine.

All 35 (100 %) of patients who have had surgical interventions (including the one lacking immunization records) were administered prophylactic antibiotic.

Recommendations:

- To update the trust guidelines according to National Guidelines, especially that, UK Health Security Agency plans to withdraw the Hib/MenC vaccine from the market in 2025.

- To increase healthcare workers’ awareness to be fully informed regarding the risk posed by infection in asplenic individuals, vaccines type and administration.

- To create a second care specific pathway for splenectomised patients or splenectomy candidates in which vaccination will be actively offered and administered in the hospital settings

An evaluation of plastic surgery operation note documentation in line with RCS standards

Dr B Carhart (presenting), Dr R Khanna, Dr W Mwaura

Introduction

Operation notes represent an essential piece of documentation. They form the point of reference for the healthcare team caring for each patient in the post-operative period in areas such as after care, follow up planning and much more. Therefore, it is important that operation notes follow a standardized format ensuring that key relevant information is included in each operation note. The key information recommended by the Royal college of surgeons (RCS) is outlined to the right.

Aims

This audit aimed to evaluate the adherence of operation notes at Bradford Royal infirmary’s plastic surgery department to the RCS guideline for operation notes with the objective of determining which areas of the guideline were met well and which areas were neglected, with the ambition of improving the compliance with the guideline, therefore enhancing and developing the surgical service provided.

Methods

Using an RCS good surgical practice guideline, operation notes from cases in January 2021 were reviewed.

A total of 112 procedures that were undertaken in both theatres and plastics dressing clinic were audited.

The results were collated and analysed using Microsoft Excel. As a result of data analysis, interventions were created whereby results were presented at a local meeting, posters displaying the RCS guideline were distributed throughout the department and the guideline was disseminated via WhatsApp to members of the surgical team.

A re-audit then occurred using all plastic surgery procedures in May 2021, totaling 112 patients again.

Conclusions

Initially, the guideline was met to a reasonable standard, however, improvements were made following the intervention. This led to an improvement in the documentation of nine subsections of this guideline. There remains, however, room for further improvement as explained in the results section. This audit has demonstrated a positive impact by improving the standard of operation note documentation and developi ng the surgical service as was aimed. Moving forward it would be beneficial to perform further cycles of this audit in order to ensure the standards of documentation continue to improve, and to consider alternative interventions which could further add to the changes invoked by this audit.

Audit of acute scrotal pain and scrotal exploration for suspected testicular torsion in the paediatric population at a District General Hospital.

S.

INTRODUCTION:

Testicular torsion (TT) is a surgical emergency and requires prompt surgical exploration and management. Scrotal exploration within six hours of symptom onset has been shown to result in the highest salvage rates, due to the ischaemic damage that occurs during TT. The recent Getting It Right First Time (GIRFT) review into Paediatric Surgery and Urology highlighted the challenges of managing scrotal pain in the paediatric population and the issues with delayed or missed diagnosis of TT.

AIM:

The clinical audit was designed to measure the current practice within Royal Berkshire Hospital NHS Trust with regards to the management of children with acute scrotal pain.

STANDARDS:

In 2015 the East Midlands Clinical Network commissioned and facilitated a national guideline for the management of paediatric torsion. The national guideline recommend two main criteria:

• 100% of scrotal explorations should occur within 3 hours of the decision to operate.

• Provision of surgery locally where possible

METHODOLOGY:

Data of all emergency paediatric scrotal exploration was collected prospectively over a 15-month period from April 2018- July 2019 for the first cycle.

• Inclusion criteria: 0-16 years of age male patients

A subsequent second cycle was performed, and data was collected retrospectively over a 12-month period from September 2021. We collected data on demographics, date and time of presentation, onset of acute scrotal pain, intraoperative findings and outcomes and time from decision to operate to arrival in theatres. We further analysed the positive scrotal exploration rate and data on the negative scrotal explorations.

RESULTS:

44 Patients were identified during the first cycle.

• Median age: 13 yrs (range 7-16)

• Positive exploration 34% (n=15)

• 95% (n=42) fulfilled the 3-hour target

• Median time from decision to operate to theatres: 76 min

47 patient were identified during the second cycle .

• Median age: 12 yrs (range 4-16)

• Positive exploration 32% (n=15)

• 96% (n=45) fulfilled the 3 hour-target

• Median time from decision to operate to theatres: 80 min

CONCLUSION:

Table 1. Negative exploration

DISCUSSION:

• The positive exploration rate was 34% and 32% in the first and second cycle, respectively.

• 3-hour target met 95% and 96% of cases. Altogether 4 cases did not meet that target across both cycles.

• In cycle 1 – Salvageable vs Unsalvageable 325 min vs 1507 min (25hrs)

• In cycle 2 - 87% (n=13) of these were salvageable and were treated with bilateral orchidopexy. Salvageable vs Unsalvageable 372 min vs 3766 min (62 hrs)

The audit has highlighted the importance of promptness to take patients to theatres for scrotal exploration when TT is clinically suspected.

• Literature review – positive scrotal exploration range 13%51%

• Compliance of 3-hour target around 80%

Overall, our compliance against national guidelines remained consistently high. This is largely due to the paediatric service cover and it appears the Covid pandemic has not impacted the ability to manage these patients promptly. Timely referral of such cases from partner departments such as ED and the out of hours service is important. Results were relayed to the Emergency Department and presented at the Local Urology Clinical Governance meeting.

Theivendrampillai, T. Theivendrampillai, J. Thomas Royal Berkshire NHS Foundation Trust

Table 2. Outcomes of testicular torsions

MANAGEMENT OF DELIBERATE FOREIGN BODY INGESTION REQUIRING ENDOSCOPIC RETRIEVAL

Dr B Jones, Universities Hospitals Sussex

• Deliberate foreign body ingestion (DFBI) can be seen amongst patients with psychiatric disorders; it is often recurrent and requires frequent medical attention.

• During the Coronavirus (COVID -19) pandemic, increased incidences of DFBI were noted across our acute hospital site.

• Ingestion of dangerous objects required retrieval via endoscopy under general anesthetic (GA).

• Guidance regarding appropriate timeframes for endoscopic intervention are set out by the European Society of Gastrointestinal Endoscopy (ESGE), despite this it was felt that cases were delayed in their referral to gastroenterology and there was no clear internal protocol for the management of such patients that aligned with published guidelines.

• Identify patient’s presenting with FBI requiring endoscopic intervention over a 4-month time period.

• Review the type of FBI and subsequent timing of endoscopy against ESGE guidance.

• Review timing of gastroenterology referral and outcomes of patients.

1 - Presentations of DFBI incidence are increasing and and are not being managed in line with ESGE guidance. Concerns were raised around timely escalation and referral to gastroenterology.

4 - Propose use of a standardised proforma (below) to ED, acute medicine and gastroenterology colleagues with a view to enhance patient care, effective handover and reduce admission length.

2 - Patients with DFBI should have FB removed via endoscopy within a set time as defined by ESGE guidelines. The table

above shows ESGE recommendations for if an object type is emergent (removal within 26hrs), urgent (within 24hrs) or non-urgent (within 72hrs ).

3 - Performance was measured against ESGE’s guidelines to assess if endoscopic intervention occurred within the appropriate timeframe from presentation.

Data collected over a 4 -month period between November 2021 and February 2022 identified 11 cases of FBI requiring endoscopy under GA.

Object(s) swallowed, and timing of initial imaging, gastroenterology referral, and endoscopy were reviewed.

o 10 of 11 were DFBI and comprised of 4 individual patients with MH diagnosis.

• Gastroenterology referral was frequently delayed or not documented.

• No recognised pathway existed for emergency staff to follow for DFBI presentations.

• ESGE guidelines were not readily adhered to, and time targets were frequently missed.

• More work needs to be done to better support care for these high-risk patients.

Repeat the cycle:

• Has the implemented proforma reduced time to gastroenterology referral and therapeutic endoscopy?

• Signpost colleagues to ESGE guidelines.

• Education to MH hospitals.

RESULTS

o 82% of presentations had initial imaging within 1-hour.

o 18% of presentations were not referred to gastroenterology within 12-hours from presentation and referral was undocumented in a further 37% .

o Mean time to endoscopy was 20-hours [4-hrs – 38.5-hrs] after initial presentation, 27% of cases falling outside the endoscopy recommendation as per ESGE guidelines.

o FB was post-pyloric at endoscopy in 27% of episode –patients were subsequently converted to surgical-led care, requiring serial AXRs with prolonged stays and concurrent escalation in challenging mental health behaviors.