Title : Improving follow-up and post-operative care in patients with acute pilonidal and perianal disease: A closed-loop clinical audit
Abstract:
Background: Pilonidal sinus disease recurs in roughly 15 to 40 percent of patients after incision and drainage, with recurrence rates varying by surgical technique. Each emergency admission costs the NHS approximately £1,081 per episode, with the wider socio-economic burden estimated at £8,791 per patient when lost working days are included, amounting to an estimated £96.7 million annually across England. NICE guidance mandates same-day incision and drainage, outpatient review within six to eight weeks, and patient education on perianal hygiene and hair removal to reduce recurrence. Working in a busy emergency general surgery unit seeing a high volume of these presentations, we identified that post-operative documentation and follow-up arrangements were falling short of these standards, prompting a two-cycle closed-loop audit.
Methods: The first cycle was a retrospective review of 37 patients who underwent incision and drainage for acute pilonidal or perianal abscess at Northwick Park Hospital between November 2021 and January 2022. Admission clerking sheets, operative notes, discharge summaries, and outpatient records were reviewed and benchmarked against NICE standards. On the basis of the results, we introduced targeted changes: a purpose-built clerking proforma, staff education at a clinical governance meeting, printed patient information leaflets for every admission, and a clear process for booking outpatient appointments directly from the Surgical Assessment Unit. A second cycle, a mixed retrospective and prospective review of 51 patients seen between May and July 2022, was then conducted using the same data collection approach.
Results: The first cycle revealed significant shortfalls. Follow-up was documented in operative notes for only 51 percent of patients and in discharge summaries for 49 percent. Outpatient clinic appointments were booked for just 35 percent of patients. Clerking sheets recorded prior presentation history in none of the cases, and not a single patient received recurrence-prevention advice. The overall RAG rating was Amber. Following the changes, the second cycle showed clear improvements across all measures. Follow-up documentation in operative notes rose to 88.2 percent (from 51 percent) and in discharge summaries to 90.1 percent (from 49 percent). Outpatient clinic appointments increased to 60 percent (from 35 percent). All clerking sheets captured prior presentation history, and every patient received recurrence-prevention advice and a printed information leaflet. Same-day incision and drainage was achieved in 74.5 percent of patients. The RAG rating improved to Green.
Conclusions: Introducing a structured set of practical changes including a disease-specific clerking proforma, staff education, and routine patient information led to meaningful and sustained improvements in the management of acute pilonidal and perianal disease, bringing practice in line with NICE standards across all measured outcomes. Given recurrence rates of 15 to 40 percent with simple incision and drainage alone, ensuring every patient receives proper follow-up and recurrence prevention advice has direct financial implications. Across our combined cohort of 88 patients, preventing a conservative 15 percent recurrence rate represents approximately 13 avoided emergency re-admissions, equating to a saving of roughly £14,000 in direct NHS costs for this cohort alone. Scaled to national volumes of around 11,000 acute admissions per year, this framework could translate into substantial NHS savings. Closed-loop audit proved an effective tool for identifying gaps in care and confirming that change made a real difference. The approach is straightforward to replicate and could benefit other busy emergency surgical units managing this patient group.
Keywords: pilonidal disease; perianal abscess; clinical audit; quality improvement; NICE guidelines; follow-up; NHS costs
