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Annals of the Royal College of Surgeons... Mar 2018Introduction Rapid, reliable and efficient communication in healthcare systems with finite resources promises to improve patient care. Telephone engagement has... (Review)
Review
Introduction Rapid, reliable and efficient communication in healthcare systems with finite resources promises to improve patient care. Telephone engagement has effectively monopolised the referral process in the acute setting. Hence, traditional inter-hospital referral networks are potentially time consuming, not expeditious and frustrating. There is often no comprehensive documented communication record or audit trail. Social media, however, suggest that instantaneous, secure and dependable exchanges of information can occur via alternative conduits, potentially transforming the acute clinical referral system. The National On-Call Referral System (NORSe) was established in 2010 as an alternative referral paradigm. We explore the literature evidence surrounding the clinical impact of the NORSe referral system and analogous models. Early evidence suggests that NORSe may minimise delays in obtaining specialist advice and management, particularly in the acute setting. It enables the specialist to receive and address a large number of fact intense referrals that would otherwise be unpalatable and unmanageable. We summarise recent developments with the NORSe and give an overview of its clinical applications and links with clinical governance. NORSe and similar models promise to change the way we communicate as doctors, making the process more efficient, with a robust audit trail facilitating service appraisal and training.
Topics: Clinical Audit; Documentation; Electronic Mail; Humans; Internet; Interprofessional Relations; Referral and Consultation; State Medicine; Text Messaging; United Kingdom
PubMed: 29493351
DOI: 10.1308/rcsann.2018.0020 -
PloS One 2019Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist... (Review)
Review
BACKGROUND
Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions.
METHODS
MEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach.
RESULTS
Multiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities.
DISCUSSION
The field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.
Topics: Developing Countries; Economics, Hospital; Health Resources; Hospital Administration; Hospitals; Humans; Poverty; Program Evaluation; Quality Improvement; Referral and Consultation; Surgical Procedures, Operative
PubMed: 31560716
DOI: 10.1371/journal.pone.0223328 -
BMJ Open Jan 2018The primary aim of the review was to determine the effectiveness of strategies to improve clinician provision of psychosocial distress screening and referral of patients... (Review)
Review
OBJECTIVES
The primary aim of the review was to determine the effectiveness of strategies to improve clinician provision of psychosocial distress screening and referral of patients with cancer.
DESIGN
Systematic review.
DATA SOURCES
Electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched until July 2016.
INCLUSION CRITERIA
Population: adult patients with cancer and clinical staff members.
INTERVENTION
any strategy that aimed to improve the rate of routine screening and referral for detected distress of patients with cancer. Comparison: no intervention controls, 'usual' practice or alternative interventions.
OUTCOME
(primary) any measure of provision of screening and/or referral for distress, (secondary) psychosocial distress, unintended adverse effects.
DESIGN
trials with or without a temporal comparison group, including randomised and non-randomised trials, and uncontrolled pre-post studies.
DATA EXTRACTION AND ANALYSIS
Two review authors independently extracted data. Heterogeneity across studies precluded quantitative assessment via meta-analysis and so a narrative synthesis of the results is presented.
RESULTS
Five studies met the inclusion criteria. All studies were set in oncology clinics or departments and used multiple implementation strategies. Using the Grades of Recommendation, Assessment, Development and Evaluation, the overall rating of the certainty of the body of evidence reported in this review was assessed as very low. Three studies received a methodological quality rating of weak and two studies received a rating of moderate. Only one of the five studies reported a significant improvement in referrals.
CONCLUSIONS
The review identified five studies of predominantly poor quality examining the effectiveness of strategies to improve the routine implementation of distress screening and referral for patients with cancer. Future research using robust research designs, including randomised assignment, are needed to identify effective support strategies to maximise the potential for successful implementation of distress screening and referral for patients with cancer.
PROSPERO REGISTRATION NUMBER
CRD42015017518.
Topics: Adaptation, Psychological; Anxiety; Humans; Neoplasms; Quality of Life; Randomized Controlled Trials as Topic; Referral and Consultation; Stress, Psychological
PubMed: 29306881
DOI: 10.1136/bmjopen-2017-017959 -
Lancet (London, England) May 2019
Topics: Africa, Southern; Ethics, Medical; General Practitioners; Humans; Male; Medicine; Referral and Consultation; Surgeons; Work Performance
PubMed: 31057157
DOI: 10.1016/S0140-6736(19)30898-0 -
The Milbank Quarterly Mar 2011In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite... (Review)
Review
CONTEXT
In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines.
METHODS
This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care.
FINDINGS
PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co-management).
CONCLUSIONS
There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.
Topics: Decision Making; Health Services Accessibility; Humans; Interprofessional Relations; Physicians, Primary Care; Referral and Consultation; Specialization; United States
PubMed: 21418312
DOI: 10.1111/j.1468-0009.2011.00619.x -
CoDAS 2015To analyze the effectiveness of the referral and counter-referral flow in a speech-language pathology and audiology clinic-school and to characterize the patients'...
OBJECTIVE
To analyze the effectiveness of the referral and counter-referral flow in a speech-language pathology and audiology clinic-school and to characterize the patients' profiles.
METHODS
Evaluation, retrospective, and prospective study, in which 503 patient records, without age restriction, were selected from a clinic-school and the following variables were analyzed: demographic information, speech and hearing diagnosis, and references. Patients were distributed into two groups according to the referrals made: internal (G1, n=341) and external (G2, n=162) to the clinic-school.
RESULTS
A prevalence of male subjects under 12 years of age and with diagnosis of language disorders (primary and secondary) was found. It was observed that 83% patients in G1 were recalled for evaluation and speech therapy after an average of 7 months of waiting; and from the patients in G2 that were contacted (n=101), 13.9% were summoned and are satisfied with the place indicated for therapy after an average of 4 months of waiting. From those who did not receive care, 46% sought another service, and of these, 72.5% were successful.
CONCLUSION
The data show the effectiveness and appropriateness of referrals made internally, suggesting that, when the team works together, the network operates more adequately. However, in relation to external referrals, they did not reach the proposed goals, indicating a lack of speech-language pathologists in public services and the low interest of patients in looking for other places of care.
Topics: Adolescent; Adult; Child; Clinical Competence; Female; Hearing Loss; Humans; Language Disorders; Male; Middle Aged; Prospective Studies; Referral and Consultation; Retrospective Studies; Speech Therapy; Speech-Language Pathology; Voice Disorders; Young Adult
PubMed: 26222945
DOI: 10.1590/2317-1782/20152014158 -
Australian and New Zealand Journal of... Jun 2011Professional guidelines define the risk categorisation of patients for a genetic predisposition to cancer based on family history. These guidelines inform the... (Review)
Review
OBJECTIVE
Professional guidelines define the risk categorisation of patients for a genetic predisposition to cancer based on family history. These guidelines inform the appropriate referral of patients to specialist familial cancer services. Our study aimed to determine the quality of referral letters from general practitioners and specialists to genetic services for breast, ovarian and colorectal cancers, and their compliance with relevant professional guidelines.
METHODS
A retrospective review of the referral letters and patient files of 241 consecutive patients referred between June and October 2008.
RESULTS
Sufficient information to make a risk assessment was provided in 71% of referrals. Of these, 89% were compliant with guidelines. Genetic counsellors collected further information on 167 of the 241 referred patients and of these 83% were appropriate for referral according to guidelines.
CONCLUSIONS AND IMPLICATIONS
Overall, referrals to familial cancer genetic services complied with professional referral guidelines. The majority of referrals were high quality, and with additional information, most patients were shown to be appropriate for review in a familial cancer clinic. Despite this, a better understanding of the reasons for non compliant referrals, and appropriate targeted education and resources is recommended to improve referral quality and compliance.
Topics: Breast Neoplasms; Colorectal Neoplasms; Female; General Practitioners; Genetic Counseling; Genetic Predisposition to Disease; Guideline Adherence; Humans; Medical Audit; Ovarian Neoplasms; Practice Guidelines as Topic; Practice Patterns, Physicians'; Quality of Health Care; Referral and Consultation; Retrospective Studies; Western Australia
PubMed: 21627722
DOI: 10.1111/j.1753-6405.2010.00655.x -
European Radiology Jun 2022To explore radiographers' actions toward inappropriate referrals and hindrances to assessing referrals.
OBJECTIVES
To explore radiographers' actions toward inappropriate referrals and hindrances to assessing referrals.
METHODS
An online survey was distributed to radiographers via the International Society of Radiographers and Radiological Technologists (ISRRT) networks. The questionnaire consisted of 5-point Likert scale questions on radiographers' actions to supplement referral information, actions for unjustified referrals and hindrances to referral assessment. The questionnaire was validated using a test-retest reliability analysis. Kappa values ≥ 0.6 were accepted. SPSS software was used for data analysis and chi-square tests to compare subgroups.
RESULTS
Total responses received were 279. The most reported actions to supplement missing referral information were to ask the patient or relative, examine the body region of concern and check medical records (73%, 70%, 67%, responded often/always, respectively). The actions when confronted with unjustified referrals were reported equally to consult the radiologist, referring clinician and radiographer (69-68% often/always responses). The hindering factors ranked high (agreed/strongly agreed responses) pertained to inadequate information in referral forms (83%), ineffective communication among healthcare professionals (79%), lack of training (70%) and allocated time (61%). Statistically significant associations were observed for a few actions and hindrances with education level, modality of practice and responsibility to screen imaging referrals.
CONCLUSION
Radiographers consult colleagues about suspected unjustified referrals. Effective communication pathways, training and time allocation to improve radiographers' skills to assess referrals may enhance appropriate imaging and delivery of quality patient care.
KEY POINTS
• Radiographers' actions of supplementing missing information in radiology referrals facilitate provision of high-quality health services. • Radiographers' strategy when confronted with inappropriate referrals is to consult radiologists and referring clinicians. • Better inter-professional communication and organisation of tasks can facilitate radiographers' participation in referral assessment to ensure appropriate imaging.
Topics: Humans; Radiography; Radiologists; Radiology; Referral and Consultation; Reproducibility of Results
PubMed: 34989841
DOI: 10.1007/s00330-021-08470-z -
Applied Ergonomics Nov 2020Consultations entail transitions in care between referrers and consultants, as patients visit different clinicians and care sites. This complex process has been...
Consultations entail transitions in care between referrers and consultants, as patients visit different clinicians and care sites. This complex process has been consistently prone to communication breakdowns. Despite expectations and benefits of electronic health records (EHRs), incomplete, vague, or inappropriate referrals continue to hinder consultations; referrals can be sent to the wrong specialty service; and consultation findings frequently fail to reach referrers. Due to the inadequate support of interpersonal communication afforded by EHRs, these issues persist. Important aspects of ergonomics and human factors engineering frequently appear overlooked during the design and implementation of EHRs. Usability issues have contributed to delays in medical diagnosis, treatment, and follow-up. Some of these delays contribute to patient harms. Our multidisciplinary team of clinicians and ergonomics professionals reflects on referral and consultation. We describe how computerization in healthcare should benefit from approaches informed and developed through applied ergonomics and human factors.
Topics: Electronic Health Records; Ergonomics; Humans; Referral and Consultation; Systems Analysis; Transitional Care
PubMed: 32768721
DOI: 10.1016/j.apergo.2020.103227 -
PloS One 2020Trained community workers (CWs) successfully deliver health and social services, especially due to greater community acceptance. Orphans and vulnerable children (OVC)...
BACKGROUND
Trained community workers (CWs) successfully deliver health and social services, especially due to greater community acceptance. Orphans and vulnerable children (OVC) and their caregivers (CG) often need support from several sectors. We identified CW, program and referral characteristics that were associated with success of referrals provided to OVC and their CG in Tanzania in a cross-sectoral bi-directional referral system.
METHODS
Data for this secondary analysis come from the first two years (2017-2018) of the USAID funded Kizazi Kipya project. Referral success was defined as feedback and service received within 90 days post-referral provision. We analyzed factors that are associated with the referral success of HIV related, education, nutrition, parenting, household economic strengthening, and child protection services among OVC and CG, using generalized estimating equations.
RESULTS
During the study period, 19,502 CWs in 68 councils provided 146,996 referrals to 132,640 beneficiaries. OVC had much lower referral success for HIV related services (48.1%) than CG (81.2%). Adjusted for other covariates, CW age (26-49 versus 18-25 years, for OVC aOR = 0.83, 95%CI (0.78, 0.87) and CW gender (males versus females, for OVC aOR = 1.12, 95%CI (1.08, 1.16); CG aOR = 0.84, 95%CI (0.78, 0.90)) were associated with referral success. CWs who had worked > 1 year in the project (aOR = 1.52, 95%CI 1.46, 1.58) and those with previous work experience as CW (aOR = 1.57, 95%CI (1.42, 1.74) more successfully referred OVC. Referrals provided to OVC for all other services were more successful compared to HIV referrals, with aORs ranging from 2.99 to 7.22. Longer project duration in the district council was associated with increased referral success for OVC (aOR = 1.16 per month 95%CI 1.15,1.17), but decreased for CG (aOR = 0.96, 95%CI 0.94, 0.97). Referral success was higher for OVC and CGs with multiple (versus single) referrals provided within the past 30 days (aOR = 1.28 95%CI 1.21, 1.36) and (aOR = 1.17, 95%CI (1.06, 1.30)) respectively.
CONCLUSION
CW characteristics, referral type and project maturity had different and often contrasting associations with referral success for OVC versus for CG. These findings could help policymakers decide on the recruitment and allocation of CWs in community based multi-sectoral intervention programs to improve referral successes especially for OVC.
Topics: Adolescent; Adult; Caregivers; Child; Child Welfare; Child, Orphaned; Child, Preschool; Community Health Workers; Female; Health Plan Implementation; Humans; Infant; Infant, Newborn; Longitudinal Studies; Male; Nutritional Status; Program Evaluation; Referral and Consultation; Social Work; Tanzania; Vulnerable Populations; Young Adult
PubMed: 32946528
DOI: 10.1371/journal.pone.0239163