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Aim The handbook to the NHS constitution for England pledges a maximum four-hour wait in the Emergency Department (ED) from arrival to admission, transfer, or discharge. We present a closed-loop audit of ED waiting times for patients admitted under Trauma and Orthopaedics (T&amp;O), before and after implementation of a change in practice, with the aim of reducing the number of patients that breached the four-hour target. Method An initial single-centre audit of patients that were admitted under T&amp;O through ED was undertaken (25/11/2019 – 02/12/2019). All stakeholders were educated on audit findings through departmental meetings. Protocols were updated and new guidelines were synthesised and implemented in collaboration between the ED and T&amp;O departments. Waiting times were re-audited (21/06/2021 – 28/06/2021). Data was collected retrospectively from clinical e-documentation. Results 57 patients were included in the initial audit and 51 patients in the loop closure. The total number of breaches improved from 86% to 65% (p &amp;lt; 0.05). The first audit highlighted that the biggest cause of breaches was ‘waiting for an ED review’ (56%) followed by ‘waiting for over thirty minutes for a bed’ (28%). Following our intervention, breaches due to ‘waiting for an ED review’ reduced (28%) and the biggest cause of breaches changed to ‘waiting for over thirty minutes for a bed’ (45%). Conclusions Our closed-loop audit identified that improved formalised protocols for ED referrals to specialities and clinical guidelines agreed upon by both parties (ED and T&amp;O) reduces the number of breaches in ED.

243 How to Reduce Breaches of Trauma & Orthopaedics Patients in the Emergency Department: A District General Hospital Experience