Abstract POSTER
BAPIOAC19-P01
INCIDENCE OF PROSTHETIC GRAFT INFECTION FOLLOWING LOWER LIMB AND OPEN AAA REPAIR SURGERY AT THE MANCHESTER VASCULAR CENTRE.
Basim Ali, Manchester, UK

Cite as: Ali,B. INCIDENCE OF PROSTHETIC GRAFT INFECTION FOLLOWING LOWER LIMB AND OPEN AAA REPAIR SURGERY AT THE MANCHESTER VASCULAR CENTRE. The Physician 2020 vol 6; issue 2 :abp01

BACKGROUND Prosthetic graft infection is a major complication of vascular surgery. Infection is associated with higher morbidity and mortality along with prolonged hospital stay. We investigated the incidence of prosthetic graft infections within a tertiary vascular centre over a 40 month period, from 2016 to 2019. 
METHOD This is a retrospective cohort single site study of prosthetic vascular grafts involving the lower limb, abdominal and axillary arteries. The primary objective was to find the incidence of vascular graft infection in patients undergoing graft procedures at the Manchester Vascular Centre. The outcome of each prosthetic graft infection was evaluated. Patient age, location of graft, type of prosthetic material and pathogen isolated were recorded. Data was extracted from the vascular activity log. 
RESULTS Of the 427 graft procedures performed between 2016 and 2019, 254 prosthetic grafts were identified. Procedures included were axillo-femoral, abdominal aorta and all lower limb interventions. There was a graft infection incidence rate of 4.7%. Patient outcomes ranged from recovery with antibiotic therapy, surgical intervention, amputation and death. The most common pathogens isolated were Enterococcus faecalis and Staphylococcus aureus. 
DISCUSSION The incidence of prosthetic graft infection identified here is 4.7%. After review of available literature, we have only been able to identify some studies which have looked at some but not the entire range of graft areas, notably we included abdominal aortic aneurysm repairs. The incidence of prosthetic graft infection at our centre may be a reflection of the wide anatomical range of prosthetic grafts considered but may also reflect the significant burden of smoking, illicit drug use, diabetes and chronic kidney disease in our patient population. 
KEY MESSAGES Prosthetic graft infections lead to significant morbidity, mortality and overall poor outcome for patients. Further research is needed into factors contributing to these adverse outcomes so that effective measures can be taken to improve end results.
BAPIOAC19-P02
The cost to the NHS of unnecessary post-op bloods post trauma and elective orthopaedic surgery at two major Manchester hospitals 
Basim Ali, Manchester, UK

Cite as: Ali, B. The cost to the NHS of unnecessary post-op bloods post trauma and elective orthopaedic surgery at two major Manchester hospitals. The Physician 2020 vol 6; issue 2: abp02

Background: Despite being one of the most efficient healthcare systems in the world, the NHS remains under constant financial pressures in view of ever-increasing health care demands. Clinicians therefore have an important duty to identify areas where efficacy savings can be achieved to ensure that funds are utilised in an effective manner. Aim: To identify savings that can be achieved by eliminating unnecessary post-operative blood tests for patients undergoing trauma and elective orthopaedic surgery. Setting: Manchester Royal Infirmary & Trafford General Hospital, University of Manchester NHS Foundation Trust, UK 
Methods: A retrospective service evaluation study was conducted to assess the cost of unnecessary post-operative blood tests for 50 patients who underwent trauma or elective orthopaedic surgery at 2 different hospital sites. The patients' notes were examined with 3 aims: 1) Identify the operations that were undertaken 2) Identify blood tests done up to 5 days post-operatively 3) Whether there was any clinical indication for the blood tests. 
Results: A cumulative of over 150 unnecessary blood tests were identified. The most common inappropriately ordered tests were CRP, Liver Function Tests, Bone profile and Coagulation screen. The total cost of these tests exceeded £750, a significant cost considering these figures are for only 50 patients. It was also noted that a higher number of unnecessary blood tests were carried out at Manchester Royal Infirmary, where most patients underwent trauma surgery, compared to Trafford General Hospital, where most patients underwent elective surgery. 
Conclusion: This study identified that significant savings can be achieved if the practice of ordering unnecessary post-operative blood tests is eliminated. We therefore recommend: 1) Education of medical and nursing staff about the financial/clinical implication of unnecessary bloods 2) A protocol is developed, potentially on the type of operation done, to order post-operative bloods so as to limit unnecessary tests.

BAPIOAC19-P03
Observational study of shoulder pain among patients undergoing cardiac procedure
Rudrik Thakkar, CIMS Hospital, Ahmedabad, India

Cite as: Thakkar, R. Observational study of shoulder pain among patients undergoing cardiac procedure. The Physician 2020 vol 6: issue 2; abp03

Background: Shoulder function and pain in patients undergoing cardiac procedures such as coronary artery bypass graft in poorly studied topic. Often due to lack of awareness of cardiac procedure complication or pre-existing shoulder pain, these patients are referred to the orthopaedics unnecessary in form of new shoulder problem. We carried out this study with an aim to identify prevalence of shoulder pain among patients undergoing elective cardiac procedure at a tertiary hospital. 
Method: A cross-sectional survey including a history and examination was carried out among patients undergoing a cardiac procedure at CIMS hospital, Ahmedabad, India. The face to face survey consisted of demographics, type of surgery, shoulder pain, past medical history including any interventions and a shoulder examination. 
Result: 31 patients were recruited and consented to the study who were undergoing an elective procedure. There were 25 (81%) men and 6(19%) women. Average age was 60. Among the patients the most common cardiac diagnosis was coronary artery disease (77%) followed by valvular disease (16%) and acute coronary syndrome (6%). The most commonly performed procedure was coronary artery bypass graft (55%) followed by coronary angiography (29%) and valvular replacement (13%). Shoulder pain was reported by 11(35%) patients and clinically identified by the shoulder exam among 9(29%) patients. Left shoulder pain was reported by seven patients in comparison to right shoulder pain which was reported by one patient. Bilateral shoulder pain was reported by three patients. There were four out of ten diabetic patients who reported shoulder pain. The most commonly diagnosed musculoskeletal following the history and examination was osteoarthritis (4) followed by frozen shoulder (3) and impingement shoulder (2). 
Conclusion: This study demonstrates that shoulder pain is extremely common among patients undergoing cardiac surgery. This study raises a key issue of patients who are unnecessary referred to orthopaedics following cardiac procedure.

BAPIOAC19-P04
Development of an acute general paediatrics service specification at a major London teaching hospital 
Julia Avery 
Cite as: Avery, J. Development of an acute general paediatrics service specification at a major London teaching hospital. The Physician 2020 vol 6; issue 2: abp04

Background and aims 28,000 patients between the ages of 0-18 present acutely to St George’s Hospital (mainly via the emergency department or following a GP consultation) and are the responsibility of the Acute General Paediatrics care group. They may be cared for in a number of settings and across a number of pathways of care. To ensure the delivery of a safe, patient centred, high quality service, we created a service specification based on the present plethora of national standards. This would also provide a means for ongoing quality analysis. 
Methods Relevant guidance was identified through a variety of search methods: direct search of national bodies’ websites, expert opinion and liaison with Trust managers to identify standards reported to regulators. 
Results 62 key standards were identified from six different guidelines. Thematic analysis of these standards identified nine overarching themes and within each, a number of sub-themes. A Red Amber Green (RAG) rating system was used to identify the performance of the service against each theme. An action plan has been created linked to the service governance strategy to ensure the standards can be achieved in the future. 
Conclusion The new service specification will be used by clinical staff to reflect on practice and outcomes. It enables clinicians to identify standards, rather than accessing them from various sources. It will aid planning, commissioning and provision of acute paediatric services and provide a framework against which to audit provision and demonstrate improvement. It would be possible to translate this for use across the UK.

BAPIOAC19-P05
Machine learning approaches to analyse effect of ethnicity on outcomes following living kidney donation in UK
Shanmugapriya Basker  

cite as: Basker, S. Machine learning approaches to analyse effect of ethnicity on outcomes following living kidney donation in UK. The Physician 2020 vol 6; issue 2: abp05

Background: Despite thousands of kidney donations every year across the world, there is decline in donations particularly within the BAME (Black Asian Minority and Ethnic community) and also there is paucity of data for risk assessment within the South Asian ethnicity. This study aims to describe the risk based on ethnicity, gender and regional variations and develop a predictive model. 
Method: This project uses Hospital Episode Statistics (HES) Admitted Patient Care (APC) data from 1997/8 to 2017/18 (20 years) with pseudo-anonymous data filtered by kidney donation codes. After trying several approaches to tackle extremely imbalanced dataset ‘Weighted Random Forest’ approach was selected as the final model. 
Results: Essential hypertension , End age and deprivation index ranked as three most important variables in risk of development of hypertension after donation in the Weighted Random Forest. The model has Negative Predictive Value (NPV) of 95% and True Negative Rate (TNR) of 77% proved that it was able to very well predict that the patients had ’No risk of hypertension’. Also the Recall rate of 65% showed the model is not overfitting due to its imbalanced nature. The stability of the model was verified by running the algorithm several times with k-fold cross validation and AUC as well. AUC was between 75% to 76% after running through 100 iterations with different set of data. Essential hypertension , End age and deprivation index ranked as three most important variables in risk of development of hypertension after donation. Logistic regression analysis showed that preexisting essential hypertension, male gender, age at kidney donation and low numbers of transplant providers are important risk factors for long term hypertension risk. In sub analysis, we found that South Asian ethnicity and obesity are additional risk factors.


BAPIOAC19-P06
Assessment of bowel motion in patients receiving pelvic Stereotactic ablative radiotherapy (SABR) 
Isobel Rycroft 

Cite as: Rycroft.I. Assessment of bowel motion in patients receiving pelvic Stereotactic ablative radiotherapy (SABR). The Physician 2020 vol 6; issue 2: abp06

Background: Stereotactic ablative body radiotherapy (SABR) is a novel technique that delivers high radiotherapy doses and is used to treat pelvic oligometastatic nodal disease. Pelvic radiotherapy can damage bowel. As a mobile structure, bowel position can change. It is unknown to what extent bowel mobility changes the dose it receives in SABR treatment. This study aimed to investigate the impact of bowel mobility on the dose it receives between and during (SABR) treatments. 
Methods: Planning CT plus pre and post-treatment Cone Beam CT (CBCT), for each fraction of treatment, were acquired for 5 patients. Bowel within a 3cm margin around the planning target volume (PTV) was contoured on all CBCTs and contours were superimposed onto the planning CT, to allow volumetric and dosimetric assessment. The volume of bowel within the 3cm margin, nearest edge of bowel to the PTV, mean dose and the maximum dose to 0.5cm2 were recorded. Measures for pre and post-treatment CBCTs were compared to determine motion during one treatment (intra-fraction). Measures for pre-treatment CBCTs and planning CT were compared to determine motion between treatments (inter-fraction). Wilcoxon signed-ranks tests were used for comparisons. 
Results: No significant differences in inter- or intra- fraction motion were noted for the whole population. However, for individual patients, bowel positions showed considerable variation and clinically relevant dosimetric changes were noted between and during treatment. 
Conclusions: Individual CBCT images should be reviewed for individual patients receiving pelvic SABR as in some cases the bowel may receive higher doses than intended.

BAPIOAC19-P07
Re-audit of variations in written consent for Laparoscopic Cholecystectomy and Inguinal Hernia Repair 
Vikramman Vignaraja 

Cite as: Vignaraja, V. Re-audit of variations in written consent for Laparoscopic Cholecystectomy and Inguinal Hernia Repair. The Physician 2020 vol 6; issue 2: abp07

Background Laparoscopic Cholecystectomy and Inguinal Hernia repair are two very common elective operations performed in general surgery. GMC guidance emphasises the process of informed consent and shared decision making. Failure to warn patients of a significant complication has ethical and medico-legal implications. 
Aim Re-audit the quality of written consent forms for elective Laparoscopic Cholecystectomy and Inguinal hernia repair at a DGH, against procedure specific consent forms(PSCF) that are being adopted in trusts nationally. 
Method We performed a retrospective analysis of written consent forms for elective Laparoscopic Cholecystectomies and Inguinal Hernia repairs for the month of November 2018, which totalled 28 and 23 cases respectively. We analysed each consent form and listed all complications consented for. This was benchmarked against studies listing all of the complications consented for in PSCFs. 
Results Laparoscopic Cholecystectomy - Between 6 and 11 complications were listed out of a possible 17 seen in PSCF. 4 complications were consented for in above 90% of forms. The other 13 complications ranged from being present in 88% to 0%. Conclusions Inguinal Hernia Repair - Between 5 and 11 complications were listed out of a possible 14 seen in PSCF. 2 complications were consented for in above 90% of forms. The other 12 complications ranged from being present in 69% of forms to 3%. 
Discussion Our results show huge variations between consent forms. Consent documentation may not have a direct effect on patient care and outcomes but has large ethical and medico-legal implications. Information regarding the risks of a procedure is important to the patient-physician shared decision-making process about the procedure. Patients may have decided not to proceed having known about a certain risk and thus may have avoided a surgical complication deemed personally unacceptable. In response the surgical department has plans to adopt formal PSCF provided by the royal college of surgeons.

BAPIOAC19-P08
Evidence for the existence of the FGFR1-NMDAR2B heteroreceptor complexes in the rat brain, and the relevance of this in treating major depressive disorder 
Ashwin Venkatesh, University of Cambridge, UK

Cite as: Venkatesh,A. Evidence for the existence of the FGFR1-NMDAR2B heteroreceptor complexes in the rat brain, and the relevance of this in treating major depressive disorder. The Physician 2020 vol 6; issue 2: abp08 

Background: Major depressive disorder (MDD) is both a ubiquitous yet heterogeneous condition, affecting around 15% of individuals at least once in their lives, who may present with an array of physical and cognitive symptoms. Accumulating evidence posits that the N-methyl-D-aspartate (NMDA) receptor may play an important underlying role in the neurobiology and thus the treatment of this disease. In addition, the FGFR1 receptor tyrosine kinase was previously shown to produce antidepressant-like effects when bound by one of its ligands. The formation of FGFR1-NMDA heteroreceptor complexes through allosteric receptor-receptor interactions may modulate downstream signalling pathways as well as recognition, trafficking and internalization of the constituent receptor protomers. Therefore we proposed the existence of a state of equilibrium between the FGFR1 and NMDA receptors and their heteroreceptor complex in the neuronal membrane, the balance of which may be altered in the depressed state. 
Methods: In our experiments, we used hippocampal and raphe nuclei sections from the brains of a wild-type Sprague-Dawley (SD) rat and in a selectively bred genetic rat model of depression, the Flinders Sensitive Line (FSL) rat, for comparison. We then localized and quantified the receptor complexes through immunofluorescence and in situ proximity ligation assay (PLA) techniques. 
Results and Conclusions: We obtained evidence for the existence of FGFR1-NMDAR2B heteroreceptor complexes in the hippocampus and midbrain areas of the adult rat brain. Analysis of the FGFR1 and NMDAR2B immunoreactivities indicate strong co-distribution of both receptor protomer in the same brain areas. Interestingly, NMDAR2B immunoreactivity studies suggest also a reduction in the expression level of the NMDAR2B subunit in the hippocampus and raphe brain regions of the FSL adult rats. Preliminary quantification analysis showed a significant reduction in the positive FGFR1-NMDAR2B PLA clusters in both studied areas in the genetic animal model for depression (FSL) with the exception of the molecular cell layer of the dentate gyrus. Taken together, this concept could pave new avenues for therapeutic exploration in reducing the global occurrence, recurrence and severity of major depressive disorder.

BAPIOAC19-P09  
The Effectiveness of Peer-Led Teaching for Medical Students 
Naomi Melamed 

Cite as; Melamed, N. The Effectiveness of Peer-Led Teaching for Medical Students. The Physician 2020 vol 6; issue 2: abp09

Background In recent years, peer-led teaching has come to the forefront of medical education demonstrating advantages for both medical students and peer-tutors. Moreover, the General Medical Council has highlighted the importance of teaching colleagues to meet the standards proposed in ‘Tomorrow’s Doctors’. This innovation in medical education has been reflected by a vast increase in the number of peer-led teaching societies at medical schools. However, the effectiveness of peer-led tutoring has been contested. Our study aims to explore the perspectives of third-year medical students and student tutors to evaluate the effectiveness of peer-tutoring programs. We also aim to identify potential obstacles peer-tutors may encounter within this process. 
Methods In 2019, 120 third-year medical students were invited to attend an extra-curricular session delivered by two fourth-year students from a London University. The session focused on developing clinical reasoning skills. All content was approved by a senior member of academic staff. Students and peer-tutors were invited to complete questionnaires following the session to evaluate their teaching and learning experience. 
Results In total, 102 students attended the session delivered by two peer tutors. Questionnaire responses were received from 95 students and both student-teachers. Of these students, 99% reported they would attend another session. Around 98% agreed the session benefited their learning. Both student-teachers stated they feel more confident and competent in clinical reasoning. However, they reported that preparing this session was time consuming. 
Conclusions Our results suggest that peer-led teaching complements medical school curricula and provides benefits to both students and student-teachers. However, the process revealed several obstacles. These include the limited clinical experience of peer-tutors and time spent preparing sessions. Despite this, we propose that peer-led teaching is an innovative concept allowing students a platform to exchange clinical knowledge.


BAPIOAC19-P10
Improving Patient Isolation Protocol Posters in a multicultural London Teaching Hospital 
Dijay Dave 

Cite as: Dave, D. Improving Patient Isolation Protocol Posters in a multicultural London Teaching Hospital. The Physician 2020 vol 6; issue 2: abp10

Background and Aims: Side rooms are used to nurse patients with clinical needs that require isolation; often to prevent cross infection but sometimes for non-medical reasons such as bed availability. The reasons for isolation are thus varied and ensuring both patients and visitors are aware of their specific isolation protocols are essential in providing personalised care. Posters are often used to convey this information however ensuring proper communication across language barriers in a multicultural setting such as London can be difficult. We thus sought to both audit and improve the current posters used in our London teaching hospital setting. 
Methods: We interviewed 10 patients, visitors and doctors at our teaching hospital. Participants were asked about their experience of side rooms, whether visitors (both personal and staff) followed trust isolation guidelines and their preference of the graphical posters we designed for both contact and airborne precautions. Fig. 1 Current and new PPE (Personal Protective Equipment) posters for contact and airborne precautions 
Results: The majority of patients did not know the reason for themselves being in a side room and did not see visitors following isolation guidelines. All participants preferred the newly drafted posters over the current PPE posters. Conclusion: We discovered that in our multicultural hospital the majority of patients had decreased adherence and understanding of Patient Isolation protocols despite the presence of the posters. Our survey data showed that all patients, staff and visitors would prefer to have a new poster. Our newly drafted poster had overwhelming support from both patients and staff. The new Patient Isolation posters are in the process of being implemented at our teaching hospital.


BAPIOAC19-P11
Introducing Emergency Simulation Training in Paediatrics
Vikramman Vignaraja  
vikram.vignaraja@nhs.net 
cite as: Vignaraja, V. Introducing Emergency Simulation Training in Paediatrics. The Physician 2020 vol6; issue2: abp11 DOI: 10.38192/1.6.2.18

Aim 
To introduce regular paediatric emergency simulation sessions for paediatric trainees at QEH, Woolwich and to evaluate early attitudes toward its role in training. 
Background 
Direct repeated experience is necessary for trainees to gain confidence and competence in management of time critical, life threatening scenarios. The relative infrequency of paediatric arrest and peri-arrest situations means opportunity to gain vital experience can be limited. Simulation offers an effective educational tool to bridge the gap between theoretical knowledge and real life implementation. Multiple studies have shown that simulation in Paediatrics correlate with better health outcomes for patients ranging from an improvement in cardiopulmonary arrest survival rates, earlier identification of a sick child and reduced serious safety incidents in A&E. 
Method 
We started off by surveying junior doctor attitudes towards simulation in training. My sample population included junior paediatric SHOs, GP trainees and ED SHOs. Though my sample size was small it showed strong support for paediatric simulation. We conducted the sessions in the paediatric resuscitation bay in A&E to make the situation as realistic as possible. This has the added benefit of making sure when in a real emergency, trainees know where to find necessary equipment. Scenarios have been run by experienced registrars for small groups of trainees. Scenarios have been run by experienced registrars for small groups of trainees. 
Results 
We initially surveyed 10 SHO grade doctors and of these, 7 reported that they felt “very unconfident” in managing paediatric emergencies. Evaluation forms from our simulation session on managing life threatening asthma showed that 7 out of 8 doctors who attended said that they felt more confident to manage the situation after having had simulation in it. 
Conclusions 
These results show the effectiveness of simulation on trainee confidence in managing emergencies by experiential learning. Good facilitators are crucial to run the simulation. Without reflection, the learning process is greatly diminished.

BAPIOAC19-P12  
Exploring Surgeon Burnout: Its Causes and How It Affects the Quality and Safety of Patient Care 
Tmam Alghunaim 

Cite as: Alghunaim, T. Exploring Surgeon Burnout: Its Causes and How It Affects the Quality and Safety of Patient Care. The Physician 2020 vol6; issue2: abp12 DOI: 10.38192/1.6.2.19

Background: 
Poor well-being may affect the performance of all types of workers. Surgeons, in particular, are inclined to suffer from burnout. However, a lack of definitive research on the link between burnout and patient care exists. Understanding this could help identify the outcomes of surgeon burnout and underline the need for interventions. 
Objective: 
The present study aimed to inform the design of a broader project investigating burnout in surgeons. Methods: A paper survey with 6 questions was developed after the review of the literature. The survey was conducted between January to March 2019 to design and develop an interview schedule and identify whether stress and burnout are issues in Yorkshire surgeons. 
Results: 
Eighty-three surgeons from different specialities, including urology, general surgery, trauma and orthopaedic surgery and neurosurgery, completed the survey. Of these 44% were consultants and 56 % were trainees. Ninety-two percent of participants believed that stress and burnout are issues for surgeons within the NHS. The results of the survey were used to develop a semi-structured interview study, which will include 15 to 20 surgeons from different specialities. The interview study will explore reasons for surgeon burnout and identify a mechanism to support surgeons in the workplace to prevent or reduce burnout. The research may also be used to improve patient safety and quality of care. 
Conclusions: 
Surgeons are more likely to experience a high level of burnout. Further study is needed to explore factors responsible for the burnout and methods to help surgeons to manage it effectively.


BAPIOAC19-P13
Rapidly Growing Cutaneous Squamous Cell Carcinoma of the Nose in Chronic Lymphocytic Leukaemia 
Seth Dhillon 
Cite as: Dhillon, S. Rapidly Growing Cutaneous Squamous Cell Carcinoma of the Nose in Chronic Lymphocytic Leukaemia. The Physician 2020 vol6; issue2: abp13 DOI: 10.38192/1.6.2.19 

Patients with chronic lymphocytic leukaemia (CLL) are at an increased risk of developing cutaneous squamous cell carcinoma (cSSC). In addition, the cSCCs appear to behave more aggressively, most likely due to the immunosuppressed state of the CLL patient. The literature documenting the clinical course of cSCCs in CLL is sparse. 

We present a case of an exceptionally fast growing cSCC of the nose in a patient with CLL. 

An 89-year old gentleman with a pre-existing diagnosis of CLL was referred to us with an cSCC of the dorsum of the nose. The tumour encompassed almost the entirety of the nose, extending to the right medial canthus. The lesion was identified as a local recurrence of a moderately-differentiated primary cSCC which was excised 11 months previously by curettage and cautery without further follow-up. The cSCC subsequently recurred and underwent a period of exceptionally rapid growth. In consideration of the patient’s age and comorbidities it was deemed that radical surgery, requiring total rhinectomy and right orbital exenteration, was not appropriate. The patient instead received palliative radiotherapy. The current guidelines state that any cSCC in an immunocompromised patient should be treated as high-risk and managed accordingly. 

This case highlights the need for an increased awareness that CLL causes progressive immunodeficiency, hence all cSCCs in these patients should be treated as high risk. Most importantly, the chosen method of excision should allow marginal clearance to be established, significantly reducing the chance of local recurrence. The case also brings to the fore the challenges in making treatment decisions for patients nearing end of life with multiple co-morbidities.

BAPIOAC19-P14
Calcium imbalance in Sarcoidosis and Renal Failure 
Abilash Sathyanarayanan 

Cite as: Sathyanarayanan, A. Calcium imbalance in sarcoidosis and renal failure. The Physician 2020 vol 6: issue 2: abp14 DOI: 10.38192/1.6.2.21

Case details: 
A 59 year old gentleman with a background history of chronic kidney disease stage (CKD) 4, type 2 diabetes mellitus, hypertension, congestive cardiac failure and bilateral lower limb below knee amputations, presented with hypercalcaemia of 3.30 mmol/L (reference range 2.20 - 2.60) and suppressed PTH at 12 ng/l (reference range 15-65),from a previously raised PTH level of 162 due to CKD. 

Investigations showed raised ACE levels of 106 U/l (reference range 10-52), enlarged mediastinal and hilar lymph nodes on CT. A presumptive diagnosis of sarcoidosis was made in view of patient’s reluctance to undergo invasive biopsy. He was treated with oral prednisolone 60 mg od. Calcium normalised to 2.56 mmol/L within one week and continued to drop further leading to symptomatic hypocalcaemia at 1.87 mmol/L in 3 weeks. The PTH rose to 268 ng/l. This was treated with alfacalcidol and the calcium normalised. He was weaned off prednisolone and patient stopped alfacalcidol in few months and the calcium remains normal with a raised PTH. 

Discussion: 
 We hypothesise that, on administering the prednisolone in this patient, there was inhibition of extra renal 1,25-OH-Vitamin D synthesis in the sarcoid granulomas. The CKD induced Vitamin D deficiency in the background was unmasked by amputating the predominantly extra-renal source of Vitamin D in this patient by treatment with prednisolone. This explains the presentation of hypercalcaemia with a suppressed PTH level initially, which then reversed. On treatment there was a high PTH secondary to low 1,25 OH Vitamin D. It is interesting to note that there is one case report of sarcoidosis ameliorating the symptoms of hypoparathyroidism. 

Conclusion: 
 We discuss the complex interactions between renal and extra renal 1-alpha-hydroxylases and the need for vigilance if multiple mechanisms of calcium homeostasis are affected in a patient.

BAPIOAC19-P15
Improving the documentation of regional anaesthesia catheter procedures at St George’s Hospital, London 
Khadijah Rashid 

Cite as: Rashid, K. Improving the documentation of regional anaesthesia catheter procedures at St George’s Hospital, London. The Physician 2020 vol 6; issue 2: abp15 DOI: 10.38192/1.6.2.22 

Background and aims: 
Regional anaesthetic techniques provide effective analgesia post-operatively and in trauma patients such as those with multiple rib fractures. Documentation of the regional anaesthesia (RA) procedures is an issue due to the recent transition from paper to iCLIP computerised system to document electronically. Documentation of pain scores in patients before and after the block on the same day is also an issue. It is useful to create an ‘Anaesthetic catheter procedure template’ suited for iCLIP to improve documentation. This template will include pre and post block pain scores which can be documented adequately. 
Methods: 
 This was a retrospective review of the available data from hospital paper notes and iCLIP from 13/05/19 to 24/05/19. A total of 21 patients were included in this study who needed a catheter for different reasons. The following were analysed: 1) documentation of catheter procedure and where it was documented, 2) documentation of pain scores pre and post catheter. 
Results: 
 Differences were found in the location of documentation varying from electronic to paper as well as variability in paper documentation. There was also considerable variation in how the electronic document was titled. A total of 12 out of 21 procedures were documented under documentation section within iCLIP. 11 out of 21 procedures were documented in paper. About 76% of the patients did not have pain scores documented prior to the nerve block. A total of 14 patients had their pain scores documented on day 0 post block. 
Conclusion: 
Documentation of RA procedures in St George’s Hospital can be improved by introducing a template ensuring less inconsistency. This enables to document the procedure as well as pain scores before and after to measure effectiveness of the nerve block received by the patients. An audit will be conducted six months after the template is in place.

BAPIOAC19-P16
Treatment Escalation Plan Quality Improvement Project 
Nikhil Aggarwal 

Cite as: Aggarwal, N. Treatment Escalation Plan Quality Improvement Project. The Physician 2020 vol 6; issue 2: abp16 DOI: 10.38192/1.6.2.23

Background: 
Treatment escalation describes the level of treatment intervention which would be appropriate, should the patient become acutely unwell. Patients may be subjected to inappropriate investigations and management by the ‘on call’ team as well as inappropriate referrals to ITU/HDU because there is often no clear documentation regarding the ‘ceiling of care.’ Furthermore, documentation of a treatment escalation plan (TEP) is often difficult to find and vague.
Methods: 
Data was collected from three care of the elderly (CoE) wards for the presence of a documented TEP in the notes. A TEP proforma was designed through collaboration with staff. The agreed version was to be filled out by doctors, grade registrar and above. It was trialled on the same three CoE wards for four weeks. Post-intervention data was collected on rates and location of TEP documentation. Qualitative feedback was sought from staff. 
Results: 
Pre-intervention, data was collected from 58 patient notes, 22 patients (37.9%) had a documented TEP. The location of the TEP varied. The documentation for 100% of patients simply stated “ward based ceiling of care.” Following our intervention, data was collected from 48 patient notes and 35 patients (60.4%) had a documented TEP. The proforma was used in 100% of cases with a documented TEP. Overall, staff felt that the proforma was quick to fill out, clear and useful. The main issue raised was having to complete an additional form as well as the DNAR form.
Conclusion: 
 The new TEP proforma has improved documentation rates of TEPs providing clarity when dealing with deteriorating patients and therefore improving patient care. The next step will be to modify and review the proforma with consultation from the legal department to merge the DNAR and TEP proformas. This proforma is a major step in maintaining and improving patient safety. 

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