Online referrals improve interspecialty communication and are preferred by referring clinicians
Introduction (Plan)
At a large university foundation teaching hospital multiple systems were in use to request inpatient review by other specialties. Thus referral was extremely time-consuming: over 91% of referrers stated that finding out how to refer to each specialty took a significant amount of time. Over 97% stated they would save a significant amount of time if a formal document detailing referral processes existed or if there was a unified process of referring.
Conversely, within gastroenterology, where referrals were received by fax, review of referrals over a 1-month period revealed that 62% of referrals could be dealt with by telephone advice, but 78% did not give contact details resulting in a mean of 3.3 bleeps/calls and 9.7 minutes/referral to contact the team (in 23% cases doctors had to visit the ward even though advice alone was appropriate). Furthermore, delayed specialty reviews were reported that were sent but not received via fax.
We set the SMART objective of reducing by 90% the number of patients seen by gastroenterology who require advice only but take >5 minutes in attempting to contact the parent team by March 2019.
Materials and methods (Do)
We worked with IT to develop an online gastroenterology referral via our existing requesting and reporting software (ICE). We also developed a function to give advice via ICE if a patient was felt not to require inpatient specialty review. This was launched on 1 February 2019 with a multi-modal education campaign highlighting the need for doctors to check the referral regularly for advice.
Results and discussion (Study)
Data were gathered for 8 weeks prior to launch of the gastroenterology ICE referral system. During this period, 48% of referrals could be managed with advice alone, but in 50% of the cases (median, range 0–66.7%), it took over 5 minutes to contact the referring team. After implementation the percentage of referrals managed with by advice alone remained the same but a median of 0% of referrals took over 5 minutes to contact the parent team (range 0–11.8%; Fig 1).
Conclusion (Act)
While these data are promising we needed to contact referrers by other means in occasional cases. A follow-up survey of referrers revealed that while 93% know how to refer to gastroenterology via ICE, only 68% know how to check for advice. We will therefore focus on education in our next Plan, Do, Study, Act (PDSA) cycle.
This follow-up survey also revealed that all responders preferred ICE to the fax system. 90% felt that referrals were easier to chase and 100% were in favour of expanding ICE referrals to more specialties; again a focus for future PDSA cycles.
Finally, while time from referral to patient review/advice given is an important outcome measure, lack of reliability in receiving fax referrals meant these data were incomplete. This is now easily visible on the ICE system where average time from referral to outcome varies widely and appears to relate to ST3+ staffing levels. These data can now be utilised to develop safer working models within gastroenterology.
- © Royal College of Physicians 2019. All rights reserved.
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