Referral Finder: Saving Time and Improving The Quality of In-hospital Referrals

The Role of Quality Improvement Projects in a Complex Abdominal Wall Service

Background Complex abdominal wall hernias have proven challenging to manage, and such patients often require abdominal wall reconstruction (AWR). However, in the context of a socialist healthcare service, which is required to provide equal and fair healthcare access to all, the heavy resource burden and non-life-threatening nature of complex abdominal wall hernias mean that this patient group may not be prioritised. In this paper, we outline the significant quality of life (QoL) burden on patients requiring AWR and the importance of quality improvement projects (QIPs) in establishing and streamlining their care as a robust, transferable model across centres. Methodology We undertook the creation of a regional AWR multidisciplinary team meeting and referral proforma, establishing a joint clinic between the Plastics and General Surgery teams and registering a standard operating procedure for the use of progressive pneumoperitoneum in a subset of AWR patients. We collected qualitative data using questionnaires sent out to clinicians and patients as well as used recognised outcome scales (pre- and post-operative European Hernia Society Quality of Life score, otherwise known as EuraHS-QoL score, and post-operative Carolinas Comfort Scale score) to assess responses to QIPs. Results Both clinicians and patients reported positive feelings towards the implemented changes, and scores following progressive pneumoperitoneum showed significant improvement. Conclusions Therefore, we propose that QIPs have a significant role in the establishment and streamlining of services for patients requiring AWR. Through the repeated use of QIPs, a robust, transferable model could be produced, which could then be shared with other regional specialist centres nationwide. As such, effective care could be offered equally to AWR patients for improved outcomes and reduced strain on healthcare resources.

Outpatient secondary care pathways for head and neck cancer referral result in patient delays for cancer treatment

INTRODUCTION

The majority of head and neck cancer referrals are received through primary care. A proportion of cancer referrals are received through secondary care specialties. Local delivery plan (LDP) targets in Scotland for cancer investigation are set at 31 days for diagnosis and 62 days to start treatment. The aim was to audit referrals made through non-primary care pathways compared with the standard primary care pathways against LDP targets.

METHODS

New head and neck cancer patients between 1 January 2014 and 1 January 2019 were included. Pathway points were recorded between referral to outpatient clinic, time to multidisciplinary team discussion (MDT) and finally MDT to treatment.

RESULTS

1,276 new patient referrals were received over a 5-year period. Of these, 136 (10%) were referred via non-primary care pathways. The mean time for urgent suspicion of cancer (USoC) referrals to start treatment was 77 days (15 days over target) and for outpatient secondary care referrals was 102 days (40 days over target) (p<0.05). When treatment intent was considered, 841/1,131 (75%) of patients referred via primary care were treated curatively compared with 49/99 (49%) (p<0.05) of patients referred through the secondary outpatient pathway.

CONCLUSION

Patients with head and neck cancer referred from other outpatient specialties face delays commencing cancer treatment and are also associated with a greater likelihood of being treated with palliative intent.

Doctors Improving Referrals project: a referrals toolkit for junior doctors

Every day in hospitals around the world, millions of interspecialty referrals are made to obtain advice on the optimal care and management of patients. In the UK, the brunt of this work is undertaken by junior doctors with less clinical experience than the specialist colleagues to which they refer. A survey of 283 junior doctors revealed that colleagues were underconfident when making referrals and struggled to know which specialty to contact, how to reach the specialty and what clinical information to include in the referral. More concerningly, 10% of those surveyed had experienced bullying or belittling behaviours and verbal aggression from colleagues when referring.The aim of this project was to design and implement a referrals toolkit for junior doctors to improve confidence making referrals and time to interspecialty advice, to improve patient care. Process mapping to understand the constituents of good referrals was combined with a failure modes and effects analysis describing how referrals fail to identify areas for intervention.A specialty referrals guide with all specialty contact information was created at the trust, demonstrating an increase in junior doctor median confidence from 3/5 (n=20) to 5/5 (n=23) (p<0.001); 65% found it quicker to refer with the guide and 81% found an improved time to discharge. A referrals cheat sheet was also created, containing specialty-specific information to be included when making a referral. This has been downloaded over 23 000 times from around the globe. Of survey respondents (n=43), 74% noted improved confidence in making referrals, 26% noted faster time to specialty advice and 19% found a positive impact on patient discharges. Overall, the referrals toolkit has been beneficial for both junior doctors and the patients for which they care and has been accessed by over 50% of new foundation doctors in 2021 and 2022.

Junior doctor-led quality improvement project to improve safety and visibility of an interspecialty referral system

Interspecialty referrals for increasingly complex hospital inpatients are common and miscommunication often leads to delays in patient care. In a district general hospital, a web-based system generated an email referral, which lacked visibility and tracking/audit of the process, with no record generated automatically in paper inpatient notes or electronic patient records (EPR). We aimed to improve the visibility and safety of the interspecialty referral system.

We canvassed stakeholders, informally and via an online satisfaction survey, collecting qualitative and quantitative data about attitudes to the existing system, generating ideas for change. We process mapped the system, identifying points of weakness. We adapted our EPR system, using a work-around solution, to develop a form that could be emailed from the EPR. This generated a permanent record within the EPR and an electronic record of the referral having been sent. We measured the visibility of referrals and responses within the EPR. We generated an online training ‘how-to’ video and reaudited stakeholder satisfaction.

There was a significant increase in the proportion of junior doctors satisfied or very satisfied with the interspecialty referral system (27/31 postintervention; 87.1% vs 26/55 preintervention; 47%; p<0.0001) and more believed that the visibility was adequate or very adequate (24/31 postintervention; 77.4% vs 9/55 preintervention; 16.4%; p<0.0001). Visibility of referrals by project team members on the EPR increased from a baseline of 3.5% to 83.6% and the visibility of responses to these referrals on the EPR increased from 4.6% to 40.7%. Qualitative feedback was excellent, hospital executive approval was gained and our work-around system spread to non-team members.

We developed a more visible and reliable interspecialty referral system, adapting existing EPR capabilities, which was popular with users and led to cultural change in interspecialty referral responders. A formal EPR redesign, informed by our project, is in development.

Creating more than a directory: improving handover of information by renovating the induction app for University Hospital Wishaw

Starting in a new hospital can be an overwhelming experience for any grade of doctor. There is a vast amount of information that needs to be learnt immediately to function in the new environment. There is an annual changeover of doctors between hospitals in August nationwide and most junior doctors rotate specialties every 4–6 months. Evidence shows that doctors feel this transition has a negative impact on patient care and indicates that inpatient mortality rises during the August changeover. In our hospital, we noted problems with access to guidelines, referral information and investigations by junior doctors, especially at changeover. In an initial questionnaire, 100% of doctors had experienced difficulties with referring to a specialty and 96% felt time was wasted doing so. Furthermore, 87.5% of doctors had difficulties with ordering laboratory investigations and 100% of survey participates expressed difficulty accessing guidelines.

To tackle this issue, we created guidelines on how to refer to different specialties, order investigations and general running of the hospital. We then used a free app platform called induction and uploaded the guidelines as well as formal hospital guidelines to the app. After use of the app, we assessed these problems via further questionnaires. Doctors reporting problems with finding how to refer to specialties reduced from 100% to 0% in the final survey. Problems finding how to request investigations fell from 100% to 14.3% after 1 month to 7.7% after 3 months. Finally, problems finding guidelines fell from 100% to 15.4%. Further, 100% of doctors felt the app saved time.

Use of the induction app to access guidelines saves time and reduces problems accessing information needed to carry out tasks. This an easily replicated project with low running costs which proved to help with the universal problems around induction to a new hospital environment.

E-referrals: improving the routine interspecialty inpatient referral system

Interspecialty referrals are an essential part of most inpatient stays. With over 130 referrals occurring per week at the Royal Devon and Exeter Hospital, the process must be efficient and safe. The current paper-based 'white card' system was felt to be inefficient, and a Trust incident highlighted patient safety concerns. Questionnaires reinforced the need for improvement, with concerns such as a lack of referral traceability and delays in the referral delivery due to workload. The aims of the project were to improve patient safety and junior doctor efficiency in the referral process. Through appreciative enquiry and the PDSA (Plan-Do-Study-Act) model, an electronic referral system was developed, piloted within two specialties and later expanded to others with improvements made along the way based on user feedback. The system includes novel features including specialties 'acknowledging' a referral to allow referral progress to be tracked. The system stores all referrals, creating a fully auditable inpatient referral pathway. Qualitative data indicated improvement to patient safety and user experience (n=31). Timings for referrals were measured over a 6-month period; referrals became faster with the electronic system, with average time from decision to refer to referral submission improving from 2.1 hours to 1.9 hours, with a noted statistically significant improvement in timings on a statistical process control chart. An unexpected benefit was that patients were also reviewed faster by specialties. Measuring these changes presented a significant challenge due to the complexity of the referral process, and this was a big limitation. Overall, the re-design of a paper-based referral system into an electronic system has been proven to be more efficient and felt to be safer for patients. This is a sustainable change which is being rolled out Trust-wide. We hope that the reporting of this project will help others considering reviewing their inpatient referral pathways.