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Supplemental material, sj-pdf-1-cpj-10.1177_00099228221149279 for Provider Perspectives of Transitions of Care at a Tertiary Care Children’s Hospital With a Hospitalist-Run Discharge Clinic by Abigail Nelson, Heather Stuckey, Bethany Snyder, Lauren J Van Scoy, Carrie Daymont, Christine Irvin, Emily Wasserman and Michael Beck in Clinical Pediatrics

Aim: Gore-Tex® is a widely used durable patch for repair of congenital diaphragmatic defects yet results in complications. Early reherniation has been reported in alternative xenografts such as Surgisis®. We wondered whether the matrix or decellularization (decel) process led to failure. We compared diaphragmatic reconstructions using SIS and decel porcine diaphragm (DPD), processed with a comparable decel protocol, to Gore-Tex in a fast-growing rabbit model. Methods: Twenty-three 6-weeks-old rabbits underwent intubation, left subcostal laparotomy and 3*3cm hemi- diaphragmatic excision. Defect closure was with a 3,5*3,5cm patch of (a) Gore-Tex® (n=10), (b) Surgisis® (n=6) or (c) DPD (n=7). Rates of herniation or eventration, uniaxial biomechanical testing, and histology were studied at 90days. Results: Eighteen (78%) rabbits survived to 90days. There was mesh failure in all decellularised matrices (p, Introduction: Children commonly present to Emergency Departments (ED) with a non-blanching rash (NBR) in the context of a feverish illness. The approach to assessment of these children is controversial. Aims: Validate clinical practices guidelines (CPGs) for the management of fever and NBR Methods: Prospective multicentre validation study evaluating the performance of available CPGs for feverish children with NBR. The full protocol has been published and is available at https://rdcu.be/bFEtb. Results: 1423 children were recruited from 37 UK sites between the 11th November 2017 to 30th June 2019. This included 77 children with serious bacterial infections (5.4%) and 17 children (1.2%) with confirmed invasive meningococcal disease (MD). Four CPGs (NICE, NBL, London & Nottingham) were prospectively validated. All four demonstrated 100% Sensitivity for identifying children with MD. NICE guidance demonstrated the lowest specificity 10% recommending that 75.3% of children receive parenteral antibiotics and admission to hospital. The NBL, London and Nottingham CPGs all demonstrated a greater specificity ranging from 28% to 41%. Discussion: NICE guidance for the management of NBR performed poorly in this national validation exercise. The alternative CPGs were 100% sensitive and offered greater specificity. Adopting an alternate CPG would reduce painful interventions, parenteral antibiotic use and hospital admissions. Trial registration - NCT03378258. Retrospectively registered on December 19, 2017.., Introduction: Vascular Ehler-Danlos (vEDS or type IV EDS) is the most dangerous subtype of Ehler-Danlos and is rarer than most EDS subtypes, thought to affect 1-200,000. It is autosomal dominant affecting COL3A1 or COL1A1 genes. Symptoms include those of EDS alongside being easily bruised, visible blood vessels on chest, late miscarriage, unusual facial features and aneurysms/dissections, bowel perforation and uterine perforation. Case: A woman presented with acute onset back pain radiating down her right leg after bending over to pick up a heavy object. History and findings were in keeping with sciatica, she was prescribed analgesia. Discharge was delayed due to a trauma call. On reassessment the patient had deteriorated and was noted to be hypotensive and tachycardia and subsequently transferred to resus. She underwent a CT angiogram revealing a ruptured external-iliac artery. She underwent emergency repair. Discussion: The patient has made a full recovery but had she not remained in the department during the trauma call she may have been sent home. This case serves to highlight the dangers of Ehlers-Danlos syndrome and remind clinicians to be aware of such patients and treat them with caution. This is an example of how younger patients compensate physiologically before acutely deteriorating, Problem: The Renal Association guidelines for management of kidney transplant patients (KTP) recommend yearly review of immunosuppression (IS). Patient survival improves by addressing IS related mortality risk factors (MRF) and carefully reducing IS. In our unit, baseline data showed IS reviews were carried out every 32 months. Strategy for change: With multidisciplinary team (MDT) input driver diagrams were generated to set out aims and objectives. Plan-Do-Study-Act cycles facilitated change which was analysed continuously using statistical process charts. A transplant clinic template letter and MDT review assessments were created which were refined through subsequent cycles. Measurement of Improvement: Percentage KTP with documented IS plan and modification of MRF at each clinicFollowing adoption-adherence to template Effects of change: Over 3 month period percentage KTP with IS review rose from 9% to 85% enacting 29% more changes to IS compared to pre-intervention weekly. Modifiable risk factors addressed rose from 8% to 56%. Adherence once template adopted reached 93%. Project generated other change ideas e.g. information & dermatology leaflets. Discussion: This project demonstrates that by utilising the MDT and introducing a standardised approach increased frequency of IS review, adaptions to IS and addressing MRF. This could potentially be replicated by other transplant teams., Background: The traditional method for arthroscopic training relies on appropriate clinical cases, costs particularly with operative time and has implications for patient safety. The Virtamed ArthroS was released in December 2017 and is the world’s first high-fidelity simulator for ankle arthroscopy. The primary aim of this study was to determine the utility of this arthroscopic simulator for training. Methods: Volunteers were recruited from medical students through to consultants. They performed five arthroscopic procedures under control conditions. A 10-minute demonstration on the setup and operation of the simulator was given prior to testing. Performance was evaluated by obtaining predefined metrics for each procedure within the simulator with photo and video acquisition. A questionnaire was administered to evaluate previous arthroscopic and video gaming experience, levels of stress, usefulness and authenticity. Results: Each arm consisted of a minimum of 5 participants from medical students, foundation level, core trainees, orthopaedic registrars and consultants. All groups demonstrated an improvement in time, economy and safety with 20 minutes exposure, reporting high levels of satisfaction and usefulness. Conclusion(s): The Virtamed ArthroS ankle module provides an authentic simulated experience for all levels of training with demonstrable improvements in performance, anatomy knowledge and reductions in adverse events. In the current climate of reduced working times and increased indicative arthroscopy numbers for completion of training the real-world benefits for orthopaedic trainees is promising., Introduction: Colorectal cancer (CRC) is the 4th most common cancer in the UK and approximately 50% of colorectal cancers demonstrate mutations in TP53. Cdc7 kinase is a protein with essential functions in DNA replication initiation and cell-cycle checkpoint responses. It is up- regulated in malignant cells, especially in the presence of a functional TP53 mutation. Aims: To utilise cdc7i to exploit TP53 mutation in CRC, either alone or in combination with current standard of care (SoC) therapies. Methods and Results: Using in-vitro analyses of a novel cdc7i (LY3177833), CRC cell lines with functional mutations in TP53 have an increased sensitivity to cdc7i. Additionally these cells arrest within S and G2/M phases of the cell cycle. SoC chemotherapy in CRC elicits an S- and G2/M- phase accumulation in cells which lack functional p53, with an increased dependency on DNA replication checkpoints, in which cdc7 is involved. Combinations of LY3177833 and SoC chemotherapy significantly reduced long-term survival in cells lacking functional p53. Discussion: Cdc7i either alone or in combination with SoC in CRC, may represent a potential future treatment option, particularly in TP53 mutant CRC. A phase 1 clinical trial of a novel cdc7i as monotherapy is ongoing., Introduction: INR is one of the most common laboratory tests among hospital inpatients. Coaguchek point of care (POC) system has been introduced as a fast and minimally invasive alternative to standard laboratory INR testing in some hospitals. Aims: To assess the correlation between Coaguchek POC and STAGO lab INR readings. Methods: Prospective study involving all patients on warfarin on a single ward. POC and lab readings were taken at the same time and compared. The product-moment correlation coefficients (PMCC) were calculated for various INR ranges. Results: 73 paired samples were received. 62(86%) POC INR readings were higher than lab readings. When lab INR> 2.0, 17 of 35 (49%) POC INR were higher by more than 1.0. Linear correlation between POC and lab INR was strongest between lab INR 1.0-2.0 (PMCC 0.94) but weakens at higher values. When POC INR is between 2.0-3.0, 13 of 24 (54%) lab INR were also between 2.0-3.0. Discussion: Coaguchek system has been recommended by NICE for outpatient self-monitoring. Our data cast significant doubt in its use in hospital inpatients as lab substitute. Inpatient procedures or medications such as enoxaparin may account for the significant difference., Introduction: Submucous clefts are a variant of cleft palate, usually signified by the presence of a bifid uvula. Patients with a submucous cleft tend to present later than patients with complete cleft defects resulting in late primary repair and potentially irreversible speech and language problems. Aim: To review submucous cleft repairs as the rates were increasing in our unit. Methods: The Northern Ireland cleft lip and palate database was used to identify patients born with a submucous cleft over a 7 year period, 1988-1995, and a further 7 year period 15 years later, 2003-2010, for comparison. The Electronic medical records system and the joint cleft palate clinic database were used to collect the data required. Results: A significant rise in submucous cleft numbers over a 15 year period, from 6 to 25 cases. Average age at primary repair reduced from 6 to 5.2years. The unrepaired rate increased from 17->24%. Significant reduction noted in: total length of hospital inpatient stay from 6.3 to 2.7days and total outpatient appointments from 11.7 to 5.3. Conclusions: This review highlights significant changes in the detection and management of patients with a submucous cleft over a 15 year period. Adequate provision must be made to resource the rising demands of cleft surgery., Introduction: The Cleft Nurse Specialist (CNS) plays a key role in counselling and supporting parents from the diagnosis onwards. Aim: The CNS started in 2012 and we aimed to perform a qualitative study to determine the benefits this brought to the cleft community from the parents’ perspective. Methods: The cleft database was used to locate babies born in 2010/2011 and 2013/2014. Parents were contacted by phone and completed a questionnaire on the care and support they received following the diagnosis. Results: Parents of 38 babies completed the survey. In 2010/2011 only 21% had an antenatal diagnosis compared to 47% in 2013/2014. In 2010/2011 68% were counselled by a surgeon, 42% were seen >1week after birth, with some over a month. In 2013/2014 84% were counselled by the CNS, 53% were seen within 48 hours and 100% within 7 days. Parents in 2013/2014 felt more supported by the cleft team throughout pregnancy and the early days, with home visits being particularly advantageous. Conclusion: The introduction of the CNS to the cleft multidisciplinary team has significantly improved the pathway for parents and is a key link with the wider cleft team., Introduction: The diagnosis of cleft lip and/or palate (CLP) can be a difficult time for expectant parents. Antenatal diagnosis ensures the cleft team can spend time with the parents counselling them regarding potential difficulties their baby may have in the early weeks of life as well as providing a support network. Aim: NHS guidelines target: 75% of babies born with a cleft lip should be diagnosed on antenatal ultrasound. Methods: The regional cleft lip and palate database was reviewed over a 5 year period (2014-2018). Numbers of babies born with CLP and rates of antenatal ultrasound diagnosis were reviewed. Results: Over the 5 year period 168 babies were born in the regional unit with CLP. Those with involvement of the lip (cleft lip only or cleft lip and palate) made up 55% of the cohort (92/168). Overall the rate of antenatal detection over the 5 years was 79% (73/92). The annual rates were; 2014: 75%, 2015: 74%, 2016: 89%, 2017: 77%, 2018: 86% Discussion: Over the past 5 years the antenatal diagnosis rate has remained above the NHS guideline target. We are striving towards 100% in the future to ensure parents are counselled antenatally and have time to adjust to the diagnosis before birth., Introduction: Overactive bladder (OAB) is a prevalent, distressing condition. Approximately 40% women will not respond to routinely offered non-invasive interventions (1). Evidence is accruing for the effectiveness of Transcutaneous- Posterior-Tibial-Nerve-Stimulation (TPTNS) (2). This qualitative study is part of a mixed-methods, randomised, feasibility trial of TPTNS in the home versus hospital setting. Quantitative results will be reported separately (NCT03727711). Aims: To explore experiences of women having TPTNS in home and hospital and discover perceived barriers/ facilitators to self-management. Methods: Identification of a subgroup from the larger trial, with a purposive sample of 8 women from each group. Thematic analysis using the method proposed by Braun and Clarke (Nvivo 12 software used) (3). Results: A total of 16 women were interviewed (8 home, 8 hospital). Mean age: 60 years (range 42-78 years). Data saturation was achieved. TPTNS was described as providing ‘confidence’ in addition to physical benefits. Home treatment was viewed favourably as ‘convenient’, especially if the participant was bound by work commitments. Cost of purchasing the machine was seen as a barrier to future use. Discussion: This analysis highlights the willingness of women to use TPTNS as part of a self-management strategy; treatment at home was favoured among those who were working., Introduction: OASIS is a relatively common complication following childbirth with an increasing overall rate which is possibly due to improved reporting and better recognition. Aims: To determine the risk factors for obstetric anal sphincter injuries (OASIS) and to investigate the mode of delivery and recurrence rate in future pregnancies. Methods: A retrospective cohort study of singleton deliveries in the South Eastern trust between April 2012 and March 2017 (n=59236) Results: The overall OASIS rate was 3.7% (593/59236). There was a significantly increased risk of OASIS with an instrumental delivery (p4kg (p25 (p, Introduction: The risk of vertebral artery injury (VAI) secondary to cervical spine fracture is well recognised. Although typically asymptomatic at presentation, VAI can result in neurological deficit, stroke and death. Depending on injury grade and site, management can range from observation, to medical, endovascular and surgical intervention. Aims: To determine the incidence and clinical features of VAI amongst patients found to have cervical spine fractures presenting to the Royal Victoria Hospital, and to establish current practice regarding VAI management. Methods: A retrospective review of 1,894 computed tomography (CT) reports of patients who underwent imaging of their cervical spine and/or vertebral arteries over a 12-month period was conducted. Results: Sixty-eight patients were found to have acute cervical spine fracture. Of these, five (7.4%) were diagnosed with VAI, all of which resulted from fractures of the upper cervical vertebrae following high-energy trauma. One patient sustained an incomplete spinal cord injury. All five patients underwent repeat CT-angiography, none of which demonstrated injury progression. Three patients were commenced on aspirin therapy, one of whom also underwent posterior cervical stabilisation. Discussion: CT-angiography is recommended following identification of fractures involving the foramen transversarium or Type C/ subluxation-type injuries and should also be considered amongst those sustaining upper cervical fractures., Introduction: Management of Dysplastic naevi (DN) is controversial with opinion divided regarding their significance. A recent systematic review and US multi-centre study evaluated subsequent cutaneous melanoma (CM) risk in patients with DN but a paucity of outcome data remains amongst UK and Irish patients. Aims: To evaluate long-term outcomes of histologically confirmed DN in a Northern Ireland Healthcare Trust and incidence of subsequent CM. Methods: Retrospective study of histologically confirmed DN recorded in Trust Pathology Database between 01.01.2008 - 31.12.2013. Cases analysed for demographics, referral source, site, procedure, margins, severity and development of CM. Results: 248 reports were evaluated in 237 patients (104 male, 133 female). Median (range) age 44 (16,82) and mean follow-up period 7.5 years. 93% of DN were removed by excisional biopsy (93%). The back was commonest anatomical site (39%). The majority of cases had clear histological margins (93%). No patients developed CM at the site of a previously excised DN. 2.53% (6/237) patients developed subsequent CM at separate site. Discussion: This is the first long-term study of outcomes for patients with DN in Northern Ireland. Findings support previous studies suggesting subsequent CM risk is low in patients with histologically confirmed DN without prior history of CM., Introduction: Risk-prediction scoring systems are widely used by surgeons to calculate operative morbidity and mortality. They help to stratify level of post-operative care, enable patients to make a fully informed consent and facilitate surgical audit and comparison of units’ performance. Multiple systems have been used for prediction of patient outcome following abdominal aortic aneurysm repair; not much has been done in patients undergoing MLLA. Aim: Our aim was to evaluate VPOSSUM for accuracy of prediction of early mortality and morbidity following MLLA. Methods: Retrospective case review of MLLA carried out in a regional vascular service between Jan-2014 and Jul-2017. Demographic, pre-operative, operative and post-operative data were collected from patient notes and hospital database. VPOSSUM scores were calculated for every procedure and compared with observed morbidity and mortality using SPSS. Results: 181 patients (male=133, female=48, average age 67.6y) underwent MLLA during this study period. Of these, 20 had re-interventions. Revision to a higher level was required in 7 patients on ipsilateral limb within a mean 14.3 days (range=5-33). 13 patients required MLLA on contralateral limb within a mean 216 days (range=5-648). 7 patients had bilateral MLLA at the same session; these procedures were recorded as a single event. Therefore, total number of events was 201. Receiver-Operator Curve (ROC) showed an area-under-curve (AUC) of 0.833 (95% CI 0.740-0.926) for 30-day mortality, suggesting that VPOSSUM was a good score for predicting patient outcome; but was poor for predicting post-operative morbidity (AUC 0.640 (95% CI 0.556-0.724)). Discussion: VPOSSUM performed well with respect to predicting 30-day mortality in patients following MLLA and could be used to stratify patients’ risk from surgery, thus helping us plan level of post-operative care for this group of patients., Introduction/Aim: Oesophagectomy is a complex procedure and associated with high morbidity and mortality. In an effort to reduce the postoperative morbidity associated with open esophagectomy, laparoscopic-assisted oesophagectomy (LAO) has been introduced and developed in recent years. The aim of this study was to present our experience with LAO and assess surgical and oncological outcome and survival. Methods: 100 patients were identified from a prospectively- filled database from July 2010-2017 at a tertiary referral centre. All underwent MIO performed by a single consultant surgeon. Laparoscopic abdominal and trans-hiatal phase plus mini-thoracotomy was performed. Outcome data was retrieved from hospital, laboratory, GP, NHS Spine and coroner’s records. National average (NA) statistics were obtained from National Oesophago-gastrectomy Cancer Audit (NOGCA) 2016 and 2018. Results: Median age of patients 68y (range=41-80). 85% male, 15% female. Pulmonary complications were most common (pneumonia 34%, pleural effusion 19% and pneumothorax 8%). 5% patients had an anastomotic leak. 30- and 90-day mortality was 1 and 2% respectively, compared to NA of 2.4 and 3.9%. Median length of stay 11.5d compared to NA of 9d. Median number of lymph nodes excised was 17 (range=3-32); 58% patients had adequate number of lymph nodes examined (>15). 3-year survival for Stages 1, 2 and 3 was 86.1, 85.7 and 35.3% respectively, compared with NA of 84, 71, and 34%. Discussion: LAO appears to offer marginal benefit to open surgery and is not inferior in the outcomes measured here. This is consistent with current RCTs and adds to the growing body of evidence supporting minimally-invasive surgery., Introduction: Severe fingernail glue burns arising from the exothermic polymerization reaction of cyanoacrylate with the cellulose in cotton fibres have been documented. However, warnings on nail glue bottles, packaging and websites remain poor. We also consider what the optimal first aid should be for such an injury and suggest the publication of this for nail glue consumers, practitioners and pharmacists. Description of Case: A healthy 18-year-old female spilled nail glue whilst applying her acrylic nail tips. The glue eroded through her jeans to leave a substantial deep partial thickness burn on her left medial thigh. No first aid was given. The burn was managed conservatively with silver-impregnated dressings and regular follow-up. Discussion: Review of literature highlighted that pre-teen and teenage girls are most at risk with the majority of incidents occurring in this age group. They are also at high risk of surgical intervention with 80% requiring excision and splitthickness skin grafting compared to 0% of the young children described. The authors recommend publication of first aid advice including: removal of the source - immediate removal of clothing unless already adherent to skin (soak first) and reducing the temperature of the skin as rapidly as possible to minimize thermal injury by soaking in cool water., We report an unusual case of a nineteen-year-old man with Wolff-Parkinson-White syndrome who successfully underwent accessory pathway catheter ablation but subsequently suffered ST segment myocardial infarction (STEMI) through a previously unrecognised mechanism. Post-ablation, the patient complained of new and severe central chest pain. Electrocardiography suggested inferior STEMI and coronary angiography revealed a distal occlusion of the posterior left ventricular branch of the right coronary artery. Flow was established using a ‘standard’ angioplasty wire and a 2.5mm compliant balloon. Given the vessel’s tendency to recoil, despite using a drug coated balloon, stent insertion was necessary to maintain luminal patency. Intravascular ultrasound revealed an oedematous extrinsic compression at the site of the lesion. Subsequent high sensitivity Troponin T assay and echocardiogram were consistent with posterior myocardial infarction. Immediate ECG changes following catheter ablation have been acknowledged and linked to the proximity of ablation site and coronary arteries. This is the first case of post-ablation STEMI caused by oedematous extrinsic coronary obstruction we have noted in our facility, and we have not found any other report in the literature. We recommend that patients describing new post-procedural chest pain should undergo urgent clinical and ECG assessment to consider ischaemia., Introduction: Aortic dissection is a devastating cause of mortality in patients with connective tissue disorders. Personalised external aortic root support (PEARS) is a pioneering approach that utilises a personalised 3D mesh to prevent aortic root dissection without the need for anticoagulation. Description: We describe a retrospective case series of all PEARS procedures performed to date at the Cardiac Surgical Unit, Belfast. Twelve patients have undergone the PEARS procedure of which 2 had concomitant mitral valve repair (9 males; 3 females; median age: 37 years). All cases had evidence of aortic root dilatation. The procedure was technically successful in all cases. Complications: 6 developed tachyarrhythmias, 3 demonstrated ST changes not in keeping with infarction, 1 developed a right coronary artery pseudoaneurysm requiring reoperation and 1 developed circumflex artery occlusion requiring bypass grafting. There were no deaths. The median total hospital admission was 8.5 days (range: 6 – 118 days). Discussion: Although our experience thus far is limited, we demonstrate that a single centre can safely establish a PEARS programme. Our experience highlights the significant learning curve associated with beating heart dissection. Nevertheless, the PEARS procedure offers young patients the advantage of avoiding lifelong warfarin therapy whilst likely preventing further expansion of aortic root aneurysms., Introduction: Timely diagnosis of osteomyelitis is essential for its successful treatment but it is often difficult to recognise despite extensive radiological workup. Case: We outline a case of recurrent sepsis over a seven year period in a patient injured by a car bomb blast and the use of an innovative imaging technique to localise two culprit foci of osteomyelitis. This was a prolonged and difficult diagnosis due to extensive shrapnel injury and associated inflammation as well as significant anatomical disruption from the blast. Discussion: Sites of inflammation associated with shrapnel injury acted as decoys to the true foci of active infection on Fluorodeoxyglucose (FDG) Positron emission tomography/ Computed Tomography) (PET/CT) and a new technique was required to differentiate these. This involved administering a course of antibiotics between two separate FDG-PET/ CT scans and is known as Subtraction PET. Two sites of osteomyelitis were identified among 20-30 other sites of benign granulomatous inflammation and calcification. These two sites of infection were characterised by a significant drop in tracer uptake on FDG-PET/CT after a course of antibiotics while tracer uptake at the remaining sites remained relatively unchanged. This ultimately guided surgical excision of the sequestra and at follow up of two years, the patient has experienced no further septic episodes., Introduction: Over the new year period we recognised a high number of admissions with complications following cosmetic surgery abroad. We aimed to determine the driving forces behind this and financial impact on the NHS. Cases: 6 patients were admitted to the regional unit after independently organising surgery abroad. Countries visited included; Turkey, Belgium, Poland, Estonia and India. Reasons included; cost and access to procedures not recommended by UK surgeon. Type of surgery included; Breast (5), abdominoplasty (2), liposuction (2), labiaplasty (1) and 50% had multiple procedures. Complications included; necrotic wounds (33%), infected breast implant (33%), VTE investigated (33%), wound infection (17%). Overall, 67% required surgery on the NHS. The estimated total cost was £23,976.82 with an average of £4000/patient. Discussion: This surge in cosmetic complications occurred over the New Year. Complications were seen after a range of surgical procedures. All patients required an inpatient stay and 2/3 required surgery with a significant cost burden to the NHS. Patients are unaware of the risks involved, highlighted by the lack of pre-operative counselling and follow up. In addition, this series has highlighted the risks associated with travelling in the peri-operative period., Introduction: Dysarthria is one of the commonest neurological speech disorders resulting from brain injury. It adversely affects psychosocial functioning and rehabilitation due to the inability to communicate effectively. In the majority of patients, it is irreversible. It may be possible to improve the intelligibility and articulation of speech with a pharyngoplasty procedure. This procedure is more commonly performed in patients with velopharyngeal insufficiency (VPI) and a cleft palate. Methods: Data was collected from the regional plastic surgery unit over a ten-year period. Medical records and speech and language notes were reviewed. Outcomes; speech improvement, complications and need for surgical revision. Results: Six patients had a pharyngoplasty. Either a Hynes or the Jackson variant of a flap pharyngoplasty were performed. The majority were male (5/6). Mean time between injury to surgery; 5-years. Overall, 83% of patients had a clear improvement in speech intelligibility and articulation. One patient experienced self-limiting sleep apnoea and one patient developed obstructive symptoms and required a revision. Discussion: We have shown that surgical intervention is an effective method of improving speech intelligibility and articulation in patients with both traumatic brain injury and following CVA. Although speech and language therapy is the pillar of management, certain patients have the potential to benefit further from surgical intervention. The aim of this paper is to highlight this option and heighten the awareness that a pharyngoplasty has the potential to make a significant difference to the lives of patients with brain injury by restoring communication., Introduction: Forces capable of causing chyle leak usually result in bowel and pancreatic injury. High index of suspicion required to avoid missing concurrent injuries. Only 10 reported isolated chyle leaks following blunt trauma. Description: A 34-year-old male presented with a blunt injury to the epigastrium after falling onto the handlebar of a bicycle. On examination, he had epigastric tenderness with no evidence of peritonism. CT demonstrated a fluid collection posterior to proximal jejunum, with appearances suggestive of jejunal perforation but no free air was observed. The patient developed worsening generalised abdominal pain 12 hours after admission. Clinical examination revealed 4-quadrant peritonism, prompting an emergency laparotomy. At laparotomy, no free fluid was observed. Retroperitoneally, milk-coloured diffuse fluid infiltration was noted. Inspection of the duodenum, small bowel and pancreas revealed no obvious injury. Drains were placed at the tail and head of the pancreas where largest pooling of fluid. There was an uncomplicated post-operative recovery with discharge at day 6. Discussion: Diagnostic uncertainty intra-operatively prompted an urgent radiological consult on CT imaging, suggesting pancreatic transection. Intra-operative amylase analysis of the retroperitoneal fluid guided surgical management, which would otherwise have proceeded with a distal pancreatectomy and its associated consequences., Introduction: All psychiatrists will encounter patient suicide during their careers, however little has been written about the impact this can have on them, professionally and personally. Aims: To examine the unconscious communications between suicidal patients and psychiatric trainees based on the trainees’ lived experience. To consider how this data could be used to support trainees in their clinical practice, and inform and shape institutional processes, such as serious adverse incident reviews, as well as the training programme. Methods: Semi-structured interviews were carried out with 3 psychiatry trainees and the material analysed using Interpretative Phenomenological Analysis (IPA). Results: Three main themes were identified, namely “A Deep and Painful Wound”, “Strategies for Survival”, and “A Path to Recovery”. They describe how patient suicide affected the participants personally and professionally, how their colleagues and the organisation responded to them and their thoughts about what was helpful and what could be changed in future. Discussion: Losing a patient to suicide can be an extremely distressing, isolating and anxiety provoking experience All trainees felt that the training programme inadequately prepared them for it, and it is important that training organisations address this., Introduction: In 2014, NCEPOD reported hospital patient care for those with tracheostomies and laryngectomies posed significant safety issues. Subsequently Intensive Care Society guidelines stipulated staff exposed to such patients be competent in managing airway emergencies. Medical patients with tracheostomies and laryngectomies are typically cared for by junior doctors yet juniors often express concern in respect to managing such patients, particularly in the emergency setting. Aim: To establish junior doctor training for tracheostomy and laryngectomy patients.Evaluate junior doctor confidence in the acute and nonacute assessment of such patients. Methods: Junior doctors attached to the acute medical and respiratory wards of a local hospital were invited to complete an online survey regarding previous training and their current confidence regarding managing tracheostomy and laryngectomy patients. Results: Twenty-four junior doctors received the survey with 18 respondents. 55.56% reported previous undergraduate training in this area with 44.4% receiving postgraduate training. Despite this, 77.7% of respondents stated they were not confident in conducting routine reviews of patients with trachyectomies or laryngectomies. 66.6% did not feel confident in managing an acutely unwell patient with a tracheostomy/laryngectomy with 66.6% stating they were ill equipped to manage an airway emergency in such patients. Respondents felt simulation (88.8%) and clinical bedside teaching (77.8%) would improve their confidence. Conclusion: Results indicate junior doctors working with tracheostomy and laryngectomy patients demonstrated low confidence, both in the acute and non acute management setting, an issue which may generate significant patient harm. Evidently there is a need for additional training with the authors proposing such training form a formal component of hospital induction., Aim: To determine if students and paediatric trainee doctors level of knowledge meets a non-faculty clinician-determined minimum accepted competency (MAC). Methods: A 30-item multiple-choice (MCQ) paper (MAC exam) was created, formed of questions proposed by practising non-academic consultant paediatricians, which are deemed as ‘must know’ for paediatric trainees prior to commencing clinical work. A ‘passing score’ was determined using the Angoff technique by the paediatric faculty. The paper was given to undergraduate students and also paediatric senior house officers (SHO’s). Student’s performance on the MAC was compared with their performance on their official university examination. Test item analysis and psychometrics were also performed. Results: The passing score was determined at 13/30 (41.2%) 366 undergraduate students participated. Mean score 45.9% (s.d 9.9%, range 23-73%). 240/366 (65.4%) of students achieved the passing score whereas 99% of these students passed their official university exam. However, positive correlation between students result in the MAC exam and results from their official university exams (spearman R=0.44. p, Introduction: The SHO rota (first on call) in most hospitals is staffed mainly by GP specialty trainees or Foundation doctors on rotation. They are required to attend obstetric emergencies whilst on call. This can be a daunting experience as there is limited postgraduate training for non-specialty trainees in O+G. Aims: Improve training, confidence + competence for all non-specialty trainees in managing obstetric emergencies. Methods: An afternoon of simulation based training was held for all junior doctors currently working in O+G within the SEHSCT. Scenarios included shoulder dystocia, PostPartum haemorrhage, maternal collapse and eclampsia. A questionnaire was completed by all delegates pre and post training. Results: All delegates reported a significant increase in confidence to manage obstetric emergencies for all scenarios post training. Discussion: Working within O+G can be a daunting experience for non-speciality trainees covering the SHO rota. This programme has shown that simulation based training in managing obstetric emergencies not only will improve the clinician’s confidence and competence but also will improve patient safety., Problem: The poor compliance to local guidelines for antibiotic prescription in acute cholecystitis and cholangitis. Strategy for change: A 3 week prospective review of antibiotic prescription in all patients admitted with suspected or confirmed acute cholecystitis or ascending cholangitis. 22 patients admitted within audit window, 18% of which received correct antibiotics. Teaching delivered to surgical team on current antibiotic guidelines and appropriate escalation, information posters displayed in ED and wards and guidelines included in trust induction pack. Measurement of Improvement: Following education on correct prescription, further audit period carried out. 25 patients admitted with suspect or confirmed diagnosis, 84% of which received correct antibiotic therapy as per local guidelines. Effects of change: Correct education to surgical and emergency department staff led to an improvement of 66% in compliance to local antibiotic guidelines. Discussion: Acute cholecystitis and cholangitis are some of the most common presentations on the acute surgical ward, with the mainstay of treatment being intravenous or oral antibiotic therapy, IV fluids and analgesia. Correct antibiotic therapy can ultimately lead to improved patient safety and avoid future potential antibiotic resistance., Problem: Preparing accurate discharge documentation is a central aspect of good clinical practice in accordance to guidelines outlined by SIGN. Seeking clarification regarding a patient’s medications, follow up and correct diagnosis is a common, time-consuming frustration for F1 doctors upon discharge. Strategy for change: A commonly used acronym, ‘MFD’ – ‘Medically Fit for Discharge’ was modified to ‘Medications, Follow up, Diagnosis’ as an aide memoire. We aimed to improve the inclusion of ‘MFD’ information in the notes/ kardex by 50%. Measurement of Improvement: F1s completing discharge letters collected ‘MFD’ data from 100 patients. Baseline data was recorded and two PDSA cycles implemented; Cycle 1 – presentation delivered at departmental teaching and Cycle 2 – posters outlining MFD placed at ward level. Effects of change: At baseline, 20% of discharge letters had ‘MFD’ documented without need for further enquiry. Following PDSA cycles 1 & 2, full documentation was 54% and 62% respectively, representing a 210% improvement from baseline. Discussion: The MFD acronym use increased significantly following simple interventions. Follow-up information was the most commonly omitted. Scope for further improvement includes: Qualitative data regarding time improvement for F1s comparison of consultant diagnosis versus immediate discharge summary diagnosis., Problem: For vascular access in haemodialysis (HD) the mantra is ‘arteriovenous fistula first’ as one benefit is a reduction in bacteraemia incidence. However, a significant proportion of the HD population require a central venous catheter (CVC) for dialysis. Thus, the morbidity and mortality associated with CRB is a relevant and preventable problem. Strategy for change: 2009-11: Improved documentation to facilitate prospective monitoring of CRB rates. 2011: Antimicrobial catheter locks implementation. 2012: Monthly infection MDT meetings. 2016: Visual CVC score streamlined to increase detection of exit site infection (a CRB precursor). 2016: A ‘DRESS’ survey implementation to ensure exit site covered. 2016: Process for swab result review. Measurement of Improvement: CRB rates are quoted between 0.6 – 6.5/1000 catheter days in international studies. Prior to practice change, our unit CRB incidence was 0.41/1000 catheter days. Present incidence is 0.17/1000 catheter days representing a >50% reduction. Effects of change & Discussion: Introduction of antimicrobial catheter locks produced the most significant impact on CRB rates however; it has been the establishment of a collaborative quality improvement culture within the Ulster Renal Unit that has sustained improvement. Meaning for patients, the chance of getting a CRB is 3.5 times less than the lowest rate quoted in the literature., Problem: The gold standard for diagnosis of acute pulmonary embolism (PE) is radiological investigation with Computed Tomography Pulmonary Angiogram (CTPA). Patients undergoing CTPA examinations receive a full volume CT scan of the chest (lung apices to extreme bases) which, after reviewing literature, is unnecessary and leads to higher than necessary radiation doses to the patient. Strategy for Change: Audit current practice to find out radiation dose to patients having CTPA examinations and ascertain whether important diagnoses would be missed by the introduction of a truncated scan range from aortic arch to base of heart. Measurement of Improvement: Re-audit after the implementation of the truncated scan range to see if there is a significant reduction in radiation dose to the patient. Effects of change: Reducing the scan range form aortic arch to base of heart results in an average dose reduction of 56% to the patient whilst still being able to accurately diagnose acute pulmonary embolus. Discussion: With increasing requests for CTPA studies, using the principle to keep radiation dose ‘as low as reasonably possible’, a reduced scan range can help to reduce radiation dose to patient whilst still maintaining diagnostic accuracy., Problem: No pre or post list briefs were being performed in the RVH trauma theatres Strategy for change: A formal pre-list brief and post-list debrief was implemented into two orthopaedic operating theatres over a 2 week period (January 2019). All operating lists were included (15 lists). A post-implementation survey was performed assessing impact (n=17). Measurement of improvement: The initial audit identified non-adherence to mainland policy of pre and post list briefs. All staff surveyed before introduction of pre-list briefing felt it would improve communication, patient safety, staff morale and theatre efficiency thereby advocating its introduction. Resurveyed staff confirmed improvement of each factor by 65%, 47%, 53% and 53% respectively. Effects of change: Furthermore >75% staff surveyed before introduction of post-list debriefing felt it would aid identification of issues and improve communication, which on resurveying equated to and improvement 59% and 71% respectively. Discussion: Our initial audit highlighted non-adherence of NPSA guidance. This project supports the implementation of pre and post list briefing. They take minimal time and can save significant time overall, reducing delays and identifying issues early., Problem: 25% of N.Ireland’s children are overweight/obese but there has been a lack of specialist services to support children with BMI> 98th centile achieve a healthier weight. Strategy for Change: We launched N.Ireland’s first multidisciplinary paediatric obesity service in May 2019. Children are referred from school nurses, general practitioners and paediatricians. Families are invited to participate in holistic assessment by a paediatrician, physiotherapist, associate psychologist and dietician. Measurement of Improvements: Outcome measures including BMI, 6-minute walk test, grip strength, blood pressure, dietary history and quality-of-life are assessed at baseline, 3,6 and 12 months. Parents/siblings also have their weight/BMI monitored. Personalised family plans are co-produced. Treatments include educational evening classes and/or one-to-one input from dietetics/physiotherapy/ psychology. Effects of Change: Currently 30 children (4-16 years) have attended multidisciplinary assessments and are in the treatment phase. 8 families completed the first 5-week cycle of evening classes. Attendance averaged 73%. 75% (6/8) reduced their BMI including one family who collectively lost >12kg. One child’s BMI increased, and another’s remained static. Discussion: After positive family feedback we have extended our evening programme to 6-weeks, introduced appointment text reminders and developed a more extensive outreach programme with local councils. We are excited to recruit more families and develop a sustainable business plan for this gap in paediatric services., Problem: Paediatric burns referred to Plastic Surgery are often given an appointment within the week to attend Paul Ward (RBHSC) for assessment. Plastics trainees are not always scheduled to work in RBHSC however, and the closest staff are in the Burns Unit (RHV). Trainees there manage the ward, admissions, theatre and clinics and so leaving is difficult. Strategy for change: The aim was to encourage appointments to be made on days where staff work in RBHSC. Weekly rota was not being sent to staff nurses, and there were issues in interpreting it. Interventions: Ensuring rota sent to ward staffTeaching session to Plastics traineesEnsuring ward staff understand rota Measurement of Improvement: Change measured by percentage of days medical staff were required that they were scheduled to be in RBHSC. Effects of change: In February 2019 staff were present on 16% of the days they were required, rising following interventions to 88% in June 2019. Discussion: It is not realistic to achieve 100%, as emergency admissions should not be delayed. However where there is flexibility it is better for patient and staff if assessments can be carried out promptly., Problem: Patients with certain mental health diagnosis are required to inform DVLA of their diagnoses and refrain from driving. It is medical professionals’ responsibility to advise patients to adhere to DVLA guidelines. Patients can be fined up to £1000 if they failed to inform DVANI of their medical condition. Strategy for change: Cycle 1 – baseline and review guidance; Cycle 2 – medical staff education and developed driving advice pathway and patient leaflet; Cycle 3 – admin staff was involved for putting driving advice pathway in admission pack; Cycle 4 – medical staff was educated again regarding importance of documenting electronically. Outcome: Completeness of driving advice given to consecutive patients discharged from T&F hospital from April 2019 to early August 2019 in % Process: Document in electronic and written notes on following - (1) has driving status been asked (2) has patient been advised to inform DVA if required (3) has patient been advised likely how long he/she is to refrain from driving for. Effects of change: After cycle 3, there was an increase of mean of 25% completeness of driving advice to over 90%. Discussion: This QI project has shown improvement in the completeness of driving advice given. Further cycles are to be completed to obtain patient feedback., Problem: 50-70% of hospitalised patients without a formal diagnosis of Diabetes Mellitus will develop corticosteroid- induced hyperglycaemia. An audit cycle conducted on an inpatient respiratory ward identified deficiencies in recognising and treating this common, but important complication of steroid therapy- some 90% of clinical episodes failed to comply with national and trust guidance. Strategy for change: A PDSA cycle was employed to address this issue, with focus placed upon 3 key areas: Multi-disciplinary educational seminarsChanges in ward-based documentsEnhancing accessibility of guidelines through poster displays. Measurement of Improvement: Closed loop audit cycle (n=140) of blood sugar monitoring frequency, HBa1c measurement and implementation of appropriate hyperglycaemic therapy compared with national standards. Effects of change: Universal improvements in audited standards with >90% of patients on appropriate monitoring regimes and >50% receiving appropriate hyperglycaemic therapy. Discussion: Corticosteroids are employed by physicians in a variety of clinical circumstances. Corticosteroid-induced hyperglycaemia is a common but often overlooked side effect, with important implications for inpatient morbidity and mortality. National and Hospital Trust guidance is readily accessible but requires multi-disciplinary engagement for effective implementation.

Introduction: Pancreatitis is a common condition on the acute general surgical take. Common aetiologies in the UK include gallstones, alcohol excess and iatrogenesis. Hypothermia is scarcely documented in literature among the rarer causes of pancreatitis, and whilst little scientific literature exists to support this clinical observation, this case adds to the growing evidence for hypothermia as a clinically relevant risk factor for acute pancreatitis. Discussion: We present the clinical course of a 44 year-old male open water swimmer who was admitted to ICU for mechanical ventilation in view of hypoxic respiratory failure and severe hypothermia (27oC). Following cardiorespiratory stabilisation and uncomplicated extubation, the patient complained of sudden, severe epigastric pain, refractory to strong opiate analgesia. CT images were in keeping with acute pancreatitis. The patient was managed conservatively at ward level and made an uncomplicated recovery prior to discharge. Thorough clinical history and biochemical testing excluded all other typical aetiologies of acute pancreatitis. This case is unique from previous reports in literature, where the relationship between hypothermia and pancreatitis has been more ambiguous. It is essential to be vigilant in hypothermic patients and remember this uncommon link, as diagnostic delay may lead to serious local or systemic complications of pancreatitis., Introduction: Differentiating between a bacterial infection and a self-limiting viral illness is challenging. Adrenomedullin (ADM) has many physiological roles and is reported to rise during severe infection. The novel biomarker Mid-regional proadrenomedullin (MR-proADM) is produced during the synthesis of ADM. It proportionally represents the level of ADM and is easier to measure. Aims: To assess the diagnostic accuracy of MR-pro-ADM in detecting bacterial infection in febrile children presenting to the Royal Belfast Hospital for Sick Children Emergency Department (ED) with a non-blanching rash. Methods: Prospective diagnostic accuracy study. Samples tested using the BRAHMS MR-proADM assay on Samsung LABGEO IB10® analyser. Results: 39 patients underwent MR-proADM testing. In all but 2 patients the MR-proADM was under 0.70nmol/l. The two patients with elevated MR-proADM levels were found to have sepsis and tonsillitis. At 0.70nmol/l cut-off MR-proADM demonstrated a sensitivity of 0.11 (95% Confidence Interval 0.02 to 0.35) and a specificity of 1.0 (95% Confidence Interval 0.80 to 1.0) for bacterial infection. Discussion: MR-proADM is highly specific for bacterial infections but lacks sensitivity. Given the physiological roles of ADM it maybe that MR-proADM is better suited as a prognostic marker of sepsis rather than as a diagnostic marker of bacterial infection., Introduction: In a neonatal emergency, if intubation is indicated, it is imperative the correct equipment is collected promptly. Currently no neonatal intubation equipment guide exists. Aims: This study aimed to develop a Neonatal Intubation Flowchart (NIF) and test effectiveness of NIF 1 and NIF 2. Methodology: A prototype NIF was created (NIF 1). Using a simulation, a control group (n = 21) was compared to an intervention group (n = 24), employing NIF 1. These cohorts consisted of paediatricians, neonatal nurses and midwives. The outcomes measured were Percentage of Correct Equipment (PCE) collected and Time Duration (TD) to collect equipment. An improved NIF 2 was created and the simulation was repeated to an intervention group (n= 28) utilising NIF 2. Results: Between the control, NIF 1 and NIF 2, the PCE results were 59%, 87% and 96% respectively. The TD of the control, NIF 1 and NIF 2 showed a median of 90 seconds (Interquartile Range (IQR): 70.5 - 121.5), 140 seconds (IQR: 99.5 - 182) and 60 seconds (IQR: 53.5 - 73.5). Discussion: The NIF 2 improves intubation equipment collection, within a quicker time. Quicker and effective preparation aids quicker intubation which may limit hypoxic brain injuries., Introduction: There is an urgent need to develop efficacious and tolerable therapies for Mycobacterium avium complex (MAC) pulmonary disease. Mesenchymal stromal cells (MSCs) have known antimicrobial properties against common bacteria but their effect on MAC species is not known. Aims: To determine the effect of MSCs on intracellular and extracellular M. avium. Methods: Human MSCs were infected with M. avium at a multiplicity of infection (MOI) of 2. Human monocyte- derived macrophages (MDMs) were also infected with M. avium at MOI of 2. After 4hrs, MSCs were added at a ratio of 1 MSC: 3 MDMs. After 24hrs and 72hrs, colony counts were performed on supernatants and cell lysates. Results: MSCs reduced total bacterial counts of M. avium by 24% at 24hrs (from 295x103/ml to 225x103/ml, p40% (from 381x103/ml to 209x103/ml, p70% after 72hrs (from 1050x103/ml to 314x 103/ml, p, Introduction: This study uses eye-tracking technology to objectively assess the differences in gaze behaviours between consultant and trainee ophthalmologists before and after a taught search strategy was introduced, while interpreting retinal images. Methods: Nine trainee and 10 consultant ophthalmologists were asked to interpret 6 retinal images before and after watching a 5-minute tutorial that suggested a search strategy. Participants were asked to complete questionnaires of clinical signs seen, appropriate retinopathy grade, and confidence. Eye movements were tracked during each interpretation. Results: Overall, trainees compared to consultants demonstrated more uncertain and unstructured gaze behaviours. Trainees eye gaze metrics compared to consultants included: longer interpretation time, 36.5s(SD=6.2) vs 31.4s(SD=4.2)(P=0.024), a higher visit count, 17.38visits(SD=5.13)vs 12.18visits (SD=2.64)(P=0.01), a higher proportion of fixation, 57.0%(SD=5)vs 50.5%(SD=5) (P=0.05) and a shorter time to first fixation, 0.232s(SD=0.10) vs 0.821sec(SD=0.77)(P=0.001), respectively. The teaching intervention did result in more focused gaze patterns in both groups. Pre-intervention and post- intervention mean proportion fixation on areas of interest were 38.6%(SD=6.8) and 51.8%(SD=13.9) for the trainee group, respectively, and 39.9%(SD=4.1)and 50.9%(SD=9.3) for the consultant group(P=0.01). Conclusions: Consultants used a more systematic and efficient approach than trainees in interpreting images. After the introduction of a suggested search strategy, trainees showed trends towards the eye gaze behaviours of consultants. The implication is that eye tracking may have future use in teaching programmes and objectively assessing different teaching strategies., Introduction: Mycobacterium abscessus is an emerging multi-drug resistant pathogen, which is difficult to treat. There is a need for new antimicrobial strategies. Zafirlukast, a leukotriene receptor antagonist, inhibits growth of Mycobacterium tuberculosis, by inhibiting complexation between DNA and protein Lsr2. Lsr2 is present in M. abscessus. Aims: We aimed to investigate the effect of Zafirlukast on extracellular and intracellular M. abscessus growth. Methods: We examined Zafirlukast’s effect on free growth of M. abscessus, and survival of M. abscessus in infected THP-1 cell line derived macrophages. We measured colony- forming units per millilitre in broth, or supernatants and lysates, at 24 and 72 hours. Also, we investigated whether Zafirlukast reduced inflammation as assessed by interleukin-8 secretion (measured by ELISA) by infected THP-1 derived macrophages. Results were analysed by Kruskal-Wallis and Dunn’s tests. Results: At 24 hours, 100μg/ml Zafirlukast reduced M. abscessus free growth by 62% (p=0.0039), also reduced total M. abscessus growth in THP-1 derived macrophages by 94% (p=0.0062), and finally, reduced interleukin-8 concentration in supernatants from M. abscessus-infected THP-1 derived macrophages by 99% (p=0.0412). Discussion: Data suggest Zafirlukast may reduce growth of M. abscessus and modify M. abscessus-induced inflammation. Further work is required to assess the potential therapeutic role of Zafirlukast in treating M. abscessus infection., Introduction: Sepsis represents a dysregulated host response to infection. Underlying mechanisms are unclear, but deficits in the function of monocytes, central to the innate immune system, are implicated. A heterogeneous condition, recent transcriptomic work has revealed two distinct sepsis-response signature profiles; immunosuppressed and immunocompetent, which are linked to outcome. Aims: We propose that these distinct profiles impact differentially on volunteer monocytes, and hypothesize that there will be differences in their phagocytic activity and phenotype when conditioned in plasma from patients in these two groups. We therefore aimed to validate a functional assay for this purpose using lipopolysaccharide (LPS) to represent ‘septic’ plasma. Methods: CD14+ monocytes were isolated from healthy volunteers, and incubated overnight in media and human plasma +/- 10ng/ml LPS. Surface phenotype and phagocytosis were assessed by flow cytometry. Results: LPS exposure decreased monocyte surface CD14, as previously reported, and PD-1, whilst phagocytosis of E.coli particles and expression of CD86, and expression of PDL-1 increased. Discussion: Our LPS model of ‘septic’ plasma/monocytes demonstrated the ability to alter monocyte phenotype and function, providing a positive control for subsequent analysis of patient samples., Case Study: Small bowel malrotations are a rare congenital abnormality (symptomatic in 1 per 6000 live births 1). The majority of these present as a neonate or in early childhood (adult presentation between 0.0001% and 0.19%2,3). Our case is a patient with a rare form of malrotation, a reverse malrotation, presenting as an adult. An 18-year-old woman presented with 1 week of epigastric pain radiating through to her back. The pain had worsened in the 3 days preceding admission and was associated with vomiting. Bowels had been opened the previous day with no diarrhoea, mucus or blood reported. On examination the patient had a tender epigastrium and RUQ with associated guarding. Biochemical tests were unremarkable; WCC, CRP, LFT and Amylase all grossly normal. CT demonstrated small bowel volvulus and incomplete obstruction with a “whirlpool sign” of the small bowel mesentery. At Laparotomy the transverse colon was found running through the small bowel mesentery, ultimately a Right hemicolectomy with end ileostomy was performed. Discussion: Cases of malrotation are rare and there is often a delay in diagnosis. We hope the discussion generated by this report will improve the diagnosis of intestinal malrotation and therefore improve outcomes for patients., Case study: Ocular cicatricial pemphigoid (OCP) is an autoimmune disease that affects the conjunctiva. It is a subtype of mucous membrane pemphigoid (MMP), a disease that affects the skin and the mucous membranes. Initial signs and symptoms can overlap with other conditions such as pseudomembranous conjunctivitis. OCP is sight threatening and requires systemic steroids and immunosuppression while pseudomembranous conjunctivitis is self-limiting. We present the case of a 72 year-old gentleman with multiple attendances to eye casualty with red eyes. He was initially diagnosed with pseudomembranous conjunctivitis before developing cicatricial conjunctivitis and mouth ulcers. The conjunctival biopsy confirmed the diagnosis of OCP and the patient was started on oral steroid and immunosuppressive therapy. Discussion: The diagnosis of OCP was delayed in our case and affected one eye more than the other. Extra-ocular signs and positive direct immunofluorescence can help differentiate OCP from other cause of chronic conjunctivitis. Early diagnosis is important as immunotherapy takes few weeks to achieve maximal effect. A step-wise approach was used in this case, starting with oral Dapsone and escalating to oral Mycophenolate. Close monitoring of the patient will continue under the joint care of the ophthalmology and rheumatology team., Case Study: A lady who was 7 weeks pregnant presented to the Emergency Department at 4am with her partner. She had been out for dinner with friends at 7pm and developed severe vomiting and diarrhoea from 10pm. Whilst in the waiting room she fainted & was faecally incontinent so was brought into a bed. On examination she was clammy and had generalised abdominal tenderness. Observations were normal except a Heart Rate of 105BPM. Initial haemoglobin on her Venous Blood Gas was 145. The obstetrics registrar was called - he could not see an intrauterine pregnancy. Her VBG was repeated showing a haemoglobin of 85. She was rushed to theatre and had 2 Litres of blood in her abdomen. Discussion: Ectopic pregnancy should be considered in any female who presents with abdominal pain. All women presenting with abdominal pain should have a pregnancy test performed. Pregnant women should also have an ultrasound scan to confirm intrauterine pregnancy. This is a potentially life threatening condition if not managed promptly. This case highlights how it can present with atypical features which mimicked gastroenteritis. It also highlights that initial bloods can be normal. This lady survived., Case Study: This patient had a normal delivery with a postpartum haemorrhage of 800ml. Her haemoglobin was 94g/L on discharge. She was a Jehovah’s Witness and refused transfusion of blood products. She was readmitted day 8 following delivery with sepsis. Ultrasound showed a 9x4cm area of retained placental tissue. Her haemoglobin on readmission was 82g/L. Instead of immediate intervention the patient was reviewed weekly to assess for infection and there was multidisciplinary input including pre-operative counselling, anaesthetic review and completion of an advance directive. She was admitted 8 weeks postpartum for resection of retained tissue. Her haemoglobin was 135g/L and intravenous tranexamic acid bolus and infusions were given prior to the procedure. Hysteroscopy showed adherent placental tissue on the right lateral wall and posterior wall of the uterus. As there was moderate bleeding following tissue resection a urinary catheter with 20ml saline was inserted into the uterus. Discussion: Hysteroscopic resection of retained placental tissue is relatively new however has been supported by the literature and warrants further trials. When compared with uterine curettage it may reduce blood loss and long term complications such as Ashermans syndrome., Case Study: A 35 year old female self-detected a lump in left breast July 2017. Triple assessment confirmed node positive, triple negative, infiltrating ductal carcinoma. No evidence of distant metastases on staging investigations. Completed six cycles of neo-adjuvant chemotherapy 08/01/2018 and left partial mastectomy and ANC 05/02/2018. Presented 5 days post-surgery with headache, photophobia, nausea, vomiting; CT Brain was normal - discharged. Admitted to Oncology 11 days later with ongoing symptoms; Normal examinations; MRI Brain and whole Spine normal; LP – cytology confirmed epithelial cells consistent with metastases from a primary breast carcinoma; Rapid decline with death on 11/05/2018. Discussion: Early breast cancer carries an excellent prognosis when treated with neo-adjuvant chemotherapy and surgery. Commonest sites for metastases include bone, lung, liver, brain and leptomeningeal involvement usually occurring months to years post initial diagnosis. Leptomeningeal metastases alone are very rare especially early in the natural history of the disease. Diagnosis requires a high clinical index of suspicion. Gold standard Investigations include T1-W MRI scan of brain and spine with gadolinium enhancement and CSF analysis. Treatment options are limited with continued debate over the effectiveness of systemic chemotherapy, radiotherapy and intra-thecal chemotherapy. Life expectancy following diagnosis of leptomeningeal metastasis is measured in terms of weeks., Case Study: A 41-year old male athlete presented acutely to the Royal Victoria Hospital emergency department with sustained resting typical angina chest pain 30 minutes following completion of an ultra-triathlon. 12-lead ECG demonstrated hyper acute t waves in precordial leads V3 and V4. Serial high-sensitivity Troponin T assays were elevated at 186 – 330 – 603ng/L respectively. Invasive coronary angiography demonstrated acute LAD dissection and significant thrombus burden with TIMI 3 flow distally. Optical coherence tomography (OCT) confirmed coronary dissection. A 6.0(width)/18 (length) mm Herculink bare metal stent was deployed following catheter thrombectomy, with a successful angiographic result. Following 3 months of dual antiplatelet therapy he remains on life-long Aspirin. At 1 year he has had no further major adverse cardiovascular events (MACE), angina free (CCS class 0) and exercising regularly. Discussion: Spontaneous coronary artery dissection (SCAD) is a rare and clinically challenging cause of acute myocardial infarction most commonly affecting younger patients with low risk of atherosclerotic heart disease. The low incidence of SCAD has resulted in a paucity of information on optimal treatment. Our case highlights a challenging case successfully treated with percutaneous coronary intervention including intra-coronary imaging, and antiplatelet therapy., Introduction: Trauma contributes significantly to adolescent morbidity and mortality. Currently a dearth of literature exists, specific to this field in the UK. This study aims to highlight the epidemiology of UK adolescent trauma. Methods: TARN (Trauma Audit Research Network) records all trauma cases which meet pre-specified criteria. Adolescents were defined as 10-24 years old as per recent literature. TARN data from English sites over a ten-year period (2008-2017) were included in this analysis. Results: TARN recorded 26,330 trauma cases, 5,266 aged between 10-15 years and 21,064 aged between 16-24 years. Median age was 19.4 years (IQR 16.7-21.7 years). There was a 2.2-fold increase in the annual number of cases reported during this period with an increase in the number treated in MTCs (44% 2008 vs 73% 2017). Trauma was more likely to occur between 08.00 and 00:00 (77.4%), at weekends and between April and October. Mortality rate was 4.4% (4.47% in 16-24 year old group and 3.84% in 10-15 year old group). Road traffic collision (RTC) was the leading cause of adolescent trauma (52%). Intentional injuries accounted for 19.8%; 16.2% alleged assault and 3.6% suspected self-harm. Conclusions: There has been an increase in reported adolescent trauma. RTC and intentional injuries, including stabbings are leading aetiologies. Health care professionals need to prioritise national preventative public health measures and early interventions to reduce the incidence of trauma in this vulnerable group., Background: Informed consent is an integral component of good medical practice. Many have investigated measures to improve the quality of informed consent, but it is not clear which techniques work best and why. To address this problem, we propose developing a ‘core outcome set’ to evaluate interventions designed to improve the consent process for surgery. Part of that process involves reviewing outcomes that have been reported in existing research that reportedly capture the quality of a consent process. Aims: To systematically review all qualitative studies to determine which factors determine the quality of informed consent for surgery as viewed by patients and clinicians. Methods: This qualitative synthesis comprises four phases: identification of published papers and determining their relevance; appraisal of the quality of the papers; identification and summary of the key findings from each paper while determining the definitiveness of each finding against the primary data; comparison of key themes between papers such that findings are linked across studies. The study protocol has been registered on the International Prospective Register for Systematic Reviews (PROSPERO ID: CRD42017077101). Results: Searches of the databases returned 11,073 titles. Of these, 16 studies met the inclusion criteria. Studies were published between 1996 and 2014 and included a total of 367 patients and 74 health care providers. Thirteen studies collected data using in-depth interviews and constant comparison was the most common means of qualitative analysis. A total of 94 findings were extracted from the primary papers. These findings were divided into 12 categories and ultimately 6 synthesised findings. These synthesised findings were; trust, knowledge, patient characteristics, situational factors, choice and the model patient. Discussion: This qualitative meta-aggregation is the first to examine the issue of informed consent. The review has revealed several outcomes deemed important to capture by patients and clinicians when evaluating the quality of a consent process. Some of these outcomes have not been previously been examined in informed consent research. This review forms the basis for the development of a core outcome set to evaluate interventions designed to improve the consent process for surgery., Introduction: Nowadays most people use the Internet to access health-related information. Aim: To objectively analyse online information regarding vertigo, in terms of quality, readability and reliability. Methods: The term vertigo was searched using the most popular search engines. The top 30 websites were analysed. The readability was assessed using Flesch-Kincaid Reading Ease score (FRES) and Simple Measure of Gobbledygook score (SMOG). The quality and reliability were analysed using DISCERN instrument, JAMA criteria and presence of Health on the Net (HON) Foundation seal. Results: The websites Nhs.uk, Patient.info and NIdirect.gov.uk had the highest readability scores. The average FRES score was 48 which correlates to the reading ability of a college student. Thirteen websites had the HON seal and most websites met 2 out of 4 JAMA criteria. The websites Cks.nice.org, Nhsinform.scot and Menieres.org.uk had the highest DISCERN scores and average DISCERN score was 41. Discussion: On average, information online about vertigo is difficult to read and is of fair quality. The highest ranked websites on search engines are not always the most reliable. Clinicians should be aware of available health information online and advise patients accordingly., Introduction: Studies have shown that disease recurrence after LLETZ is higher in patients with positive resection margins; however rates vary possibly due to technique and extent of margin cautery. We analysed patient records to determine if margin status affected test of cure (TOC) rates. Methods: 100 margin positive LLETZ specimens and 103 margin negative specimens were identified in the WHSCT for high grade CIN (CIN 2/3) from January 2016- June 2017. Case records were examined to determine TOC post excisional therapy. Results: Of 203 patients who had LLETZ for high grade CIN 5% of patients were immunocompromised (n=10).6 cases had co-existing CGIN (4 in margin positive group). 63% of the margin positive group and 68% of the margin negative group had negative TOC (p=0.22). 7% of the margin positive group and 3% of the margin negative group required repeat excision (p=0.09). DNA rates for TOC were 10% and 5% in the margin positive and negative groups, respectively. Discussion: Our results show that after TOC smears post LLETZ for high grade CIN margin status of the LLETZ specimen made no significant difference to the outcome. This is perhaps due in part to the treatment technique involving cautery of the residual margins., Introduction: Burnout in doctors has been widely reported on. However, there is limited information in the literature on resilience in doctors. Despite this, workshops and seminars are offered by organisations for clinicians to attend to improve their personal resilience. These may not benefit doctors if they are already highly resilient individuals. Aims: To measure resilience, professional quality of life and coping mechanisms in doctors. Methods: During a 4-week period all medical staff within a single NHS trust in Northern Ireland were invited to complete an online survey that was made up of three validated psychological tests. Results: 283 doctors across a wide range of specialties and grades responded. Mean resilience was 68.9, higher than population norms. 100 (37%) doctors had high burnout scores. Burnout was positively associated with low resilience, low compassion satisfaction, high secondary traumatic stress and more frequent use of maladaptive coping mechanisms, including self-blame and substance use. Non-clinical issues in the workplace were the main factor perceived to cause low resilience in doctors. Discussion: Despite high levels of resilience, doctors had high levels of burnout and secondary traumatic stress. As doctors already have high resilience, improving personal resilience further may not offer much benefit to professional quality of life., Introduction: Osteoporotic acetabular fractures in the frail elderly patient are associated with high levels of morbidity and mortality. Aims: We describe the results of a coned hemipelvic acetabular reconstruction and total hip replacement as the treatment of these fractures. Methods: We have prospectively monitored a series of fifteen patients (16 cases) with a mean follow-up of 22 (12-42) months. Results: The mean age was 79 (67-87), and mean ASA score 3.3 (3-5). Thirteen had low-energy injuries, two had high-energy injuries. Mean operative time was 94 minutes. There were seven minor post-operative complications. Fourteen of 15 patients were full weight bearing day one post-operatively. Mean length of hospital stay was 13 (5-27) days. Preoperative mobility status was maintained in 8 patients. At one year mean Harris hip score was 73.13, Merle d’Aubigné score 12.7 and mean EQ-5D score 0.59 (data from 10 patients). Mortality at 30 days was 0%, and 7% at 1 year. There have been no thromboembolic events, dislocations or deep infections. Discussion: The coned acetabular prosthesis minimises operative time and bypasses the fracture, creating an immediately stable construct that allows immediate weight bearing. Early results show an acceptable complication rate, satisfactory patient reported outcomes and excellent survivorship., Introduction: FFRCT can determine the functional significance of stenosis and guide safe deferral of invasive angiography, however intermediate prognostic implications have not been assessed. Aims: The study aim was to examine the prognosis of fractional flow reserve derived from coronary computed tomography (FFRCT) in routine clinical practice. Methods: Patients referred for FFRCT analysis with stable chest pain at a single centre between October 2015 and June 2017 were retrospectively included and followed up for rates of vessel related late (>90days) unplanned revascularization, MI, and cardiac mortality. Results: 200 (mean age 62.4±10.0 years) patients were sent for FFRCT analysis. A Cox Regression model was used to determine hazard ratios from FFRCT status. FFRCT+ patients were significantly more likely to undergo invasive angiography (p, Introduction: Skin cancer incidence is rising in Northern Ireland (NI)1. The Department of Health, Social Services and Public Safety’s (DHSSPSNI) ‘Skin Cancer Prevention Strategy and Action Plan (2011-2021)’2, aims to reduce skin cancers by raising awareness of the dangers of ultraviolet radiation. Target groups include children and outdoor sports participants. Aim: We surveyed NI sports clubs to gauge whether such messages are reaching members. Methods: Links to sun-safety material accompanied surveys emailed to 562 clubs (158 complete; 75 partially complete). Results: Amongst 158 complete responders, highest responding clubs included Gaelic football (54%), running/ athletics (10%) and golf (9.5%). 67% were unaware of the DHSSPSNI strategy ;< 6% recall receiving promotional material. The majority of clubs provide no sunscreen; 5% supply free sunscreen and 2.5% offer it for special events. Considering future sun-safety promotion, 129/158 clubs would use the material accompanying the survey. Discussion: Evidence shows that safe-sun and skin cancer education does not always lead to behavioural change3,4. Club-level health policies result in healthier behaviours5, with those connected to regional bodies being more inclined to partake. NI clubs are willing to promote sun-safety. They propose better use of social media to target members, with the literature suggesting improved member websites6. Future campaigns could target governing bodies to encourage member-clubs to promote sun-safe behavior., Introduction: Traditional outcome measures (e.g. mortality, length of hospital stay) may not provide a full depiction of patients’ post-operative state, especially for low-risk interventions such as inguinal hernia repair. Patient reported outcomes (PRO) are becoming increasingly common as primary outcomes in clinical trials. Aims: The aim of this study is to report and summarise the PROs in randomised controlled trials (RCT) comparing laparoscopic versus open inguinal hernia repair techniques. Methods: A systematic review and meta-analysis was carried out in accordance with PRISMA guidelines. PubMed, Embase, SCOPUS, Cochrane Library and four clinical trials registries were searched. Identified publications were independently reviewed by two authors. Results: 7,129 records were identified, resulting in 53 RCTs being selected. In total 17,148 patients were identified and 18,004 hernias were repaired. After meta-analysis the laparoscopic group was associated with significantly less post-operative pain, except that reported within 2 weeks post- operatively. Numbness and patient reported satisfaction was also significantly better in the laparoscopic group. Discussion: This study reflects the most up-to-date evidence available for the surgeon to council their patient. It was constrained by the heterogeneity of outcome reporting., Introduction: The recently updated NICE guidelines regarding investigation and treatment of stable ischaemic heart disease advise CTCA for investigation of chest pain and reserve non-invasive ischaemia tests for patients with known coronary artery disease. In practice, choice of investigation often depends on local availability and expertise and options for non-invasive ischaemia testing include DSE, MPI and CMR. This audit aimed to assess safety outcomes and sensitivity/specificity of stress CMR in Northern Ireland. Methodology: A retrospective audit of patients undergoing CMR from 1st Jan 2016 - 1st January 2017 was undertaken. For patients with a positive CMR, findings at angiography were assessed. For patients with a negative study, the electronic care record was reviewed to assess incidence of adverse outcomes including acute coronary syndrome and mortality. Results: In total, 74 patients were included in the audit. Follow-up was undertaken from 14-26 months. Twenty nine (39.2%) had a positive CMR. Of the 45 stress CMR negative patients, no patient had myocardial infarction or mortality during follow-up. Of the 29 CMR positive patients, 20 (68.9%) had invasive angiography, of which 19 (95.0%) had PCI and 1 (5.0%) had bypass surgery. The remaining 9 patients were felt inappropriate for angiography due to comorbidities. Sensitivity was 0.96 for coronary artery disease according to post CMR angiogram. Discussion: Stress CMR correctly identified patients with obstructive coronary disease which required further therapy with a high degree of sensitivity. Patients with negative studies appear to have a low risk of cardiac events in the short to medium term., Introduction: A survey of Emergency Medicine Trainees indicated that the progression from lower into higher specialty training (HST) is a stressful transition. Aims: Our aim was to develop a course which met the needs of our trainees based on the feedback obtained from our survey. Methods: We developed a one day course which simulated a busy night shift. The candidate was required to manage simulated patients and the rest of the department represented on a “board”. It tested their ability to prioritise, delegate, lead and managing other staff, deal with difficult situations and maintain situational awareness. Results: Feedback showed improved confidence in managing staff, giving advice, delegating appropriately, making decisions and dealing with difficult situations. All trainees felt the course would improve patient safety and would recommend the course to other trainees. Discussion: The transition into HST is stressful. Our survey identified that the reasons underpinning this are in relation to leadership & management skills and non-technical skills. We showed how a simulated teaching session could help provide a “safe” environment to learn these skills and provide strategies for overcoming common problems. Overall this improved leadership skills, confidence and patient safety., Introduction: In recent years, clinical negligence claims are a growing reality for dental professionals. Defence organisations report both increasing claim numbers and higher levels of compensation being awarded. Aim: We aim to undertake root cause analysis of negligence claims reported on by a single consultant oral to improve understanding of the root causes and to direct quality improvement activities. Method: Claims were identified between 1993 and 2015 through consultant records and a systematic approach taken to review each case to determine both active and latent factors contributing to the claim. Results: 30 negligence cases were identified with 53% of claimants being male and the most common age group 31-40 (33%). Extractions were the most frequent cause of claims. Other reasons included misdiagnosis, patient injury and complications of treatment. Several latent and active contributing factors were identified for each including organisational (30%), task (97%) and communication (57%) factors amongst others. Discussion This study highlights that the cause for dental negligence claims is often multifactorial. It reinforces an often significant variation in recollection and perception of events by both complainant and dentist. Communication frequently features as a factor although other organisational and task factors also play a significant role. Many root causes identified are preventable or modifiable and therefore measures can be put in place to reduce the impact of these and ultimately risk of negligence and negligence claims., Introduction: Previous literature identifies authenticity and the holistic nature of the long case as advantages; however its unreliability makes it unsuitable for summative assessment. The views of students are not well represented in existing research. Aims: To ascertain the views of medical students on the value of the long case. Methods: A questionnaire and focus groups were used to discover students’ views on a rheumatology long case. Eighty- six percent of 106 students returned questionnaires and 19% attended focus groups. Qualitative thematic analysis was undertaken. SPSS® was used for statistics. Results: There was overwhelming support for the long case (92% in favour). Students reported it provided them with a ‘real’ encounter and ‘integrated’ their learning. There were mixed opinions on the educational value of the long case. Opinions that it was ‘unfair’ were prominent in focus groups. There was frequent mention of practical difficulties completing the case. Views on the importance of feedback were expressed. Discussion: Students used the terms ‘real’, ‘integrated’ and ‘fair/unfair’ when describing the long case which correspond to the academic terms ‘authentic’ ‘holistic’ and ‘reliable’. We may improve students’ experience by minimising practical obstacles and maximising the quality of feedback., Aim: A General Surgery firm of a District General Hospital noted an opportunity to improve knowledge and skills for Foundation Year Doctors caring for surgical patients with Peripherally Inserted Central Catheter lines. Shift pattern demands prevented trainees from attending a single education session. Our aim was to improve confidence and knowledge through education with Trust Specialist Nurses. Methods: An initial questionnaire was circulated amongst Foundation Doctors working in Surgery to determine baseline familiarity and confidence with PICC lines. Following education, the questionnaire was recirculated. Results: Pre-education - 14 responses received. 100% encountered a patient with a PICC. 57% had taken blood from a PICC without formal training. 64% encountered difficulty drawing a blood sample from a PICC. The average level of confidence was 6/10. 100% felt they would benefit from formal training on PICC lines. Following formal education: Average level of confidence was 7/10 – demonstrating a 10% increase. Average rating for quality of teaching was 9/10. Conclusion: This unique, combined medical education and patient safety QI project confirmed issues in Junior Doctor training. Results demonstrated simple education can increase confidence in PICC management. As a result, Doctors can deliver safer care for this group of patients., Introduction: Many surgeons write directly to patients with updates on their care. The readability of this correspondence was not subject to the same standards expected from other patient literature. New guidance on patient correspondence has further highlighted this issue. Aim: To show results from a study we undertook regarding readability in January 2018 and to highlight some of this new guidance. Methods: One hundred consecutive letters written directly to patients from the General Surgery Department, Ulster Hospital in December 2017 were analysed. The Simplified Measure of Gobbledygook (SMOG) was calculated for each letter. Results: The mean SMOG was 11.23. 82% of letters were classified as difficult to read. Discussion: Only 3% of letters included in our initial study were considered ‘easy to read’. Although new guidance does not specify a target age for readability, it does give some advice; this includes words to avoid, sentence length, and avoidance of medical jargon. As part of an ongoing quality improvement project we hope to demonstrate improvement in the readability of patient correspondence., Introduction: Anaemia is a key contributor to poor obstetric outcome including increased mortality from obstetric haemorrhage. It is associated with fetal death and premature delivery and UK antenatal prevalence is 24.4%. Aims: To review the diagnosis, treatment and follow up of antenatal anaemia and determine the incidence of avoidable anaemia and transfusion at delivery. Methods: A proforma based upon national guidelines was completed following a chart review of mothers with antenatal anaemia who delivered in the Ulster hospital over a one- month period. Results: Of the 22 patients haemoglobin was checked at 28 weeks in 86%. Oral iron was prescribed when indicated in 50% of patients, with 1/3 experiencing a significant delay. 13% received dietary counselling and of those applicable only 7% were referred to secondary care. 31% were appropriately followed up with a 45% adequate response to treatment. There was a 4.5% incidence of avoidable red cell transfusion and 41% avoidable anaemia at delivery. Discussion: To summarise, 31% of patients with confirmed anaemia received oral iron at the correct dose resulting in avoidable anaemia and transfusion at delivery. This review represents substandard practice and creates baseline data for a quality improvement project which is ongoing., Aims: To determine the presentation, management, waiting times and conversion to SCC of Oral Epithelial Dysplasia (OED) at the School of Dentistry (SOD). Methods: A retrospective review of cases of OED referred to the SOD between March 2011 and July 2017. Hard copy and electronic patient records were used. Results: Overall 45 patient records were reviewed over the time (24 male and 21 female). Over 84% of patients were aged over 50 on referral. Most lesions were located on the tongue or floor of mouth (82%) with almost half appearing as homogenous white patch lesions (69% asymptomatic). Just under one third were referred on the red flag pathway. Management of lesions varied between monitoring (60%), surgical removal, referral or laser excision. Overall 9 of the 51 lesions were re-biopsied and a diagnosis of OSCC made. No link was made between degree of dysplasia and likelihood of conversion. Discussion: OED occurred most frequently in patients over 50 and appears strongly linked to factors such as excessive alcohol intake and smoking. Characteristics of the presenting lesion vary and as such so does triage grade on referral. Management of lesions varied depending on histopathology, clinical findings and risk factors. 20% of lesions later converted to OSCC. Using these findings we aims to formulate a management protocol for these patients in conjunction with histopathology and our head and neck surgery colleagues which will be applicable to both the oral surgery and oral medicine department in the school of dentistry., As a rheumatology trainee I was aware that for those patients with raynauds syndrome, who were being assessed for an underlying connective tissue disease, there was no facility to perform capillaroscopy. Capillaroscopy is a non-invasive method of examining the nail bed capillaries of patients to assess for any abnormalities. This allows for earlier diagnosis and treatment for those with scleroderma and it also can facilitate discharge of those patients with primary raynauds with normal capillaroscopy findings. My aim was to create a nurse led capillaroscopy clinic for the Belfast Trust by August 2018. I was able to secure funding in order to learn how to perform capillaroscopy in May 2017 and successfully completed a capital funding bid to secure a video capillaroscope for the Belfast Trust. After developing my skills in the procedure I was able to encourage one of our specialist nurses, Donna Torrens, to learn the skill herself. We have now completed 6 capillaroscopy clinics at RVH, reviewing 20 patients (16 Female: 4 Male) who were referred via our online form. For those seen 4 patients were given a connective tissue disease diagnosis, 2 patients had their disease staged, 7 patients were able to be discharged from rheumatology services and the remaining 7 patients require ongoing review due to either abnormal capillaroscopy findings or concerning history. The service shall now continue as a nurse led service., Introduction: The UK National Vascular Registry (NVR) records and publishes outcomes for procedures performed by vascular consultants. It aims to audit and improve vascular patient care. Difficulty in extracting data from patient notes have led to incomplete entries and underreporting of results. Aims: To improve the accuracy of data entry into the NVR for all patients undergoing carotid endarterectomies (CEAs) at a Regional Vascular Centre. Methods: A total of 5 PDSA cycles were completed. Data was collected over four months from consecutive CEA patients. Deficiencies in data entries were analysed. At month two, a new proforma was introduced highlighting the key data components required for the NVR database along with further sections for MDT input and inpatient note keeping. Staff were unaware that notes were being audited. Data completion rates were then compared. Results: There was a significant improvement in completion of NVR entries after pro forma introduction; admission details improved from 48% to 98% completion and demographics from 68% to 99%. Discussion: The proforma has resulted in an improvement in the accuracy and completion of NVR data entries for CEA patients permitting outcome data to be audited to ensure high standards of patient care., Introduction: The current pathway is that these patients are referred to a spinal specialist. This generally requires an ambulance trip, often long since the N. Irish population is covered by a single spinal centre. Aim: We propose treatment can be done locally on selected patients. Methods: Retrospective study of new referrals seen in the spinal clinics at the Royal Victoria hospital between October 2017 and March 2018 - 395 patients. The segmental kyphotic angle was compared between imaging at diagnosis and in clinic. We’ve excluded patients: younger than 65yo; with neoplastic/ metastatic fractures; with associated myopathy/neuropathy; clinic letter not typed (n=2). N = 109 patients Results: 20% discharged at 1st encounter. Spinal bracing fitted on 45% but no patients offered surgical intervention. Mean segmental kyphotic angle increased 5.25°. Discussion: There was a minimally significant increase in the mean segmental kyphotic angle. Surgical intervention was not necessary for any of the patients, being analgesia and physiotherapy the treatment modalities chosen. We believe this patient group can be managed locally and only referred to a specialist if meeting defined criteria. This should be less cumbersome for all., Introduction: Head and neck patients are subject to national requirements to establish a diagnosis by 31 days. Timely communication is key to assisting this. Red flag signposting of letters in medspeech is key step in process. Prior to this project the majority of letters for red flag patients were being dictated as routine and so typing of the dictations could vary between 1 - 4 weeks depending on the secretarial support. One of the issues we faced was clinicians can remove patients from the red flag process and thus think red flag dictation was unnecessary. Aims: To ensure that by start of July 2018, 75% of Red Flag patient Letters are graded correctly in dictation with 100% graded correctly by end of September 2018 Resulting dictations will thus be typed within 24hrs of seeing the patient This complies with the trust’s standard operating procedure, and ensures efficiency within our systems Methods: Baseline data collection to confirm that improvement was required. PDSA 1 Email to OMFS team. PDSA 2 Audit Reminder. PDSA 3 2nd Email to OMFS team. PDSA 4 Notice on Computers. Results: Aim: 75% compliance. Overall steady rise in compliance after every PDSA cycle. Median Prior to first intervention 33% (Week 1-15) Median after PDSA cycle 1= 50% Median after PDSA cycle 2= 49% Median after PDSA cycle 3= 58% Median after PDSA cycle 4= 66% Discussion: Unfortunately we didn’t reach our aim compliance. I feel that we made a substantial improvement in the practises of the staff and that over time we will be able to reach out aim of 75% compliance for red flag dictations., Introduction NI has one BSGE Endocentre established in 2014 with a team of gynaecologists, colorectal and urology surgeons and one nurse. Aims To determine symptoms and QOL outcomes for women with severe endometriosis since Endocentre was established and patient feedback on current services. Methods BSGE endometriosis database was analysed (previous surgery or hormonal therapy, symptoms and pre- and post-surgery quality of life (QOL) measures). Telephone questionnaires about endometriosis services were undertaken. Results 60 patients on database had QOL score (EQUVAS numeric 0-100 score) recorded. 37% used hormonal therapy pre-surgery, 62% had previous surgery for endometriosis. Most common hormonal therapy was COCP (15%) Most prevalent symptom was menstrual pain (81%). Average pre- surgery QOL score was 57, with average scores at 6 months, 12 months and 24 months post-operatively 67, 71 and 57. Telephone questionnaire (17 patients), 88% attended gynaecology before the endometriosis clinic, 35% noticed improvement since then. Feedback was positive (88%). All felt a patient support group would be beneficial. Discussion On average patients had improved QOL scores at 6 months and 12 months post-operatively. Based on patient feedback, the first endometriosis support group in the Northwest is being established, run by charity and the Patient Client Council., Introduction Heart failure symptoms are non-specific therefore diagnosis can be challenging. If suspected, the European Society of Cardiology recommends that natriuretic peptide (NP) levels are measured prior to requesting an echocardiogram, as patients with normal NP levels are unlikely to have heart failure and do not require echocardiography. Aims: To ascertain how often an NT-ProBNP is checked prior to requesting an echocardiogram for left ventricular (LV) function assessment. Methods: We reviewed 44 echocardiogram requests submitted between May-October 2017. We used ECR to see if an NT-Pro BNP had been requested beforehand, and how these results correlated. Results: Of 25 inpatient requests, 23 had an NT-ProBNP checked beforehand, compared with 8 out of 19 outpatients. When analysed by grade, the majority of requests came from general practitioners. No patients with normal NT-ProBNP values were shown to have LV dysfunction. Discussion: In the majority of patients in whom LV dysfunction was suspected, echocardiographic assessment was normal. Therefore, a test which can reliably exclude LV dysfunction has significant potential to reduce unnecessary referrals, which would in turn reduce waiting list pressures, patient anxiety and hospital spending. Recommendations for improvements are discussed., Aim: Evaluating time from admission acute gallstone pancreatitis to cholecystectomy. Method: UK working party guidelines for management of acute pancreatitis. “All patients should undergo definitive management during same admission or within 2 week period.” All coded diagnosis of gallstone pancreatitis Ulster hospital Dundonald admissions 2016. Dataset: Discharge date, ERCP/Surgery, repeat admissions prior to surgery, mode of procedure and 30 day readmission/morbidity/mortality. Results: 51 patients 47 deemed surgically fit. 14.9% had same admission cholecystectomy; 43.5% performed within guideline 2 week period. 96.1% diagnosed MRCP, 2% CT, 2% USS only. 33.3% positive MRCP findings all underwent ERCP Cause of delay: 15% failed or delayed ERCP, 5% required repeat imaging,14% no noted medical/surgical cause 21% Repeat pancreatitis admissions: 27% before ERCP, 36% After ERCP and 36% no evidence of choledocholithasis. 88% performed Laparoscopically, 9.5% lap conversion to open 11% 30 day readmission rate following surgery, 7% with post operative pancreatitis Conclusions: 43.5% had surgery performed within guidelines period. Delays majorly observed due to ERCP availability; however 14% had no medical/surgical reason. Therefore waiting list factors may have had some effect. Delay to surgery is thought to have directly affected rate of readmission with pancreatitis., Introduction: Within the Mater Hospital admission packs there is a 1 page discharge summary sheet for consultants to fill in when patients are fit for discharge. This ensures vital information eg final diagnosis and review information is communicated. This document was however rarely used. Aims: Increase use of IDD by medical consultants to 90% Methods: - Information session for all medical staff about changes and to gather feedback - All medical consultants emailed to ask for support - Layout of page streamlined - Document changed to yellow paper and moved to front of admission pack - GPs surveyed on what is important in a discharge letter Results: 4 PDSA cycles carried out. Before changes implemented (first audit) 8% were filled out from a random sample of 5 per ward. Improved to 36% on first re-audit, 44% second and 52% on the third. A further re-audit 2 years later (March 2018) showed implementation was at 37%. Discussion: Change can be slow! Project overall a success and improving discharge accuracy has obvious benefits for patient care in community as well as making discharge letters a more accurate document for ECR reference., Introduction: Nice Guideline 53 recommends standards for the transition of care between inpatient mental health facilities and community follow-up. GP`s should receive discharge summaries within 7 days. At baseline 0% of letters were completed within this timeframe within the T&F. Aim: Discharge summary should to be completed within 7 days for at least 60% of patients in the T&F hospital, and to achieve this within 12 months. Method: The baseline data for all patients admitted and discharged in the 8 months prior were also gathered prior to any intervention. 5 PDSA Cycles were used to introduce a new discharge trolley to each inpatient ward, a new discharge checklist introduced. The letter itself was restructured in a way that made it easier to read and easier to complete. Results: Changes implemented correlated with an improvement from 0% of letters complete within 7 days to over 80% completed. The mean time taken for community teams receiving letters improved from 51 days to 4 days. Discussion: This project attained sustained improvement. Microsystems meetings at a local level also allowed a time allocated to focus on this project within a QI minded approach., Aim: To reach 90% adherence to DVANI ADHD guidance in East Belfast OPC Background: According DVLA’s guidance, patients with ADHD must notify DVLA/DVANI of their condition. According to DVLA and GMC, it is medical professionals’ responsibility to advise patient to do so. Measures Process: Staff and patient education, use of checklist, information leaflet. Outcome: % of patients per month informed by medical team to notify DVANI of their diagnosis of ADHD Results: Cycle 1 (baseline): 33.3% of patients were advised by medical staff to notify DVANI Cycle 2 (staff educated):56% of patients were advised Cycle 3 (Update existing ADHD checklist to include driving): 75% of patients were advised Cycle 4 (Educate admin staff and update existing checklist): 100% of patients were advised Cycle 5 Questionnaire given to patients and aim to co-produce driving advice leaflet following focus group Conclusion: It is the legal duty of ADHD patients to notify DVANI of diagnosis however it is the responsibility of medical professionals to advise patients to do so. 100% of patients were informed by medical staff to notify DVANI by education and updating the physical health ADHD checklist., Introduction: Angiosarcoma of the breast and anterior chest wall are extremely rare malignant endothelial cell neoplasms that develop either spontaneously or secondary to radiotherapy treatments. To date lack of published data is limiting best practice guidelines. Aims: To describe incidence, management and outcome of breast angiosarcomas within Northern Ireland as part of the national Breast Angiosarcoma Surveillance Study (BRASS). Methods: An electronic chart review of Northern Ireland patients with histologically confirmed breast angiosarcomas between 01/01/2000 and 31/12/2015. Results: Nine cases (all female) were identified with mean age of 57 at diagnosis. Primary angiosarcomas occurred only with younger patients. 77.8% were secondary angiosarcomas (mean time ∼ six years from receiving radiotherapy to diagnosis). None was discussed by the sarcoma multidisciplinary team (MDT). Seven of the nine patients received surgery (five with curative intent). Chemotherapy was offered to those with non-resectable disease and adjuvant radiotherapy followed inadequate margin of resection. Local recurrence was high with poor survival (shortest three months). Patients with > five year survival had no local recurrence. Discussion: Owing to small sample size, a collaborative approach is required to produce valuable data that shapes future studies and practice guidelines. These cases should all be discussed at sarcoma MDT meeting., Introduction: As volunteer doctors in Kiwoko Hospital Uganda we demonstrated a lack of uniformity in antibiotic prescription amongst healthcare professionals for the same diagnoses through clinical audit. The WHO is very clear regarding prudent antibiotic prescription by healthcare professionals and its role in reducing the problem of antimicrobial resistance. Aims: Improving patient safety by ensuring the most appropriate antibiotic is chosen for a given illness. Methods: Based on Uganda Clinical Guidelines 2016 and medications available locally, an accessible antibiotic protocol was devised, printed and placed on four of the wards with education for medical staff. The same exclusion criteria were used as the initial audit and same parameters were measured following introduction of the protocol. In total 228 cases were used. Results and Discussion: An improvement was demonstrated in uniformity of antibiotic prescription with the ‘correct’ choice rising from 17% to 41% following introduction of protocol. The hospital management has introduced the protocol to a number of different clinical areas as a result of the QIP. Anti-microbial resistance is everyone’s responsibility and this intervention resulted in improvement in suitable empirical choice of antibiotic in a low resource setting., Introduction: Challenge: Mental Health Bed Crisis, Bed Occupancy >110%, Reliance on out of Trust beds Safety issues, Difficulties engaging carers, Cost Aims: Decrease bed occupancy to 85% Decrease length of stay by 30% Increase service user/staff satisfaction Methods: Solution: Purposeful Inpatient Admission (PIpA) Based on the Toyota Production System Model Used in healthcare in the Virginia Mason Medical Centre Key features: Patient’s experience central Replaces batched decision making with continuous flow Standardised processes for each step Continuous monitoring of changes/outcomes Formulation and purposeful treatment plan within 72 hours of admission Patient’s journey mapped out on a Visual Control Board Daily report out instead of weekly ward round Daily tasks board Delays immediately identified and escalated Results: ‘Green’ bed status (>5 available beds) for 24 consecutive days 85% Bed occupancy (Royal College of Psychiatrists’ recommendation) >30% reduction in length of stay Reduction in violent incidents No complaints during pilot Increased staff satisfaction Discussion: Conclusion/Next steps Aims met (bed occupancy/length of stay/satisfaction) Sustain improvements in bed occupancy and length of stay Implementation to remaining general adult acute wards.

Model set and results.

VCU Theses and Dissertations