You & type 2 @ home: Testing a fully remote model for diabetes annual reviews using the you & type 2 personalised care and support planning pathway in combination with remote monitoring technologies at two primary care practices in South London

Aims: A proof-of- concept pilot investigating the profile of person who engaged with remote testing for their annual diabetes review, and service user (SU) and primary care practice acceptability for completing annual diabetes review tests remotely (blood pressure, finger-stick blood test and urine test). Method(s): A mixed methods evaluation based on SU surveys sent to all 144 pilot participants, semi-structured SU and staff interviews, and demographic and clinical data extraction from primary care electronic patient record system. Result(s): Profile: The pathway was considered suitable for people who were working, digitally capable, younger, had household support to complete the tests, had non-complex diabetes, or a combination of these attributes. It was deemed less suitable for the very elderly, the less digitally capable, those with complex health needs or socially isolated. SU Acceptability: Interviewees and survey respondents overall deemed the remote tests acceptable for use. Convenience and reduced exposure to Covid-19 were motivating factors for participation. Preference for face-to- face care or concerns around using digital technologies were key reasons for decline. Staff Acceptability: The pathway was deemed acceptable and was successfully implemented at both practices. Support from a designated pathway co-ordinator and project manager were key factors linked to acceptability and success. The remote pathway was seen as an opportunity to reduce primary care pressures on in-person care. Conclusion(s): It is possible to successfully conduct annual diabetes reviews remotely. Although not appropriate nor desirable to everyone, remote testing provides a viable alternative to in-person testing for certain individuals.

Retrospective review of vaccination status in patients with newly diagnosed chronic lymphocytic leukaemia

Introduction: Patients with chronic lymphocytic leukaemia (CLL) are at increased risk of infection. CLL is associated with a secondary immunodeficiency and impaired response to vaccination. Recent British Society of Haematology guidelines recommend that patients with CLL should receive vaccination against pneumococcal infection at diagnosis, an annual influenza vaccine and COVID-19 vaccination. Patients aged 70-79 years should also receive the Shingrix vaccine. Patients with CLL should not receive live vaccines. In response to this guideline, a letter detailing vaccination requirements was created for patients to give to their general practitioner (GP). The local process for vaccination referral has since changed. Previously, vaccination requirements were communicated to the GP via letter. There is now a dedicated Vaccination Hub to which clinicians can directly refer patients for appropriate vaccinations. Aim(s): The aim of this project was to assess vaccination referral and vaccination status in patients with newly diagnosed CLL. Method(s): All new diagnoses of CLL from 2021 to 2022 were identified by review of the Haematology Multi-Disciplinary Team meeting electronic registration forms. Electronic patient records were reviewed to determine vaccination referral completion and vaccination status. Result(s): A total of 29 patients were identified as new diagnoses of CLL. Seventeen patients were diagnosed in 2021 and 12 in 2022. Sixty-nine percent of the patients were male and the average age was 70.9 years. Vaccination was discussed with 11 patients (38%) and 10 patients (34%) were referred for vaccination. Eleven patients (38%) had never received a pneumococcal vaccine. Nine patients (31%) had previously received the vaccine but not within the past 5 years. Five patients (17%) patients had received one dose of Pneumovax 23 following referral. No patients had received the initial Prevenar 13 vaccine. Twelve patients (41%) had not received an influenza vaccine. Of those who had received the vaccine, the majority (70%) had received this routinely. Similarly, 71% of patients had received the COVID-19 vaccine routinely as opposed to three patients who received this postreferral. Of those who were eligible, 50% had received the Shingrix vaccine. Conclusion/Discussion: Local rates of vaccination in patients with CLL are low. Numbers were too small to allow for comparison between the methods of referral. Of those referred, not all received the appropriate vaccinations. Further work is therefore required to improve both the number and completion of the referrals. Future steps will include local teaching on vaccinations in CLL and the referral pathway.

TL,DR - Improving handover through the use of an integrated electronic discharge proforma in neurocritical care

Introduction: Effective handover between treating clinical teams is an important part of communication in the care of patients leaving the intensive care environment.1 This can be even more vital in neurocritical care, where patients may be unable to communicate their own history due to neurological deficits and whose families are unable to visit due to COVID. These patients often have had complex neurosurgical interventions and ongoing complex MDT discussion due to the nature of their illness. Handover needs to represent this. Furthermore, as a specialist tertiary centre, many patients leave the unit as repatriations to other intensive care units. In these situations, it is even more important for good handover to contain the relevant and succinct information for ongoing care. Objective(s): We aim to improve the quality of handover from the intensive care team to ward teams at a specialist neurocritical care centre through the use of an electronic discharge proforma integrated into the electronic patient record (EpicCare Epic Systems Corporation). This is a system that has only recently been introduced locally and has required modification for the intensive care environment. Method(s): We performed a retrospective cohort study of documented transfer of care (TOC) summaries for patients entering the ICU in a month-long period. 67 patient admissions were identified as possible candidates with 11 cases excluded as not meeting criteria. The TOC summaries of suitable cases were compared to standards set by the Faculty of Intensive Care Medicine and Intensive Care Society and criteria tailored to the neuro-intensive care environment. Following this, we implemented a curated discharge proforma for all patients leaving intensive care. Through the use of smart lists and specific prompts, we aim to improve compliance with the guidelines and improve the quality of TOC. The project is currently ongoing and we aim to repeat the analysis in March 2022 to review if there has been improved compliance. Result(s): Compliance for the first round of discharges was variable. There was generally good quality information on the summary of stay of the patient (96%) and ongoing plan for the care of the patient (88%). However, documentation of the rehabilitation needs (32%), psychological needs (14%), communication needs (16%), safeguarding issues (4%), and resuscitation and escalation status of the patient was suboptimal (4%). Documentation of verbal handover to the parent team (25%) and critical care outreach team (45%) was mixed. Conclusion(s): Here we present the use of an electronic discharge proforma to improve the quality of handover in patients leaving the intensive care environment. While the study is ongoing, we show that currently local patient handover is often incomplete with a lack of detail in the TOC summary and poor verbal communication between teams. Through the use of this proforma, we aim to improve the quality of this handover and improve the continuity of care for patients leaving the neuro-intensive care unit.

Evaluating the Use of Patient Reported Outcome Measures to Assess Intra-Pandemic Psoriatic Arthritis Disease Activity and Comparing Them with Pre-Pandemic Clinical Assessments

Background/Aims In our department, patient reported outcome measures (PROMs), including RAPID-3 and PSAID12, were employed during the COVID-19 pandemic in asynchronous consultations for patients with psoriatic arthritis (PsA). We compared pre-pandemic DAS28-CRP with intrapandemic PROMs to assess changes in disease activity since the pandemic. Whilst previous studies have primarily compared PsA PROMs with clinician-assessed scores (e.g. PASDAS), we compare PsA PROMs with clinicians' overall assessment of disease activity;this judgement considers PROMs, serology studies and individual patient feedback. Finally, we assess whether patients with PROMs indicating active disease were followed up appropriately. Methods Clinician-assessed scores were collected between 01/01/2019-01/03/ 2020 (''pre-pandemic''). Between 01/12/2020-31/03/2022 (''intrapandemic''), patient data from electronic surveys were analysed in a secure database for calculation of PROMs. These data, alongside blood results and patient comments, informed clinicians' triage decisions. Clinical outcome data were collected from electronic patient records;>=3 months follow-up appointment allocation was the target for patients with active disease (moderate/high disease activity). Data analysis was performed using r (version 4.2.2). Results In our pre-pandemic cohort (n=393), 79.8% of patients were in remission (per DAS28-CRP). Conversely, the intra-pandemic cohort (n=231) showed remission rates of 14.3% (per PSAID12) and 0% (RAPID-3). Indeed, 33.7% (based on PSAID12) vs 75.8% (RAPID-3) had moderate/ high disease activity. These results were validated in a paired cohort (n=38, score recorded in both windows). Disease activity worsened during the pandemic for 63.2% (PSAID12) and 97.4% (RAPID-3) of patients. PSAID-12 correlated positively with RAPID-3 (r=0.52, p<0.001), especially when RAPID-3 >=6.5 (r=0.75, p<0.001). When comparing PROMs with clinicians' assessment of PsA activity in our paired cohort, PSAID12 and RAPID-3 accurately reflected disease status in 70.6% and 58.8% of patients respectively. 3/9 and 9/27 patients with active disease, based on PSAID12 and RAPID-3 respectively, were seen within three months. Conversely, 7/10 patients who clinicians had deemed to have active disease were seen within three months. Conclusion Despite approximately 80% of patients being in pre-pandemic remission, the majority reported active intra-pandemic PsA. Whilst RAPID-3 skewed patients towards active disease, PSAID12 skewed patients towards remission/low disease activity. PSAID-12 and RAPID- 3 have been previously correlated;however, here we suggest that they could be used interchangeably in patients with high disease activity. PSAID-12 was a better predictor of clinicians' assessment of disease activity, although neither PROM correlated well with >=3 months followup appointment allocation. Although RAPID-3 and PSAID12 helped inform clinicians' decisions, neither alone sufficiently reflects patients' disease states. Remote management is practicable, but future studies should validate these findings across a larger cohort and assess the utility of different PROMs across PsA disease activity categories. Furthermore, multivariate analysis is warranted to ascertain which (combination of) variable(s) (e.g., PROMs, serology results, tender/ swollen joint count) best correlates with clinician judgement.

Advances in medical image watermarking: a state of the art review.

Watermarking has been considered to be a potent and persuasive gizmo for its application in healthcare setups that work online, especially in the current COVID-19 scenario. The security and protection of medical image data from various manipulations that take place over the internet is a topic of concern that needs to be addressed. A detailed review of security and privacy protection using watermarking has been presented in this paper. Watermarking of medical images helps in the protection of image content, authentication of Electronic Patient Record (EPR), and integrity verification. At first, we discuss the various prerequisites of medical image watermarking systems, followed by the classification of Medical Image Watermarking Techniques (MIWT) that include state-of-the-art. We have classified MIWT's into four broader classes for providing better understanding of medical image watermarking. The existing schemes have been presented along with their cons so that the reader may be able to grasp the shortcomings of the technique in order to develop novel techniques proving the inevitability of the presented review. Further, various evaluation parameters along with potential challenges pertaining to medical image watermarking systems have been discussed to provide a deep insight into this research area.

Is a hybrid skin cancer surveillance service for organ transplant recipients feasible? Lessons from the pandemic

Organ transplant recipients (OTRs) are highly vulnerable to SARS-CoV-2 infection and routine transplant consultations were converted primarily to virtual (VC) rather than face to face (F2F) from the outset of the pandemic. A similar strategy was adopted in our tertiary OTR dermatology clinic, but the implications of this on safe and effective skin cancer surveillance are uncertain. We audited clinical and patient experiences of our hybrid service with the aim of identifying the benefits and limitations of this approach, and improvements required to optimize a future hybrid VC-F2F model for skin cancer surveillance. All OTRs consultations held between 1 April 2020 to 31 March 2021 were identified through electronic patient records. Data collected included proportions and reasons for VC and F2F consultations, teledermatology requests, VC to F2F conversion rate, rates of skin cancer diagnoses and adherence to established follow-up protocols. All patients were invited to complete an online service evaluation. In total, 554 encounters (80.3% VC, 19.7% F2F) were recorded in 247 OTRs (42% with previous skin cancer). Of routine F2F consultations, this was patient preference in 17 of 109 (16%) and clinician-based risk assessment for the remainder. In 108 (25%) VCs, photographs were requested and received for 63%, of which 82% were adequate for diagnosis. Overall, 12% of VCs were converted to F2F and in 19 of 45 (42%) OTRs this was due to suspected skin cancer, which was confirmed in nine of 19 (47%). All other skin cancers were diagnosed in routine F2F consultations. Surveillance in 167 of 192 (87%) assessable OTRs adhered to established follow-up protocols. Of patients who responded to the online survey, 74% felt that there were benefits to VCs, but 41% expressed concern about the lack of skin examination and 57% reported little/no confidence in self-monitoring. Despite this, 59% expressed a preference to continue hybrid VC-F2F surveillance, with VC as routine and F2F consultation when required. Our audit provides preliminary evidence supporting the effectiveness, safety and patient acceptability of a VC-F2F hybrid model for the delivery of OTR skin cancer surveillance. We did not identify major delays in skin cancer diagnosis, although not all patients have yet been seen F2F. Certain aspects of service delivery will require optimization. In particular, despite routine skin cancer education, many patients expressed concerns about self-monitoring. Programmes specifically tailored to address this need will be required, as will information technology support for some OTRs. With this information we are redesigning our service to incorporate a VC-F2F model for routine skin cancer surveillance and are evaluating the incorporation of a patient-initiated follow-up pathway.

COVID-19 in Pregnancy: Patterns of Community and Hospital Infection and Maternal Outcomes in Oxfordshire, UK

Background & Purpose: Pregnant women with COVID-19 are at higher risk of severe disease than non-pregnant women of the same age1,2. Unvaccinated individuals are at substantially greater risk3,4. Much data published focuses on women hospitalized with moderate to severe infection. Outcomes of pregnant women with mild COVID-19 managed in the community are less well described, in part due to the system by which UK COVID results were reported. This study aims to analyze maternal outcomes of women with COVID-19, particularly those with mild infection, and look at patterns of vaccination and infection in Oxfordshire, UK. Method(s): This is a regional population-based prospective observational cohort study of 1012 pregnant women with COVID-19. Community and hospital cases were reported to a central database and electronic patient records used to collect demographic and pregnancy outcome data. This enabled a large cohort of women with mild COVID-19, managed in the community, to be assessed who may have otherwise not been included in analysis. Result(s): We found 96.6% of our patients had mild COVID-19 and did not require admission to hospital. Data shows that in Oxfordshire the population is older, with fewer women from black and minority ethnicities than COVID-19 data published nationally3. There are also lower rates of smoking and obesity. 62% of the cohort were vaccinated but when analyzed by ethnicity, only 28% of Black women and 49% Asian women were vaccinated. Most patients requiring admission to hospital were unvaccinated. Of those community cases with mild COVID-19 there were no adverse maternal outcomes reported. Conclusion(s):We demonstrate that COVID-19 in pregnancy frequently presents as a mild infection with no adverse maternal outcomes. High vaccination rates and a predominantly Caucasian population are likely to have been protective in our Oxfordshire cohort. Promotion of COVID-19 vaccine uptake particularly amongst groups most at risk is essential.

Anxiety in Paediatric Patients: A Summary of Routinely Recorded Data at Gosh

Aims We performed an analysis of GOSH's Electronic Patient Record (EPR) data derived insights relating to patients diagnosed with an ICD-10 anxiety code. This analysis examined trends in frequency distribution and duration of anxiety diagnoses over time, alongside the medication administrations and procedures performed on these patients. Methods Routine data for all patients diagnosed with an ICD-10 anxiety code (F41-) from July 2019 to March 2022 were extracted, de-identified, and analysed in the secure GOSH Digital Research Environment (DRE). The Python package Pandas was used to clean and analyse data. Interactive visualisations were created using Plotly. Medication drug classes for these patients (Hypnotics, Anxiolytics, and Antidepressants), and OPCS-4-classification-identified-procedures were analysed. Results Across 1573 patients in the cohort, 'Anxiety disorder, unspecified' (F419) was the most common anxiety type until 2021, gradually being replaced by 'Other specified anxiety disorders' (F418). The monthly sum of anxiety diagnoses demonstrated a seasonal variation, peaking in July 2019 and July 2021, with a trough spanning UK COVID-19 lockdowns. Chronic Kidney Disease, Autism, and other developmental disorders were the most prevalent comorbidities. Stratifying by drug class, Hypnotics & Anxiolytic administrations were more popular than Antidepressants for patients diagnosed with anxiety. Melatonin was the most administered medication. The OPCS-4 Class 'U' ('Diagnostic imaging, testing and rehabilitation') was the most common group of procedures performed on the same day as an anxiety diagnosis. Transthoracic Echocardiography and CSF Injection were most prevalent. Conclusion This analysis of EPR data found a seasonal variation in anxiety diagnosis frequency, with a gradual change in the specific type. Hypnotics & Anxiolytics are more popular than Antidepressants. Anxiety diagnoses relate mostly to imaging and testing procedures. Further work includes the same analyses and trends on earlier data.

Rate and spectrum of incidental findings on CT pulmonary angiogram of COVID-19 patients

Introduction: Patients admitted with COVID-19 infection and had suspected pulmonary embolism were investigated with CT pulmonary angiogram(CTPA). Apart from the features of COVID pneumonitis, other incidental findings can be reported on the scan. Aim(s): This study illustrates the rate and spectrum of incidental findings on CTPA performed on patients admitted with COVID-19 in a busy district general hospital. Method(s): Electronic patient record and CTPA report of patients admitted with COVID-19 confirmed from SARS-COV2 PCR test were retrospectively analysed using Allscripts Gateway and Sectra software respectively between March 2020 to March 2021. Descriptive and statistical data analysis were undertaken in Excel and GraphPad Prism software. Result(s): 874 patients with COVID-19 with median age of 69 yrs were studied and 218 patients had CTPA (25%). 219 Incidental findings were noted in 112 (51%) patients who had CTPA. Patients with incidental findings are older (68 yrs vs 59yrs, p value 0.0005). 35 patients(16%) were found to have pulmonary embolism in our cohort. Conclusion : This study illustrates that incidental findings are common when COVID-19 patients had CTPA scans, and these patients were older. These incidental findings were both varied and clinically significant. This would increase the pressure on respiratory and cardiology services to investigate these incidental findings, further management and subsequent follow up.

Crf Adaptations during Covid-19 - Creative Solutions to Deliver Quality Clinical Research during a Pandemic

To highlight how we continued to carry out early phase clinical trials throughout the pandemic and found innovative ways to tackle a number of operational challenges we faced in the past year. The COVID-19 pandemic presented a unique set of challenges to continuing clinical research activity and providing quality care for our research patients. In order to keep essential research going the CRF adapted to new ways of working. The CRF implemented processes to deliver IMPs throughout the national lockdown methodologies to prioritise early phase clinical trials to remain open technological adaptations to our electronic patient record system to enable video appointments the introduction of remote monitoring visits via GOSHLink for secure off site access to study documentation, ensuring our young patients still had a high quality patient experience by introducing personalised play boxes as well as maintaining staff morale and a sense of team spirit. The CRF team also needed to introduce changes. Those staff not redeployed to the clinical service introduced a change to shift patterns incorporating long days to reduce exposure and to ensure adequate cover for the essential on-site visits. All staff trained to cross-cover all prioritised trials that needed on site dosing visits. We received positive feedback from families regarding remote visits as well as the changes within the unit which ensured a safe environment for our patients Despite the challenges faced our adapted way of working has had a number of benefits and will inform our process moving forward.

The impact of telesensors on neurosurgical service demand: A cohort cost-effectiveness analysis from institutional and patient perspectives

Introduction: Implantable telemetric intracranial pressure sensors (telesensors) enable routine, non-invasive ICP feedback which can assist with clinical decision-making and attribution of pressure-related symptoms in patients with CSF shunt systems. Here, we aim to characterise telesensor cost-effectiveness and impact on service demand. Methods: A single-centre, retrospective, cohort study and costeffectiveness analysis of 80 patients (78% Female;30% IIH, 22% Chiari malformation, 48% other) with MScio® (Christoph Miethke) telemetric ICP monitors. Service demand in the two years before and after implantation were retrieved from the centre's electronic patient record system. Intentionally, data did not overlap with the COVID-19 pandemic period. The frequencies of hydrocephalusrelated neurosurgical admissions, outpatient clinics, and scans were recorded along with A&E, neurology, and ophthalmology encounters. Tariffs were used to compare expenditure before and after implantation. Results: Significant reductions were seen in the frequencies of neurosurgical admissions (1.9/year to 0.6;p < 0.001), ICP monitoring (0.4 to 0.01;p < 0.001), and CT scans (0.5 to 0.3;p = 0.013) following implantation. There were also significant reductions in the proportion of patients requiring admissions (91% to 45%;p < 0.001) and ICP monitoring (30% to 3%;p < 0.001). There were non-significant reductions in other invasive procedures, neurology encounters, and A&E admissions. Overall, there was a £341 (SD = 1069) per patient per year saving (22% reduction in included costs). Conclusions: From an institutional perspective, the implantation of telesensors contributes to a reduction in service demand and a net financial saving. From a patient perspective, fewer appointments, invasive procedures, and radiation exposures suggest an improvement in patient experience and safety.

The impact of telesensors on neurosurgical service demand: A cohort cost-effectiveness analysis from institutional and patient perspectives

Introduction: Implantable telemetric intracranial pressure sensors (telesensors) enable routine, non-invasive ICP feedback which can assist with clinical decision-making and attribution of pressure-related symptoms in patients with CSF shunt systems. Here, we aim to characterise telesensor cost-effectiveness and impact on service demand. Method(s): A single-centre, retrospective, cohort study and costeffectiveness analysis of 80 patients (78% Female;30% IIH, 22% Chiari malformation, 48% other) with MScio (Christoph Miethke) telemetric ICP monitors. Service demand in the two years before and after implantation were retrieved from the centre's electronic patient record system. Intentionally, data did not overlap with the COVID-19 pandemic period. The frequencies of hydrocephalusrelated neurosurgical admissions, outpatient clinics, and scans were recorded along with A&E, neurology, and ophthalmology encounters. Tariffs were used to compare expenditure before and after implantation. Result(s): Significant reductions were seen in the frequencies of neurosurgical admissions (1.9/year to 0.6;p < 0.001), ICP monitoring (0.4 to 0.01;p < 0.001), and CT scans (0.5 to 0.3;p = 0.013) following implantation. There were also significant reductions in the proportion of patients requiring admissions (91% to 45%;p < 0.001) and ICP monitoring (30% to 3%;p < 0.001). There were non-significant reductions in other invasive procedures, neurology encounters, and A&E admissions. Overall, there was a 341 (SD = 1069) per patient per year saving (22% reduction in included costs). Conclusion(s): From an institutional perspective, the implantation of telesensors contributes to a reduction in service demand and a net financial saving. From a patient perspective, fewer appointments, invasive procedures, and radiation exposures suggest an improvement in patient experience and safety.

A review of peri-operative diabetes care at Watford General Hospital

Diabetes affects around 15% of surgical patients and is associated with significant morbidity [1]. Poor peri-operative glycaemic control can result in longer hospital stays, up to 50% increased mortality and adverse postoperative outcomes including wound infection [1, 2]. Therefore, it is important to ensure diabetic peri-operative care is optimal, and as noted, in recent years, there is room for improvement. Methods A retrospective re-audit of electronic patient records was conducted to determine if peri-operative diabetic management was in line with local and national guidelines. We included all diabetic adults undergoing emergency or elective surgery, excluding obstetrics, in January 2022 at Watford General Hospital. Results Forty-seven of 618 (7.6%) patients who underwent surgery in January 2022 were diabetic adults meeting inclusion criteria. Of these 87% had type 2 diabetes, 51% were male and 55% were elective cases. Median age was 67 years (interquartile range 58-78.5 years). The majority (49%) were designated ASA status 2. Five of 21 elective cases had a glycated haemoglobin (HbA1c) result of > 69 mmol.l-1. Median surgical start time for elective diabetic patients was midday with 38% of cases occurring after midday. Starvation time was more than one missed meal or 12 h in 49% of patients. Variable rate intravenous insulin infusions (VRIIIs) were indicated in 43% of patients but only 10% received VRIIIs. Peri-operative blood glucose was maintained between 6-10 mmol.l-1 in 34% patients, 70% had intra-operative glucose monitoring but none hourly. Ketone testing occurred in one of two patients where indicated. Dexamethasone was given to 51% of patients (five of those were diet-controlled). Discussion A larger sample size was obtained on re-audit with 47 patients vs. 10 patients in January 2021, likely due to effects of the COVID-19 pandemic on elective surgery. Blood glucose monitoring pre- and postoperatively in diabetic patients has remained at least 70% in both audit cycles, but use of VRIIIs fell from 60% to 20%. We presented the findings at a clinical governance meeting and discussion of the guidelines identified that multiple documents and significant text acted as barriers to implementation. Therefore, we designed a flowchart to improve compliance and placed this in theatres and pre-operative areas. We hope this initiative, in addition to local teaching, will improve peri-operative diabetic care. We plan to re-audit and consider implementing further changes if care remains suboptimal. (Figure Presented).

Development of a remote model for pharmacist verification of chemotherapy during the COVID-19 pandemic

Background: Dr Gray's Hospital Elgin provides an outpatient chemotherapy service as a satelite unit to Aberdeen Royal Infirmary (65 miles away). Treatment is ordered at Dr Gray's by a suitably trained and experienced clinical pharmacist, pending patient blood test results. Purpose(s): The COVID-19 pandemic has brought with it many challenges. Anticipated staff shortages, coupled with the complete removal of shielded staff from the department, have necessitated changes to normal working practices. Method(s): Remote access to the NHS Grampian network was enabled for a pharmacist, working at home on an NHS Grampian device. Subsequently it was possible to access Chemocare, the chemotherapy prescribing and administration system, and Trakcare, the electronic patient records system. Following patient toxicity screening and reporting of their blood test results, the Macmillan nurses authorise the prescription, allowing final verification by the pharmacist. The technician then accuracy checks the chemotherapy and releases it for delivery to the unit, ready for administration to the patient. Result(s): The clinical pharmacy service to the outpatient chemotherapy clinic has been safely maintained by an appropriately qualified pharmacist, while minimising the level of input required from pharmacy technicians. Conclusion(s): There have been minimal alterations to the service. This has been possible through small adaptations to access existing electronic resources, and frequent communication between the pharmacist and technician. Through full utilisation of remote access to NHS systems it has been possible to implement this alteration to service whilst maintaining at all times patient confidentiality and full professional accountability.

A retrospective analysis of facial trauma related to e-scooter injuries in level 1 trauma centre - London

Background: Electric scooters (e-scooters) have become a popular mode of transportation. There use has been accelerated by the COVID-19 pandemic, which called for methods of transport allowing social distancing. Here we investigated injury patterns in patients presenting with escooter related trauma in a major trauma centre. Method(s): We retrospectively evaluated all e-scooter injuries presenting to our adult emergency department unit between March 2018 and March 2021. Case notes were retrieved through our electronic patient record system. Specifically, we focused on facial injuries and calculated costs associated with managing them. Result(s): A total of 299 patients were seen with injuries relating to e-scooter. 209 (70%) were male and 90 (30%) Female. Age range was between 18 and 78. 31 cases had major injuries and needed admission. The majority of injuries (30%) were related to upper extremity followed by (26%) lower extremity. 19% (53) of injuries involved the head and neck area. 20% (11) of these specifically needed admission. There was more than 50% increase in total number of injury in quarter 1 in 2021 comparing to same period in 2020 in keeping with the UK opening up from lockdown. Conclusion(s): Our results show there is an increase in number of injuries caused by e-scooter. This is in keeping with e-scooter becoming more popular mode of transport after the start of the pandemic. A significant proportion of these injuries are treated in the maxillofacial department. We believe our study can make treating clinicians aware of common injury patterns, guide further research and help inform policy change to improve e-scooter safety.

The Use of Telephone Versus Face to Face Appointments in Two Week-Wait Colorectal Surgery Clinics -a Single Centre Experience

Aim: Telephone appointments have replaced face-to- face hospital clinic appointments due to the Covid-19 pandemic. We evaluated the impact of telephone appointments on patients referred on a two week-wait (2WW) suspected lower gastrointestinal tract (LGIT) cancer pathway. Method(s): Two independent patient samples between the 01/06/2019-31/ 10/2019 (face-to- face cohort) and 01/06/2020-31/ 10/2020 (telephone cohort) were identified using a prospectively maintained local database and electronic patient records. Data were retrospectively collated using Excel (Microsoft, USA). Chi-square and Man-Whitney- U statistical tests were performed using SPSS (IBM, USA). Result(s): A total 1531 (median age = 70, interquartile range [IQR] = 60-79, female = 679, 44.4%) were analysed. Of these, 757 (49.4%) were assessed via telephone;the remainder were face-to- face (n = 774,50.6%). The age, gender and ethnicity distributions across the two groups were similar. A total of 92 (6%, telephone = 44, face-to- face = 48) patients had malignant pathology and 64 (4.2%) were colorectal cancer (CRC). Of those with a CRC diagnosis, 46 (3.0%, telephone = 26, face-to- face = 20) underwent surgical or endoscopic treatment with curative intent. There was no significant difference in diagnoses made (P = 0.749) or treatment of CRC (P = 0.785) following telephone versus face-face- appointments. The median waiting times for index appointment, investigation and diagnosis for telephone appointments were significantly lower compared to face-to- face appointments (P < 0.001). There was no significant difference in median time to index treatment for CRC between the two groups (P = 0.156). Conclusion(s): Patients referred to 2WW LGIT clinics were efficiently and safely assessed and manged using telephone clinics during the Covid-19 pandemic. The cost-effectiveness and stakeholder views on permanent use of telephone assessments in these clinics must be evaluated.

Does the CholeS pre-operative risk score for laparoscopic cholecystectomy correlate to operative time? A single centre experience

Background: NHSwaiting lists for elective surgeries including non-urgent laparoscopic cholecystectomies (LC) have severely escalated during the Covid-19 pandemic, with some patients waiting over 2 years for their operations. LCs are highly variable in terms of operative time, difficulty, and risk making theatre utilisation a challenge to effectively clear waiting lists. Nassar et al.[1] developed and validated a pre-operative risk prediction score for predicting the difficult LC using an objective operative difficulty grading system. We aimed to assess if application of CholeS could be used to predict which LC may have longer operative times, and so aid theatre utilisation planning. Method(s): Consecutive elective LCs performed between May and October 2021 at our institution's day surgery unit were included and analysed. Each patient was scored retrospectively using the CholeS pre-operative risk score from electronic patient records. Operative time was obtained from theatre electronic record systems. Data was collected on conversion to open surgery, post-operative day of discharge, and intra or post-operative complications. Outliers with operating time recorded as <20 minutes were considered data entry errors and excluded from analysis. A ROC analysis was used, which determined a threshold value of 3. This value was used to divide patients into a low-risk (<=3 points) and high-risk (four and above) group. Two-sample independent t-test was used to compare mean operative time between the high-risk and low-risk CholeS score groups. Levene's test was used to determine if variance was equal between groups. SPSS version 27[2] was used for data analysis and statistical tests and p<0.05 was deemed significant. Result(s): 81 LC were included for analysis. 53 patients were low-risk and 26 patients were high-risk. There was a significantly lower operative time in the low-risk group: Low-risk = 57.6 minutes (95% CI 52.4-63.0) vs high-risk = 75.8 minutes (95% CI 58.7-92.9), p=0.046. Nine patients had surgeries lasting >90 minutes;66% of these were in the high-risk LC group. 95% of patients were discharged on day 0, two patients on day 1, and two on day 2 or later. Three patients had conversion to open cholecystectomy and five patients had post-operative complications. Two out of three patients who required conversion to open cholecystectomies were in high-risk patients with high CholeS scores (7 and 10). In one patient, a cholecystoduodenal fistula was found. Cystic duct avulsion occurred in the other. Three out of five patients with post-operative complications were in the high-risk group, with corresponding higher Clavien-Dindo scores (3b, 2 and 2) when compared to the low-risk group (1 for both patients). Conclusion(s): The CholeS pre-operative scoring system could be used to optimise LC theatre allocation. Ascore of <=3 has a shorter operative time than a patient with a score of four or more (mean difference = 18.1 mins, 95% CI 4.4-31.9). Prediction of which LCs will be shorter operations could improve theatre utilisation and allow extra cases booking on the operating list. This, in turn, could help reduce the number of patients on the waiting list. Additionally, CholeS could be used to predict patients with more challenging and prolonged operations as well as those at higher risk of open conversion and complications. This could allow such patients to be managed by allocation to inpatient specialist upper GI specialist lists.

Management and outcomes of gallstone disease during the SARS-CoV-2 Coronavirus pandemic

Aims: The aim of this study was to compare The patient demographics and management of acute manifestations of gallstone disease during The COVID-19 pandemic with an equivalent period in 2019 and assess The differences in recurrence patterns over The period of first and second wave of The pandemic. Method(s): A retrospective cohort study of all adult patients aged >16 years presenting to The Emergency Department at a large District General Hospital with symptoms related to gallstones was conducted. Data was obtained from electronic patient records. Primary outcome assessed were incidence and management of gallstone disease while secondary outcome studied included length of Stay, re-admission rate and recurrence. Data was tabulated and analyzed using Excel (Microsoft, 2016 version). Chi square, t-test and one way ANoVA tests were used. Result(s): 51 patients presented during The period of first wave and 105 patients during second wave as compared to 71 patients in The study period during 2019. The median age of patients during The first wave of COVID was significantly higher than pre COVID and that in second wave. During both The waves of The pandemic, there was a no significant difference in patients presenting with cholecystitis compared with 2019 (47 and 94 versus 60;P value 0.39). There was no significant increase in use of cholecystostomy. There was no significant difference in recurrence and readmissions. Majority of The patients still await surgery. Conclusion(s): During The pandemic, older patients with higher comorbidity presented with acute gallstone disease. Conservative management was effective in The management of these patients.

COVID-19: Influence on Stoma Outcomes & Post-Operative Mortality

Introduction: The COVID-19 pandemic resulted in cessation of elective Surgery and a shift towards Emergency surgery, of ten non-curative with stoma formation. Our hospital stoma database scores Surgical complications (retraction, prolapse, stenosis and hernia) and patient symptoms (leakage, soiling, skin changes and odour), recorded by The specialist nurse at varying post-operative points Aim: To compare stoma scores and post-operative mortality pre-and mid-pandemic. Method(s): The stoma database (Microsoft Access) was interrogated for two periods: 16/03/19-16/09/19 (pre-pandemic) and 16/03/20-16/09/20 (mid-pandemic). Mortality at 6 and 12 months was extracted from electronic patient records (Clinical Portal). Result(s): Pre-pandemic, 28 patients underwent stoma formation. Median stoma score at post-operative day 3, day 10,6 months and 12 months was 0(0-4), 0(0-4), 1(0-8) and 1(0-3) respectively. Post-operative mortality was 21% at 6 months and 36% at 12 months. Mid-pandemic, 19 patients underwent stoma formation. Median stoma score at equivalent time intervals was 0(0-2), 1(0-8), 0(0-5) and 4 (n=1 patient score recorded). There was a relative paucity of data recorded mid-pandemic with a maximum of 9 patient scores recorded at any one time. Post-operative mortality was 16% at 6 months and 26% at 12 months. Conclusion(s): While acute Surgery during The pandemic does not appear tobeassociated with increased stoma complications and post-operative mortality was less during The pandemic, limited data recording makes true Comparison of pre-and mid-pandemic stoma outcomes difficult. Assessing The impact of The COVID-19 pandemic on Surgical outcomes may be limited by poor quality of data collected.