The effect of the disruption caused by the COVID-19 pandemic on the rates of post-tonsillectomy complications after the recovery of services

Aim: In June 2020, and after the first wave of the COVID outbreak has settled, we resumed operating in our trust for elective surgery in three different hospitals. However, it was thought that the number of posttonsillectomy complications had increased. We performed an audit to evaluate the rate of post-tonsillectomy complications in our trust and investigate possible causes. Method: We measured the rates of patients who developed complications post-operatively during the period from June to November 2020 and compared it to the rates in the pre-COVID year and the national rate. Moreover, we scrutinized retrospectively the operative notes of each patient presenting with a post-tonsillectomy complication and identified risk factors. Results: In the study period, we performed 129 tonsillectomies. Of these patients, 14 presented with complications;11of which had bleeding, while 3 had post-operative pain. Two patients needed to return to the theatre to control the bleeding. During the same period in 2019, 28 patients had complications out of a total of 199 patients. The rate of complications in 2020 was 10% which compared favourably with the previous year (14%). The highest number of patients (9/14) was in a hospital which posed a new environment to our surgeons. Dissection by Bipolar diathermy was the most contribute factor for bleeding in most patients (11/14). Conclusions: The disruption caused by the pandemic situation did not influence overall rates of complications. However, the hospital which presented a new operating environment had the highest rate.

Consenting surgical patients for the risk associated with contracting COVID-19 during their stay at the hospital

Aim: Literature is suggesting significant perioperative mortality and morbidity associated with COVID-19. Therefore, the Royal College of Surgeons (RCS) has produced guidance detailing additional considerations in consenting for surgery whilst COVID-19 is prevalent within society. Section 3A of this document emphasizes the need to discuss the risk of contracting COVID-19 while patients are in hospital. We conducted a multi-cycle closed-loop audit to examine the adherence to this guidance. Method: We completed four audit cycles, each comprising data collection and educational intervention to disseminate the guidance. Data was obtained from consent forms for patients who had consented to both emergency and elective surgery over a two-month period at a large NHS Trust in London. The intervention consisted of teaching sessions, regular emails to the general surgical department, and posters displayed in common areas. Results: Consent forms from 139 patients were reviewed over the four cycles (n=38, 41, 28, and 32). The proportion of patients consented for the risk of contracting COVID-19 during the perioperative period rose serially between the cycles (37%, 61%, 71%, and 85% respectively), and was significantly increased between the first and last cycle (p , 0.01, two-sided Z-test). The interventions proved most effective for senior house officers who improved from consenting 8% initially to 100% on completion of the audit. Conclusions: We demonstrate the marked effectiveness of simple interventions combined with serial auditing to disseminate this message. The same practice may help improve consenting practice at other centres whilst COVID-19 is prevalent in society.

A quality improvement project: novel electronic operative note templates to improve the continuity of post-operative patient care

Introduction: Good Surgical Practice from RCS England encourages the use of e-health records and detailed typed operative notes. The Covid- 19 pandemic has led to multi-site operating. ENT operations in our trust were split over three sites including the private sector leading to potential disruption in continuity of patient care. Physical operation notes are difficult to access in emergencies, telephonic clinics or for audit purposes. We aim to have operative notes available on patients' erecords which adhere to RCSEng guidelines. Method: In this QIP, we reviewed all ENT operations over a retrospective one-month period recording percentage of notes uploaded to patient e-record and the number of surgeons in theatre. We created two novel RCSEng compliant e-operative notes with a user guide, generic and tonsillectomy-specific, and prospectively collected data to complete the cycle. Results: 261 patients were included in both study periods. Only 36/ 134(27%) had e-operative pre-intervention improving to 71/127(56%) post-intervention. In the latter period, 76% of operations included a registrar and were more likely to have e-operative notes(72%) compared to when a consultant was operating alone(6%). There was low uptake of our tonsillectomy e-proforma(33%). Conclusions: Our QIP has already proved effective with our templates increasing operative documentation on e-records. Increased use of etemplate was more likely with the presence of a registrar in theatre. Room for improvement remains and we will re-audit after the introduction of further user-friendly operative templates and IT training. This QIP has also revealed additional operative training opportunities of which registrars can take advantage.