EP.TU.673Optimising the referral process to the Surgical Emergency Clinic through mutual education of primary and secondary care teams: an audit cycle

Aims The Surgical Emergency Clinic (SEC) in our Hospital facilitates access to General Surgical consultant-led emergency assessment. Anecdotally, referrals are often (likely inadvertently) inappropriate and / or incomplete, which may delay assessment by the correct specialist. We audited the quality of GP referrals to the SEC against four standards: Methods Retrospective analysis of 50 GP referrals to the SEC between November - December 2017, after recording data pertinent to the above standards in a spreadsheet. Results were presented at a local GP development day, a re-designed referral form incorporating GP feedback received was uploaded onto the Trust’s intranet and an email inbox created for e-referrals. 50 further referrals between September - November 2018 were analysed. Results Full completion of the referral form increased from 0% (initial audit) to 29% (re-audit), and appropriateness of referrals from 62% to 90%. The proportion of patients having had specified blood and urine tests in advance improved overall also. Conclusions Our experience demonstrates that primary and secondary care teams actively communicating and working closely together can improve the referral process for both parties, and most importantly enhance patient access to timely, appropriate specialist care.

1277 A Closed-Loop Audit of the use of qFIT in Symptomatic “Two Week Wait” referrals in Somerset Foundation Trust

Introduction Quantitative faecal immunochemical test (qFIT) is recommended as the replacement test for faecal occult blood testing by NICE. We audited qFIT use in two week-wait (2WW) referrals in Somerset Foundation Trust (SFT) following its introduction in 2019. Method Following qFIT being made available to general practitioners, all 2WW referrals received before (July 2019) and after (December 2019) the introduction of the new 2WW referral form were reviewed. Electronic patient records were analysed to determine investigations performed and if a diagnosis of cancer was made. Results July 2019: 288 2WW referrals with 74 patients eligible for qFIT – only 7 of these underwent qFIT; total of 93 qFIT performed by GPs with 11 positive tests. December 2019: 222 2WW referrals with 18 patients eligible for qFIT – all of whom underwent qFIT; total of 155 qFIT performed by GPs with 18 positive (and 137 negative) tests. 1 patient with a positive qFIT was found to have colorectal malignancy (qFIT = 267 g/dL, investigation showed benign TVA). An increase in qFIT was observed over time, coinciding with a reduction in 2WW referrals, including reduction in patients who were qFIT eligible. The 2WW service identified 11 (3.8%) cases of colorectal cancer in July 2019 compared to 12 (5.4%) cases in December 2019, showing an increased pickup rate. Conclusions High proportions of 2WW referrals undergo investigation. The results of this audit highlight the utility of qFIT in screening 2WW referrals and reducing burden on the service, particularly where access to investigations is severely restricted due to coronavirus.

Improving the quality of GP referrals to the Croydon Assessment & Liaison Team

AimsTo increase the percentage of GP referrals to the Croydon Assessment & Liaison (A&L) Team deemed to be of ‘good quality’. The A&L Team receives a large number of referrals daily from GPs, and it was identified that many of these referrals did not include important and relevant information, leading to delays in patient assessments.MethodA questionnaire was distributed to A&L MDT members to collect information about what information they consider important in a GP referral. The project team reviewed the results of the questionnaire, along with current policies and guidelines, to create a set of criteria by which to assess the quality of GP referrals, as there was no pre-existing gold standard available. A random sample of 6 GP referrals per week stratified by locality was collected and assessed against these criteria.Using Plan-Do-Study-Act (PDSA) methodology change ideas were generated, and a GP referral form was identified as an important intervention to adopt. A previously-developed draft form was updated after a round of consultations with various stakeholders including Assessment & Liaison staff, GPs and the CCG. The new GP referral form was uploaded to the GP DSX electronic referrals platform and GP practices were also emailed directly to encourage them to use the new form.The proportion of GP referrals deemed to be of good quality was compared pre and post-intervention. Uptake of the new GP referral form was recorded as a process measure, and the length of time taken to discuss referrals at A&L daily referrals meetings as a counterbalance measure.ResultAt baseline 33% of GP referrals were deemed to be of good quality using the developed criteria. This improved to 58% after implementation of the new referral form in January 2021. There was poor overall uptake of the form, with only 32.5% of GP referrals utilising the new form so far, however of the referrals received on the new form 69% fulfilled the criteria for good quality. Comparison of length of discussion required for referrals with and without the new form showed no significant difference (7.7 and 7.6 minutes respectively).ConclusionImplementation of a standardised GP referral form was effective at increasing the proportion of referrals deemed to be of good quality. However, further PDSA cycles focused on improving uptake of the form will be required.

An assessment of referrals to a liaison psychiatry team within a large district general hospital – Completing the Cycle

AimsIn 2019 members of the Liaison Psychiatry Department at Frimley Park Hospital completed an audit of the referrals to the service1. The quality of referrals was found to be highly variable, for example only 28% included a risk assessment and frequently omitted both past psychiatric and past medical histories. As such an intervention was designed involving three parts;Multidisciplinary education of staffNew and more readily available referral guidelinesNew referral formThis re-audit seeks to complete the audit cycle and assess the impact of the intervention.MethodThe first 50 referrals to the Liaison Psychiatry Department of Frimley Park Hospital during February 2021 were assessed using the following criteria:Staff type, referral source, physically fit for assessment, physical cause ruled out, drugs / alcohol involved, appropriate reason for referral, clinical question asked, did final diagnosis match referral diagnosis, risk assessment included, information about admission included, past psychiatric history included and past medical history included.The percentage of referrals received for each criterion (e.g. the percentage with a risk assessment completed) was then derived from the data.ResultThere has been a marked improvement in a variety of areas. The percentage of referrals containing a risk assessment increased from 28% to 96%. This is likely due to the risk box now requiring an entry prior to being able to submit the referral form. Similarly the percentage containing past psychiatric history has risen from 38.8% to 90%. Previously 46.2% of referrals contained a working diagnosis which was not consistent with the clinical picture, but again this has improved, with 60% of initial diagnoses now matching the final outcome. There are however areas for improvement. Only 14% of referrals contained a specific clinical question, which is lower than the 20% achieved previously. This may be because the new referral form does not provide a specific free text box for this.ConclusionThe intervention yielded a marked improvement in the quality of referrals received by the Liaison Psychiatry Department at Frimley Park Hospital, and it is the intention to continue to use the current process. Based on the new results we will look to make small adjustments, for example adding a free text box for a specific clinical question and emphasising the importance of this information.

Service evaluation of the mental health assessment service (MHAS) in Dudley, West Midlands

AimsTo assess how well MHAS meets the service specificationTo ascertain areas of good practiceTo examine whether the referral form is being used in an appropriate mannerTo elucidate areas of good communication and whether any improvement can be madeBackgroundLaunched in 2012, MHAS is the single point of access service for mental health services for patients aged 16–65 years, with a general practitioner (GP) in Dudley, who are not currently open to secondary care. Assessments are completed by a medic, community psychiatric nurse or jointly. It aims to identify the most appropriate care pathway for patients. This audit was a comprehensive assessment of how effective MHAS is at ensuring patients are adequately triaged.Method10 cases from each month between April 2018 and March 2019 were randomly selected from all 980 anonymised MHAS referrals. A proforma was developed based on current practice, previous audits and service specification. A team of four doctors assisted in the data collection and only electronic health records (EHR) were reviewed.Result88.3% of referrals were recorded on the EHR. Only 61.7% of referrals used the proforma with the other referrals mostly being in the form of a letter, which often missed out information vital to the triaging process. Only 4.2% of referrals are from Primary Care Mental Health Nurses (PCMHN) with 85.8% arising from GPs. Urgent referrals were not discussed with MHAS via telephone contact in about 60% of cases. The majority of patients had telephone screening completed the same day and were then discussed the next working day at the daily referral meeting. Although a brief summary for the GP was being sent the same day in all cases, over half of the comprehensive assessments were not being sent within the five day timeframe.ConclusionAll referrals must be uploaded to the EHR and completed using the service's proforma. PCMHNs may be currently under-utilised or effectively doing their jobs at managing mental health patients in primary care. GPs regularly referring via letter require further training and support to use the proforma. The proforma may require simplification to make it easier to complete. The service specification requires review as it makes unrealistic demands of the service. All referrals must be discussed at the daily referral meeting. Further investigation is required to understand why MHAS is struggling to meet timeframes for appointments and letters.

Appropriateness of referrals to Whiston hospital Mental Health Liaison Services

Aims1. The aim of this study was to assess the appropriateness of referrals to Whiston Mental Health Liaison Services (WMHLS) according to Royal College of Psychiatrists and local trust guidelines.2. To assess whether the referrals were being reviewed in timely manner as per the trust's guidelines.MethodData collection was completed using a proforma to ensure uniform data collection. The proforma included information on patient demographics, previous mental health service involvement, other details like reasons and time of referral and their outcomes. Data sample comprised of 46 patients who had been referred to the WMHLS in the month of August 2019 were randomly selected.Result44 of the 46 referrals analyzed were found to be appropriate. 40 patients were deemed to have appropriate documentation. The ratio of males to females was 20:26. 21 referrals were from the observation ward, 14 from A&E, and 11 from medical wards. 40 patients were previously known to mental health services. The reasons for referral ranged from suicidal ideation/attempt (48%), Drug related (12%), Assessment (7%) and more. There were various outcomes recorded. One of them was that 18 (28%) referrals were assessed for Depression and for other mental health problems.78.6% of patients referred from A&E, and 95.2% of patients in the observation ward, were not seen in the 1 hour window set out by the Trust's guidelines. 91.1% of patients referred from the wards were seen within the 24 hour target.ConclusionThe vast majority of referrals were found to be appropriate (44/46). It was found that the referral form used across the Trust, contained different levels of details and information on the patient depending on the source of referral. Using a standard process to complete referral forms to be used across the whole trust may ensure that all patients receive a standardized and appropriate referral based on the guidelines. Making the form electronic may reduce problems deciphering handwriting, and could allow WMHLS have a better understanding of the patient, and allow them to identify a patient that may be more appropriate for another service, e.g. drugs and alcohol team. This may and make the overall referral process quicker and reduce waiting times in A&E, as well as faster referrals to the appropriate services.

365 Arrival to Decision: Improving Waiting Times in Surgical Ambulatory Care

Introduction An audit of the newly established Surgical Emergency Ambulatory Care Unit (SEAC) at Furness General Hospital found perceived patient waiting times were high. This Quality Improvement Project assessed the patient flow through the SEAC unit and aimed to improve the average time from arrival in the department to senior review by 10%. Method The Plan Do Study Act (PDSA) methodology for quality improvement was used, the time from arrival in the unit to senior decision was recorded for each patient seen over one-week data collection periods. Analysis of the data allowed for a patient process map to be created to visualise bottlenecks in patient flow. The findings were discussed with all team members and an agreed intervention was implemented and tested. Results Over three PDSA cycles, a significant improvement in the overall time from arrival to decision was achieved, from an average time of 193 minutes to 150 minutes. This was achieved by introducing a referral form, which altered how and when members of the multidisciplinary team communicated with each other. Conclusions Clear communication at the appropriate time between all members of the SEAC team significantly improved the average time from arrival to decision.

146 Improving Outcomes in Aspiration Pneumonia: A Collaborative Approach

Introduction Aspiration pneumonia is a major cause of morbidity and mortality especially in older adults. Our Trust recorded higher than expected mortality ratios in this group of patients. Aim To investigate reasons behind higher than expected mortality and improve outcomes. Intervention We developed a collaborative approach of investigating mortality in aspiration pneumonia with joint input from Speech and Language (SALT) specialists. Method We conducted structured retrospective review of annual mortality in aspiration pneumonia in 3 PDSA (plan, do, study, and act) cycles in 2015/18/20. We collected data on clinical care, diagnostic accuracy, SALT referral/input, feeding at risk discussion, communication with primary care. We monitored mortality ratios on national systems. Results We improved clinical and nursing care by auditing mouth care, bed elevation and safe feeding. We also developed electronic-SALT referral form to improve timings for the reviews (first PDSA cycle). SALT team developed “feeding at risk proforma” to formalise risk feeding where safe swallow plan was not possible (second PDSA cycle). We modified discharge summaries and made this a multidisciplinary document in the Trust so that SALT can communicate feeding plans to primary care (third PDSA cycle). Mortality ratios improved significantly in this period from Relative risk of 152 (higher than expected range) in 14/15 to 86 (within expected range) in 19/20. Conclusion We have demonstrated significant improvement in hospital mortality ratios from aspiration pneumonia and therefore improved care by collaboratively working with SALT team and bringing changes in stepwise manner. Multidisciplinary mortality reviews are key to improving outcomes for our patients.