Assessment of the Low Referral Rate of Cardiologists to Dietitians/Nutritionists

Background: Dietary factors are a leading contributor to cardiovascular disease. Cardiologists are ideally positioned to initiate dietary discussions with patients and to make appropriate referrals to dietitians/nutritionists, yet the frequency of such referrals is unknown. Methods: A national survey was distributed to cardiologists to assess the frequency of their referrals to dietitians/nutritionists, their assessment of the efficacy of such referrals, and the perceived barriers to patient implementation of dietary changes following referral to dietitians/nutritionists. Results: A total of 123 cardiologists responded to the survey. The majority of respondents (71%) reported that they referred 10% or fewer of their patients to dietitians/nutritionists. Cardiologists who participated in a nutrition-focused continuing medical education activity were nearly twice as likely to refer patients to a dietitian/nutritionist as those who did not. Thirty-two percent of cardiologists believed that 25% or more of their referred patients made significant gains in achieving dietary goals. Most cardiologists (63%) attributed the primary challenge to achieving dietary goals to “the patient’s lack of interest and motivation in making dietary changes” while 6% believed the lack of desired results were related to the quality of the counseling provided. Overall, 59% of cardiologists endorsed the belief that dietary interventions can improve outcomes to an equal or greater degree than pharmacologic therapy Conclusion: Cardiologists reported making few referrals to dietitians/nutritionists; however, those who received continuing education in nutrition were significantly more likely to make a referral than those who did not receive nutrition education. The efficacy of referrals to dietitians/nutritionists was considered to be limited, which the majority of cardiologists attributed to a lack of patient interest and motivation—a belief that is not aligned with prior surveys of patient preferences.

Specialist palliative care teams and characteristics related to referral rate: a national cross-sectional survey among hospitals in the Netherlands

Background Specialist palliative care teams (SPCTs) in hospitals improve quality of life and satisfaction with care for patients with advanced disease. However, referrals to SPCTs are often limited. To identify areas for improvement of SPCTs’ service penetration, we explored the characteristics and level of integration of palliative care programmes and SPCTs in Dutch hospitals and we assessed the relation between these characteristics and specialist palliative care referral rates. Methods We performed a secondary analysis of a national cross-sectional survey conducted among hospitals in the Netherlands from March through May 2018. For this survey, a previously developed online questionnaire, containing 6 consensus-based integration indicators, was sent to palliative care programme leaders in all 78 hospitals. For referral rate we calculated the number of annual inpatient referrals to the SPCT as a percentage of the number of total annual hospital admissions. Referral rate was dichotomized into high (≥ third quartile) and low (< third quartile). Characteristics of SPCTs with high and low referral rate were compared using univariate analyses. P-values < 0.05 were considered significant. Results In total, 63 hospitals (81%) participated in the survey, of which 62 had an operational SPCT. The palliative care programmes of these hospitals consisted of inpatient consultation services (94%), interdisciplinary staffing (61%), outpatient clinics (45%), dedicated acute care beds (21%) and community-based palliative care (27%). The median referral rate was 0.56% (IQR 0.23–1.0%), ranging from 0 to 3.7%. Comparing SPCTs with high referral rate (≥1%, n = 17) and low referral rate (< 1%, n = 45) showed significant differences for SPCTs’ years of existence, staffing, their level of education, participation in other departments’ team meetings, provision of education and conducting research. With regard to integration, significant differences were found for the presence of outpatient clinics and timing of referrals. Conclusion In the Netherlands, palliative care programmes and specialist palliative care teams in hospitals vary in their level of integration and development, with more mature teams showing higher referral rates. Appropriate staffing, dedicated outpatient clinics, education and research appear means to improve service penetration and timing of referral for patients with advanced diseases.

Assessing improvements in emergency department referrals to a hospital-based violence intervention program

Background Youth violence is a major public health concern in the United States. Hospital-based Violence Intervention Programs (HVIPs) are integral in connecting youth sustaining interpersonal violence-related injuries to medical, mental health, and social services. At our pediatric emergency department, our baseline referral rate to the established HVIP was 32.5%. From November 2018–2019, we aimed to increase the percent of eligible patients referred to our HVIP from 32.5 to 70% for patients aged 7–18 years who present to our Level 1 emergency department/trauma center with a violent injury. Methods For this quality improvement project, we recorded key aspects of the referral process, such as patient eligibility, who placed referrals, and when referrals were placed in relation to the ED admission. Key stakeholders were interviewed to identify specific interventions. Our key interventions were: 1. Educating providers on eligibility requirements. 2. Encouraging nurses to enter consults at the time of admission. 3. Publishing information about program referrals in the weekly nursing newsletter. 4. Updating social workers on eligibility requirements for the HVIP. We used PDSA cycles to inform our project. Our primary outcome measure was the number of eligible patients referred to our HVIP and measures were analyzed using statistical process control charts. Results The HVIP-eligible population had the following demographics: 31.1% female and a mean age 14.3 ± 2.7, 82.6% assaults and 17.4% gunshot wounds. From 11/2018 to 11/2019, there were 78 referrals to the HVIP, out of 167 eligible patients. The referral rate improved from 32.5% pre-interventions to 61.1% post-interventions, showing an 88% increase. Conclusion(s) We noted an increase in referrals to our HVIP following our interventions that centered on educating, advertising, and encouraging. Future studies will focus on analyzing other aspects of the enrollment process, such as obtaining patient consent.

A retrospective cross-sectional analysis of re-contact rates and clinical characteristics in diabetic patients referred by paramedics to a community diabetes service following a hypoglycaemic episode

Aims: To report the re-contact rates and clinical characteristics of individuals referred to community diabetic teams following non-conveyance by HCPC paramedics.Methods: A retrospective cross-sectional study of routinely collected data by the Northern Ireland Ambulance Service HSC Trust of individuals referred to a community diabetic service following ambulance attendance and non-conveyance. Data were collected over a 3-month period with ambulance service re-contact and clinical data analysed.Results: 418 emergency calls were identified as relating to hypoglycaemia with 169 referrals being made, a referral rate of 40.4%. Patients treated with insulin represented the majority of calls and tended to have a lower Glasgow Coma Scale score, but demonstrated many successful referrals. Increased age and multimorbidity were associated with repeat hypoglycaemic episodes and EMS attendance while other subgroups traditionally considered higher risk, such as patients with infections or under the influence of alcohol, showed potential for safe community management.Conclusion: The majority of paramedic referrals to community diabetic teams were successful, with less than 5% re-contacting the ambulance service within 3 days. This study, although demonstrating a lower referral rate than previous research, reinforces the safety of paramedic management and community referral for hypoglycaemia.

Referrals from community optometrists to the hospital eye service in Scotland and England

Objectives This audit assesses communication between community optometrists (COs) and hospital eye service (HES) in Scotland and England. Methods Optometric referrals and replies were extracted from six practices in Scotland and England. If no reply was found, replies/records were copied from HES records. De-identified referrals, replies and records were audited against established standards, evaluating whether referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated. Results From 905 de-identified referrals, RR ranged from 2.6 to 8.7%. From COs’ perspective, the proportion of referrals for which they received replies ranged from 37 to 84% (Scotland) and 26 to 49% (England). A total of 88–96% of referrals (Scotland) and 63–76% (England) were seen in the HES. Adjusting for cases when it is reasonable to expect replies, RRR becomes 45–92% (Scotland) and 38–62% (England) with RRR significantly greater in Scotland (P = 0.015). Replies were copied to patients in 0–21% of cases. Referrals were to the appropriate service and judged necessary in ≥90% of cases in both jurisdictions. Accuracy of referral ranged from 89 to 97% (Scotland) and 81 to 98% (England). The reply addressed the reason for referral in 94–100% of cases (Scotland) and 93–97% (England) and was meaningful in 95–100% (Scotland) and 94–99% (England). Conclusions Despite the interdisciplinary joint statement on sharing patient information, this audit highlights variable standard of referrals and deficits in replies to the referring COs, with one exception in Scotland. Replies from HES to COs are important for patient care, benefitting patients and clinicians and minimising unnecessary HES appointments.

On the Correlation Between Examination Day and the Referral Rate of Secondary Hearing Screening Among Non-High-Risk Newborns

Background: Otoacoustic emissions (OAEs) and auto-auditory brainstem response (AABR), as two safe and equally accurate techniques, are used for hearing screening among newborns. However, the screening time of such tests is under debate. Objectives: The present study aimed to assess the correlation between examination day and the referral rate of secondary hearing screening among non-high-risk newborns. Methods: A retrospective review of secondary hearing screen data collected from June 2012 to June 2019 was conducted on infants who had no confirmed risk factors introduced by the Joint Committee of Infant Hearing 2007 (JCIH). Results: Of the 2493 newborns included in this study, 2129 cases (85.4%) passed the test bilaterally, and 364 newborns (14.6%) failed the examination. The referral rate of the 1366 newborns taking OAE was 13.1%. Among 1127 newborns taking both OAE and AABR, the referral rate was 16.5%. Moreover, the referral rate of the OAE and OAE+AABR techniques was the lowest in the 42-56-day group. Conclusions: All newborns with no high-risk factors should be screened for hearing as such we recommend 42 - 56 days after birth as the best re-examination period to reduce the false positive rate and caregivers' anxiety.

Effect of faecal calprotectin testing on referrals for children with chronic gastrointestinal symptoms in primary care: study protocol for a cluster randomised controlled trial

IntroductionChildren with chronic gastrointestinal symptoms are frequently seen in primary care, yet general practitioners (GPs) often experience challenges distinguishing functional gastrointestinal disorders (FGID) from organic disorders. We, therefore, aim to evaluate whether a test strategy that includes point-of-care testing (POCT) for faecal calprotectin (FCal) can reduce the referral rate to paediatric specialist care among children with chronic gastrointestinal symptoms. The study findings will contribute to improving the recommendations on FCal use among children in primary care.Methods and analysisIn this pragmatic cluster randomised controlled trial, we will randomise general practices into intervention and control groups. The intervention group will use FCal-POCT when indicated, after completing online training about its indication, interpretation and follow-up as well as communicating an FGID diagnosis. The control group will test and treat according to Dutch GP guidelines, which advise against FCal testing in children. GPs will include children aged 4–18 years presenting to primary care with chronic diarrhoea and/or recurrent abdominal pain. The primary outcome will be the referral rate for children with chronic gastrointestinal symptoms within 6 months after the initial assessment. Secondary outcomes will be evaluated by questionnaires completed at baseline and at 3- and 6-month follow-up. These outcomes will include parental satisfaction and concerns, gastrointestinal symptoms, impact of symptoms on daily function, quality of life, proportion of children with paediatrician-diagnosed FGID referred to secondary care, health service use and healthcare costs. A sample size calculation indicates that we need to recruit 158 GP practices to recruit 406 children.Ethics and disseminationThe Medical Research Ethics Committee (MREC) of the University Medical Center Groningen (The Netherlands) approved this study (MREC number: 201900309). The study results will be made available to patients, GPs, paediatricians and laboratories via peer-reviewed publications and in presentations at (inter)national conferences.Trial registration numberThe Netherlands Trial Register: NL7690 (Pre-results)

Analysis of the Referral Rates of Newborn Hearing Screening Test According to Childbirth Delivery Methods in Neonatal Care Units

It is known that neonates born by cesarean delivery (CD) may have higher referral rates than those born by vaginal delivery (VD) for newborn hearing screening (NHS). False-positive NHS results can increase costs and parental anxiety. This study analyzed the differences in NHS referral rates according to delivery methods in Level I, II, and III neonatal care units. A retrospective chart review was done for 2322 infants (4644 ears) with delivery records who underwent NHS between 2004 and 2017. The first NHS was performed immediately before discharge when the infant was in good condition via the automated auditory brainstem response (AABR) or automated otoacoustic emissions (AOAE). There were 98 neonates (196 ears) who underwent both AABR and AOAE simultaneously as the first NHS, 30 of which failed. We used a total of 4810 ears in this analysis. Of all enrolled ears, 2075 ears were of neonates born by CD, and 2735 ears were of neonates born by VD. A total of 2460 ears were from patients in Level III neonatal intensive care units (NICU) and 2350 ears were from Level I and II neonatal care units. The overall referral rate was higher in infants born via CD (4.5%) than VD (3.2%). In Level I and II neonatal intensive care units, the referral rate was significantly higher in those born via CD (3.0%) than via VD (1.4%). Further, based on the screening method, AABR (75.8%) was more frequently used than AOAE (24.2%), thereby revealing AABR’s higher referral rate in CD (2.9%) than in VD (1.2%). The referral rate of infants who underwent the NHS within three days of birth was higher in the CD group (3.0%) than in the VD group (1.3%). There was no significant difference in the referral rate depending on the delivery method when infants were hospitalized for more than four days or hospitalized in the NICU. The referral rate according to the delivery methods was significantly higher when the NHS test was performed for healthy newborns in the Level I and II neonatal care units born by CD within 72 h using AABR. Therefore, we recommend that the hearing screening test for newborns delivered by cesarean section be performed after 72 h of age. The results of this study may reduce the false-positive NHS results, unnecessary further tests, and parental anxiety.

Providing a Model for the Optimal Allocation of Hospital Beds Based on Markov Chain Approach (Case Study: Shiraz-Shahid-Faghihi Hospital)

Background: As was observed in the corona crisis, in situations, such as war or natural disasters or epidemic diseases, the intensity of the applicants for medical services causes congestion problems. In this situation, due to the limited capacity of the system, queuing phenomenon for service applicants and in some cases, rejection of clients occur. Reducing the length of hospital stays by improving performance productivity can compensate for the shortage of hospital beds. In order to increase the productivity of personnel and equipment, it is necessary to eliminate unemployment and improve service scheduling. One of the ways to achieve these goals is to optimize the distribution of beds between wards. In the present study, in the form of Markov chain approach, according to the referral rate and service rate, the existing beds were allocated to different wards of the hospital to maximize service and minimize rejection of patients. Methods: The present study is an applied study conducted in 2019 for the optimal distribution of beds between the 3 wards of Shahid Faghihi Hospital in Shiraz. The research problem was modeled in the form of Markov chain approach and assuming the referral of clients according to the continuous-time Markov chain, the model parameters value was identified. The obtained mathematical model was solved by GAMS 24.1.3 software. Results: The proposed model led to an improvement in ward performance in terms of reducing patient waiting time and increasing the number of admitted patients. The proposed model reduced patient rejection by 8.6 %. According to the patients' referral rate to the wards and the service rate of each ward, based on sensitivity analysis, the number of beds allocated to each of the 3 wards was determined. Conclusion: Queuing theory can be applied as a tool to analyze the phenomena of the treatment system and determine the features of the waiting time, queue length, and capacity of the system. Appropriate allocation of hospital beds results in improving the efficiency and decreasing the patient rejection. Therefore, it could be useful in crisis, congestion in patients, and when increasing facilities is required.