Background: As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may reduce waiting lists. However, evidence is needed to show that day-case surgery is safe for many ENT operations including endoscopic sinus surgery (ESS). We aimed to investigate the safety of ESS in England. Methods: This was an observational, secondary analysis of administrative data. Participants were all patients in England undergoing elective ESS procedure aged ≥ 17 years during for the five years from 1st April 2014 to 31st March 2019. The exposure variable was day-case or overnight stay. The primary outcome was emergency readmission within 30 days post-discharge. Results: Data were available for 49,223 patients operated on across 129 NHS hospital trusts. In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 100% to 20.6%. Rates of day-case surgery increased from 64.0% in 2014/15 to 78.7% in 2018/19. Day-case patients had lower rates of 30-day emergency readmission (odds ratio 0.71, 95% confidence interval 0.62 to 0.81). For secondary outcomes measures, there was no evidence of poorer outcomes for day-case patients. Outcomes for patients operated on in trusts with ≥80% day-case rates compared to patients operated on in trusts with <50% rates of day-case surgery were similar. Conclusions: ESS can safely be performed as day-case surgery at current rates. There is a potential to increase rates of day-case ESS in England, especially in departments that currently have low rates of day-case ESS.

Objectives: We aimed to characterise the use of tracheostomy procedures for all COVID-19 critical care patients in England and to understand how patient factors and timing of tracheostomy affected outcomes. Design: A retrospective observational study using exploratory analysis of hospital administrative data. Setting: All 500 National Health Service hospitals in England. Participants: All hospitalised COVID-19 patients aged ≥ 18 years in England between March 1st and October 31st, 2020 were included. Main outcomes and measures: This was a retrospective exploratory analysis using the Hospital Episode Statistics administrative dataset. Multilevel modelling was used to explore the relationship between demographic factors, comorbidity and use of tracheostomy and the association between tracheostomy use, tracheostomy timing and the outcomes. Results: In total, 2,200 hospitalised COVID-19 patients had a tracheostomy. Tracheostomy utilisation varied substantially across the study period, peaking in April-June 2020. In multivariable modelling, for those admitted to critical care, tracheostomy was most common in those aged 40-79 years, in males and in people of Black and Asian ethnic groups and those with a history of cerebrovascular disease. In critical care patients, tracheostomy was associated with lower odds of mortality (OR: 0.514 (95% CI 0.443 to 0.596), but greater length of stay (OR: 41.143 (95% CI 30.979 to 54.642). In patients that survived, earlier timing of tracheostomy (≤ 14 days post admission to critical care) was significantly associated with shorter length of stay. Conclusions: Tracheostomy is safe and advantageous for critical care COVID-19 patients. Early tracheostomy may be associated with better outcomes, such as shorter length of stay, compared to late tracheostomy.

Introduction: Litigation against the National Health Service (NHS) in England is rising, costing £2.4 billion in 2018/19. The aim of this study was to determine the incidence and characteristics of otolaryngology clinical negligence claims in England. Methods: A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to otolaryngology between April 2013 and April 2018. Analysis was performed using information for cause, patient injury and claim cost. Where claim information was adequately detailed, the authors categorised claims by subspecialty, diagnosis and operation. Results: A total of 727 claims were identified with an estimated potential cost of £108 million. From these, 463 were closed claims. Including open claim reserves, the mean cost of a claim was £148,923. Head and neck surgery was the subspecialty with the highest number of claims (n=313, 43%) and highest cost (£51.5 million) followed by otology (n=171, £24.5 million) and rhinology (n=171, £13.6 million). Over half of claims were associated with an operation (n=429, 59%) where mastoid surgery (n=46) and endoscopic sinus surgery (n=46) were equally associated with the greatest number of claims. The most frequent reasons for litigation included failure or delay to diagnose (n=178, 25%) failure or delay to treat (n=136, 19%), intra-operative complications (n=130, 18%) and failure of the consent process (n=107, 15%). Discussion: Clinical negligence claims in otolaryngology are related to several different components of patient management and is not limited to post-operative complications. This study highlights the importance of robust pathways in outpatient diagnostics and the consenting process, especially in the high-risk speciality of head and neck surgery, in order to deliver better patient care and reduce the impact of litigation.

Rationale, aims and objectives: The Getting It Right First Time (GIRFT) programme was set up to reduce unwarranted variation in healthcare practice and outcomes in England. The aim of this study was to investigate early changes in practice in urology based on the recommendations made. Key recommendations included: 1) to increase rates of day-case surgery for transurethral resection of bladder tumour (TURBT), 2) to reduce use of stenting as a primary procedure for emergency presentations with ureteric stones and 3) to reduce waiting times for male bladder outflow tract surgery following emergency presentation with urinary retention. Methods: Data on patient age, the treatment provider, dates of admission and discharge, diagnoses and procedures conducted were extracted from the Hospital Episodes Statistics database from January 2014 to December 2019. The dates of visits by members of the GIRFT team was taken as the intervention point. Interrupted time series analysis was used to identify trends pre- and post-intervention. Results: There was evidence of a significant increase in the proportion of patients seen as day-cases for TURBT and decreased use of stents and increased use of ureteroscopy or extracorporeal shock-wave lithotripsy on first presentation with ureteric stones following GIRFT visits. However, there was no significant change in waiting times for surgery to treat patients who had an emergency presentation with urinary retention. Conclusions: In the first 18 months following the last of the GIRFT visits, there is some evidence that the recommendations made are already having an impact on clinical practice. The reasons why some recommendation appear to be harder to implement requires further investigation.