Referral patterns: an audit into referral practice among doctors in emergency medicine

Abstract

Objectives: To develop a standard for safe patient referral from emergency medicine (EM) staff to hospital inpatient specialities; to audit adherence to that standard, and from this audit, to identify potential risk areas in this aspect of patient care; to make recommendations for reducing such risks; and to implement those recommendations. Method: A standard was introduced and practice was compared to that standard using a telephone questionnaire.Results: Many problems arising at referral were identified. From these, recommendations were made for improvements. At the base hospital, those recommendations were implemented. These potential pitfalls are highlighted, together with strategies for improving safe handover of patient care. The discussion includes a review of the literature on safe handovers, which underpins both the importance of this subject and our findings and recommendations. Conclusions: Referral is an important skill for many doctors, particularly those in EM. It requires teaching and practice. The corollary to this is that education in this arena is also essential for those receiving referrals, to ensure smooth communication and safe systems of handover for patients. Handover of patients from doctor to doctor or from one team to another has been identified as a high risk area. Appropriate communication is essential to ensure the safe ongoing care of patients.1-4 For doctors working in emergency medicine (EM) this communication is usually in the form of referrals to medical staff working for inpatient specialities. One of the skills integral to efficient working in EM is the art of referral. In this study, we explored the factors influencing EM doctors' referring habits.A literature search revealed much work on aspects of emergency admissions. Relevant features from these papers are explored in the discussion. However, no formal guidelines were identified on the subject of referrals. As a basis for this audit, we took as our the standard that:''The decision to refer to a particular specialty should be based on clinical evaluation by the emergency medicine clinicians, and current local practices''.Discussion within our department suggested that other factors, such as the approachability and helpfulness of the receiving specialist, were important. In an attempt to determine what additional factors influence referrals, an audit was carried out questioning EM junior doctors (senior house officers (SHOs), specialist registrars (SpRs), and staff grades (SGs)) about their referral experiences. METHODSA questionnaire was developed (table 1). This was piloted on 30 junior doctors in a 2 week period in December 2001. A further 42 doctors were contacted in a 2 week period in May 2002. Two researchers, (CM and KF) filled in the questionnaires, in person or by telephone. The timing was such that the doctors interviewed could be expected to have had several months of EM experience.Subject selection was by either telephoning or attending departments, and speaking to those doctors on duty at that time. FindingsTh...

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