Improving the inpatient referral system in the acute medical unit

Anant Gurung; Nikhil Patel; Karen Sarmiento; Thomas Hickman-Casey; Allen Shakya; Rabia Kiani; Wut Yee Thazar

doi:10.7861/clinmed.22-4-s85

Introduction

The acute medical unit (AMU) receives high number of acutely unwell patients with variety of medical conditions. For an AMU to function well, it needs to maintain strong links with all hospital specialties.¹ Specialist team input is part of patient care. An efficient referral pathway is vital for timely management of acute patients. In our AMU, we found that patients were waiting longer for specialty team review. This impacted on patient care, discharge and flow of patients to and from the AMU.

Aim

To improve the inpatient specialty referral system in our AMU.

Objectives

To identify:
- time taken for review of the patient after referral to specialty team from AMU
- any impact on length of stay of patients in hospital due to delay in specialty review
- specialty team referral process.
To reduce delay:
- for specialty team review
- improve method of referral
- improve junior doctors' efficiency in the AMU.

Materials and methods

Location: AMU, Eastbourne District General Hospital (EDGH).
Time: 16 November–4 December 2020: 3 weeks' continuous data.
Study patients: all patients admitted to the AMU who required specialist input after the consultant post-take ward round.
Data collected:
- date of referral
- specialty referred
- date/time seen by the specialty team
- discharges from AMU – whether a delay in referral is present.
- Source: Medical notes, eSearcher, Evolve.
- Data analysed: MS Excel, Google Survey.

Results and discussion

185 of 475 (39%) patients were referred to a specialty.
Eight (4%) referrals were missed by the junior doctor, despite planned on post-take.
The top five specialties for referrals were gastroenterology (22%), cardiology (16%), respiratory (11%), oncology (11%) and mental health team/psychiatry (6%).
24 (13.6%) patients were identified as having an avoidably delayed discharge due to delayed specialty review.
Of all the referrals, only 53.1% of referrals were seen by the specialty team within 24 hours, 22.03% in 24–48 hours, 7.9% in >48 hours. 16.96% of referrals were omitted due to missing data.

Common causes of delays included paper referral requiring hand delivery, limited accessibility and communication, lack of junior doctor awareness, increased admin work and duplication, impact of the pandemic.

Interventions/actions:

Electronic referral system for all specialties. Key advantages included faster submission, paperless, secure, minimising errors, shared access and improved communication between referrer and reviewer.
Hospital referral pathway poster (mobile phones, intranet accessibility), see Fig 1.

Fig 1.

Hospital referral pathway poster.

Fig 2.

Electronic referral system for all specialties.

Reaudit and outcome:

June 2021, 155 patients.
Specialties on board with the electronic referral pathway in EDGH: respiratory, cardiology, gastroenterology, endocrine, neurology, acute oncology, rheumatology.
Patients seen within 24 hours of referral increased from 53% to 91%, those seen within 24–48 hours reduced from 22.03% to 9%.
No referrals were seen after 48 hours. Previously 7.9%.
No discharge delays from AMU were due to delayed specialty referrals seen. Previously 13.6%.
No referrals were missed by junior doctors. Previously 4%.
Post-intervention, a junior doctors' survey showed that 100% preferred the electronic referral system to paper and agreed that it was easy and straightforward. 87.5% of doctors had made a referral while being on call, rather than leaving it for the ward team after liaising with the registrar/consultant.
Overall reduction in ward work by 16.7 mins per referral (time from generating to submission).
Immediate benefit also to referrals generated from wards outside AMU which adopted the same platform.
Adoption by acute oncology team is cross-site and expanding.

Conclusion

We have shown that the flow of patients through the AMU can be improved by streamlining the hospital referral system. This provides timely patient care, ensuring a positive patient experience while in hospital. An electronic referral system was found to be an efficient means of making an inpatient referral. This project has also helped improve junior doctor morale, efficiency and communication, which had a positive impact given the challenges of the pandemic in the hospital.