GP Referral Letters Research Articles

196 AN AUDIT OF PROTON-PUMP INHIBITOR PRESCRIBING IN PATIENTS ATTENDING A RAPID ACCESS FRAILTY ASSESSMENT UNIT

Abstract Background Proton-Pump Inhibitor (PPI) usage has revolutionised gastroenterology practice with clinical indications for conditions such as Gastro-Oesophageal Reflux Disease (GORD), gastric and duodenal ulceration and Barrett's Oesophagus. However, these drugs are inappropriately prescribed, particularly among patients with an already heavy polypharmacy burden. PPI usage has been linked with electrolyte disturbances, most commonly hypomagnesaemia, resulting in higher rates of osteoporosis. It has also been shown to have adverse effects on renal function, an increased correlation with clostridium difficile and most recently, a deleterious impact on cognitive function. The purpose of this audit was to assess the appropriateness and clinical indication of PPI prescribing among patients attending Rapid Access Frailty Assessment Unit (RAFAU) in 2022. Methods A database of patients attending RAFAU in an Irish regional hospital was accessed. Records from years 2021-2022 were searched and documents citing patients’ medical history and clinical indication for prescribed medications included hospital discharge letters, outpatient clinic letters and GP referral letters. NICE guidelines from the UK NHS were used as comparison for prescribing guidelines. Results 120 patients’ records were assessed. 63 (52.5%) patients were found to be prescribed a PPI among this cohort. Of those taking PPIs, only 15 (23.8%) patients were prescribed a PPI with a documented clinical indication in accordance with NICE Guidelines. Although several patients were taking gastro-erosive drugs including antiplatelets, anticoagulants and steroids, only one patient record mentioned PPIs being prescribed for iatrogenic gastritis. No records mentioned deprescribing or cessation of PPIs. Conclusion Most patients prescribed PPIs were without documented appropriate clinical indication and without clear duration of use. This is of particular importance among a frailty population where de-prescribing medications associated with significant co-morbidities should be prioritised.

Interception of chronic medication discrepancies by the clinical pharmacist in the emergency department.

The emergency department (ED) is a high-risk setting for the occurrence of medication discrepancies (MDs) due to inconsistencies between real and documented chronic medication therapies. A clinical pharmacist (CP) improves medication safety by performing a structured medication reconciliation on ED admission. The main objective was to identify the frequency and type of MDs in the chronic medication therapy by comparing the medication displayed in the home medication module of the electronic medical record and in the genereal practitioner's (GP) referral letter with the best possible medication history by performing a structured medication reconciliation on ED admission. This prospective, monocentric, interventional study was carried out in the ED of a tertiary care university hospital in Brussels, Belgium. Inclusion criteria were patients of at least 65 years, polypharmacy, ED admission between 8 a.m. and 4 p.m. on weekdays, hospitalization and signed informed consent. During 24 days, a CP performed a structured medication reconciliation in order to obtain the best possible medication history and registered all MDs. The CP compared the best possible medication history with the home medication module and the GP's referral letter and registered the different types of MDs. Eighty-three patients were included. The median number of medications in the home medication module and the best possible medication history was significantly different {7.0 [interquartile range (IQR), 5.0-11.0] vs. 8.0 (IQR, 6.0-11.0)/patient; P < 0.0001} with a median of 5.0 (IQR, 3.0-8.0) MDs per patient. Main MDs were omission (38.8%), addition (18.4%) and a deviant administration time (15.2%). Only 22.9% of patients ( N = 19) had a GP's referral letter containing their chronic medication therapy. The median number of medications in the GP's referral letter and the best possible medication history were significantly different [6.0 (IQR, 4.0-9.0) vs. 8.0 (IQR, 7.0-11.0)/patient; P < 0.0001] with a median of 6.0 (IQR, 5.0-11.0) MDs per patient. Main MDs were omissions (39.9%), deviant frequencies (35.3%) and doses (16.7%). A CP, integrated in a multidisciplinary ED team, enhances medication safety by intercepting MDs on ED admission. Few patients possess a GP's referral letter containing their chronic medication therapy and when they do, the accuracy and completeness are poor.

Assessing the Anticholinergic Burden in the West Memory Assessment Service (MAS)

AimsAim: Evaluate the recording of the Anti-Cholinergic Burden (ACB) score for patients referred to the West Leeds Memory Assessment Service (MAS). Objectives: 1) Calculate the Anti cholinergic Burden score of all patients referred to the West MAS in June 2021 where this has not already been done. 2) Determine if there is a need to review the process for assessing this component of the cognitive assessment in MAS.MethodsAll patients who were referred to the West MAS in June 2021 were included in this project. Data were collected from GP referral letters, the referral meeting documentation and patients’ GP prescriptions.These records were checked for a documented ACB score. If ACB scores were not found, they were calculated based on a patient's GP prescription. Several ACB calculators were used to do this, as NICE does not recommend a specific scoring system.ResultsThere were 60 referrals in June 2021. Within this data set, there were no documented ACB scores found at the point of referral.The different scoring systems used led to considerably different ACB scores, with the lowest figure suggesting 20.4% of patients had a raised ACB score (n = 10).In all three scoring systems used, the medication most frequently leading to a larger anticholinergic burden is Amitriptyline.ConclusionWithin the service, during the referral process we are not routinely documenting anticholinergic burden. We are in the process of agreeing a standardised ACB tool to review all new referrals to the service and determine how we can communicate these findings with referrers. We are looking to improve local awareness of ACB scoring across the memory pathway and will undertake a re-audit of practice in 3 months to establish if the proposed changes improve our results

P109 Early diagnosis of inflammatory arthritis (IA) using machine learning analysis of GP referral letters and blood tests to improve pre-hospital referral triage

Abstract Background/Aims The diagnosis of inflammatory arthritis (IA) from referral letters is challenging. We aimed to develop a model integrating GP referral letter data and pre-referral blood test results (BTR) to identify clusters of patient phenotypes (characteristics) that predict at referral that patients will have any of three types of IA (rheumatoid arthritis, seronegative inflammatory arthritis and psoriatic arthritis) requiring early DMARD treatment. Methods The anonymised text of original GP referral letters of patients on our departmental DMARD monitoring database with diagnoses of IA was compared with referral letters of patients with other inflammatory rheumatological conditions (OICs) entered into the same database over the same period. We developed and used novel natural language processing (NLP) methods based on bidirectional encoder representations from transformers (BERT) to identify patients with IA and OICs for triage purposes. Results We have analysed 867 OIC patients and 267 IJD letters using our NLP methods. Data augmentation was used to address imbalance and small data challenges in this real-world application. Our method using only GP referral letters achieved overall accuracy (using confirmed diagnosis as the outcome) of 80% in identifying IJD and OCIs, reaching 86% sensitivity and 84% precision (reproducibility) at detecting OICs, compared with 71% sensitivity and 68% precision in detecting IA patients. Conclusion Our NLP methods alone identified OIC with &amp;gt;80% sensitivity and precision. In data science terms our NLP based method thus has high sensitivity for identifying a wide variety of OICs likely to need DMARD treatment. Our methodology may have great practical value if GP referral letters can be analysed at source. For high specificity and precision very large amounts of data are required to train the NLP model; we had many more OIC letters than IA letters available in analysable formats from other databases in our department. Analysable text of referral letters from primary care is currently difficult to obtain and performing NLP on photographs of referral letters in electronic patient records (EPRs) is a major challenge. These significant bottlenecks in NHS data systems must be removed to allow direct access and analysis of GP referral letters in the compatible format. BTR will be easier to analyse in the EPRs. Combined analysis of pre-referral NLP and BTR may increase the efficiency of automated triage of GP referrals with suspected early IA. Machine learning analysis of GP referrals potentially allows triage of the right patient into the right clinic first time, assisting demand management and capacity in stretched rheumatology clinics and improving patient experience by ensuring the right clinic appointment. Further work is underway to improve the precision of the system with a view to embedding this into our advanced Advice and Guidance triage process. Disclosure A. Bradlow: None. B. Wang: None. W. Li: None. E. Bazuaye: None. A.T.Y. Chan: Member of speakers’ bureau; UCB, Novartis, Sanofi, AbbVie, Celgene and Janssen.

Prospective Validation of Edinburgh Dysphagia Score as a Triaging Tool beyond the COVID-19 Era

The Edinburgh Dysphagia Score (EDS) was previously developed to identify patients referred to secondary care with dysphagia, who were most likely to have oesophageal cancer. The aim of this study was to use the EDS prospectively during the COVID pandemic to risk stratify patients to either urgent or routine investigation of dysphagia. Between 1st April and 1st July 2020, 283 patients were referred to NHS Lothian with dysphagia. An EDS score was calculated utilizing information in the GP referral letter or information gained in a “HOT clinic.” Patients with a score ≥ 3.5 were prioritized for investigation under the “urgent suspicion of cancer” pathway. 243 patients underwent investigations. 18 patients were diagnosed with oesophageal cancer, all of whom had an EDS ≥ 3.5 (range 4-10). Approximately one third of patients with dysphagia had a score of &lt;3.5. Using this cut-off, sensitivity was 100% and negative predictive value 100%. This study shows that the EDS can be used prospectively when triaging patients referred to secondary care with dysphagia. The high negative predictive value using the EDS means that patients who have an EDS &lt; 3.5 can be downgraded to a routine waiting list without leading to delays in diagnosing oesophageal malignancy. This will enable faster investigations for patients who remain on the “urgent suspicion of cancer” waiting list. In the age of COVID-19, with increasingly long waiting lists, the EDS is a useful scoring system to identify patients with the greatest need for urgent endoscopy.

EP.TH.81Contribution of Information on GP Referral Letters to Patient Management in a Rapid-diagnosis Breast Clinic

Abstract Aims GP referral letters to rapid-diagnosis breast clinics are often poorly scanned copies of standard 2 week-wait proforma that are difficult to read, lengthy, and contain a large amount of irrelevant information. We studied the contribution of information in referral letters in patient management and compared this with information provided by patients themselves. Methods Patients completed a standard questionnaire (one side of A4) on arrival at clinic. This included all information relevant to a breast clinic such as family history and comorbidities. A consultant surgeon then saw the patients with the questionnaire and performed clinical assessment and imaging as necessary, without referring to GP letters. The letters were read before patients left clinic. Any additional useful information was noted. Results 202 consecutive new patients, median age 44 (16-93) seen in 23 clinics by 2 consultants were studied. The median number of pages in referral letter was 5 (1-14). Patient questionnaire took less than 30 seconds to read. The presenting complaints were real or perceived lump (n = 105), pain (n = 44), both (n = 14) and others (n = 39). 21 patients had cancer. Additional useful information in the referral letter was noted in 20 patients (10%). However, in no case this affected the patient management adversely. Conclusions GP letters are lengthy but contribute relatively little to the initial assessment and management of patients in a busy rapid diagnosis breast clinic. A patient-completed targeted questionnaire is quicker and can potentially replace a GP referral letter in most patients.

EP.FRI.57 Audit of Medical Records on Structure and Content of T&amp;O Documentation

Abstract The aim of the audit was to assess if Trauma &amp; Orthopaedic admission documentation and record-keeping met the national standards. Standards used included the ‘Royal College of Physicians-Generic Record Keeping Standards 2, 4, 6, 10’ and ‘Professional Records Standards Body, Section 2 Admission Record’. Seventeen admission criteria and eight documentation criteria where audited from the respective standards. Retrospective data were collected using A&amp;E clerking documents, GP referral letters, admission clerking proformas and continuation notes from hospital admission. Initial data showed that only 41% of pages of documentation had appropriate patient identification details listed. Of the 17 admission criteria audited, only 7 criteria scored above 90%. The major downfalls were in vital signs (38%) and assessment scales i.e. Abbreviated Mental Test Score (18%) and venous thromboembolism assessment (32%). With regards to subsequent separate entries, the main failure was entries not listed in chronological order (48%), with only two criteria scoring above 90% (entries dated and legibility). Following the implementation of an updated admission proforma and education on documentation; only 5 of the 17 admission criteria scored 90% or above. However, 46% of pages had the correct patient identification details on admission. On subsequent ward entries, 7 out of the 8 sections had improved, with 62% of notes in chronological order. Furthermore, 4 out of the 8 documentation criteria scored above 90%. Informing staff on correct documentation helped improve doctors’ entries in patients’ notes. Improvements in the admission proforma need to be made to help meet record-keeping standards.

Selection of headache cases for expedited scanning to assist prompt diagnosis of brain tumour

Abstract Aims Patients with brain tumours and headache commonly have poorer cognitive skills, either overtly or covertly, when cognitively tested. Cognitive changes reflect, tumour mass, fronto-temporal location or hydrocephalus, Previous work has demonstrated that the “semantic Verbal Fluency Test (SVFT) -“How many animals can you think of in a minute?” is a useful fast screening test for cognitive issues. Median SVFT in patients with brain tumour on admission is 10 animals. Most GPs can now order “direct access cerebral imaging (DACI)” in patients with headache suspicious of cancer. The waiting times for scanning can be many weeks. The aim of this study was to determine whether low SVFT scores: might be useful to help stratify or expedite DACI. We present data from referrals through and electronic Protocol Based Referral (PBR) pathway for CT scanning over 3 years, to determine whether SVFT might be a useful adjunct to history and examination. Method From 2017, in Edinburgh/Lothians, Scotland, an electronic PBR was developed with involvement of Primary Care Cancer Lead, PBR lead, Neurology, Neurosurgery and Neuro-Imaging for outpatient imaging of patients in the community with Headache Suspicious of Cancer, to expedite their scans. The PBR sat alongside the routine outpatient DACI system. If the forms were correctly filled in Neuro-Radiology prioritised their appointments. The referrer (GP) was asked to complete the ePBR form and SVFT at the time of referral. Other data were also gathered, including: Past Medical History of cancer; other symptoms/signs; and co-morbid conditions and medications filled automatically from the GP system. This formed the dataset. We also retrospectively assessed a) whether English was first language b) past history of Pain Clinic Attendance or Functional Illness and subsequent final diagnosis of headache/condition, through evaluation of electronic GP referral letters through SCI Gateway system of those cases where SVFT was recorded. Results Between March 2017 - November 2019, 669 scans through PBR pathway. (62% females; Mean age 53 years: 60% cases &amp;lt;60 years). SVFT was completed in only 381/669 (57%). Median SVFT was 17. Eleven of 381 cases had cancer (2.9%). 10 cases with cancer had SVFT &amp;lt;17 animals (median 10) (5.32%). One case had SVFT &amp;gt;=17 (35 animals) (0.5%) - CT scan showed small multiple intra-cerebral calcified and non-calcified lesions, consistent with metastases. 12% with PMH cancer had a tumour. Other possible reasons for low SVFT were: co-existing presumed dementia/mild cognitive impairment (19); non native English speakers (12); headache after traumatic brain injury (5); significant small vessel disease/vascular(5); intracranial cysts (4)(pineal / arachnoid, Giant Cell Arteritis (4) (all new - symptomatic); Chiari 1 malformations (2), PMH – encephalitis (1). Interestingly, there were 53 cases with known psychiatric/pain conditions on drugs (e.g. codeine/antidepressants/antipsychotics) with SVFT &amp;lt; 17 words/min. Conclusion People with Headache "Suspicious of Cancer" + SVFT &amp;lt;17 words in a minute are more likely to have a tumour (5.32% vs 0.5%) or other secondary cause for poor cognition. Other probable causes /associations, with SVFT &amp;lt;17 are age, poor English skills, co-existing dementia. SVFT score may be a useful adjunct or “red flag,” to consider, to expedite DACI scan in patients with “Headache Suspicious of Cancer”. A SVFT &amp;gt;=17 in those with Headache Suspicious of Cancer, does not exclude the possibility of an intracranial tumour. Excluding cases with recognised causes for low SVFT e.g. dementia and those with existing chronic pain/psychiatric disease further increases the likelihood of a secondary cause for headache. SVFT should be tested in the persons native language. A larger prospective study is required to establish whether these pilot study data and to examine whether chronic pain, functional neurology are negative predictive factors for secondary headache.

The impact of GP referrals on overcrowding in emergency departments and acute medicine

Background/Aims A long-standing issue common to most emergency departments worldwide is overcrowding, and the UK is no exception. Overcrowding can have many adverse consequences, such as increased medical errors, decreased quality of care and poor patient outcomes. This service evaluation aimed to review the number of patients referred to acute specialties by their GPs and to evaluate the impact of these referrals on the flow of patients in and out of the emergency department and acute medicine. Methods GP referral letters were collected at an emergency department in Greater Manchester, England, between 15 May 2019 and 28 May 2019. A proforma was used by a consultant in acute medicine and a consultant in emergency medicine to evaluate each letter. Result A total of 139 GP referrals were received by the emergency department, of which 43 were to general medicine and 96 to other specialties. Of the latter, 54 cases were directed to the emergency department, 20 were directed to a different specialty and 23 did not have a specialty clearly specified. The majority of referrals were for gastrointestinal conditions or abdominal pain, with the next largest category being chest infections. Most of these patients were eventually seen in the trust's ambulatory assessment area to relieve pressure on the emergency department. Conclusions Planned and specific use of urgent care centres and ambulatory assessment areas can help to relieve pressure on emergency departments, but appropriate intervention at the primary care level is also necessary to improve patient flow.

280 Acute Hospital Presentations among Nursing Home Residents: A Retrospective Observational Analysis

Abstract Background Nursing home residents are prone to acute illness due to their advancing age, underlying illnesses and immobility. The decision to refer a nursing home resident for acute hospital admission is a complex one, and there is no consensus among health care professionals about what constitutes an ‘appropriate admission’ to hospital from a nursing home. We aimed to explore patterns of acute nursing home patient presentations to the emergency department. Methods This was a retrospective cohort study of emergency hospital admissions to a tertiary university teaching hospital. Emergency admissions through the emergency department were included. Elective admissions, outpatient admissions, or inter-hospital transfers were excluded. Cases were validated by scrutiny of the patient medical records, and where possible an assessment of the Rockwood clinical frailty scale (CFS) was carried out. Results There were 126 nursing home residents who presented to ED over a two month period for emergency assessments. 87.3% (n=115) presented via ambulance. Just over half had a GP referral letter (53.2%). 72.3% of patients who presented to ED were admitted. 25.2% of patients were re-referred to ED within 30 days of hospital discharge. All patients were classified as frail. 21.3% of patients had died at the 90 day follow up mark. 66% of those with a CFS 8 or 9 died, in comparison to 16% of those with a CFS or either 6 or 7. Conclusion We noted high numbers of patients from nursing homes attending our emergency department. A very high proportion were admitted, along with a high number of subsequent re-presentations. Death rates were higher in those with more advanced frailty status. We would suggest advanced care planning and strategies to improve the patient experience. This study highlights the requirement for improved advance care planning in the nursing home setting. This is however a complex issue. Early discussion about end of life preferences with patients and family is required.

Primary Care Referral Letters to the Emergency Department; An Audit of the National Standardised Patient Referral Template

An introduction: (comprising context and problem statement) Effective communication at the interface of primary and secondary care is critical for the provision of effective, high quality and safe patient care. The aim of this audit was to examine current standards and use of the National Standardised Patient Referral Template when referring from General Practice to St. James’s Emergency Department. Short description of practice change implemented: GP letters received by the Emergency Department of St. James’s Hospital over a one week period in October 2013 were reviewed retrospectively and examined under the following headings: - Legible GP Name - GP Medical Council Registration Number - GP Contact Details - Reason for referral and/or anticipated outcome - Symptoms - Examination Findings - Past Medical History - Medication List - Allergies Results were distributed to a sample of general practitioners within the St. James’s catchment area along with information on the referral template. Also included was a questionnaire seeking feedback on discharge letters from the Emergency Department. Referral letters from a one week period in May 2014 were then re-audited, and requested feedback collated. Aim and theory of change: The aim of this study was to explore use of the National Standardised Patient Referral Template. A secondary aim was to increase engagement between General Practitioners and the Emergency Department in order to improve the transfer of information between primary and secondary care. It was envisaged that opening a forum for dialogue between these two care areas would lead to improvement. Targeted population and stakeholders: All patients referred to St James' Emergency Department by their GP, GP's in the local area and staff of the Emergency Department. Timeline: October 2013 to May 2014 Highlights: (innovation, Impact and outcomes) 188 GP referral letters were received by the Emergency Department over a one week period in October 2013. 64% of these letters were typed and 14% were from an on call service. Only one referral of the 188 used the National Standardised Patient Referral Template. Information pertaining to allergies was documented in only 22% of letters. Results on reaudit in May 2014 demonstrated little difference from the October 2013 data. This project failed to improve the overall content of GP referral letters to the Emergency Department. The most significant success from this project came from the opportunity for GP's to provide feedback to the Emergency Department on patient care and information transfer systems. This resulted in increased awareness of staff in the Emergency Department of the needs of local Primary Care providers, helped to illustrate some of the difficulties that GP's can encounter in trying to provide comprehensive information in emergency referral letters and highlighted the need for further engagement in order to inform improvement. Comments on sustainability: This project highlights the need for sustainable and continuous engagement between GP's and their local Emergency Department in order to improve the quality of care transitions. Comments on transferability: The learning gained from this project is transferable across all care transition settings. Conclusions: (comprising key findings) This study demonstrates that the National Standardised Patient Referral Template is not being used routinely for referrals from general practice to the Emergency Department in St. James’s Hospital. Discussions: The referral letters studied in this project fall short of the desired standards in identification of the referring doctor and inclusion of essential clinical data. The failure of this intervention highlights the need to develop further engagement between Primary and Secondary care. Lessons learned: Development of the interface between primary and secondary care should be prioritised in order to improve the quality of care transitions.

Inclusion of Plain-film Radiographs with GP Referrals to Lower-limb Orthopaedic Clinics: A Retrospective Study

Background: It has been reported that 40% of new patients referred to orthopaedic clinics had radiographs in the previous 12 months. This means that radiographs very often have to be obtained during clinics, thus increasing outpatient clinic waiting time. This is especially so in District General Hospitals (DGHs) where long out-patient clinic waiting times cause dissatisfaction among patients. Purpose: To determine whether new patients to orthopaedic clinics were being referred with plain film radiographs. Design and setting: Retrospective study over a one month period in a DGH and a Tertiary referral centre. Method: All new patient referrals to two consultant surgeons in a DGH and to four consultants in a Tertiary referral centre were reviewed over a one-month period to identify whether radiographs had been performed prior to referral. Information on previous radiographs was obtained from GP referral letters, orthopaedic clinic letters and this was verified through the imaging system at the hospitals. Results: There were 414 patients seen in the two hospitals in the study period, of which 102 were new GP referrals. 37.3% of these new patients were referred with no plain-film radiographs. Conclusion: More than a third of new patient GP referrals to orthopaedic clinics were not accompanied by plainfilm radiographs. The efficiency of clinics and patient satisfaction is likely to be improved if this is addressed.

Access Pathway Delays and Burden of Disease for Patients with Severe Chronic Skin Conditions Requiring Systemic and Biologic Therapies at an Irish Dermatology Centre

Diseases that directly affect the skin are the fourth most frequent cause of all human illnesses. Despite this, skin diseases continue to receive little attention. Dermatology waiting times in Ireland are longer when compared to other health systems abroad. In this study we highlight a cohort of dermatological patients with inflammatory skin conditions, that require attention with regards to access to dermatological services. Aim of this study was to analyse our patient cohort currently taking biologic therapy to determine how they accessed the hospital system and the time course of transition to systemic and biologics therapy. This was a retrospective study with analysis of patients on biologic agents: etanercept, adalimumab, ustekinumab, infliximab and golimumab for chronic dermatoses from 2006-2012. We identified 157 patients on biologics between this period, with 114 of these patients currently on biologic therapy. Although 55% (62) were seen within 6 months of referral the mean wait from receipt of a GP referral letter to being seen in the outpatient was 11.6 months (range 0-87 months). This study shows that patients with severe inflammatory skin disease face significant delays in accessing the hospital system. This is partly due to inadequate infrastructure and staffing of Dermatology units.

PWE-138 The Value of The Straight to Test (STT) Specialist Nurse in Expediting Patients Referred on A Routine Pathway with Red Flag, Lower Gastrointestinal (LGI) Symptoms To A Diagnostic Endoscopy Procedure

Introduction Our Trust has a well-established STT service to reduce the wait until a definitive diagnostic test in patients with LGI symptoms. STT receives routine18 Week Wait (18 WW) referrals through Choose and Book with a patient- controlled 3 week window. GPs, therefore, currently refer non-target patients to the service. Patients referred on the pathway wait an average of 31 days for procedure (range 13–44). However, it was found from triage assessment that some patients needed to be fast-tracked and investigated within 2 weeks due to the onset and severity of their symptoms, particularly patients with symptoms suggestive of inflammatory bowel disease (IBD). Methods Routine referrals are vetted and prioritised by specialist colorectal nurses using information from the GP referral letter and patient-reported history during telephone assessment. Triage is based on a structured algorithm following 2 Week Wait (2 WW) and National Institute of Clinical Evidence (NICE) guidelines and a symptom questionnaire is completed. A prospective database captures patients’ symptoms, outcomes of triage, procedures and demographic details. Patients with red flag symptoms referred on a routine pathway were expedited and their outcomes documented. Chi Square statistics were applied to test for significance of findings. Results 569 patients have been triaged since we began formally fast-tracking (August 2014) .Of those patients, 104 (18%) have been expedited following telephone assessment. 57% of those fast-tracked were female and the mean age was 58 years (range 18–88 yrs). 79% underwent colonoscopy, 3% had a flexible sigmoidoscopy, 1% were referred for an ultrasound scan and 17% were directed for an initial clinic review. The mean number of days from triage to test was 5, which is a 96.5% time-saving on the 18 WW pathway. Of all the patients fast-tracked, 65% had pathology, of which 14% had IBD (age range 18–57 yrs with mean of 39 yrs), compared to 45% pathology findings in routine referrals (p-value Conclusion These data suggest that there is a benefit to having a comprehensive history taken by a colorectal specialist nurse in determining the patient pathway in a timely way for diagnosis and start of treatment. With 14% of patients expedited found to have new-onset IBD, the result was prompt treatment of symptoms, and potential avoidance of a hospital admission. Disclosure of Interest None Declared

Using vignettes to understand variations in patient screening and recruitment

The INVESTIGATE-I study was designed to inform a future definitive randomised trial of invasive urodynamic testing compared to basic clinical assessment with non-invasive tests, prior to surgical treatment in women with stress urinary incontinence or stress predominant mixed urinary incontinence. In a pilot RCT, women from seven participating sites were screened, consented and randomised. Overall, 771 patients were identified by clinic notes and correspondence as being potential recruits, and were sent the patient information sheets. Of those screened, 284 were deemed eligible, giving a ‘screen positive’ rate of 37%. The numbers screened at individual centres varied between 14 and 399; the percentage of eligible women recruited varied between 55% and 100%. To explore why ‘screen positive rates’ may have varied across sites, we asked all 11 screeners from the seven sites to respond to a series of 20 identical vignettes. These were mainly based on actual GP referral letters. Sixteen vignettes mentioned one or more definite inclusion criteria; the remainder had possible inclusions. Four had definite exclusions; 15 had possible exclusions. Free text comments were sought to clarify the screeners' decisions. For six vignettes everyone agreed that the patient was eligible; for one all agreed she was not eligible; the breakdown for the remainder was mixed. Comments amplified decisions. The findings indicated that inclusion and exclusion criteria should be more explicit and that where information is missing from referral letters, the default action should be to invite the woman to attend for detailed screening. Vignettes could usefully be used as training tools for those screening and consenting patients.

Comments on the paper “Medicolegal implications of accuracy of GP referral letters to specialist breast clinic”

Ahmed and colleagues [1] have described well the dilemmas faced by clinicians when diagnosing women with symptomatic breast disease. However, one important factor was omitted that helps to explain the poor correlation between general practitioner findings and those assigned by the specialist in the breast clinic. The positive predictive value of symptoms, signs and non-diagnostic test results (that is, the likelihood that a patient who tests positive actually has the disease) varies strongly with disease prevalence [2, 3]. The same test with the same sensitivity and specificity will have more false positives in a lower disease prevalence setting (e.g. primary care) than in a higher disease prevalence setting (e.g. hospital) [4, 5]. Thus, a clinician with a certain standard of skills in clinical history taking and clinical examination, if working in primary care, will have more false positives than the same clinician working in a hospital setting. References

71. Managing Oa In General Practice: Can Training Enhance The Oa Consultation?

quality letter also facilitates a more efficient use of outpatient appointments. Our study describes referral patterns to our rheumatology department and assesses the content of the referral letters and proposes measures to improve their quality. Methods: A prospective review of consecutive referral letters to the rheumatology department at Cannock Chase Hospital over a 6-week period in April and May 2013 was conducted. Data were collected on age, gender, source of referral, reason for referral, duration of symptoms, investigations documented in referral letter, time from referral to clinic appointment and clinic outcome. Results: A total of 224 referral letters were assessed, of which 195 (87%) were from general practitioners. Mean age of the patients was 52 years (range 9–89 years) and 155 (69.2%) of them were females. Of the 195 GP referral letters, 125 (64.1%) did not indicate the duration of symptoms, 51 (26.3%) either had no investigations in primary care or none was documented, while 32 (16.7%) did not volunteer a provisional diagnosis. Thirty one of the 79 (41.1%) cases referred as suspected inflammatory arthritis turned out to have the diagnosis after clinical assessment. Only 8 (10.1%) of the 79 cases were triaged as urgent based on the information in their referral letters. The overall mean wait time was 11 weeks (range 2–27) while patients who received a clinic outcome of inflammatory arthritis had a mean wait time of 10 weeks (range 2–19). Cases triaged as urgent at referral had a mean wait time of 5 weeks (range 2–11). Conclusion: This study provides further evidence that primary care referral letters to rheumatology services are often lacking in key information needed for an accurate triage of cases. Some cases of suspected inflammatory arthritis may be marked as non-urgent because of inadequate information in the referral letter. Measures to improve the quality of the content of referral letters have often focussed on the use of referral templates, but these have a poor uptake in primary care. Clinical audit may offer an alternative tool for improving letter content and we propose the development of an audit tool containing agreed minimum data sets to be used in primary care for monitoring the quality of referral letters. Disclosure statement: The authors have declared no conflicts of interest.

Clinician assessment, advice and referral for multiple health risk behaviors: Prevalence and predictors of delivery by primary health care nurses and allied health professionals

ObjectivePrimary care clinicians have considerable potential to provide preventive care. This study describes their preventive care delivery. MethodsA survey of 384 community health nurses and allied health clinicians from in New South Wales, Australia was undertaken (2010–11) to examine the assessment of client risk, provision of brief advice and referral/follow-up regarding smoking inadequate fruit and vegetable consumption, alcohol misuse, and physical inactivity; the existence of preventive care support strategies; and the association between supports and preventive care provision. ResultsPreventive care to 80% or more clients was least often provided for referral/follow-up (24.7–45.6% of clinicians for individual risks, and 24.2% for all risks) and most often for assessment (34.4–69.3% of clinicians for individual risks, and 24.4% for all risks). Approximately 75% reported having 9 or fewer of 17 supports. Provision of care was associated with: availability of a paper screening tool; training; GP referral letter; and number of supports. ConclusionThe delivery of preventive care was limited, and varied according to type of care and risk. Supports were variably associated with elements of preventive care. Practice implicationsFurther research is required to increase routine preventive care delivery and the availability of supports.

AUDIT OF HEADACHE REFERRALS FROM PRIMARY CARE TO A REGIONAL HEADACHE SERVICE

IntroductionHeadache is the most common neurological symptom with which patients attend their GPs and is also the commonest reason for referral to neurology outpatient clinics. The Neurological Services Task and...

PTH-132 Iron Deficiency Anaemia Nurse Led Clinic: Audit of 1st Year

IntroductionIron deficiency anaemia accounts for 4–13% of gastrointestinal referrals occurring in 2–5% of adult men and post menopausal women. Current guidelines suggest that the work up of asymptomatic anaemia remains...