Steve Ramcharitar

Anomalous origination of a coronary artery from the opposite sinus

Anomalous origination of a coronary artery from the opposite sinus (ACAOS) is estimated to be present in 0.2–2.0% of the population. In the majority of individuals, ACAOS has no hemodynamic or prognostic implications, but in a minority of cases, typically where the anomalous coronary artery takes an interarterial course to reach its correct myocardial territory, it can precipitate ischemia and sudden cardiac death (SCD). With the growing use of CT coronary angiography (CTCA) in the investigation of ischemic heart disease, we can expect increasing rates of incidental detection of this anomaly. Although CTCA and magnetic resonance coronary angiography can effectively characterize these lesions anatomically, they fail to describe and quantitatively assess the basic defect that leads to coronary insufficiency, such as mural intussusception. The key challenge lies in the identification of which patients are at risk of SCD and, therefore, who should be offered corrective surgical or (potentially) percutaneous intervention. Conventional, noninvasive stress testing has limited sensitivity, but emerging, invasive stress tests, which utilize intravascular ultrasonography and measurements of fractional flow reserve, show the potential to provide more-accurate hemodynamic and prognostic assessment.

SHOUT to improve the quality of care delivered to patients with acute kidney injury at Great Western Hospital

Abstract Acute kidney injury (AKI) affects up to 20% of all patients admitted to hospital, and is associated with a higher risk of adverse clinical outcomes, increased healthcare costs, as well as long term risks of chronic kidney disease and end stage renal failure. The aim of this project was to improve the quality of care for patients with AKI admitted to the acute medical unit (AMU) at the Great Western Hospital (GWH). We assessed awareness and self reported confidence among physicians in our Trust, in addition to basic aspects of care relevant to AKI on our AMU. A multifaceted quality improvement strategy was developed, which included measures to improve awareness such as a Trust wide AKI awareness day, and reconfiguring the admission proforma on our AMU in order to enhance risk assessment, staging, and early response to AKI. Ancillary measures such as the dissemination of flashcards for lanyards containing core information were also used. Follow up assessments showed that foundation year one (FY1) doctors’ self reported confidence in managing AKI increased from 2.8 to 4.2, as measured on a five point Likert scale (P=0.0003). AKI risk assessment increased from 13% to 57% (P=0.07) following a change in the admission proforma. Documentation of the diagnosis of AKI increased from 66% to 95% (P=0.038) among flagged patients. Documentation of urine dip results increased from 33% to 73% (P=0.01), in addition to a rise in appropriate referral for specialist input, although this was not statistically significant. Our results suggest that using the twin approaches of improving awareness, and small changes to systemic factors such as modification of the admission proforma, can lead to significant enhancements in the quality of care of patients with AKI.

Iatrogenic mitral stenosis following transcatheter aortic valve replacement (TAVR).

A 57 year old female underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Mild iatrogenic mitral stenosis was noted intraoperatively. Attempts to reposition the device were hampered by aortic angulation. One year later, severe mitral stenosis was confirmed on transoesophageal echocardiography. It is important to recognise that iatorgenic mitral stenosis due to TAVR may progress over time. Care should be taken to minimise the risk of this rare complication.

Simple interventions can greatly improve clinical documentation: a quality improvement project of record keeping on the surgical wards at a district general hospital

Abstract Clinical documentation is an integral part of the healthcare professional’s job. Good record keeping is essential for patient care, accurate recording of consultations and for effective communication within the multidisciplinary team. Within the surgical department at the Great Western Hospital, Swindon, the case notes were deemed to be bulky and cumbersome, inhibiting effective record keeping, potentially putting patients’ at risk. The aim of this quality improvement project was therefore to improve the standard of documentation, the labelling of notes and the overall filing. A baseline audit was firstly undertaken assessing the notes within the busiest surgical ward. A number of variables were assessed, but notably, only 12% (4/33) of the case notes were found to be without loose pages. Furthermore, less than half of the pages with entries written within the last 72 hours contained adequate patient identifiers on them. When assessing these entries further, the designation of the writer was only recorded in one third (11/33) of the cases, whilst the printed name of the writer was only recorded in 65% (21/33) of the entries. This project ran over a 10 month period, using a plan, do study, act methodology. Initial focus was on simple education. Afterwards, single admission folders were introduced, to contain only information required for that admission, in an attempt to streamline the notes and ease the filing. This saw a global improvement across all data subsets, with a sustained improvement of over 80% compliance seen. An educational poster was also created and displayed in clinical areas, to remind users to label their notes with patient identifying stickers. This saw a 4-fold increase (16%-68%) in the labelling of notes. In conclusion, simple, cost effective measures in streamlining medical notes, improves the quality of documentation, facilitates the filing and ultimately improves patient care.

Improving accessibility of trust guidelines and protocols at the Great Western Hospital, Swindon

Abstract Trust guidelines and policies outline recommendations for the management of common clinical and non-clinical situations, serving to standardise best practice. Prior to this project, there was no consolidated location for these documents. Lack of organisational structure and inadequate search functionality within the trust intranet led to time wasted locating information, acting outside of recognised best practice, and ultimately potentially compromising patient safety. We surveyed 55 junior doctors, 95% of respondents were dependent on guidelines on a daily basis. 20% spending greater than 5 minutes to locate protocols and 38% unable to locate some relevant documents at all. We analysed the time taken for junior doctors to locate six randomly selected protocols. Pre-intervention mean time was 133 seconds (on six occasions doctors were unable to locate the guideline). All trust guidelines and protocols currently available on the intranet were collated, consolidated, and renamed according to content. These were then re-alphabetised and new search terms linked to each document. Existing links were then uploaded and a single web page made available via the trust intranet homepage. The new page was publicised by email, posters and interdepartmental presentations. In our post intervention survey, 97% of respondents were aware of the project and had made use of the page. All protocols were located during re-testing with 90% of those resurveyed stating it was easier to locate protocols. Overall, a reduction in the time and number of clicks required to locate protocols was demonstrated: mean time 16 seconds vs 133 seconds pre-intervention (n=60). 53% of guidelines located in <30s and 86% <2 minutes.

The Tryton® dedicated bifurcation stent: Five year clinical outcomes

AIMS We report the first 5 year clinical follow-up data for the Tryton® bifurcation stent. METHODS AND RESULTS Clinical outcomes at five years were collected from 8 centres. Non-hierarchical Major Adverse Cardiovascular Events (MACE) and Major Adverse Cerebrovascular and Cardiovascular Events (MACCE) were collected. Diabetic and non-diabetic populations were compared, along with small (≤2.5 mm) vs large (>2.5 mm) side branch size. 173 patients with a follow up rate of 98% at 5 years were analysed. Non-hierarchical MACE was low at 9.8%, consisting of cardiac death of 1.2% (n = 2) and MI of 1.7% (n = 3). Target lesion revascularization (TLR) rate was 6.9% (n = 12). Non-hierarchical MACCE was also low, with major bleeding in 2.3% (n = 4) and strokes in 1.7% (n = 3) of patients. There was only 1 case (0.6%) of stent thrombosis that was definite and occurred very late (782 days). All-cause mortality was low, with 8.7% combined cardiac and non-cardiac death (n = 15). Diabetic patients had significantly higher event rates, but there was no difference in events with lesion stratification by side branch size. CONCLUSIONS The Tryton® Side-Branch Stent has a non-hierarchical MACE of 9.8% and MACCE of 13.9% at 5 years. The TLR was 6.9% with only 1 case of stent thrombosis recorded.

89 Implementation of a Modified Version of Nice Clinical Guideline 95 On Chest Pain of Recent Onset: Experience in a District General Hospital

Introduction NICE Clinical Guidance 95 was introduced to Rapid Access Chest Pain Clinics (RACPC) to aid investigation of possible stable angina based on pre-test probability of coronary artery disease (CAD). Following a recent 6 month audit of its implementation in our centre, we introduced a modified version, such that all patients with low or moderate risk of CAD were referred for computated tomography coronary angiography (CTCA), whilst those at high or very high risk were referred for invasive angiography. Methods The electronic patient records of 546 patients consecutively referred to our RACPC from primary care over a 6 month period were retrospectively analysed. Initial pre-test probability of CAD, referral for initial investigation, incidence of significant CAD and rates of revascularisation at a minimum follow-up time of 6 months were documented. Results A large proportion of patients assessed had symptoms that were unlikely to be anginal in origin and were discharged directly from RACPC without further investigation. Rates of CAD generally correlated well with pre-test probability. Moderate risk patients showed low rates of CAD and revascularisation. CTCA had a shorter time to investigation than stresse cho, but a number of false positive results. High and very high risk patients had high rates of revascularisation and a large proportion of this was for prognostically significant disease. Conclusions Low rates of CAD in low and moderate risk groups justifies the use of CTCA as a first line investigation in these patients, reducing waiting times to investigation. Routine investigation of very high risk patients allows a significant proportion to undergo revascularisation for prognostically significant disease. Strict adherence to NICE CG95 could possibly lead to these patients being missed.Abstract 89 Figure 1 Incidence of coronary artery disease and revascularisation by pre-test probability group

‘Stack of coins’ indicative of arrhythmogenic right-ventricular dysplasia

A 30-year-old South East Asian man presented with presyncope. His 12-lead ECG showed a broad complex tachycardia with left bundle morphology which reverted to sinus rhythm with intravenous Amiodarone and Bisoprolol. Subsequent resting ECG demonstrated incomplete right bundle branch block and antero-septal T-wave inversion. Coronary angiography was normal, but his right ventriculogram had changes consistent with arrhythmogenic …