Referral writing: Consensus building on a tool for writing structured referrals

Competency in referral writing skill is needed by doctors for which they are never trained. Although there is a lot of work done about improvement of consultation letters still priority is not given. There must be a course for teaching and learning medical referral writing skills to students along with the assessment. Currently there is such tool to assess the way communication letter are written. An 18-point assessment scale has been developed through Delphi technique to increase the quality of referral letters. The objective of the present study was to design a structured Performa for writing referrals, validated by 7 participants using Delphi. Results were finalised after the acceptance of structured referral by selected participants through Delphi. The response rate was 70%. The validity and interrater reliability were calculated using SPSS25. The Cronbach’s alpha was 0.7 and Kappa was 0.3. Both were statistically significant. The designed Performa for writing referrals, with its inter-rater reliability calculated, is best for writing effective and structured referrals. The study further recommending training junior doctors in making proper referrals. MeSH Words: Referral and consultation, improving quality and referral, Checklists and referrals and consultation.

P-L06 Establishing minimum datasets and disease specific forms for cancer patients in multidisciplinary team meetings

Background Multidisciplinary team (MDT) meetings aim to ensure standardised access to cancer pathways and treatment. It is thus important that minimum datasets are established and provided to the MDT clinicians to facilitate thorough discussion and encourage shared decision making. To determine the effectiveness of pre-established minimum dataset proformas for periampullary tumours, hepatocellular carcinoma (HCC), colorectal cancer with liver metastases (CRLM) and hilar cholangiocarcinoma in cancer MDT meetings. Methods Cancer specific minimum dataset forms were developed by consultants to be implemented in MDTs for the four types of hepatobiliary pancreatic cancers: HCC, periampullary cancer, hilar cholangiocarcinoma and CRLM. 189 MDT reports and 184 referral letters were analysed from three weekly MDT meetings to determine the outcomes reported against those outlined in the proformas. The proformas were then implemented by consultants leading the weekly MDT meetings for three consecutive weeks. 128 MDT reports and 126 referral letters were re-audited from these MDT meetings to determine if there was a change in the outcomes reported. Results In this quality improvement project, 21.25% (11/52) of outcomes in MDT and 19.23% (10/52) of outcomes in the referral letters had a statistically significant difference in the reporting of outcomes from Cycle 1 to Cycle 2 across all four cancers. Greater changes in reporting were observed for outcomes that may carry higher prognostic value, such as tumour size and vascular invasion. Despite the notable difference in reporting seen for datasets consisting of smaller cohorts, the change was not statistically significant due to the insufficient statistical power proving the need for trialling such proformas in a wider population. Conclusions The minimum dataset proformas were associated with a limited gain in compliance with data reporting. Further work, with particular focus on user acceptability and attitudes is required to improve use of minimum dataset proformas in MDT.

Retrospective Analysis of Intra-Departmental Requests for Consultation To Hematology Department

Aim: To investigate how much information a specialist hematologist receives at the time of initial assessment of referred patients through a referral letter. Study design: Retrospective study Place and duration of study: Haematology department BVH, October 2020 to February 2021 (5 months) Methods & Results: Among the 96 referral letters received, Majority 45 (47%) was referred from medicine department. Most common reason for referring the patient was evaluation of Pancytopenia n=19 (19.8%), Request for bone marrow biopsy n=14 (14.6%), being the second most common. The reason for referral was not properly stated in n=9 (9.4%) of patients in our study. Majority of referred patients were above 46 years of age n=22 (22.9%). CBC was mentioned only in n=35 (36.5%). Conclusion: Our study concludes that quality of referral letter was well below the acceptable standards. A well-documented protocol for referral letter is the need of hour to improve the quality of a referral process. Keywords: referral letter, pancytopenia, bone marrow, hematology clinics

Household contact tracing with intensified tuberculosis and HIV screening in South Africa: a cluster randomised trial

Background Household contact tracing for tuberculosis (TB) may facilitate TB diagnosis and identify individuals who may benefit from TB preventive therapy (TPT). In this cluster-randomised trial, we investigated whether household contact tracing and intensive TB/HIV screening would improve TB-free survival. Methods Household contacts of index TB patients in two Provinces of South Africa were randomised to home tracing and intensive HIV/TB screening (sputum Xpert and culture; HIV testing with treatment linkage; and TPT, if eligible), or standard of care (SOC, clinic referral letters). The primary outcome was incident TB or death at 15-months. Secondary outcomes included tuberculin skin test (TST) positivity in children ≤14 years and undiagnosed HIV. (ISRCTN16006202). Results From December 2016-March 2019, 1,032 index patients (4,459 contacts) and 1,030 (4,129 contacts) were randomised to the intervention and SOC arms. 3.2% (69/2166) of intervention arm contacts had prevalent microbiologically-confirmed TB. At 15-months, the cumulative incidence of TB or death did not differ between the intensive screening (93/3230, 2.9%) and SOC (80/2600, 3.1%) arms (hazard ratio: 0.90, 95% confidence interval (CI): 0.66-1.24). TST positivity was higher in the intensive screening arm (38/845, 4.5%) compared to the SOC arm (15/800, 1.9%, odds ratio: 2.25, 95% CI: 1.07-4.72). Undiagnosed HIV was similar between arms (41/3185, 1.3% vs. 32/2543, 1.3%; odds ratio: 1.02, 95% CI: 0.64-1.64). Conclusions Household contact tracing with intensive screening and referral did not reduce incident TB or death. Providing referral letters to household contacts of index patients is an alternative strategy to home visits in high TB/HIV-prevalence settings.

EARLY MANAGEMENT OF SEVERE PRE-ECLAMPTIC AND ECLAMPTIC REFFERAL PATIENT AT KOTABARU REGENCY

ABSTRACTBackground: The maternal mortality rate is 305 per 100,000 live births in Indonesia. The most common cause of maternal death is preeclampsia / eclampsia. The maternal mortality rate is 247 per 100,000 live births in 2017 in Kotabaru Regency. Most preeclamptic referral patients are in critical condition when they arrive at the hospital. Method: This type of research is an observational descriptive study. The population is all patients with severe preeclampsia and eclampsia in the delivery room of RS Pangeran Jaya Sumitra Kabupaten Kotabaru from January - December 2018. The sample is total sampling.Results: PEB referral patients was 57 cases. Most of those are in the group age of 20 - 35 years which are 35 people (61.4%), not nullipara is 31 people (54,4%), 34-40 weeks of gestation is 43 people (75,4%), as many as 44 people (77,2%) with previous severe preeclampsia/ hypertension, 41 people (71,9%) brought referral letters, referred by Puskesmas are 47 people (82.5%), most of the locations of referral is from Pulau Laut as many as 35 referrals (61,4%). The initial management of PEB and eclampsia: IV Pathway in 11 patients (19.3%) of severe preeclamptic and eclamptic patients, 50 patients (87.7%) were not given MgSO4, 51 people (89.5% ) did not get anti-hypertension, 52 patients (91.2%) were not installed catheters. Conclusion: Early management of severe preeclamptic and eclamptic patients is not optimal and does not fulfil the standard yet. Proper and appropriate early management can reduce morbidity and maternal mortality from complications of severe preeclampsia and eclampsia that can be prevented by providing right initial management.

EP.TH.81Contribution of Information on GP Referral Letters to Patient Management in a Rapid-diagnosis Breast Clinic

Aims GP referral letters to rapid-diagnosis breast clinics are often poorly scanned copies of standard 2 week-wait proforma that are difficult to read, lengthy, and contain a large amount of irrelevant information. We studied the contribution of information in referral letters in patient management and compared this with information provided by patients themselves. Methods Patients completed a standard questionnaire (one side of A4) on arrival at clinic. This included all information relevant to a breast clinic such as family history and comorbidities. A consultant surgeon then saw the patients with the questionnaire and performed clinical assessment and imaging as necessary, without referring to GP letters. The letters were read before patients left clinic. Any additional useful information was noted. Results 202 consecutive new patients, median age 44 (16-93) seen in 23 clinics by 2 consultants were studied. The median number of pages in referral letter was 5 (1-14). Patient questionnaire took less than 30 seconds to read. The presenting complaints were real or perceived lump (n = 105), pain (n = 44), both (n = 14) and others (n = 39). 21 patients had cancer. Additional useful information in the referral letter was noted in 20 patients (10%). However, in no case this affected the patient management adversely. Conclusions GP letters are lengthy but contribute relatively little to the initial assessment and management of patients in a busy rapid diagnosis breast clinic. A patient-completed targeted questionnaire is quicker and can potentially replace a GP referral letter in most patients.

Informative value of referral letters from general practice for child and adolescent mental healthcare

Although referral letters (RLs) form a nodal point in a patient’s care journey, little is known about their informative value in child and adolescent mental healthcare. To determine the informative value of RLs to child and adolescent psychiatry, we conducted a chart review in medical records of minors registered at specialized mental healthcare between January 2015 and December 2017 (The Netherlands). Symptoms indicated in RLs originating from general practice (N = 723) were coded and cross-tabulated with the best estimate clinical classifications made in psychiatry. Results revealed that over half of the minors in the sample were classified in concordance with at least one reason for referral. We found fair to excellent discriminative ability for indications made in RLs concerning the most common psychiatric classifications (95% CI AUC: 60.9–70.6 for anxiety disorders to 90.5–100.0 for eating disorders). Logistic regression analyses suggested no statistically significant effects of gender, age, severity or mental healthcare history, with the exception of age and attention deficit hyperactivity disorders (ADHD), as RLs better predicted ADHD with increasing age (OR = 1.14, 95% CI 1.03–1.27). Contextual problems, such as difficulties studying, problems with parents or being bullied were indicated frequently and associated with classifications in various disorder groups. To conclude, general practitioners’ RLs showed informative value, contrary to common beliefs. Replication studies are needed to reliably incorporate RLs into the diagnostic work-up.