Effective pre-operative assessment of patients awaiting elective surgery should entail appropriate use of scarce NHS resources, as well as underpin patient safety. The pre-operative admissions service in district general hospitals is often junior doctor led, with a new cohort of clinicians taking over its running every four months. Lack of familiarity on the part of these clinicians with the investigative work up required for certain surgical procedures often results in over investigation of patients in the pre-admission setting, wasting time and NHS resources. A retrospective audit of 53 patients who underwent laparoscopic cholecystectomy over a representative two month period demonstrated that 33% of patients received unnecessary pre-admission blood tests, including clotting screen and 'group and save'. Design and implementation of a "Pre-Admission Handbook", for use by junior doctors and nurse practitioners in the pre-operative setting, reduced the rate of over investigation to 12% in a subsequent, prospective audit cycle of 50 patients, and has improved patient care by standardising the preadmissions process for elective surgery at Gloucester Royal Hospital. ProblemThe pre-operative admissions service at district general hospitals is often junior doctor led, with a new cohort of clinicians taking over its coordination and running every four months. New to both the surgical department and to clinical practice, these clinicians are often uncertain about the pre-operative investigative work up required for the range of surgical interventions offered by the department, and therefore request a battery of inappropriate and unnecessary tests in the pre admission setting in an attempt to ensure thoroughness. In particular, lack of awareness of the NICE pre-operative guideline for laparoscopic surgery was anecdotally felt to be resulting in a high rate of over investigation of patients awaiting laparoscopic cholecystectomy at Gloucester Royal Hospital. Inappropriate requests for clotting screens and 'group and save' blood tests increase the workload of the hospital laboratories with no clinical gain, as the risk of major bleeding and need for intraoperative transfusion is low for this procedure. This indiscriminate use of resources has clear financial implications in an increasingly resource limited NHS.

Aims Globally, an estimated 0.8 million children under five die of diarrhoea annually. Clear, evidence-based clinical management protocols exist, but their successful implementation in resource-limited clinical settings remains challenging. This clinical audit aimed to evaluate the impact of a simple, novel integrated care pathway (ICP) on standards of assessment and management of children with acute diarrhoea in a rural hospial in Bangladesh, and to assess any cost implication for the family. The ICP includes a simple checklist of clinical symptoms and signs which allow the severity of dehydration to be accurately assessed, and integrates this with the relevant treatment algorithm. The impact of the new ICP was measured against the 4 endpoints listed in the results section. Methods Retrospective case notes study of admitted children (1 month to 12 years) with acute diarrhoea in 2012. Patient management was evaluated against hospital guidelines. As the ICP was implemented at the end of May 2012, the patients were split into two cohorts: A (pre-ICP) and B (post-ICP). 183 patients were included in total. Admission Period Jan-May (Cohort A – pre ICP) Jun-Dec (Cohort B – post ICP) Number of Admissions 115 68 Results Accuracy of Dehydration Assessment: Children diagnosed with degree of dehydration inconsistent with their documented clinical signs were 34 (29%) in cohort A and 3 (4%) in cohort B. WHO rehydration plan: Children rehydrated with recognised rehydration plan (A, B or C) were 38 (33%) in cohort A and 55 (81%) in cohort B. Use of inappropriate IV fluids: Children given IV fluids without severe dehydration were 56 (49%) in cohort A and 13 (16%) in cohort B Cost implications: Average cost for rehydration fluids (oral and IV) was £3.26 for patients in cohort A and £0.92 for patients in cohort B. Conclusion The implementation of the ICP in this clinical setting improved the quality of acute diarrhoea management. Rates of incorrect dehydration assessment fell by 25%, rates of evidence-based rehydration increased by 48% and rates of unnecessary IV fluid administration decreased by 33%. In addition, there was a 72% reduction in cost of fluids for the family.