Electronic Referral Research Articles

Neurosurgical Referral Patterns During the Coronavirus Disease 2019 Pandemic: A United Kingdom Experience

BackgroundCoronavirus disease 2019 (COVID-19) is a severe respiratory viral illness that has spread rapidly across the world. However, the United Kingdom has been particularly affected. Evidence has suggested that stroke, cardiac, and spinal presentations decreased during the pandemic as the public avoided seeking care. The effect on neurosurgical presentations and referrals during COVID-19 is unclear. Our aim, therefore, was to describe the referral patterns to a high-volume neurosurgical department in the United Kingdom during the COVID-19 pandemic.MethodsElectronic referrals were identified from the referrals database from January 1, 2020 to May 31, 2020, inclusive, with January used as the baseline. The demographic data and referral diagnoses were captured on Excel (Microsoft, Redmond, Washington, USA). Statistical analyses were performed using SPSS, version 22 (IBM Corp., Armonk, New York, USA). Differences between referral volumes were evaluated using χ2 goodness-of-fit tests.ResultsA total of 2293 electronic referrals had been received during the study period. The median age was 63 years. Overall, the referrals had decreased significantly in volume during the study period [χ2(4) = 60.95; P < 0.001]. We have described the patterns in the daily referrals as the pandemic progressed. The reduction in the volume of referrals for degenerative spine cases and traumatic brain injuries was statistically significant (P < 0.001).ConclusionsThe referrals for degenerative spine and traumatic brain injuries decreased significantly during the pandemic, which can be explained by the lower vehicular traffic and patient avoidance of healthcare services, respectively. The risk of neurological deterioration and increased morbidity and mortality, as a consequence, is of concern, and neurosurgeons worldwide should consider the optimal strategies to mitigate these risks as the pandemic eases.

Feasibility of implementing Integrated Management of Childhood Illnesses through Mobile Technology

Abstract Background The Integrated Management of Childhood Illnesses (IMCI) strategy was launched by WHO and partners in 1995 to reduce child mortality by enhancing frontline health workers' (FHWs) ability to diagnose and manage childhood illnesses, and strengthen overall health systems. However, although IMCI is associated with decreased child mortality, numerous studies have shown its impact has been limited due to persistent barriers to implementation. Methods We developed a digitized version of IMCI (eIMCI) using Android technology to overcome implementation problems, including poor protocol compliance, lengthy trainings, paper-based data collection, and gaps in the referral system. The feasibility and efficacy of eIMCI was assessed through a mixed-methods pilot study encompassing baseline and end-line surveys, interviews, and Focus Group Discussions, in a low-resource rural district of Punjab, Pakistan. During the 8 weeks of deployment, a total of 1,978 children were enrolled in the eIMCI application by 10 participating FHWs, and 47 electronic referrals were generated. Results Preliminary outcomes showed reduced disease occurrence (for example, diarrhea decreased from 48% at baseline to 29% at endline), increased adherence to IMCI protocol, and strengthened health system linkages (facility referrals increased from 5% at baseline to 45% at endline). FHWs reported enhanced performance, as well as an improved community response to their services. Discussion Indicating the feasibility and efficacy of eIMCI deployment in a low-resource setting, evidence from the pilot demonstrates the benefit of digitizing the IMCI protocol. eIMCI is a digital health solution with the potential to significantly reduce child mortality and improve service delivery and performance of FHWs. Key messages eIMCI is a feasible solution for the implementation of IMCI strategy in developing countries and demonstrates increased compliance and enhanced performance by the frontline health workers. Implementation of eIMCI can result in a significant reduction in child morbidity and mortality via timely referrals of patients and reduced disease occurrence.

AUTOMATED ELECTRONIC REFERRALS ARE CHANGING DONATION

Introduction: It is broadly understood and supported by previous studies that disruptive inefficiencies exist in the hospital to Organ Procurement Organization (OPO) donor referral process, including failure to notify the OPO and delayed referrals. Without a reliable and timely donor referral, life-saving organs cannot be procured and transplanted. A secure direct and automatic electronic donor referral interface was collaboratively developed and implemented to confront the issue of inefficient donor referrals by 1) eliminating the need for nurses to step away from patient care and place the phone call; and 2) automating the donor referral trigger with the goals of increasing referrals and donations while also reducing critical time spent by the hospital and OPO. Materials and Methods: The multi-disciplinary team collaborated to create a secure technical interface directly connecting the OPO and Hospital systems, as well as design seamless donor referral triggers within the Hospital EMR. These triggers automatically deliver electronic donor referrals from the Hospital to the OPO upon staff entry of pre-determined clinical data into the EMR, greatly reducing the need for donation knowledge and decision making by the hospital staff. The interface includes an additional manual trigger for staff to utilize in cases such as early family mention of donation and other exceptional situations. Upon receipt of the initial electronic referral, the OPO can quickly retrieve critical details for donation screening without pulling the hospital staff away from their critical duties of care. The above described interface has been successfully implemented in all 4 facilities in the hospital system. Results and Discussion: The interface has led to a significant increase in referrals and donations. Comparing the data from previous (2018) and following years (2019), during which time the only major process change at the hospital was the implementation of the electronic interface, there was a 49% increase in donor referrals (389 to 579) and a 333% increase in organ donors (3 to 13). Over the same period, over 190 hours of staff time were saved by the hospital and the OPO, regardless of the increase in referrals. There are several case studies of the OPO receiving an automatically triggered donor referral when the nurse was unable to connect on a phone call due to duties in a busy ICU. OPO staff were then able to retrieve the appropriate data directly from the EMR, allowing them to mobilize and ultimately recover organs and tissue which likely would have otherwise timed out. Conclusion: The results demonstrate increased efficiency in the donation referral process and project goals fulfillment by significant increase in referrals and donations as well as reduced burdens on both the Hospital and OPO through time savings. The initiative has been successful due to both the electronic interface and automating the donor referral trigger, leading to more donation and transplantation.

Rejection of Patients With Opioid Use Disorder Referred for Post-acute Medical Care Before and After an Anti-discrimination Settlement in Massachusetts.

To determine how commonly medical inpatients with opioid use disorder (OUD) referred for postacute medical care were rejected due to substance use or treatment with opioid agonist therapy (OAT). Additionally, to assess for changes in rejection rates following the United States Attorney's May 2018 settlement with a Massachusetts nursing facility for violating anti-discrimination laws for such rejections. We linked electronic referrals to private Massachusetts postacute medical care facilities from Boston Medical Center in 2018 with clinical data. We included referrals with evidence of OUD using ICD-10 diagnosis codes or OAT receipt. We identified the frequency of referrals where the stated rejection reason was substance use or OAT and classified these as discriminatory. We used segmented regression to assess for changes in proportion of referrals with substance use and OAT-related rejections before and after the settlement. In 2018, 219 OUD-associated hospitalizations resulted in 1648 referrals to 285 facilities; 81.8% (1348) were rejected. Among hospitalizations, 37.4% (82) received at least 1 discriminatory rejection. Among rejections, 15.1% (203) were discriminatory (105 for OAT and 98 for substance use). Among facilities, 29.1% (83) had at least one discriminatory rejection. We found no differences in proportion of discriminatory rejections before and after the settlement. Individuals hospitalized with OUD frequently experience explicit discrimination when rejected from postacute care despite federal and state protections. Efforts are needed to enhance enforcement of anti-discrimination laws, regulations, and policies to ensure access to postacute medical care for people with OUD and ongoing medical needs.

Quitting the quitline: a qualitative study of patient experience of electronic referrals to quitlines

BackgroundThe use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient’s perspective in order to inform strategies for improving QL engagement.MethodsWe conducted interviews with 55 patients who agreed to an eReferral at a primary care visit to 1 of 8 safety-net community health centers in Cuyahoga County, Ohio (September 2017–August 2018). Interviews were designed to explore the experiences of three subgroups of patients who subsequently: 1) declined participation in the QL; 2) were unreachable by the QL; or 3) were enrolled in or had completed the QL program. Analysis was guided by a phenomenological approach designed to identify emergent themes.ResultsReasons for QL program non-completion included changing life circumstances and events making cessation unviable; misunderstandings about the QL; discomfort with telephonic counseling; perceived lack of time for counseling; cell phone barriers; and having already quit smoking. We found that some individuals who were no longer engaged with the QL still desired continued support from the QL.ConclusionsParticipants intentionally and unintentionally disengage from the QL for a wide variety of reasons, several of which are mediated by low socioeconomic status. Integrating QL care with community-based resources that address these mediators could be a promising strategy.

Pediatric resident training and the role of the EHR in addressing tobacco smoke exposure: A survey of pediatric program directors

Purpose Pediatricians and trainees should address tobacco smoke exposure (TSE) with adolescents and parents, but this is not consistently done. Pediatric Program Directors (PDs) reported in 2011 that 65% of residency programs had tobacco control curricula, but the curricula primarily focused on health effects, not on clinical intervention. Features of electronic health records (EHRs) such as prompts, order sets and electronic referrals may facilitate addressing TSE. Objectives of this study were to assess if and how addressing …

Challenges to Quality Primary Health Care in Saudi Arabia and Potential Improvements Implemented by Other Systems: Systematic Review

INTRODUCTION: As primary healthcare centres play an important role in implementing Saudi Arabia&amp;rsquo;s health strategy, this paper offers a review of publications on the quality of the country&amp;rsquo;s primary health care. With the aim of deciding on solutions for improvement, it provides an overview of healthcare quality in this context and indicates barriers to quality. &#x0D; &#x0D; METHOD: Using two databases, ProQuest and Scopus, data extracted from published articles were systematically analysed for determining the care quality in Saudi primary health centres and obstacles to achieving higher quality.&#x0D; &#x0D; RESULTS: Twenty-six articles met the criteria for inclusion in this review. The components of healthcare quality were examined in terms of the access to and effectiveness of interpersonal and clinical care. Good access and effective care were identified in such areas as maternal health care and the control of epidemic diseases, whereas poor access and effectiveness of care were shown for chronic disease management programmes, referral patterns (in terms of referral letters and feedback reports), health education and interpersonal care (in terms of language barriers). Several factors were identified as barriers to high-quality care. These included problems with evidence-based practice implementation, professional development, the use of referrals to secondary care and organisational culture. Successful improvements have been implemented by other systems, such as mobile medical units, electronic referrals, online translation tools and mobile devices and their applications; these can be implemented in Saudi Arabia for improving the quality of the primary healthcare system in this country.&#x0D; &#x0D; CONCLUSION: The quality of primary health care in Saudi Arabia varies among the different services. To improve quality, management programmes and organisational culture must be promoted in primary health care. Professional development strategies are also needed for improving the skills and knowledge of healthcare professionals. Potential improvements can be implemented to improve the quality of the primary health system.

A multidisciplinary immune-related toxicity (IR-Tox) program for immune-related adverse events: A two-year experience.

e15074 Background: Immune checkpoint inhibitors (ICIs) cause immune-related adverse events (irAEs) that may require multidisciplinary input. We developed an IR-Tox program consisting of an electronic irAE referral platform +/- in-person consultation, and a monthly irAE tumor board, run by an IR-Tox team comprising 38 organ-specialists and oncologists. Herein, we present our 2-year experience. Methods: Electronic referrals for patients (pts) treated with ICIs at an academic center were sent to the IR-Tox team between 08/2017-12/2019. Demographic, treatment, and irAE data, including in-person consultations and hospitalizations, were collected in an IRB-approved database. Results: The IR-Tox Team received 270 referrals from 227 discrete pts (outpt: 64% inpt: 36%). Median age was 63 years (range: 3-91), 52% were male, 23% had a prior autoimmune condition, and 28% had a prior irAE. Pts had thoracic (30%), gastrointestinal (18%) or melanoma/skin cancers (17%). The majority of pts received ICI monotherapy (56%) vs. combination (44%). Referrals were for suspected irAE (92%, 209/227) or pre-ICI assessment for known autoimmune disease (8%, 18/227). Referrals for confirmed irAEs (147/209) were mainly for high-grade toxicity (G1 = 8%, 2 = 37%, 3 = 54%), 49% were hospitalized (72/147), and 86% (127/147) improved/resolved. In those who did not have a confirmed irAE (n = 62), an alternative medical condition was the most frequent diagnosis (27%, 17/62). The most common irAEs were pneumonitis (51%), dermatitis (11%), arthritis (7%), hepatitis (6%), and colitis (5%). In the entire cohort, organ-specialists were consulted electronically in 92% of pts (209/227), and 73% were subsequently seen in-person (166/227), with the majority (90/166; 54%) undergoing an invasive diagnostic procedure to confirm the irAE. Of outpatients referred, 64% (94/146) required subsequent in-person consults from organ-specialists and only 12% (18/146) were hospitalized. After all irAE-hospitalizations, continued irAE management was delivered in conjunction with organ-specialists in 51% of cases (32/72). Conclusions: A multidisciplinary IR-Tox program is a utilized service that has assisted in irAE identification and management over 2+ years. Use of an electronic referral platform may impact subsequent need for in-person specialist consultations and/or hospitalizations for irAEs. Ongoing management of complex irAEs is now commonly delivered in a multidisciplinary fashion.

Specialist Participation in e-Consult and e-Referral Services: Best Practices.

Electronic consultations (eConsults) and referrals (eReferrals) are being implemented to improve access to specialist care. As eConsult and eReferral services rely on a roster of engaged specialists for their success, careful attention must be paid to how the term "specialist" is defined, what criteria inform specialists recruitment, and how quality of specialist responses can be monitored and maintained. Key considerations, informed by our personal experiences, review of best practice documents, international frameworks of specialists roles and competencies and a focused small group discussion among providers, health service planners and researchers for each of these important elements is discussed. Individuals participating in services should receive clear expectations around their role and responsibilities and be provided equitable access assuming they meet the necessary requirements. Training and feedback should be provided to ensure timely, quality responses. Paying attention to these key elements will reduce confusion, frustration and disengagement amongst specialists and ensure high quality responses.

P192 Crystallising care: improving hospital gout management

Abstract Background Gout is the most common cause of a hot swollen joint, and a major contributor to inpatient rheumatology workload. Recently published data demonstrated that hospital admissions due to gout increased by 59% in England from 2006 - 2017. The mean length of stay for a gout admission was 6 days in 2017; a figure that has not changed significantly over the last decade. We hypothesised that a key contributing factor to prolonged hospital stays in patients presenting with gout attacks is delayed joint aspiration and synovial fluid analysis. We investigated time to joint aspiration, and time taken to obtain a crystal analysis result, in acute rheumatology referrals at a large tertiary centre. Methods Electronic Health Records (EHR) system data were accessed for all joint aspirate crystal analyses in a 4-month window in 2017. EHR system documentation contains all clinical notes, electronic referrals, and laboratory requests with indicative coded timestamps. Pre- and post-aspirate differential diagnoses were compiled from the clinical record. Manual verification of the clinical records ascertained whether there was any delay in discharge pertaining to a crystal analysis. For representation, time figures were rounded to the nearest hour. Results Over a 4-month period, 38 patients who had been referred to the inpatient rheumatology team at King’s College Hospital had crystal analysis performed following joint aspiration; 24 from an emergency department setting, and 14 from an inpatient ward setting. The proportions of these cases by articular distribution (with the specific joint aspirated in brackets) were: 55% monoarthritis (knee), 16% oligoarthritis (knee), 16% polyarthritis (knee), 10% polyarthritis (wrist), 3% monoarthritis (elbow). Mean time from rheumatology referral to joint aspiration was 7 hours (range 1-21; median 5; IQR 3-8). The mean time from sample acquisition to crystal analysis result was 20 hours (range 1-95; median 16; IQR 4-21). Discharges for 17/38 (45%) patients were pending crystal analysis results, of which 10/17 (59%) patients were discharged without results. Rheumatology clinician pre-test diagnostic accuracy was 55%. Comparing pre-aspirate diagnosis with final diagnosis, proportionately septic arthritis was over-diagnosed, whilst gout was under-diagnosed. Conclusion Gout remains a difficult condition to promptly differentiate and treat in hospital. Clinician workload and joint aspiration burden are rising due to global incidence trends. A move to establish a “7-day NHS” and significant bed pressures have developed since the British Society for Rheumatology (BSR) hot swollen joint guideline was published. In our centre, inadequate crystal diagnostics appear to be driving prolonged length of stay. Further evaluation of causal factors in the delay of recognition, referral and diagnostics is required. Through application of quality improvement methodology, process-mapping and driver diagrams we plan to implement a point-of-care testing (POCT) and door-to-needle (DTN) programme, researching how to improve the gout patient’s experience. Disclosures B.D. Clarke None. M.D. Russell None. A.I. Rutherford None. J.B. Galloway None. J. Stack None.

A service evaluation of e-triage in the osteoporosis outpatient clinic\u2014an effective tool to improve patient access?

SummaryWe introduced an electronic triage system into our osteoporosis service to actively manage referral demand in a busy outpatient service. Our study demonstrated the effectiveness of e-triage in supporting alternative management pathways, through use of virtual advice and direct to investigation services, to improve patient access.PurposeOsteoporosis referrals are increasing with awareness of the potential for prevention of fragility fracture and with complex decision making around management with long-term bisphosphonate therapy. We examined whether active triage of referrals might improve referral management processes and patient access to osteoporosis services.MethodsWe implemented electronic triage (e-triage) of referrals to our osteoporosis service using the Northern Ireland electronic health care record. This included the option of ‘advice only’, direct to investigation with DXA or face-to-face appointments at the consultant-led complex osteoporosis service. We anticipated that there was scope to manage patient flow direct to investigation, or to provide referring clinicians with clinical advice without the need for a face-to-face assessment, at the consultant-led specialist service.ResultsWe reviewed e-triage outcomes of 809 referrals (692 F; 117 M) to osteoporosis specialist services (mean age 65 ± 16.5 years) over a 12-month period. There was a high degree of agreement for the triage category between the referring clinician and specialist services (741/809). 73.3% attended a face-to-face appointment at the consultant-led clinic, while active triage enabled direct to investigation (18.4%) or discharge (8.3%) in the remainder. The mean time between receipt of an electronic referral and e-triage was 3 days over the 12-month period as compared with 2.1 days (median 1.1 days) when annual leave periods were excluded.ConclusionE-triage supports effective referral management in a busy osteoporosis service. Efficiency is limited by reliance on a sole clinician and 5 day working at present. There is scope to further improve systems access through multidisciplinary team working, virtual clinics and future information technology developments.

Improvement of the Efficiency and Completeness of Neuro-Oncology Patient Referrals to a Tertiary Center Through the Implementation of an Electronic Referral System: Retrospective Cohort Study.

BackgroundQuality referrals to specialist care are key for prompt, optimal decisions about the management of patients with brain tumors.ObjectiveThis study aimed to determine the impact of introducing a Web-based, electronic referral (eReferral) system to a specialized neuro-oncology center, using a service-developed proforma, in terms of waiting times and information completeness.MethodsWe carried out a retrospective cohort study based on the review of medical records of referred adult patients, excluding follow-ups. Primary outcome measures were durations of three key phases within the referral pathway and completion rates of six referral fields.ResultsA total of 248 patients were referred to the specialist center during the study period. Median (IQR) diagnostic imaging to referral intervals were 3 (1-5) days with eReferrals, and 9 (4-19), 19 (14-49), and 8 (4-23) days with paper proforma, paper letter, and internal referrals, respectively (P<.001). Median (IQR) referral to multidisciplinary team decision intervals were 3 (2-7), 2 (1-3), 8 (2-24), and 3 (2-6) days respectively (P=.01). For patients having surgery, median (IQR) diagnostic imaging to surgery intervals were 28 (21-41), 34 (27-51), 104 (69-143), and 32 (15-89) days, respectively (P<.001). Proportions of complete fields differed significantly by referral type in all study fields (all with Ps <.001) except for details of presentation, which were present in all referrals. All study fields were always present in eReferrals, as these are compulsory for referral submission. Depending on the data field, level of completeness in the remaining referral types ranged within 69% (65/94) to 87% (82/94), 15% (3/20) to 65% (13/20), and 22% (8/41) to 63% (26/41) in paper proforma, paper letter, and internal referrals, respectively.ConclusionsAn electronic, Web-based, service-developed specific proforma for neuro-oncology referrals performs significantly better, with shorter waiting times and greater completeness of information than other referral types. A wider application of eReferrals is an important first step to streamlining specialist care pathways and providing excellent care.International Registered Report Identifier (IRRID)RR2-10.2196/10.2196/15002

Electronic primary care to specialist referral: A pilot project to evaluate referral expedience and efficacy.

Delayed referrals to specialists often result in increased morbidity and mortality. A time delay in specialist care access of over 1 month identified a gap in efficient care provision in a rural south central United States outreach clinic within a multispecialty group affiliated with a hospital system. A pilot project with a mixed-methods design that compared the established referral process with direct primary provider referral to a specialist's electronic medical record (EMR) schedule. Authors conducted the study over 16 weeks using a convenience sample size of 74 patients. Direct primary care nurse practitioner provider to specialist EMR schedule referral based on specialty referral needs. All electronically referred patients were seen by specialists in less than 1 month. All electronic specialist referrals were completed more expediently than those referred by the standard process and patients reported an efficient and satisfactory process.

Replicating state Quitline innovations to increase reach: findings from three states

BackgroundReaching tobacco users is a persistent challenge for quitlines. In 2014, ClearWay MinnesotaSM changed its quitline services and media campaign, and observed substantial increases in reach and strong quit outcomes. Oklahoma and Florida implemented the same changes in 2015 and 2016. We examined whether the strategies used in Minnesota could be replicated with similar results.MethodsWe conducted a cross-sectional observational study of Minnesota’s QUITPLAN® Services, the Oklahoma Tobacco Helpline, and Florida’s Quit Your Way program. Each program offers free quitline services to their state’s residents. For each state, data were compared for 1 year prior to service changes to 1 year after services changed and promotions began. Registration and program utilization data from 21,918 (Minnesota); 64,584 (Oklahoma); and 141,209 (Florida) program enrollees were analyzed. Additionally, outcome study data from 1542 (Minnesota); 3377 (Oklahoma); and 3444 (Florida) program enrollees were analyzed. We examined treatment reach, satisfaction, 24-h quit attempts, 30-day point prevalence abstinence rates, select demographic characteristics, registration mode (post period only), and estimated number of quitters. Data were analyzed using χ2 analyses and t-tests.ResultsTreatment reach rates increased by 50.62% in Oklahoma, 66.88% in Florida, and 480.56% in Minnesota. Significant increases in the estimated number of quitters were seen, ranging from + 42.75% to + 435.90%. Statistically significant changes in other variables (satisfaction, 24-h quit attempts, 30-day point prevalence abstinence rates, gender, and race) varied by state. During the post period, participants’ method of registration differed. Online enrollment percentages ranged from 19.44% (Oklahoma), to 54.34% (Florida), to 70.80% (Minnesota). In Oklahoma, 71.63% of participants enrolled by phone, while 40.71% of Florida participants and 26.98% of Minnesota participants enrolled by phone. Fax or electronic referrals comprised 8.92% (Oklahoma), 4.95% (Florida), and 2.22% (Minnesota) of program enrollees, respectively.ConclusionsChanging quitline services and implementing a new media campaign increased treatment reach and the estimated number of participants who quit smoking in three states. Quitline funders and tobacco control program managers may wish to consider approaches such as these to increase quitline utilization and population health impact.

Closing the Loop on Electronic Referrals: A Quality Improvement Initiative Using the Care Coordination Model.

Primary care providers refer nearly one-third of their patients to specialty care services. Despite provider recommendations, approximately 1 in 4 referrals are never completed. Incomplete referral rates are higher among vulnerable and medically underserved individuals. Sixty-seven percent of federally qualified community health centers report difficulty obtaining specialty care appointments and incomplete referral rates as high as 73%. Effective electronic referral processes can improve health outcomes, reduce waste, and mitigate risks. Using the Care Coordination Model as its framework, this quality improvement initiative implemented evidence-based interventions aimed at improving patient support and organizational accountability for electronic referrals.

The role of dentists in nicotine replacement therapy.

Dear Editor, We read the article titled “Nicotine replacement therapy: A friend or foe” with great interest.[1] As authors pointed out smoking is one of the greatest causes of premature death and preventable illness in both developed and developing countries. Health-care professionals, especially dentists, can play an important role in assisting their patients with tobacco cessation.[2] We would like to share few more literature regarding the role of dentists in nicotine replacement therapy (NRT). Though most of the dental curriculums around the world don't have structured modules to train dentists in specific smoking cessation strategies, multiple studies exploring knowledge, attitude, and practice regarding tobacco cessation methods among dental practitioners have provided encouraging insights. Rajput et al. explored the attitudes, practices, and perceived barriers in Tobacco cessation counseling (TCC) among dental practitioners in India and found that seventy-three percent of the dentists agreed that TCC is their responsibility.[3] Moreover, Madhu et al. studied the attitude and practice of the dental students toward tobacco cessation methods using a cross-sectional design and found that almost 50% preferred to recommend nicotine replacement therapies (NRT) as a tobacco cessation advises to the patients.[4] Existing literature supports the fact that dental practitioners have the motivation and knowledge base to support tobacco cessation in their patients. It is the need of the hour for establishing tobacco cessation clinics in dental clinics especially in rural areas where a dentist does the behavioral counseling during which patients are advised to stop the tobacco use, with structured counseling methods.[5] There are no standardized tobacco intervention model for dental care settings. However, the American Dental Hygienists Association recommends a three-steP “AAR” brief tobacco intervention model for dental care settings: Ask every patient about tobacco use, Advise all tobacco users to quit, and Refer tobacco users to nationally available tobacco quitlines via fax or electronic referral.[6] Moreover, dentists can also assess the severity of tobacco addiction using Fagerstrom scale, i.e., the patient is asked a series of 6 questions and scores are given based on the patient's responses and based on the scoring, the patient can be prescribed pharmacotherapy in the form of nicotine replacement therapy (NRT).[5] There are multiple ways in which a dentist can assist their patient with NRT. One potential model for incorporating the provision of NRT in dental practices is NRT sampling (NRTS), in which a short starter course (e.g., 2 weeks) of NRT is given to all medically eligible smokers irrespective of their motivations to quit or seek treatment. Another specific area were dentists can contribute is in modifications NRT practices such as nicotine replacement therapy with tooth-whitening agents. Availability of NRT with stain removal or tooth-whitening activity would provide an opportunity for dentists to illustrate some early measurable benefits of smoking cessation, reinforce smokers’ commitment to quit, and support them on the path to a stable state of not smoking. Dentists can also play a key role in maximizing the benefits of NRT by educating the public regarding the relative safety of NRT when compared to smoking, as most of the studies from around the world indicate that the public incorrectly believes that nicotine is responsible for most of the cancer caused by smoking. Considering the need of the hour and the multiple role a dentist can play in tobacco cessation, the dental councils should consider including tobacco cessation training modules in the curriculum at the BDS level.[5] Furthermore, conferences, workshops, and CDEs regarding tobacco cessation services also should be promoted among dentists to educate and motivate them to start or continue their tobacco cessation services to their patients.[4] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Do e-referral systems have a detrimental effect on patient care - an investigation into the impact of digitalisation on the diagnostic quality of radiographs accompanying electronic referrals to a maxillofacial department outpatient clinic

Introduction/ Aims E-referrals to secondary care have replaced paper referrals in a number of PCTs. The process of digitalisation of conventional films is leading to diagnostically unacceptable radiographs being sent in with e-referrals, leading to need for repeat imaging and increased exposure to the patient. This study was undertaken to evaluate the image quality of radiographs supporting electronic dento-alveolar referrals to the Oral and Maxillo-Facial Department of the Royal Surrey County Hospital, Guildford, and identify the technical and processing errors associated with sub-optimal imaging.

Pharmacist implementation of a transitions of care electronic referral process to provide hand-off between inpatient and outpatient settings

ObjectiveTo describe the implementation of an electronic transitions of care referral process within a large, academic medical center. Practice setting and descriptionTo improve communication between the inpatient and ambulatory care pharmacists, the pharmacy department created an electronic referral (e-referral) order, which becomes part of the patient’s electronic medical record. Data were collected to describe use of the electronic order and to discuss the role of the referrals in supporting a newly developed ambulatory care pharmacy service. Practice innovationThe e-referral was built to enhance the efficiency of direct patient care and prioritize patient care activities. This electronic order was built to collect specific details focused on medication-related concerns and provide hand-off to ambulatory care pharmacists for outpatient follow-up. EvaluationA retrospective, cohort analysis of patients was conducted from August 1, 2014, to July 31, 2015. Patients were included in the project if they were 18 years of age or older and received an e-referral order upon transition from the inpatient to the outpatient setting. Patients were excluded if the e-referral was sent from an outpatient setting or if they were younger than 18 years of age. Data were collected to describe the e-referral process and discuss how these referrals supported a new outpatient pulmonary clinic. ResultsA total of 268 inpatient referral orders were included for analysis. Common indications for the referrals included education (49%), follow-up from inpatient consult (46%), adherence (45%), and therapy optimization (42%). A total of 241 (90%) e-referrals were sent from an inpatient pharmacist to an ambulatory care pharmacist; the other 27 (10%) referrals were sent by a physician or mid-level provider. Of the 241 pharmacist referrals, 46 (19%) were placed by pharmacy residents. The majority of inpatient e-referrals (63.4%) were for chronic obstructive pulmonary disease and sent to the outpatient pulmonary clinical pharmacist for follow-up after discharge. The pulmonary clinic ambulatory care pharmacist completed 110 discharge calls (95.7%). ConclusionAn e-referral from inpatient to ambulatory care pharmacists provides pharmacist-to-pharmacist hand-off for medication-related needs after discharge.

116.2: Electronic hospital donor referrals have arrived.

Background: The Centers for Medicare and Medicaid Services in the United States and additional regulatory organizations require that hospitals refer all potential organ, tissue and/or eye donors to their designated Organ Procurement Organization (OPO). To replace the current time-consuming and error-prone telephonic referral process, one OPO, its software system partner, a Hospital clinical team and their Electronic Medical Record (EMR) team successfully collaborated to implement the first-ever secure direct and automatic electronic donor referral interface between a Hospital EMR system and an OPO donor management system. The goals of the interface include: (1) increase the number and timeliness of referrals (and thus transplantable organs); (2) reduce Hospital and OPO resource costs; and (3) reduce risk of error due to human verbal communication and transcription risk. Methods: The multi-disciplinary team collaboratively created a secure technical interface directly connecting the OPO and Hospital systems. The team designed seamless donor referral triggers within the Hospital EMR which expanded upon existing Best Practice Advisory (BPA) notifications that previously instructed the EMR user to call in the referral, and now automatically deliver electronic donor referrals from the Hospital to the OPO. Immediately upon receipt, the OPO’s electronic donor management system creates a new referral that is auto-populated with actionable patient information and delivers real-time notifications alerting OPO staff of the new referral. The interface automatically returns the associated OPO referral ID number to the patient’s EMR. This interface was successfully launched in the Hospital ICU in October 2018. In April 2019 (six months later), the Hospital successfully rolled out the interface to additional units and facility locations, and numerous additional interface discussions and implementations are currently underway. Results: Immediately, the monthly referral count from the Hospital ICU to the OPO quadrupled (October 2017 = 18; October 2018 = 72). Since the launch, the OPO has been able to convert on a total of 36 organ, tissue, and eye donors across the facility. The use of an existing BPA resulted in minimal change to Standard Operating Procedures and reduced the need for clinical team training. Successfully transmitted referrals contained zero (0) errors in data transmission. Higher levels of awareness of organ donation potential in the units was observed. Conclusions: The current results were successful in the following measures: 1) increased number of referrals; 2) reduction in resource cost; and 3) decreased errors. The interface was established using standard interoperability technology connecting widely-adopted OPO donation software and Hospital EMR Systems to allow for scalable expansion. There is unlimited potential for streamlining the referral process through this electronic interface, ultimately leading to more donors and transplantations.

A review of the electronic two-week rule referrals for head and neck cancer to Western Sussex Hospitals NHS Foundation Trust

Introduction The two-week rule (2WR) for referring suspected malignancies aims to improve access and outcomes for cancer patients. However, there has been criticism of the rule in the literature. GDPs have an important role in spotting head and neck cancer (HNC) and using the 2WR appropriately to ensure their patients get fast and effective treatment.Aims 1) To evaluate adherence to guidelines of electronic 2WR referrals for HNC sent to Western Sussex Hospitals Trust from GDPs in Sussex; 2) to determine the detection rate of oral malignancies from these referrals; 3) to determine the success of the maxillofacial unit in seeing referred patients within two weeks.Materials and methods Two hundred and nineteen randomised electronic 2WR referrals were analysed for adherence to the guidelines for referral of suspected oral cancer. Patient waiting times, subsequent correspondence and pathology results were analysed.Results One hundred and thirty-five referrals (62%) were deemed to be compliant with the NICE NG12 guidelines, while 186 referred patients (85%) were seen within the two-week time frame. Six referrals (2%) resulted in a positive detection of malignancy (a lower rate compared to similar previous studies).Discussion There are several possible reasons for the poor rate of guideline adherence from GDPs, such as pressure to refer defensively and a lack of knowledge of referral guidelines or oral pathology. This may contribute to a poor detection rate, although there may be other contributing factors.Conclusions Thirty-eight percent of electronic 2WR referrals from GDPs were deemed inappropriate; ongoing education is required to minimise these inappropriate referrals. Patients must be made aware of the reason for their referral to promote attendance. Further studies are required to identify the reasons for such a low detection rate.