A Health Records Review of Outpatient Referrals from the Emergency Department

Abstract

Objectives Many patients discharged home from the emergency department (ED) require urgent outpatient consultation with a specialty service. We sought to identify the best- and worst-performing services with regard to time to outpatient consultation, the proportion of patients lost to follow-up, the rate of related return ED visits prior to consultation, and common strategies used by our top-performing clinics. Methods We conducted a health records review of The Ottawa Hospital ED visits during four 1-week periods. All consecutive adult outpatient consultation requests were included for chart review and were followed up to 12 months. Outcome measures included demographics, referral attendance rates, incomplete referrals, return ED visits, and time intervals. Services with at least 15 consultation requests were included for data analysis and qualitative mapping of their referral processes. Results Of the 963 patients who met inclusion criteria, 803 (83.4%) attended their appointment, while 160 (16.6%) were lost to follow-up. The overall median time to successful consultation was 9 days (IQR = 2–27). 92 (9.6%) patients returned to the ED with a related complaint. The top-performing clinics included ophthalmology, orthopedics, and thrombosis (median = 1, 8, 1 days; incomplete consultation = 3%, 4%, 6%; return ED visits = 0%, 6%, 2% respectively). The bottom-performing clinics included otorhinolaryngology, neurology, and gynecology (median = 47, 39, 27 days; incomplete consultation = 50%, 41%, 37%; return ED visits = 11%, 15%, 26%, respectively). Processes incorporated by top-performing clinics included reserving appointment slots for emergency referrals, structured referral forms, and centralized booking. Conclusions We found a substantial variability in both the waiting times and reliability of outpatient referrals from the ED. Top-performing clinics incorporate common referral processes.

The burden of flashes and floaters in traditional general emergency services and utilization of ophthalmology on-call consultation: a cross-sectional study

“…Despite the incidence of eye-related visits to GES, several studies have highlighted the lack of comfort general emergency physicians have in managing eye-related issues. [18][19][20] Ophthalmology, along with orthopedics, represents one of the most frequently consulted services by GESs [16,21].…”

Ophthalmology on Call: Evaluating the Volume, Urgency, and Type of Pages Received at a Tertiary Care Center

“…A sampling technique was employed in which data were collected from the first seven days of each month. This sampling method was derived from a study by Prudomme et al looking at volumes of outpatient referrals in an ED [ 1 ]. This technique was selected in order to account for potential daily, monthly, or seasonal variation in pager volumes.…”

“…A significant degree of work for residents on call comes from answering and managing pages. On-call services in ophthalmology receive high volumes of consults, often in the form of pages requiring urgent patient assessment [ 1 , 2 ]. Relative to other surgical specialties, the profile of commonly received pages in ophthalmology may be different, but has never previously been studied.…”

“…Instead, the majority of pages are more likely new outpatient consults. Prudhomme et al found that the ophthalmology on-call service at an academic hospital in Canada received more than double the average number of urgent outpatient referrals from the emergency department (ED) compared to other services, and the second-highest volume overall [ 1 ]. They also found that ophthalmology sees these referrals faster than any other service, has the lowest rate of return-to-ED visits, and has the fewest patients lost to follow-up.…”

Evaluation of Interventions Targeting Follow-up Appointment Scheduling After Emergency Department Referral to Ophthalmology Clinics Using A3 Problem Solving

“…f the 2 million ophthalmology-related emergency department (ED) encounters that occur annually in the US, 44.3% to 76.6% are for nonemergent conditions that require follow-up at an outpatient eye clinic. [1][2][3] Follow-up is important for treatment continuation, 4 correction of misdiagnosis, 5,6 avoiding return ED visits, 7 and transition to long-term ophthalmic care. However, literature has reported that 25.2% to 39.0% of patients seen for eye-related issues in the ED do not receive recommended follow-up care.…”