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Shephard, Emma, Claire Stockdale, Felix May, Alistair Brown, Hannah Lewis, Sara Jabri, Daniel Robertson, Victoria Moss, and Rob Bethune. "E-referrals: improving the routine interspecialty inpatient referral system." BMJ Open Quality 7, no. 3 (September 28, 2018): e000249. http://dx.doi.org/10.1136/bmjoq-2017-000249.
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Interspecialty referrals are an essential part of most inpatient stays. With over 130 referrals occurring per week at the Royal Devon and Exeter Hospital, the process must be efficient and safe. The current paper-based ’white card' system was felt to be inefficient, and a Trust incident highlighted patient safety concerns. Questionnaires reinforced the need for improvement, with concerns such as a lack of referral traceability and delays in the referral delivery due to workload. The aims of the project were to improve patient safety and junior doctor efficiency in the referral process. Through appreciative enquiry and the PDSA (Plan-Do-Study-Act) model, an electronic referral system was developed, piloted within two specialties and later expanded to others with improvements made along the way based on user feedback. The system includes novel features including specialties ’acknowledging' a referral to allow referral progress to be tracked. The system stores all referrals, creating a fully auditable inpatient referral pathway. Qualitative data indicated improvement to patient safety and user experience (n=31). Timings for referrals were measured over a 6-month period; referrals became faster with the electronic system, with average time from decision to refer to referral submission improving from 2.1 hours to 1.9 hours, with a noted statistically significant improvement in timings on a statistical process control chart. An unexpected benefit was that patients were also reviewed faster by specialties. Measuring these changes presented a significant challenge due to the complexity of the referral process, and this was a big limitation. Overall, the re-design of a paper-based referral system into an electronic system has been proven to be more efficient and felt to be safer for patients. This is a sustainable change which is being rolled out Trust-wide. We hope that the reporting of this project will help others considering reviewing their inpatient referral pathways.
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Gorman, Mark, Chris Lochrin, Muhammad Adil Abbas Khan, and Fulvio Urso-Baiarda. "Waiting times and decision-making behind acute plastic surgery referrals in the UK." Journal of Hospital Administration 2, no. 1 (December 4, 2012): 68. http://dx.doi.org/10.5430/jha.v2n1p68.
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Over the past decade, Accident and Emergency (A&E) departments in the United Kingdom have struggled to cope with a doubling in patient attendances and the combined impacts of the ‘four-hour rule’, the European Working Time Directive and Modernising Medical Careers. Our previous prospective study suggested that A&E referrals to Plastic Surgery may not always be clinically motivated, but could have been affected by lack of blinding to the Plastic Surgery department participating in the study. The current study aims to corroborate those findings retrospectively, thereby overcoming this bias, and to conduct a detailed analysis of the reasons for observed referral behaviours. Medical notes of one hundred consecutive A&E referrals to a single Plastic Surgery Unit were retrospectively reviewed, documenting patient demographics, referral reason, time taken for referral and review, patient transfer time and referral appropriateness, defined by the need for hospital admission, surgery or senior review. ‘Appropriate’ and ‘inappropriate’ referrals were compared statistically for Referral Time, Transfer Time and Review Time using the independent samples t-test. To explore the reasons for observed referral patterns, six semi-structured interviews were carried out with all grades of A&E staff members using the previously-documented ‘framework analysis method’ of deductive analysis to investigate emerging and assumed themes systematically. 73 referrals from A&E to Plastic Surgery were included in the study, most commonly for adult males with upper limb injuries. The most frequent treatment outcomes were conservative management or wound exploration with no identifiable deep injury. Mean Referral Time and Review Time was 1:53 hours and 0:58 hours respectively. 69% of referrals were considered Appropriate according to the study definition. As in the previous study, inappropriate referrals were referred significantly more quickly than appropriate ones, whereas review time was similar irrespective of referral appropriateness. Interview themes analaysis revealed junior doctor inexperience, resource constraints and unintended consequences of targets and protocols to be major non-clinical determinants of whether a referral was made. This study confirms that priorities other than clinical need may influence A&E referral behavior and provides valuable insights into the challenges and drivers determining it. A significant proportion of referrals from A&E to Plastic Surgery are inappropriate and quicker referrals are more likely to be inappropriate. Many junior doctors currently lack the confidence and competence to manage routine cases that fall under the remit of Plastic Surgery. Significant change is needed to address the current situation. The insights of this study may help to inform such change.
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Ray, Midge N., Ellen Funkhouser, Jessica H. Williams, Rajani S. Sadasivam, Gregg H. Gilbert, Heather L. Coley, D. Brad Rindal, and Thomas K. Houston. "Smoking-Cessation e-Referrals." American Journal of Preventive Medicine 46, no. 2 (February 2014): 158–65. http://dx.doi.org/10.1016/j.amepre.2013.10.018.
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Al Shamsi, Hilal Salim, Abdullah Ghthaith Almutairi, and Sulaiman Salim Al Mashrafi. "Assessing the Quality of the Saudi Healthcare Referral System: Potential Improvements Implemented by Other Systems." Global Journal of Health Science 10, no. 11 (October 13, 2018): 113. http://dx.doi.org/10.5539/gjhs.v10n11p113.
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INTRODUCTION: The referral system authorizes and transfers the responsibility for healthcare services from one provider to another. A key component of the system is the communication between primary-care and specialist providers. Poor communication between them is detrimental to and can cause significant issues with coordination of effective care.
OBJECTIVE: The purpose of this review was to evaluate current healthcare referral systems, focusing on the communication among providers, and to suggest practices that could make the Saudi healthcare referral system more effective.
DESIGN: This systematic review identified published studies of the quality of the healthcare referral system in Saudi Arabia and other countries using two databases, Medline and PubMed. Data were summarized and extracted into two tables.
RESULTS: The review included 12 studies that met its selection criteria. These studies were conducted in various regions of Saudi Arabia, but mostly the west and north. The 12 studies included 181,192 participants, with numbers of participants ranging from 21 to 138,484. The present review found that more than 50% of the referral documents and feedback reports in these studies had incomplete patient information. Implementation of electronic referrals (e-referrals) in several countries, including Australia, New Zealand and the United States, improved their referral systems, particularly by solving the problem of incomplete referral documents. In addition, the present review found that in some specialist clinics, referral cases contributed to increased workloads. One study reported on implementation of Lean Six Sigma principles in a military hospital in western Saudi Arabia, which reduced the number of referrals delayed, inappropriate referrals and the response time to referrals (7%). E-referrals and Lean Six Sigma principles may be applicable in Saudi Arabia as solutions to referral and response-time problems.
CONCLUSIONS: An increase in healthcare referrals in Saudi Arabia has caused an increase in missing essential information in referral letters and feedback reports as well as overcrowding in specialist clinics. The results of the present review suggested that implementing e-referral and Lean Six Sigma principles may improve the quality of Saudi Arabia’s healthcare referral system.
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Strouther, Nick, and Divya Jain. "Appropriateness of referrals to Whiston hospital Mental Health Liaison Services." BJPsych Open 7, S1 (June 2021): S352. http://dx.doi.org/10.1192/bjo.2021.931.
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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.
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Wootton, R., K. Harno, and J. Reponen. "Organizational aspects of e-referrals." Journal of Telemedicine and Telecare 9, no. 2_suppl (December 2003): 76–79. http://dx.doi.org/10.1258/135763303322596354.
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Crawford, Michael J., and Dora Kohen. "Urgent psychiatric assessment in an inner-city A&E department." Psychiatric Bulletin 21, no. 10 (October 1997): 625–26. http://dx.doi.org/10.1192/pb.21.10.625.
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Data on day time referrals to a liaison psychiatry team from an inner London accident and emergency department (A&E) were analysed over a two-year period. Despite the availability of local community-based alternatives for urgent assessment almost 5000 patients were seen. A quarter were self-referrals and two-thirds had had no previous contact with psychiatric services. The most common reason for referral was aggressive or disruptive behaviour. Characteristics of patients in this inner-city population suggest a continuing need for a high quality liaison service to the A&E department.
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Khanna, Niharika, Elena Klyushnenkova, Vibha Rao, Neil Siegel, and Sara Wolfe. "Electronic referrals to the tobacco Quitline: implementation strategies in a large health system to optimize delivery of tobacco cessation to patients." Translational Behavioral Medicine 11, no. 5 (January 7, 2021): 1107–14. http://dx.doi.org/10.1093/tbm/ibaa094.
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Abstract Electronic referrals provide an efficient solution for clinicians to connect patients to free tobacco cessation services, such as the tobacco Quitline. However, strategic planning is necessary for the successful adoption of this method across the health care system. The purpose of this study was to develop an implementation strategy for electronic referrals to the tobacco Quitline in a large health system. A clinical decision support tool created a closed-loop e-referral pathway between the electronic health record system and the Quitline. Multilevel strategies were developed to implement the e-referral process across the entire health system, including leadership buy-in, Epic tip sheets, newsletters, training for practice champions and staff, physician educator, patient-focused advertisements, and video clips distribution by the Maryland Department of Health Center for Tobacco Prevention and Control. The implementation of a system-wide e-referral pathway for tobacco cessation involved continuous clinician education and training, systematic quality control, and engaging “champion” clinicians. Postimplementation data analysis revealed that 1,790 e-referrals were received by the Quitline in 2018–2019, of which 18% accepted follow-up services, 18% declined, and 64% were not reached after multiple attempts. Among 322 patients who accepted Quitline services, 55% requested nicotine replacement therapy. Overall, 282 clinicians referred patients, including 107 primary care physicians and 175 specialists; 62 clinicians e-referred 72% patients, thereby emerging as “tobacco champions.” The e-referral process is an efficient method for tobacco users to receive a cessation referral from clinicians. Sustainability can be achieved through leadership buy-in, physician ease of use, patient motivation, information technology supports, and reminders.
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Duffield, J. S., K. Craig, and W. D. Plant. "Patterns in Acute Referral to Hospital." Scottish Medical Journal 42, no. 4 (August 1997): 105–7. http://dx.doi.org/10.1177/003693309704200402.
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This retrospective observational study aimed to assess factors affecting acute referral and subsequent admission to hospital by general practitioners. Data concerning 2,303 consecutive acute referrals to hospital from all GPs in a defined study area were collected over one month. Fund holding practices cared for 13% of the population referred 13% ofall referrals resulting in 14% ofadmissions. Referral through the A&E resulted in significantly more patients being discharged upon initial assessment (p<0.001). A telephone call accompanying referral dramatically increased the chance ofhospital admission (p<0.001). Referral to hospital was more likely the more socially deprived the patient (p<0.001) but had no subsequent bearing on admission.
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Scott, Karla. "The Swansea electronic referrals project." Journal of Telemedicine and Telecare 15, no. 3 (April 2009): 156–58. http://dx.doi.org/10.1258/jtt.2009.003016.
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A system was developed to allow general practitioners in Swansea to send urgent cancer referrals electronically to consultants at the South West Wales Cancer Centre. Five practices from the Swansea area took part in a pilot trial. Information was extracted from the system to evaluate the e-referral activity of the first six months, during which a total of 99 referrals were submitted electronically; most (81%) were processed within one hour. Evaluation interviews were conducted with staff at the general practices, who were asked to rate the system on a 10-point Likert scale (1 = completely dissatisfied to 10 = completely satisfied); the lowest satisfaction rating given by the practices was 8. The staff agreed that the use of a standard form was beneficial and improved the quality of the referral information submitted to consultants.
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Munasinghe, Chathura, Jacek Parylo, Tom Hayton, and Thamala Ranasinghe. "040 Diagnosing primary brain tumours a retrospective audit at the Queen Elizabeth Hospital, Birmingham." Journal of Neurology, Neurosurgery & Psychiatry 93, no. 9 (August 12, 2022): e2.235. http://dx.doi.org/10.1136/jnnp-2022-abn2.84.
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IntroductionPrimary brain tumours (PBTs) are rare, but they can have devastating impacts. Early diagnosis and treatment of PBTs can lead to improved patient outcomes. This audit analysed the proportion of PBT patients referred from primary care by the urgent 2-week wait pathway to the neuro-oncology multi-dis- ciplinary team (MDT) at the Queen Elizabeth Hospital, Birmingham (QEHB).MethodsNeuro-oncology MDT data at the QEHB was reviewed retrospectively. A random number generator was used to select patients until a sample size of 50 was achieved. Inclusion criteria were patients presenting with a PBT. Exclusion criteria included metastatic disease and where a clear referral pathway could not be established.ResultsOf the 50 patients analyzed, 45 (90%) were secondary care referrals, and 5 (10%) were primary care referrals, via the 2-week wait pathway. Of the secondary care referrals, 26 patients were diagnosed in A&E. The most common presentations were seizure (12 patients) and headache (10 patients).DiscussionThese results indicate that few patients are diagnosed through primary care. Most diagnoses occurred in A&E departments. This data could warrant a shift in guidance for primary care practitioners, from the 2-week wait pathway, to a direct referral to A&E for earlier diagnosis.
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Linn, TY, AA Kochhar, JY Osammor, and ME Baraka. "Ear, nose and throat emergencies at the RLI: audit analysis." Morecambe Bay Medical Journal 3, no. 7 (January 1, 2000): 234–35. http://dx.doi.org/10.48037/mbmj.v3i7.617.
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The new purpose-built ENT unit at the Royal Lancaster Infirmary (RLI) was opened in February 1996. It is currently a five-day ward, open from Monday 9am to Friday 5pm. The cover for weekends and bank holidays is provided by the Royal Preston Hospital, twenty miles south of Lancaster. The two consultant ENT surgeons at the RLI share a one in six rota with their colleagues from the Royal Preston Hospital to cover the weekends and bank holidays. The inconvenience caused to patients and their relatives aswell as the disruption of continuity of care is yet to be assessed. The emergency workload of any ENT department is from three sources: in-hospital referrals, referrals from general practitioners and accident & emergency (A&E) departments. The latter account for a large proportion of this emergency workload. The most common diagnoses necessitating referral are foreign bodies in the aerodigestive tract, followed by epistaxis and some form of ear sepsis. Little work has been done, however, with regard to the ENT condition seen in the A&E unit. In our study, we looked at the referrals to the ENT departments at the RLI and the Royal Preston Hospital from the Lancaster A&E department to determine the pattern of patients' referral and their management.
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Nagiub, Youstina, and Rekha Hegde. "The effects of the first wave of the COVID-19 pandemic on the presentation of adolescents to acute mental health services in NHS Lanarkshire." BJPsych Open 7, S1 (June 2021): S276—S277. http://dx.doi.org/10.1192/bjo.2021.735.
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AimsThis project aimed to assess the effects of COVID-19 on the mental health of adolescents, reflected through their presentations to A&E departments in NHS Lanarkshire.MethodThe psychiatry liaison database was searched for referrals of 17 year olds and under from April until August 2020.All referrals to all acute hospital sites in Lanarkshire received from any source were included. The only exclusion criteria applied were age over 17 and unavailable assessment information.The sources searched for information were: patient's electronic notes, Mental Health Assessment forms, Mental Health Risk Assessment forms and electronic letters. The following information was gathered: –patient's age–date, source and reason for referral–hospital site of assessment–outcome of assessmentResult–Between April and August 2020, the number of CAMHS A&E referrals increased every month except in July.–The age range of CAMHS patients presenting to A&E were 12-17 years, with 17 being the most common age seen.–87% of referrals were from A&E.–The two most common reasons for referrals were drug overdose and suicidal ideation.–The most common outcome of assessment was a CAMHS referral.–COVID-19 was a trigger for an adolescent's presentation to A&E in 31% of cases, the most common cause being struggling with the lockdown/restrictions.ConclusionThe mental health charity YoungMinds carried out several surveys throughout the COVID-19 pandemic's first wave. They demonstrated a detrimental effect on young people's mental health in the UK.YoungMinds surveys revealed that 32% and 41% of young people experienced “much worse” mental health due to COVID-19. The findings of NHS Lanarkshire were similar, with 31% of adolescents presenting to A&E as a result of COVID-19.No adolescent included in this review had contracted COVID-19 at any point. Their mental health was therefore impacted by the indirect effects of COVID-19 rather than the direct effects of infection. For the 31% of CAMHS presentations to A&E which were due to COVID-19, most young people struggled with the lockdown/restrictions.The number of presentations to A&E increased every month between April and August 2020 except for July. This could be due to people's initial fear of coming to hospital and catching COVID-19. However, as infection and death rates decreased towards the summer, people may have regarded hospitals as safer. The general increase in referrals every month may also be a reflection of the worsening of young people's mental health the longer the pandemic extended.
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Harriet, Ball, Bosnell Rose, and Fuller Geraint. "WED 024 Acute model in gloucestershire." Journal of Neurology, Neurosurgery & Psychiatry 89, no. 10 (September 13, 2018): A4.2—A4. http://dx.doi.org/10.1136/jnnp-2018-abn.14.
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We operate a consultant led ‘post-acute’ model for Acute Neurology service delivery, with Advice and Guidance (an email service for GPs); attendance at twice daily ‘huddle’ meetings on MAU; and inpatient e-referrals. We have two sites, 683 inpatient beds in Gloucester Royal, and 379 in Cheltenham General. 10–15 of these inpatient beds (in Gloucester) are flexibly allocated under neurology.We received 153 inpatient e-referrals over a 1 month audit (October 2017). 78% of these received an inpatient review (the remaining 22% were managed by email); 97% within 24 hours, 7 days per week; 100% by consultants. This averages 5 referrals per day (range 0–9). Patients can be transferred under neurology when beds are available (49 admissions/month).The reasons for referral included focal neurological deficits (27%), headache (21%), epilepsy (14%), movement disorders (10%), unexplained loss of consciousness or possible seizure (9%), altered consciousness (8%), neurological infections (3%), and scan abnormalities (3%).This rapid input is in line with the ABN’s Quality Standard for Unscheduled Care. The referral element of this service requires approximately 1.5–2 PAs on each weekday, and 1 PA on each weekend day. We are also about to start an acute neurology clinic (approx. 20 slots per week).
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Svedberg, Kaj. "Why is hitting A&E time targets so hard?: using Nudge theory and modelling to improve response times." BJPsych Open 7, S1 (June 2021): S223. http://dx.doi.org/10.1192/bjo.2021.595.
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AimsTo improve the one hour response times to referrals made to psychiatric Liaison in A&E without adding or changing available resources.MethodResponse time data of referrals made to the Homerton University Hospital psychiatric liaison service was collected dating back from August 2016 to October 2019 (n = 10225).A nudge was introduced in the form of a large display showing referrals arriving in real time in the staff office.Data was then collected over a period of 5 weeks (n = 436) to measure if any change had occurred in response times.ResultResponse times appear to follow a Poisson like distribution curve. The average referral was responded to within 6 minutes (n = 1577) prior to the nudge, and 6 minutes (n = 88) after. Prior to the nudge the 95% referral envelope fell within 134 minutes (n = 9728) and was 122 minutes (n = 414) after the intervention. Significant statistical difference is observed upon considering response in the first 240 minutes.ConclusionNudge interventions could be a useful resource-sparing method to improve services. The average referral to the HUH liaison team was quickly responded to within 6 minutes and yet hitting the 1 hour 95% target appears ever-elusive. Hitting targets of 95% responses within 1 hour may prove very difficult if we are not considering natural distributions, such as Poisson, occuring in the backgroung which ultimately may require a change in approaches to how we set performance targets.
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Svedberg, Kaj. "Psychiatric liaison referrals and the 4PM Rush." BJPsych Open 7, S1 (June 2021): S304. http://dx.doi.org/10.1192/bjo.2021.956.
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AimsReferrals to the psychiatric Liaison team in A&E seem to come in the afternoon in kismet as the day shift is ending. This study looked at the timing distribution of referrals to try improve amount of jobs being handed over to the evening shifts.MethodReferrals made to Homerton University Hospital (HUH) psychiatric liaison was parsed into 1 hour bins and plotted as a histogram (data between August 2016–October 2019. N = 14182). The data were compared to diurnal human body temperature variation, as well as data published on Hospital Accident & Emergency Activity 2019–20 (digital.nhs.uk) for Ambulance attendances.ResultReferrals to HUH liaison team appear to closely follow the average human body temperature variations per hour (Pearson Correlation coefficient = 0.90). A peak appears to occur around 4 PM, and a low at 7AM. The referrals data also mirrored timings of official Hospital Episode Statistics (HES) reports 2019–2020 for ambulance attendance in England (Pearson Correlation coefficient = 0.94).ConclusionAttendance to A&E and referrals to psychiatric liaison appear correlated to a circadian bound rhythm. “The 4PM referrals rush” appears to be a genuine phenomenon replicated in not only HUH mental health referrals, but general ambulance attendance throughout all of England. The body temperature analogue for circadian rhythm may be humorously applied here to correlate with the increased referral rates to A&E; the emergency department could be said to be truly heating up in the afternoon. Indeed temperature and activity has already been shown to link strongly via the Arrhenius equation in cricket activity such as chirps per minute. The conclusions drawn here are that acute mental health attendances, like general health attendances as a whole follow underlying but powerful patterns, and provisions might best be allocated to address this rather than thinking of fixed 9-5 working schedules.
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Vassallo, D. J. "A Guide to Sending E-Mail Telemedicine Referrals." Tropical Doctor 33, no. 1 (January 2003): 34–35. http://dx.doi.org/10.1177/004947550303300117.
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This article describes simple e-mail protocols that have proven their effectiveness in the telemedicine links established by the Swinfen Charitable Trust. They are presented here as a guide for the benefit of those doctors who may be considering setting up their own telemedicine links.
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Amer, Mahmoud, Prosen Ghosh, and Animesh Chatterjee. "Improving medical consults for surgical inpatients: a quality improvement project using an e-referral system linked to clinical pathways." BMJ Open Quality 11, no. 2 (June 2022): e001606. http://dx.doi.org/10.1136/bmjoq-2021-001606.
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Surgical inpatients referred to medicine with acute medical problems represent a complex patient population, vulnerable to fragmented care and suboptimal outcomes. They can also be a source of staff dissatisfaction in busy or understaffed departments. Comanagement by surgical and medical staff may improve outcomes but requires dedicated resources and the evidence for other interventions is scarce. We aimed to assess staff experience, demographics and clinical outcomes of this patient population at our hospital and develop an intervention aiming to improve medical staff experience, without compromising clinical outcomes.Staff were surveyed before and after the intervention to measure staff experience. Demographics and clinical outcomes were collected for 60 referrals at baseline and 29 referrals postintervention (an e-referral system linked to locally developed clinical pathways). Clinical outcomes were delay time (time from referral submission to review), length of stay, 30-day mortality and 30-day readmissions.Medical staff experience improved from majority negative or neutral ratings to majority positive ratings postintervention and 100% of staff surveyed supported ongoing use of the intervention. There were no negative impacts on clinical outcomes, which acted as balancing measures.Medical staff experience improved, without compromising clinical outcomes. The e-referral system doubles as a platform for ongoing quality improvement.
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Ramage, G., A. Poacher, M. Ramsden, J. Lewis, A. Robertson, and C. Wilson. "A VIRTUAL FRACTURE CLINIC AUDIT: ARE WALES MATCHING THE OUTCOMES IN ENGLAND?" Orthopaedic Proceedings 105-B, SUPP_4 (March 2023): 6. http://dx.doi.org/10.1302/1358-992x.2023.4.006.
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IntroductionVirtual fracture clinics (VFC's) aim to reduce the number of outpatient appointments while improving the clinical effectiveness and patients experience through standardisation of treatment pathways. With 4.6% of ED admissions due to trauma the VFC prevents unnecessary face to face appointments providing a cost savings benefit to the NHS.MethodsThis project demonstrates the importance of efficient VFC process in reducing the burden on the fracture clinics. We completed preformed a retrospective cross-sectional study, analysing two cycles in May (n=305) and September (n=332) 2021. We reviewed all VFC referrals during this time assessing the quality of the referral, if they went on to require a face to face follow up and who the referring health care professional was. Following the cycle in May we provided ongoing education to A&E staff before re-auditing in September.ResultsBetween the two cycles there was an average 19% improvement in quality of the referrals, significant reduction in number of inappropriate referrals for soft tissue knee and shoulder injuries from 15.1% (n=50) to 4.5% (n=15) following our intervention. There was an 8% increase in number of fracture clinic appointments to 74.4% (n=247), primarily due to an increase number of referrals from nurse practitioners. Radial head fractures were targeted as one group that were able to be successfully managed in VFC, despite this 64% (n=27) of patients were still seen in the outpatient department following VFC referral.ConclusionDespite the decrease in the number of inappropriate referrals, and the increase in quality of referrals following our intervention. The percentage of VFC referrals in CAVUHB is still higher than other centres in with established VFCs in England. This possibly highlights the need for further education to emergency staff around describing what injuries are appropriate for referral, specifically soft tissue injuries and radial head fractures. In order to optimise the VFC process and provide further cost savings benefits while reducing the strain on fracture clinics.
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Dove, James, Amit Mistry, Nomi Werbeloff, David Osborn, and Nora Turjanski. "Weekday and seasonal patterns in psychiatric referrals in three major London A&E departments, 2012–2014." BJPsych Bulletin 42, no. 1 (January 30, 2018): 5–9. http://dx.doi.org/10.1192/bjb.2017.4.
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Aims and methodTo identify temporal and demographic trends in referrals made to psychiatric liaison services. Routine clinical data from 16 105 individual referrals from three central London accident and emergency (A&E) departments to psychiatric liaison services from 2012 to 2014 were obtained and analysed using the Clinical Record Interactive Search (CRIS).ResultsReferrals from A&E to psychiatric liaison services increased 16% over the 3-year study period. There were fewer referrals to psychiatric liaison services in winter months compared with other seasons. There were fewer referrals to psychiatric liaison services over the weekend compared with weekdays (average 15.4 daily weekday referrals v. 13.2 weekend, z = 5.1, P < 0.001), and weekend referrals were slightly less likely to result in admission to psychiatric hospital (11.3% v. 12.8%, respectively, χ2 = 6.33, P = 0.01).Clinical implicationsPsychiatric staffing in A&E and inpatient psychiatric wards requires planning to meet temporal and regional variations in the pattern of demand.Declaration of interestNone.
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Adeleke, Olusola Michael, Rubyyat A. Hakim, Laurence Dean, Huma Zahid, Rongyu Lin, Mariya Karova, Joao R. Galante, et al. "Reversing the Friday peak in metastatic cord compression referrals: Not as simple as previously thought?" Journal of Clinical Oncology 39, no. 15_suppl (May 20, 2021): e14050-e14050. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.e14050.
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e14050 Background: Historically, metastatic spinal cord compression (MSCC) referrals trend towards a Friday peak in incidence (Koiter E, Radioth Onc 2013). However, data from a single, tertiary centre in the UK showed a reversal in the Friday peak (Adeleke S, Annals of Oncology 2020). This was attributed to early case referrals and quicker treatment decisions. In this new study, we explored whether a similar pattern was apparent in multiple district general hospital (DGH) settings and attempt to identify underlying causes. DGHs manage a larger proportion of cancer patients in the UK. Methods: 1,069 patients between 1 Jan 2015 and 31 Dec 2020 were identified across 4 hospitals in Kent, UK with a population of 1.6 million people. 220, 181, 182, 159, 134 and 193 MSCC patients were identified annually (2015-2020). Commonest cancers were prostate (24.1%), lung (19.3%) and breast (12.3%). Thoracic and lumbar regions constituted 80% of MSCC sites. Kruskal Wallis was used to compare differences in referrals across weekdays. Data was then dichotomised to Fridays only vs. other days of the week combined, as previously reported (De Bono B, Acta Neurochir 2019). Chi squared was used to compare frequency of referrals between the two groups. Chi squared goodness of fit test was conducted to detect if Friday reflected the day with highest referrals across the week. Results: Across the region, 2015 saw the highest number of Friday referrals relative to other days, p= 0.002. Friday referrals continued to drop, year on year, until 2018 with a corresponding increase in mid-week referrals. After 2018, there was a return in trend to a further Friday peak across the region, though p= 0.836. On an individual hospital basis, the persistent Friday peak in the region was driven by two hospitals. Having a 7-day acute oncology service (AOS), 7-day radiology reporting and single referral point of contact in the department, were factors identified that kept the referrals across the week uniform. On another note, a substantial shift towards a single 8Gy fraction vs. 20Gy in 5 fractions was observed across the region. This change coincided with SCORAD III data (Hoskin P, ASCO 2017) and demonstrates adherence to evidence-based practice in the region. Conclusions: This large multi-centre retrospective study shows a differential referral pattern in the region, with hospitals with 7-day AOS/Radiology reporting and single point of referral (e.g, similar to MSCC coordinator role) having a quicker treatment turnaround and uniform referrals across the week. The MSCC coordinator has been shown to streamline service, ensure timely decision-making and improved survival outcomes (Richards L, Spine J 2017). The role is recommended by NICE UK. DGHs should consider appointing an MSCC coordinator when designing/auditing their service. The shift towards single 8Gy fraction can provide a ‘one-stop’ service where patients are scanned, planned and treated on the same day.
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Alabbasi, Khalid H., Estie Kruger, and Marc Tennant. "Strengthening Saudi Arabia’s Primary Health Care through an e-Referral System: A Case Study." Clinics and Practice 12, no. 3 (May 24, 2022): 374–82. http://dx.doi.org/10.3390/clinpract12030042.
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Health systems are becoming more complex, regulatory bodies are increasing their vigilance, and reimbursement practices are shifting toward value, making closing the referral loop an imperative for patient safety, regulatory oversight, and financial viability. The aim of this study was to examine the referral pattern in PHC services and whether a significant variation exists among them based on geographic accessibility to a referred hospital. This was a cross-sectional retrospective study that included all sequentially referred patients between 1 January 2019 and 30 December 2021. A pre-initiative comparison could not be performed, as previous data on the traditional referral system could not be collected. The primary outcome measures considered in this study were the referral rate, and the proportion of the documented appointment date. The healthcare facilities’ geographic locations and data of the hospital departments to which the patients were referred were also available. Between 2019 and 2021, the hospital received 52,143 referrals from the 9 designated PHC centres covering 34 districts. In the PHC centres located within the ≤13 km zone, 1 in every 14 patients were referred to the hospital, whereas 1 in every 20 patients visited PHC centres outside this zone. Since the introduction of the Ehalati e-referral system, the number of documented appointment schedules of the referred patients has improved over time by 16.1% (from 79.6% to 95.7%, p < 0.001). Ophthalmologic (17.1%) and dental services (15.4%) received the most referrals among all other specialties, whereas the referral rate for cardiology services was the lowest (2.5%). The documented appointment scheduling record of referred patients has improved significantly since the introduction of the Ehalati e-referral system. However, the results of this study indicate that the proximity of PHC centres to specialised hospitals is more likely associated with higher referral and documented appointment scheduling rates. Strategies that improve scheduling, decrease variation among clinics, and improve patient access will likely improve the closing rates of the referral loop.
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Smith, Kay. "Nurse phoneline berated over trivial A&E referrals." Nursing Standard 18, no. 47 (August 4, 2004): 8. http://dx.doi.org/10.7748/ns.18.47.8.s21.
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Kingdon, J., H. Aadan, S. Husain, C. Atkinson, C. Thomson, and P. Braude. "22 Design and Implementation of A Nutrition Clinical Pathway for Patients with Fractured Neck of Femur." Age and Ageing 49, Supplement_1 (February 2020): i1—i8. http://dx.doi.org/10.1093/ageing/afz183.22.
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Abstract Background Patients with a fractured neck of femur (FNOF) are commonly malnourished pre-admission, have reduced oral intake in hospital and a hypermetabolic state up to three months postoperatively (E Paillaud 2000). Malnutrition is associated with functional deterioration, higher morbidity and mortality. Evidence suggests nutritional supplementation post-surgery can reduce postoperative complications. As a result, nutritional assessment is included in the National Hip Fracture Database best practice tariff (Avenell, Cochrane Database of Systematic Reviews 2016). Introduction Our aim was to design and implement a clinical pathway for patients with FNOF to identify malnutrition and provide appropriate nutritional support. Intervention A retrospective audit of 25 patients was completed to understand baseline rates of assessment, prescription of supplements and referral to dietetics. Using these data meetings were arranged to develop a clinical pathway. Key stakeholders included dietetics, orthopaedic surgeons, geriatricians, physiotherapists and nurses. The pathway was evaluated and optimised with two Plan-Do-Study-Act (PDSA) cycles looking at 25 patients each time. Results Baseline: 79% received a nutritional assessment, 32% had nutritional supplements prescribed and 36% (n=9) met criteria for referral to a dietician, of which 55%were referred. However, an additional 5 referrals were made to dietetics for patients who did not meet criteria, a 50% inappropriate referral rate. PDSA cycle 1: increased nutritional assessment (85%), increased nutritional supplements prescribed (92%), decreased inappropriate referrals to dietetics (43%). PDSA cycle 2: increased nutritional assessment & nutritional supplements prescribed (100%), increased inappropriate referrals to dietetics (80%). Conclusions The implementation of a nutrition pathway has led to increased identification and treatment of malnutrition, which has in addition improved accrual of the best practice tariff. However, greater number of inappropriate referrals have been made to dietetics. This is partly attributed to difficulty weighing patients on admission, and where no weight is inputted on the Malnutrition Universal Screening Tool a “High Risk” score is generated triggering a referral. We are now looking at alternative methods to obtaining a weight such a mid-upper arm circumference.
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Carroll, Jamie L., Stephanie L. Amundson, Tufia C. Haddad, and Karthik Giridhar. "Optimizing internal referrals within an academic breast oncology practice." Journal of Clinical Oncology 38, no. 29_suppl (October 10, 2020): 48. http://dx.doi.org/10.1200/jco.2020.38.29_suppl.48.
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48 Background: Improving new patient access to medical oncology clinics is a priority. Unlike external referrals which undergo a review process, internal referrals (from any Mayo department or community-based, affiliated health system) are scheduled directly. At times, these internal referrals lack necessary clinical information, or may be more appropriate for electronic consultation (e-consult). This impacts the patient experience, provider satisfaction, and access to new patient visits. A pilot program was implemented in the Medical Oncology breast clinic to review new internal referrals prior to scheduling. Methods: In 2018, all internally referred patients to Medical Oncology breast clinic were reviewed by an advanced practice provider in breast oncology. Electronic medical records were reviewed to collect diagnosis, pathology, radiology information and treatment to date. Internal referrals were either accepted directly to medical oncology breast clinic, triaged to an internal medicine clinic for workup of a new breast mass, converted to an e-consult, or declined as no medical oncology need was identified. Results: 52 patients were referred internally to Medical Oncology breast clinic. Of these, 29 (55.8%) were accepted directly as new consultations, 8 (15.4%) were triaged to the Internal Medicine clinic, 6 (11.5%) were converted to e-consults, and 6 (11.5%) were declined as not requiring breast medical oncology input. Of the 8 patients that started in the IM clinic, 6 eventually required Medical Oncology breast clinic consults for invasive breast cancers. The most common e-consult was for extending adjuvant endocrine therapy (3/6). 1/6 e-consults required a follow up consultation. The most common reason for declining a consult was no diagnosis of an invasive breast cancer (4/6). A total of 16/52 referrals (30.2%) did not require a breast oncology new consultation. Conclusions: Review of internal referrals improved the efficiency of new breast cancer medical oncology consultations. This review process has been implemented across the entire Medical Oncology practice.
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Choy, B., T. Mccoll, M. Reed, and S. Bawa. "AB1832-HPR REMOTE SCREENING OF SELF-REFERRALS FOR JOINT INJECTION CLINIC." Annals of the Rheumatic Diseases 82, Suppl 1 (May 30, 2023): 2148.2–2148. http://dx.doi.org/10.1136/annrheumdis-2023-eular.6196.
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BackgroundIntra-articular steroid injections are a valuable option in the management of inflammatory joint flare-ups.[1]The Gartnavel General Hospital (GGH), Glasgow operates a joint injection clinic for rheumatological patients via a self-referral system. This allows patients to book clinics directly and enables prompt access to an appointment. This system was modified in July 2022 to include remote screening, allowing for the evaluation of self-referrals prior to booking appointments. Waiting times have decreased significantly from 3 months to 1 week since the use of remote screening.ObjectivesTo determine the efficacy of remote screening on self-referrals and identify self-referring patient groups where joint injections are not indicated.MethodsRetrospective analysis was conducted on patient self-referrals to the joint injection clinic from 07/07/2022 to 07/12/2022. Patient demographics, diagnoses, reasons for rejection and outcomes were analysed.Results108 patients self-referred for a joint injection during this period. There was a 41.7% (n=45) decrease in clinic bookings with remote screening. 50.9% (n=55) were refused on screening; 81.8% (n=45) of these patients were not indicated for a joint injection. 35.2% (n=38) of patients were not under rheumatology review. 25.9% (n= 28) of patients had solely osteoarthritis; 71.4% (n=20) of these patients were rejected and directed to outpatient physiotherapy services.ConclusionRemote screening was effective in reducing the patient waiting list for joint injections. The self-referral system used in isolation has significant limitations and has led to clinic booking beyond its capacity. This issue is also exacerbated by self-referrals from non-rheumatological patients.Reference[1] Naredo E, Rull M. Aspiration and injection of joints and periarticular tissue and intralesional therapy. Rheumatology. 6 ed. Mosby, 2015: 542-553.Acknowledgements:NIL.Disclosure of InterestsNone Declared.
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Currie, Alan, and Richard Blennerhassett. "Deliberate self-harm: how feasible are the current guidelines?" Irish Journal of Psychological Medicine 16, no. 2 (June 1999): 61–63. http://dx.doi.org/10.1017/s079096670000519x.
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AbstractObjectives: To examine the operation of a deliberate self-harm service at a large general hospital with reference to standards outlined by the Royal College of Psychiatrists. To examine the characteristics of referrals and to make recommendations for improvements to the service.Method: Data on referral and assessment characteristics were collected for 96 consecutive referrals over a three month period.Results: The services achieved the college standards in relation to the time period for assessments. Most referrals were made routinely at a predictable time but assessments were conducted on an ad hoc basis. Only a minority of those referred had a mental illness or complex problems. A significant number of patients were discharged from the A&E department without a psychiatric assessment. Assessors underemphasised the role of previous deliberate self-harm and/or the presence of mental illness in forming a judgment on the risk of suicide. After-care arrangements were predominantly medical (general practitioners or psychiatrists) with little multidisciplinary input.Conclusions: The deliberate self-harm service at the hospital could be improved by the establishment of a self-harm services planning group to oversee the delivery of the service throughout the hospital and address the deficits identified. Given the number of referrals seen within the service and the fact that deliberate self-harm is only one element of a comprehensive liaison service, consideration should be given to the establishment of a separate multi-disciplinary liaison team. Once again importance is drawn to the need for all assessors to be aware of the risk factors in relation to the future risk of suicide rather than placing undue emphasis on whether the most recent attempt was planned or impulsive in nature.
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Pannick, SAJ, and CL Ingham Clark. "Waiting Time to Lymph Node Biopsy is Dependent on Referral Method: Don't Write, Phone!" Annals of The Royal College of Surgeons of England 91, no. 8 (November 2009): 673–76. http://dx.doi.org/10.1308/003588409x12486167521118.
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INTRODUCTION Patients with lymphadenopathy are commonly referred to general surgeons for diagnostic lymph node biopsy. We were concerned at potential long waits for this service in our hospital and thus wanted to compare the efficiency of written and telephone referral with a view to identifying the optimum care pathway for these patients. PATIENTS AND METHODS Sixty patients were included in a 2-year retrospective review (excluding referrals associated with breast lumps which were managed separately). Hospital Episode Statistics data were used to analyse notes for the source and method of referral, waiting time to biopsy, clinic attendance and diagnosis. RESULTS Of referrals, 33% were from haematology and 28% from general practice. Overall, 47% of patients were referred by letter; of these, 64% were seen in clinic before biopsy. Personal referral between clinicians, by direct discussion, e-mail or fax led to a mean wait of 4 days, compared to 51 days when patients were referred by letter. Clinic attendance had no significant bearing on diagnostic accuracy or complication rate. Neoplasia accounted for 43% of diagnoses and infection (including four cases of tuberculosis) for 10%. Of biopsies, 33% showed benign changes, 8% were unrecorded and 5% were incorrect. CONCLUSIONS In this study, 43% of biopsies revealed malignancy and we advise that lymph node biopsy requests should be managed on a fast-track pathway, expedited by direct personal request. Following this study, we have implemented a fast-track pathway for such patients.
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Abali, Ayse Ebru, Cem Aydogan, Nigar Turkmen, and Mehmet Haberal. "565 Pandemia Experience in Pediatric Minor to Moderate Burns and the Role of Telemedicine in Treatment." Journal of Burn Care & Research 42, Supplement_1 (April 1, 2021): S132—S133. http://dx.doi.org/10.1093/jbcr/irab032.215.
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Abstract Introduction A huge number of pediatric burn injuries are minor to moderate burns. During covid-19 pandemia, these cases have continued to require medical attention. Aim of the present study was to share our burn center’s pandemia experience in minor to moderate burns in children. Methods Records of 117 victims (age:0 to 17yrs) were documented {study period: 3/11/2020(pandemia decleration by WHO)-9/11/2020}. Data were classified according to treatment modalities (outpatient/inpatient/telemedicine). Age; sex; extent of burns; burn cause; environment in which injury occured; referral history (time interval between injury and referral; other hospitals before arriving at our center) were noted for each case. Thereafter, subjects were divided into two subgroups according to pandemia calender: GroupIconsisted of referrals in march+april+may (national ‘lock-down’ period for children n=60) and GroupIIconsisted of referrals in june+july+august+september (‘new normal’ period with limited social life n=57) (mean±SE,p˂.05). Results: Outpatients comprised 82,1% of all referrals(n=96) with 361 in-person visits. Mean age was 4,2yrs±0,4(min:0 max:17); male/female ratio was 1,04/1. Mean total body surface area(TBSA) burned was 2,6%±0,6(min:0,2 max:20). The most common burn causes were scalds(n=79; 82,3%) and contact burns (n=11;11,5%). Number of referrals on the same day with injury was 41 (42,7%) and 65 referrals were unmediated(67,7%). Inpatients comprised of 11,1% of all referrals (n=13). Mean age was 3,9yrs ± 1,7 (min:1 max: 16). Male/female ratio was 0,9/1. Mean TBSA burned was 9,3%±1,8 (min:1 max:18). The most common burn cause was scalds(92,3%;n=12). Nine patients were hospitalized on the same day with injury (69,2%). Ten patients were referred from other hospitals (76,9%). Mean lenght of hospital stay was 6,77days±1,4 (min:1 max:14). Telemedicine visits (n=33) which were carried out for 23 children via e-mail and phone/video calls included photographic follow up visits for scars, treatment of contact dermatitis and controls of wound-dressings. Comparison of ‘lock-down’ period (groupI) with ‘new normal’ period (groupII) revealed that almost whole telemedicine service was carried out in groupI except two interurban visits in groupII. Findings were similar in both groups except the significant increase of outdoor burns and remarkable presence of sun burns in groupII(p< .05). Conclusions Covid pandemia has created extraordinary conditions; however present data suggests that minor to moderate burns in childhood continue to occur anyway. Telemedicine is an advantageous method under pandemia conditions. Therefore, attempts for basic burn-care guidelines including telemedicine facilities should be supported.
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Cumming, D. "The 4-hour window: UK Government targets versus clinical priorities." European Psychiatry 41, S1 (April 2017): S563—S564. http://dx.doi.org/10.1016/j.eurpsy.2017.01.821.
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IntroductionIn 2002, the Department of Health (United Kingdom) introduced a 4-hour target due to long waiting times. It is expected that 95% of patients who attend the A&E (Emergency) Department should be registered and admitted/discharged within 4 hours. Exceeding this is termed a “breach”.ObjectivesThe aim of this re-audit was to assess for a response following recommendations after an initial audit with concerning results. Forth Valley Royal is an acute public hospital in Central Scotland with 860 in-patient beds, covering a population of 300,000. It contains two general adult wards (42 beds), one IPCU (12 beds) and two Elderly wards (40 beds).MethodsReferral data was sourced across 4 consecutive months: April–July 2015 (initial audit) and October 2015–January 2016 (re-audit). These included all referrals from A&E to Psychiatry. Times were calculated for the 4 subprocesses listed in Table 1 below.Conclusion/discussionFollowing the initial audit, interventions such as training A&E staff to better manage psychiatric patients and encourage earlier referrals, led to a positive response in the re-audit (Subprocess 1). Breach rates reduced to 28% (from 35%) on re-audit. Less breaches (81% compared to 88%) were referred after 2-hours by A&E. Overall, the breach rates have reduced and they are less attributable to the A&E referring patients late. The outcome of patients leaving A&E without being seen by a psychiatrist was unknown – adverse outcomes would strengthen the debate to enforce the 4-hour window.Disclosure of interestThe author has not supplied his/her declaration of competing interest.Table 1Initial audit = 222 referrals (35% breach rate)Re-Audit = 348 referrals (28% breach rate)
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Macgregor, D. M., and J. A. Hiscox. "School Referral Survey." Scottish Medical Journal 43, no. 3 (June 1998): 77–79. http://dx.doi.org/10.1177/003693309804300305.
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Many schools refer children who have sustained an injury, directly to the local Accident & Emergency (A&E) department. This prospective study monitored these referrals for one school term (08.01.96 – 31.03.96). During this time 200 children under the age of14 years presented from school to the A&E department of the Royal Aberdeen Childrens Hospital (RACH). The majority presented with trivial or mild injuries and 45% of parents felt that attending A&E was inappropriate. Half the accidents happened to unsupervised children. Rural children and children of working parents were less likely to attend A&E. In Grampian Region school referrals to A&E generate a significant workload for the A&E department with resultant cost implications. It would appear that a large number of these attendances are medically unnecessary and result from a desire by the school to avoid any complaint or litigation.
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Abadin, Andre A., Jasmine Abraham, Jordan Orr, and Michael Erickson. "The Benefit Of E-referrals For Weight Loss And Health Behavior Changes." Medicine & Science in Sports & Exercise 54, no. 9S (September 2022): 327–28. http://dx.doi.org/10.1249/01.mss.0000879132.56565.bb.
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Sunderland, Michael, Rebecca Teague, Katherine Gale, Marius Rademaker, Amanda Oakley, and Richard C. W. Martin. "E‐referrals and teledermatoscopy grading for melanoma: a successful model of care." Australasian Journal of Dermatology 61, no. 2 (February 16, 2020): 147–51. http://dx.doi.org/10.1111/ajd.13230.
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Melia, Brian, Tahir Islam, Indira Madgula, and Ellen Youngs. "Contact lens referrals to Hull Royal Infirmary Ophthalmic A&E Unit." Contact Lens and Anterior Eye 31, no. 4 (August 2008): 195–99. http://dx.doi.org/10.1016/j.clae.2008.04.001.
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Rahman, S., A. Bowden, C. Green, and J. Ryan Wolf. "676 Urgent care referrals demonstrate need for “real-time” dermatology e-consultation." Journal of Investigative Dermatology 143, no. 5 (May 2023): S116. http://dx.doi.org/10.1016/j.jid.2023.03.684.
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Zadnik, Vesna, Ana Mihor, Sonja Tomsic, Tina Zagar, Nika Bric, Katarina Lokar, and Irena Oblak. "Impact of COVID-19 on cancer diagnosis and management in Slovenia – preliminary results." Radiology and Oncology 54, no. 3 (July 29, 2020): 329–34. http://dx.doi.org/10.2478/raon-2020-0048.
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AbstractBackgroundThe COVID-19 pandemic has disrupted the provision and use of healthcare services throughout the world. In Slovenia, an epidemic was officially declared between mid-March and mid-May 2020. Although all non-essential health care services were put on hold by government decree, oncological services were listed as an exception. Nevertheless, as cancer control depends also on other health services and additionally major changes in people’s behaviour likely occurred, we aimed to analyse whether cancer diagnosis and management were affected during the COVID-19 epidemic in Slovenia.MethodsWe analysed routine data for the period November 2019 through May 2020 from three sources: (1) from the Slovenian Cancer Registry we analysed data on pathohistological and clinical practice cancer notifications from two major cancer centres in Ljubljana and Maribor; (2) from the e-referral system we analysed data on all referrals in Slovenia issued for oncological services, stratified by type of referral; and (3) from the administrative data of the Institute of Oncology Ljubljana we analysed data on outpatient visits by type as well as on diagnostic imaging performed.ResultsCompared to the November 2019 – February 2020 average, the decrease in April 2020 was about 43% and 29% for pathohistological and clinical cancer notifications; 33%, 46% and 85% for first, control and genetic counselling referrals; 19% (53%), 43% (72%) and 20% (21%) for first (and control) outpatient visits at the radiotherapy, surgery and medical oncology sectors at the Institute of Oncology Ljubljana, and 48%, 76%, and 42% for X-rays, mammograms and ultrasounds performed at the Institute, respectively. The number of CT and MRI scans performed was not affected.ConclusionsSignificant drops in first referrals for oncological services, first visits and imaging studies performed at the Institute, as well as cancer notifications in April 2020 point to a possibility of a delayed cancer diagnosis for some patients during the first surge of SARS-CoV-2 cases in Slovenia. The reasons for the delay cannot be ascertained with certainty and could be linked to health-seeking behaviour of the patients, the beliefs and practices of doctors and/ or the health system management during the epidemic. Drops in control referrals and control visits were expected and are most likely due to the Institute of Oncology Ljubljana postponing non-essential follow-ups through May 2020.
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Sebastião, Sónia. "Formatos da publicidade digital: sistematização e desambiguação." Comunicação e Sociedade 19 (June 1, 2011): 13–24. http://dx.doi.org/10.17231/comsoc.19(2011).894.
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Com o presente artigo, a investigadora pretende apresentar uma sistematizaçãodos formatos publicitários em ambiente digital. Adicionalmente argumenta que opatrocínio, o product placement, os referrals e o user generated content são técnicas decomunicação integrada e não técnicas publicitárias. Finalmente, sublinha-se a necessidadede adaptação das mensagens ao meio digital e aos desejos dos utilizadores da web,ao invés de se optar pela transposição das mensagens transmitidas offline para o online.
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Zoń, Katarzyna Maria. "Kilka uwag o skierowaniu w postaci elektronicznej w kontekście cyfryzacji systemu ochrony zdrowia w Polsce." Acta Iuridica Resoviensia 36, no. 1 (2022): 225–35. http://dx.doi.org/10.15584/actaires.2022.1.18.
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The digitalisation of health care system in Poland has forced the pace recently. This is manifested, among other things, by the implementation of the electronic referral (e-referral). This paper is devoted to analysis the legal framework of these solutions and the consequences of their functioning. The validity and usefulness of the subject matter are justified not only by the fact that this issue is of the essence within providing health services but also by the current pandemic situation.To systematises the conclusions from the conducted analysis the electronic referral should be assessed as the important component of the public health care system in Poland. In the above context, it is worth highlighting that assumedly the aim of the implemented regulations was the improvement of the effectiveness of providing health care services and realisation of the referrals. Moreover, this solution was intended to increase the availability of health care services for patients and the optimisation of the working time of health professionals. What is more the application of the electronic referral enabled further development of telemedicine.
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King, Christopher, John Logan, Nicole Lim, Colm Andrews, and Susan M. Downes. "The positive impact of e-mail referrals on access to specialist macula services." Eye 33, no. 2 (October 19, 2018): 334–35. http://dx.doi.org/10.1038/s41433-018-0235-8.
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Pathak, Divya, Sajida Mamdani, and Nabina Bhujel. "Emergency referrals to a paediatric dental A&E service in London: where do we stand post-pandemic?" Faculty Dental Journal 14, no. 1 (January 2023): 12–15. http://dx.doi.org/10.1308/rcsfdj.2023.4.
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Introduction The paediatric dentistry department at St Thomas’ Hospital transformed its walk-in emergency service to an urgent dental centre during the COVID-19 pandemic, accepting referrals via the NHS 111 service. There are conflicting ethical duties for tertiary care clinicians managing paediatric dental patients. This study measured the current activity levels of the dental emergency service at St Thomas’ Hospital, the appropriateness of NHS 111 referrals, the proportion of referrals accepted for care and the outcomes of those accepted referrals. Methods A retrospective service evaluation was undertaken including 125 patients referred by the NHS 111 service to the dental emergency clinic at St Thomas’ Hospital between 1 September and 29 October 2021. Results Half (50%) of the patients seen were aged between 0 and 5 years. A quarter (24%) of referrals were true dental emergencies. Patients were referred for isolated dental pain (58%), facial swelling (25%), trauma (13%), broken fillings (3%) and other conditions (2%). Three-quarters (74%) were accepted for treatment. Most accepted patients were added to waiting lists for treatment under general anaesthesia (66%), local anaesthesia (5%) or inhalation sedation (4%). Two-thirds of accepted patients (67%) were not registered with a dentist while over three-quarters of rejected patients (79%) had their own dentist in primary care. Conclusions Following the pandemic, paediatric dental emergency services continue to be overwhelmed by children requiring non-urgent dental care. Solutions to deteriorating patient access are crucial, ensuring that provision of care remains ethical and that those who require urgent dental care are prioritised.
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Schmidt, Megan E., Jeanette M. Daly, Yinghui Xu, and Barcey T. Levy. "Improving Iowa Research Network Patient Recruitment for an Advance Care Planning Study." Journal of Primary Care & Community Health 12 (January 2021): 215013272110096. http://dx.doi.org/10.1177/21501327211009699.
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Introduction/Objectives In February 2019, recruitment began in Iowa Research Network offices for a Patient-Centered Outcomes Research Institute (PCORI) funded Advance Care Planning (ACP) study to be conducted in 7 primary care practice-based research networks across the United States and Canada. The main study trained clinicians and nursing staff in serious illness care conversations and requested they refer eligible patients. Eligible patients were those with serious illness or frailty expected to live 1 to 2 years. Clinicians indicated it was difficult to identify eligible patients. This study aimed to find better methods for increasing patient recruitment for the ACP study. Methods Research staff brainstormed and implemented strategies to increase patient referrals from clinicians. Participating offices used Epic for their medical record and the Gagne Index was used to generate a list of eligible patients in Epic SlicerDicer. When patients from the Epic SlicerDicer report appeared on the schedule, clinicians and nursing staff were notified that they might be eligible for ACP. Clinicians and nursing staff were asked to complete a survey identifying their perception of implemented strategies. A Wilcoxon signed-rank test was conducted to compare referral numbers before and after the Gagne Index/Epic SlicerDicer intervention. Results Seven clinicians referred patients prior to and 11 after the Gagne Index/Epic SlicerDicer intervention. Clinicians referred a total of 120 patients; 31 patients prior to and 89 patients after the Gagne Index/Epic SlicerDicer implementation ( P = .002). Survey results indicated that several strategies facilitated clinician referrals, including patients identified as potentially appropriate on the schedule, quarterly meetings with researchers, and e-mails with a list of potentially eligible patients. Conclusions Notifying clinical staff about potential study participants increased patient referrals in this ACP study. Research staff must have time, funding, and patience to support clinical staff who are expected to refer patients to studies.
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Buckley, Benjamin J. R., Stephanie J. Finnie, Rebecca C. Murphy, and Paula M. Watson. "“You’ve Got to Pick Your Battles”: A Mixed-Methods Investigation of Physical Activity Counselling and Referral within General Practice." International Journal of Environmental Research and Public Health 17, no. 20 (October 12, 2020): 7428. http://dx.doi.org/10.3390/ijerph17207428.
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One in four people say they would be more active if advised by a general practitioner (GP), yet 72% of GPs do not discuss physical activity (PA) with patients and 80% of GPs are unaware of the PA guidelines. The aim of this study was therefore to investigate GP perspectives on PA counselling and referral and interpret these within the context of the socio-ecological model (SEM). Fifty-six GPs completed an online survey to investigate factors influencing PA counselling and referral. Semi-structured interviews were then conducted with seven GPs to explore topics in more depth. Interview data were analysed thematically and mapped to the SEM. GPs were more likely to discuss PA with patients if they were physically active themselves (p = 0.004). Influences on PA counselling and referral were identified at the policy (provision of education, priority), organisational (feedback, e-referral), interpersonal (PA as everybody’s business, patient factors) and intrapersonal (knowledge, GP PA levels) levels of the SEM. Multi-level strategies are required to help GPs promote PA and make use of exercise referral schemes, including making PA a strategic priority, introducing systems for feedback from referrals, and involving other members of the care team in PA counselling and referral.
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Tai, Chi-Ming, Ming-Jong Bair, Tzu-Haw Chen, Cheng-Hao Tseng, Chih-Cheng Chen, Hung Lam, and Ming-Lung Yu. "Collaborative Referral Model for Hepatitis C Screening and Treatment in a Remote Mountainous Region of Taiwan during the COVID-19 Pandemic." Viruses 15, no. 4 (March 24, 2023): 827. http://dx.doi.org/10.3390/v15040827.
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Community-based screening for the hepatitis C virus (HCV) decreased during the COVID-19 pandemic. We developed a collaborative referral model between a primary clinic (Liouguei District Public Health Center, LDPHC) and a tertiary referral center to increase HCV screening and treatment uptake in a mountainous region of Taiwan. Once-in-a-lifetime hepatitis B and C screening services established by the Taiwan National Health Insurance were performed at LDPHC. Antibody-to-HCV (anti-HCV)-seropositive patients received scheduled referrals and took a shuttle bus to E-Da hospital for HCV RNA testing on their first visit. Direct-acting antiviral agents (DAAs) were prescribed for HCV-viremic patients on their second visit. From October 2020 to September 2022, of 3835 residents eligible for HCV screening in Liouguei District, 1879 (49%) received anti-HCV testing at LDPHC. The overall HCV screening coverage rate increased from 40% before referral to 69.4% after referral. Of the 79 anti-HCV-seropositive patients, 70 (88.6%) were successfully referred. Of the 38 HCV-viremic patients, 35 (92.1%) received DAA therapy, and 32 (91.4%) achieved sustained virological response. The collaborative referral model demonstrates a good model for HCV screening and access to care and treatment in a Taiwan mountainous region, even during the COVID-19 pandemic. Sustained referral is possible using this routine referral model.
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Hsu, T., S. North, B. J. Eigl, K. N. Chi, C. M. Canil, L. Wood, A. Lau, T. Panzarella, and S. S. Sridhar. "The neoadjuvant management of bladder cancer in Canada: A survey of genitourinary medical oncologists." Journal of Clinical Oncology 29, no. 7_suppl (March 1, 2011): 285. http://dx.doi.org/10.1200/jco.2011.29.7_suppl.285.
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285 Background: The uptake of neoadjuvant chemotherapy (NC) for the treatment of stage II/III bladder cancer remains variable despite evidence supporting its use. The aim of this study is to better understand the use of NC in Canada to facilitate standardization of practice and develop a platform for clinical trials. Methods: The survey was initially tested on a subset of medical oncologists. It was then e-mailed to 30 medical oncologists across Canada who primarily treat bladder cancer. Results: In total, 25 (83%) surveys were completed. Respondents were 92% academic based, 100% full time, and 52% in practice for >10 years. The majority of referrals for all stages came from urologists with 4 respondents (16%) seeing 5-10 cases/yr, 10 (40%) seeing 11-15/yr, 5 (20%) seeing 16- 20/yr and 6 (24%) seeing >20/yr. Of these 8 reported having only 1-2 referrals for NC; 7 had 3-4 NC referrals; 7 had 5-6 NC referrals; and 2 reported seeing >6 referrals/year. Patients referred for NC tended to be younger (50-65); Performance Status (PS) 0/1; T-stage T3a/T3b; or nodal status N1/N2. 96% indicated they do offer NC to selected patients as both standard of care and to downsize tumors. Key factors cited for not offering NC were: Age >85, PS 3/4; T-stage T2a or T4a; Nodal status: N3; GFR <40ml/min. Main baseline staging modalities included CT chest/abdomen/pelvis, bone scan and cystoscopy. Gemcitabine/cisplatin was most commonly used with 20% using high-dose MVAC. Six (27%) reported doing midway staging with CT abdomen/pelvis and cystoscopy; 36% report staging after completion of chemo. Average time from last chemotherapy to cystectomy was 4-6 wks, with no patients being offered adjuvant chemotherapy postoperatively. Conclusions: The majority of GU MO in Canada would offer NC. Stage, PS, renal function, and comorbidities were the biggest determinants of offering NC, while age played a lesser role. The number of overall referrals for NC, however, remains relatively low. We plan to survey urologists in Canada to determine if differences in attitudes about NC or barriers to referrals account for the low number of referrals. No significant financial relationships to disclose.
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Day, Sara, Ryan Kinsella, Sophie Jones, Victoria Tittle, Tara Suchak, and Kimberley Forbes. "Safeguarding outcomes of 16 and 17-year-old service users of Sexual Health London (SHL.uk), a pan-London online sexual health service." International Journal of STD & AIDS 31, no. 14 (October 25, 2020): 1373–79. http://dx.doi.org/10.1177/0956462420933462.
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Guidance around how to safeguard young people using online sexual health services (e-SHSs) is limited. Sexual Health London (SHL.uk) is an e-SHS, integrated with London’s sexual health clinics (SHCs), offering users aged 16 years and above sexually transmitted infection (STI) testing. For a safeguarding risk assessment, under 18s must complete a safeguarding e-triage, and any concern raised results in a ‘call back’ (CB) by the SHL.uk team. The safeguarding outcomes of CBs between 8 January 2018 and 18 September 2018 were reviewed; 261/454 (57.5%) users never triggered a CB on their e-triage (non-CB group) and 193/454 (42.5%) users triggered one or more CB(s) (CB group). Safeguarding concerns disclosed predominantly related to drug/alcohol use and partner's age imbalance. Successful telephonic risk assessment took place in 84.5% CB cases. Safeguarding outcomes comprised referrals to: SHC in 35.5%; child protection team in 8.5%; social services in 7%. STI positivity was 16.4% and 15.2% in the CB and non-CB groups, respectively. Although a high number of safeguarding triggers were disclosed, only a small proportion warranted referral for further support/intervention. Using e-triage with telephony support to screen and safeguard adolescents accessing an e-SHS was acceptable to users and enabled their clinical and safeguarding needs to be safely met. e-SHS integration within a network of SHCs further supported this model.
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Brydges, Madison, Chris Spearen, Arija Birze, and Walter Tavares. "A Culture in Transition: Paramedic Experiences with Community Referral Programs." CJEM 17, no. 6 (May 20, 2015): 631–38. http://dx.doi.org/10.1017/cem.2015.6.
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AbstractObjectivesAs an aging population continues to place strain on the health care system, many older adults are living with unmet social and medical needs. In response, Emergency Medical Services (EMS) have initiated programs that encourage paramedics to refer patients in need to community based support services. This qualitative study explores frontline paramedic experiences with referral programs to identify opportunities and challenges in their practice.MethodsThis study used an intepretivist qualitative study design involving interviews of frontline paramedics employed in a region where referral programs were in place. Interviews were semi-structured and one-on-one. Data were transcribed verbatim and analyzed using inductive open coding throughout, then grouped to identify themes. Data collection and analysis were conducted simultaneously and flexibly until saturation.ResultsTwenty-three interviews were conducted representing 6 regions. When participating with referral programs the data revealed that frontline paramedics appear to experience (a) role confusion, (b) an inadequate knowledge base, (c) inadequate feedback, (d) undefined accountability, and (e) strong patient advocacy.ConclusionsIn a strained health care system, EMS and paramedics have an opportunity to better serve patients by initiating referrals for patients they encounter with unmet social and medical needs. However, referral programs face a number of challenges that, if left poorly addressed, may threaten the success of such programs.
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Par-Young, J., J. Young, F. Kennedy, I. Kang, and X. Dong. "POS0074-HPR EFFICACY OF E-CONSULTS COMPARED TO IN-PERSON REFERRALS OF ANA POSITIVE PATIENTS TO RHEUMATOLOGY CLINIC." Annals of the Rheumatic Diseases 82, Suppl 1 (May 30, 2023): 248.2–248. http://dx.doi.org/10.1136/annrheumdis-2023-eular.5070.
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BackgroundAntinuclear antibodies (ANA) are autoantibodies associated with several autoimmune diseases but are also present in healthy individuals due to their role in the body’s biological immune response. Thus, testing for ANA in an ambulatory setting could be inappropriately ordered and misinterpreted. Yet, delay in proper management of patients with rheumatologic presentations could result in increased morbidity and health care expenditure. Electronic consultation, or eConsults, could be utilized by primary care providers (PCPs) as a convenient tool to expedite access to rheumatology specialists and optimize care.ObjectivesTo assess the efficacy of eConsults in terms of resource utilization and time to referral when compared to in-person referrals of ANA+ patients.MethodsIn this retrospective cohort study, we reviewed the charts of 131 ANA+ patients within the Yale New Haven Health System seen from August 2019 to September 2022. The charts were divided into cases referred by eConsult and by in-person referrals. Time from chart order to eConsult or in-person consultation, diagnosis after consult completion, and laboratory workup results were evaluated. Relative risks (RR) were calculated to compare the efficacy of eConsults vs. in-person referrals in diagnosing connective tissue diseases (CTD) and initiating appropriate referrals. A chi-square test of independence was conducted to determine if there was an association between ESR/CRP levels and conversion to in-person follow-up appointments in eConsult patients.ResultsAmong the 131 ANA+ patients seen by their PCPs, 91 (69.5%) were referred through eConsult and 40 (30.5%) were in-person referrals to a rheumatologist. The average time from the initial eConsult request to completion of the consult was 1.46 ± 2.54 days while in-person consults required longer wait times of 76.63 ± 48.61 days.Figure 1.Flow Diagram of ANA+ patients referred for eConsult and In-person Rheumatology specialty clinic Of the 91 eConsult patients, 44 (48.4%) were converted to face-to-face (FTF) consultation with a rheumatologist. Patients evaluated through eConsults were less likely to be referred to a rheumatologist (RR = 0.61, 95% CI 0.46 – 0.80) when compared to in-person referrals. Patients referred through eConsults were twice as likely to be diagnosed with CTD relative to those that were not scheduled for an FTF visit after an eConsult was completed (RR = 2.49, 95% CI 1.28 – 4.84). For the converted patients, 21 (47.7%) were diagnosed with CTD. For those that did not convert to a FTF referral, only 9 (19.1%) were eventually diagnosed with a CTD. Of the 40 in-person patient referrals, 31 (77.5%) were scheduled to follow-up with a rheumatologist; the majority of which (N = 30, 96.8%) were ultimately diagnosed with CTD. Elevated ESR/CRP levels were found in 19 (43.2%) eConsult patients that had converted and 16 (34%) patients that did not convert to FTF. For eConsult patients, there was no significant relationship found between ESR/CRP levels and conversion to a FTF appointment (χ2(1, N = 74) = 3.299, p = 0.07).ConclusionElectronic consultation is an easy and timely method for referral to the rheumatology clinic. In this study, ANA+ patients requiring an urgent consultation were identified earlier through an eConsult compared to an in-person referral. eConsults were also capable of identifying cases that required specialist treatment; 80.9% of patients that weren’t referred would not receive a CTD diagnosis in the future. Thus, eConsults should be considered an effective and efficient tool in properly referring patients with rheumatologic presentations and parsing out cases that would not require specialist care.References[1]Malcolm EJ, Brandon Z, Wilson LE, Shoup JP, King HA, Lewinski A, Greiner MA, Malone S, Miller J, Keenan RT, Tarrant TK, Phinney D, Cho A, Bosworth HB, Shah K. eConsults’ Impact on Care Access and Wait Times in Rheumatology. J Clin Rheumatol. 2022 Apr 1;28(3):147-154.[2]Abeles AM, Abeles M. The clinical utility of a positive antinuclear antibody test result. Am J Med. 2013 Apr;126(4):342-8.Acknowledgements:NIL.Disclosure of InterestsNone Declared.
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Buxton, P. J., and D. J. Vassallo. "Operational Telemedicine." Journal of The Royal Naval Medical Service 84, no. 3 (December 1998): 145–47. http://dx.doi.org/10.1136/jrnms-84-145.
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AbstractA simple, effective digital camera and E-mail-based telemedicine system has been developed using commercially available equipment. Initial trials were successful and this system is now deployed in several operational units. A retrospective audit has shown it to be of value in 50% of referrals.
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Bowers, Reid Christian, Sandra Tomany Korman, Michael A. Thompson, Manish Krishna Pant, Sherjeel Sana, and Federico Augusto Sanchez. "Reduced blood product utilization via implementation of an anemia clinic and consult service in a large health system hospital: Focus on cardiovascular patients." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): e18014-e18014. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.e18014.
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e18014 Background: As part of a system wide implementation of Patient Blood Management (PBM), an Anemia Clinic program was implemented at St. Luke’s Medical Center, Advocate Aurora Health in Milwaukee, WI. Methods: September 2016 the Anemia Clinic started accepting referrals for management of non-cancer anemia, predominantly pre-operative cardiovascular surgery (CVS) Pts. Hgb thresholds were < 13 g/dL in men and < 12 g/dL in women. Non-anemia cytopenias triggered Hematology referral. All Pts were screened for iron, B12, folate, and reticulocyte. Nutrient deficiency received appropriate supplementation. Pts with CKD or chronic disease were eligible to receive erythropoiesis stimulating agents. Results: PBM implementation 2015-2018 resulted in a drop in packed red blood cell (PRBC) usage during a surgical episode (Table). Of 508 CVS Pts pre-operatively anemic in 2018, 155 were referred to the Anemia Clinic and 353 were not. There was not a statistical difference between the referred and the non-referred for percentage of Pts who received PRBCs (65.4% vs. 70.3% Chi-Square p = 0.31). Of preoperatively anemic Pts who were transfused in 2018 an average of 2.23 PRBCs were used in the referred group vs. an average of 2.35 PRBCs in those in the not referred group (Poisson Means p = 0.49). Length of stay (LOS) in the referred group was a median 10d ( P25= 7d, P75 =15d) vs LOS in the non-referred group was a median 11d ( P25= 7d, P75 =20d). LOS analyses of observed-to-expected (O/E) ratios used the Premier Healthcare Providers Alliance Database (PHD) which contains data on approximately 45% of US hospital discharges.. For 2018 through Nov. the referred group was observed to have LOS mgeo = 10.19 days vs LOS mgeo = 11.72 days (N = 141, O/E 0.87). The not referred group was observed to have a LOS mgeo = 12.45 days vs. an LOS mgeo = 10.65 days (N = 311, O/E 1.17). Conclusions: Referral to the Anemia Clinic as part of a broader program of PBM was associated with shorter LOS and a decrease in PRBC use. Implementation of PBM at our institution decreased PRBC use even in patients not referred to anemia clinic due to systematization of best practices. Implementation of our methods as the initial approach to general anemia referrals may increase access and efficiencies in the systemization and treatment of hematologic malignancies. [Table: see text]
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Anderson, NaSheema. "Increasing colorectal screenings with navigation at federally qualified health centers." Journal of Clinical Oncology 40, no. 16_suppl (June 1, 2022): e18566-e18566. http://dx.doi.org/10.1200/jco.2022.40.16_suppl.e18566.
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e18566 Background: From 2017 to 2019 there were a total of 423 federally qualified health center colonoscopy referrals (FQHC's) and only 81 (19%) patients followed through and had colonoscopies completed, identifying a significant gap in cancer care within an at risk populations. Methods: The Community Outreach team used a team based problem solving tools and data analytics to increase the number of patients who received colon screenings from FQHC’s. The team held brief, weekly huddles using a variety of continuous improvement tools to identify possible causes of the problem. The team identified 14 potential causes of the 19% gap in FQHC referrals to colonoscopy screenings. The potential causes were analyzed and 4 were identified as the root cause and grouped by common themes into the following opportunities for improvement: Poor engagement with FQHC's. Lack of knowledge on FQHC healthcare effectiveness data and information sets. No standardized workflow for FQHC referrals within the navigation process. Inefficient process for filling the number of screening appointment slots. After identifying the key potential causes, the team developed a task list with countermeasures for improvement and met weekly until the tasks were completed. Through root cause analysis the following key countermeasures were identified: Countermeasure 1: Increased engagement through weekly calls and monthly in person meetings at FQHC's. Countermeasure 2: Developed a quarterly newsletter for FQHC's to review colonoscopy referrals and completed screenings. Countermeasure 3: Developed and implemented a standardized process flow for receiving referrals from FQHC's. Countermeasure 4: Worked with the analytics team to create a dashboard to analyze the real time referrals and completed screenings along with sending e-mail notifications to the navigation program manager providing daily visual management of the number of new patient referrals from FQHC's. Results: After implementing the countermeasures, the community outreach team improved the number of FQHC referrals, from 423 in January of 2017 thru January 2019 to 1399 from January 2020 of December 2021.This was a 160% improvement. They also increased the number of completed colonoscopies from FQHC's from 81 in January of 2017 thru January of 2019 to 328 in January of 2020 thru December of 2021. This was a 200% improvement. The completed screening rate is 23% up from 18%. Conclusions: This project demonstrates the value of utilizing problem solving, visual management and data analytics for continuous quality improvement projects related to patient care. Cross-disciplinary collaboration should be explored with the use of visual tools and other resources to facilitate communication that is understood by all disciplines. The use of patient navigation to schedule patient screening appointments, reminders calls and resolved barriers improved no show rates.