Reason For Referral Research Articles

Teiripe sa Bhaile: ICPOP Early Supported Discharge for Frailty

Abstract Background Older adults and particularly older adults with frailty are high users of acute hospital care which results in overall higher hospital costs and reduced functional independence. Early supported discharge (ESD) was found to have a statistically significant impact in reducing length of stay in older adults admitted for medical reasons. This poster outlines the rehabilitation pathway developed by an ICPOP team to provide early supported discharge for frail older inpatients with SMART rehab goals. Methods Suitable patients are identified and assessed prior to discharge from the acute ward. Each patient receives a comprehensive geriatric assessment in their own home. All patients receive at least 2 hours of therapy per week until they have reached their goals. Standardised outcome measures including Functional Assessment Measure (FIM/FAM) and EQ5D5L are captured for each patient. Clients are discharged once they have reached their goals or are at their new functional baseline. Results 52 patients have been seen on this pathway since 2023. Hip fracture was the most common reason for referral, followed by Falls. Average length of stay on service was 40 days. Average wait time to first assessment was 1.7 days, highlighting the responsiveness of the service. 4 patients seen in 2024 live alone, indicating this service is also appropriate for patients who don’t have supports readily available in the home. FIM/FAM scores increased from 148 to 160 on average- Indicating more functional independence. Conclusion This ICPOP Rehabilitation pathway offers a safe, person-centred alternative to traditional inpatient rehabilitation. Readmission rates post discharge were low indicating the programme's safety. Given the large number of hospital bed saved without compromising functional outcomes for the patients, the ICPOP team is working on expanding this pathway.

B - 130 Application of Item Response Theory to the MMPI-2-RF Response Bias Scale-19 (RBS-19)

Abstract Objective RBS is a cognitive overreporting scale on the MMPI-family of instruments. Recent efforts to refine the scale removed nine items lacking conceptual and empirical relationships to cognitive dysfunction (Ingram et al., 2024; Ratcliffe et al., 2022). This revised scale version (RBS-19) demonstrated improved utility and classification accuracy, although the improvements were small. Albertorio et al (2024) found that the RBS could be reduced to 14 items and identified potential “critical items”. This study uses IRT in a database of Active-Duty personnel to explore reduced item RBS forms. Method Using a 2-parameter IRT model, we examined cognitive overreporting across the 19-item MMPI-2-RF RBS-19 Scale. Participants (n = 326; 96% male) were divided into pass-all vs fail 2+ standalone PVTs for criterion-based comparisons (e.g., ROC analysis and mean difference), with indetermined profiles removed. Results Results indicate good theta coverage. Two items (24 and 26) were removed due to low α (2). RBS-14/17/19 all had similar AUC (0.72 vs 0.71 vs 0.72) and similar effect sizes between groups. Conclusions IRT analyses supported a 17-item RBS scale rather than the 14 or 19 item versions in this sample. However, no “critical items” emerged in this sample. Such differences may reflect changes in factor structure based on referral reason (Boress et al., 2023).

Enhancing Telemedicine Communication for Improved Outpatient Pediatric Trauma Care.

Pediatric traumatology is a complex field that requires a comprehensive understanding of physeal development, remodeling potential, and the ossification process in order to ensure appropriate patient treatment. The objective of this study was to assess the willingness of practicing physicians to participate in a telemedicine collaboration aimed at enhancing the exchange between the outpatient and inpatient sectors and promoting the digitalization of the pediatric sector. This is in response to the growing significance of digitalization in the medical field. A survey consisting of 15 items was sent to 800 practicing trauma surgeons, pediatric surgeons, and pediatricians within a 100 km radius of Hamburg, Germany. The survey included questions about the respondents' professional experience and telemedicine experience, as well as inquiries about possible telemedicine collaborations. The response rate was 19.3%. Less than half of the participants already used telemedicine in daily practice. In general, 75% of respondents expressed an interest in collaborating with the inpatient sector. The most common reasons for hospital referral were the need for surgery, inadequate treatment of children in practice and co-assessment. The majority were in favor of flexible communication, either via video telephony, imaging applications like or messaging applications. The study revealed a high level of interest in telemedicine collaboration. Information exchange should be tailored to individual needs, with practitioners requiring a versatile and personalized approach that includes imaging. Strict enforcement of data protection regulations is essential. Further research is needed to evaluate the effectiveness of telemedicine collaboration in the treatment of pediatric trauma in both hospital and outpatient settings.

FP1.3 - SPEC MDT in Aneurin Bevan University Health Board

Abstract Aims The SPEC (significant polyp and early cancer) multi-disciplinary team (MDT) meeting was started in ABUHB in 2022 to discuss complex colonic and rectal polyp cases, such as polyps >20mm, likely to be sessile, or difficult to remove endoscopically. The aim was to evaluate the effectiveness and clinical role of the SPEC MDT. Methods Data for patients discussed in SPEC MDT since its conception in January 2022 until September 2023 was retrospectively collected from the SPEC MDT database, a prospectively collected database. This included patient demographics, reason for referral, polyp characteristics and MDT outcomes. Results In 21 months, there have been 38 SPEC MDTs, with 355 cases discussed (average of 9 cases per MDT). There was at least one laparoscopic colorectal surgeon, gastroenterologist and a histopathologist in every MDT in accordance with BSG guidelines. Main referral reasons included endoscopy findings (72%) and re-discussion post-procedure (22%). Twenty-three patients had adenocarcinomas and three had NETs. MDT outcomes were EMR (23%), endoscopic surveillance (21%), clinic to discuss (no) surgery (19%), TAMIS (16%), urgent endoscopy (13%) or other (8%). Conclusion As the busiest Health Board in Wales for Colorectal Cancers, the formation of SPEC MDT has been an important step in improving the detection and treatment of advanced polyps and early cancers. Although too early to measure the impact on early cancer detection rates and improved decision making for these patients, formalising the MDT process in line with BSG guidelines has been an important step in improving the service offered to patients.

Evaluation of the Veterans Health Administration's Digital Divide Consult for Tablet Distribution and Telehealth Adoption: Cohort Study.

Video telehealth offers a mechanism to help Veterans Health Administration (VHA) patients overcome health care access barriers; however, many veterans lack a suitable device and sufficient internet connectivity. To address disparities in technology access, VHA established a Connected Device Program that offers veterans loaned video-capable tablets and internet service. In 2020, VHA introduced a national Digital Divide Consult to facilitate and standardize referrals for this resource. We sought to evaluate the reach and impact of VHA's Connected Device Program, leveraging Digital Divide Consult data to determine whether resources are supporting veterans with health care needs and access barriers. We examined the reach of VHA's Connected Device Program using national secondary data from VHA's electronic health records among 119,926 tablet recipients who received a tablet (April 1, 2020, to February 28, 2023) and 683,219 veterans from the general VHA population. We assessed changes in tablet recipients' demographic and clinical characteristics before and after implementation of the Digital Divide Consult compared with the general VHA population. We examined the impact of tablets and the consult on adoption of telehealth (ie, video visit use and number of visits) adjusting for differences between tablet recipients and the general VHA population. Finally, we evaluated consult implementation by assessing the use of video-based services by tablet referral reason. Common reasons for tablet referral included mental health diagnoses (50,367/79,230, 63.9%), distance from a VHA facility >30 miles (17,228/79,230, 21.7%), and social isolation (16,161/79,230, 20.4%). Moreover, 63.0% (49,925/79,230) of individuals who received a tablet after implementation of the Digital Divide Consult had a video visit in the first 6 months of tablet receipt. Some consult reasons were associated with a higher-than-average percentage of video telehealth use, including enrollment in evidence-based mental health programs (74.8% [830/1100] with video use), living >30 miles from a VHA facility (68.3% [10,557/17,228] with video use), and having a mental health diagnosis (68.1% [34,301/50,367] with video use). Tablet recipients had nearly 3 times the likelihood of having a video visit within a month once provided a tablet compared to the general VHA population, with an adjusted risk ratio of 2.95 (95% CI 2.91-2.99) before consult implementation and 2.73 (95% CI 2.70-2.76) after consult implementation. Analyses of telehealth adoption suggested that veterans receiving tablets for mental health care and evidence-based programs have higher rates of video visits, while those who are homebound or receiving tablets for hospice have higher rates of nonuse. This evaluation of VHA's Connected Device Program suggests that tablets are facilitating video-based care among veterans with complex needs. Standardization of referrals through the Digital Divide Consult has created opportunities to identify groups of tablet recipients with lower telehealth adoption rates who might benefit from a targeted intervention.

An Overview of Avascular Necrosis of the Hip in Patients with Sickle Cell Disease

Abstract Background: Avascular necrosis (AVN) of the femoral head is a devastating complication of sickle cell disease characterised by hip pain and dysfunction. The prevalence of this condition in patients with sickle cell disease in Ghana is unknown. Objectives: This study aims to look at the demographics of sickle cell disease patients presenting with AVN, the pattern of the disease on presentation, and the severity of the disease. Materials and Methods: Data were collected from patients referred to the Orthopaedic clinic over three years. Data collection forms were created and filled out for all patients. Analysis was done with Microsoft Excel (Windows 10 version), and the ensuing data were represented with descriptive statistics such as proportions, ratios, percentages, tables, and histograms. Results: A total of 134 patients were seen over a 3-year study period. The vast majority, 109 (85.3%), were below 40 years of age. The sex distribution of the patients was predominantly female (78%). Genotype SS was in the majority (89), representing (66.4%). The majority of the patients, 104 (77.6%), were regular attendees of the Ghana Institute of Clinical Genetics or other specialised sickle cell disease clinics. The main reason for referral was on account of X-ray changes seen by the referring doctor (90, 67.1%). Unilateral disease was seen in 94 (70%) patients. Seventy (52.2%) presented with stage III disease, and 42 (31%) had symptoms for more than 2 years. Conclusions: Most of our patients were young, predominantly with genotype SS. They presented late with advanced disease stages and were referred to the orthopaedic clinic only after X-ray changes were seen.

Interdisciplinary Pain Board for Managing Patients with Palliative Care Needs and Substance Use Disorder: A Pilot Study.

Context: Patients with cancer-related pain and concurrent substance use disorder (SUD) present a unique set of challenges for palliative care clinicians. A structured forum for interdisciplinary collaboration is needed to effectively manage this complex population. Objectives: Describe the feasibility and acceptability of a palliative care Complex Pain Board (CPB), an interdisciplinary team meeting to provide concrete care recommendations for patients with cancer-related pain and concurrent SUD and/or psychosocial complexity. Methods: We conducted a retrospective analysis of cases presented at CPB between May 2021 and June 2022 and a cross-sectional analysis of CBP participant surveys. Results: Among 28 cases included for analysis, gastrointestinal cancers (n = 7, 25.9%) and multiple myeloma (n = 5, 18.5%) were the most frequent cancer diagnoses. Primary reasons for referral were SUD (n = 22, 78.6%) and provider/team distress (n = 13, 46.4%). The most frequent recommendations made at CBP were encouraging interdisciplinary collaboration (n = 18, 64.3%), maintaining healthy boundaries (n = 15, 53.6%), and SUD management (n = 13, 46.4%). Of 14 scheduled meetings, most meetings involved the presentation of ≥1 cases (n = 12, 86%). Among 40 CBP participant surveys, most attendees (n = 38, 95%) were likely or highly likely to continue to attend. Conclusion: CPB is a feasible and acceptable intervention that allows for palliative care clinicians to collaborate and receive interdisciplinary team feedback and peer support on the management of patients with cancer-related pain and concurrent SUD and/or psychosocial complexity in the ambulatory care setting. Key Message: A regular, interdisciplinary team meeting (CPB) is a feasible and acceptable intervention to help palliative care clinicians manage challenging cases involving patients with cancer and concurrent SUD and/or psychosocial complexity.

Experiences of podiatrists in the delivery of routine foot care with self-management

Objective: Explore the experiences of podiatrists in the provision of foot care and identify gaps in promoting self-care to their patients. Methods: This study adopted a qualitative research paradigm comprising semi-structured interviews with 16 podiatrists from diverse clinical settings and varying experiences from February to May 2023. The data was analyzed inductively to develop themes. Results: Four themes emerged from the data: 1) Provision of nail care service, 2) Perceived reasons for referral for podiatric nail care, 3) Self-management with various patient sub-groups, and 4) Effectiveness of self-management, all from our participants’ perspective. Podiatrists agree that pathological nails and high-risk feet warrant continual podiatry care. However, the majority are ambivalent about providing care for non-pathological nails due to fear, indifference, lack of social support, and physical limitations. Interviewees reported the importance of managing patients’ expectations of the role of podiatry in nail care from the first visit to avert potential over-reliance on the service. Clear explanations and equipping patients with the appropriate tools helped promote self-management. Conclusion: This paper examined the complexity of the demand for podiatry nail care services, focusing on podiatrists’ perspectives. It emphasized the importance of effective communication with patients to clarify the purpose of podiatry and to ensure sustainable podiatry care for the future. Level of evidence V; Therapeutic studies - investigating the results of treatment; Expert Opinion.

Diagnosis of tuberculosis infection in children with a novel skin test and the traditional tuberculin skin test: An observational study.

A novel skin test-called Diaskintest (DT)-containing specific M. tuberculosis antigens is in clinical use in the Russian Federation (RF). This test may improve diagnosis of tuberculosis (TB) infection. The use and performance of the DT was described and compared to the tuberculin skin test (TST). Data on children <18 years referred to a TB reference centre (Jan/2018- Dec/2019) with ≥1 DT and TST result available were analysed. An immune correlate of TB infection was defined as a positive TST (≥10 mm induration) or a positive DT (any induration). Of 2710 included cases, the median age was 9.0 (IQR 5.7-13.1) years and 97.5% were BCG immunised. Overall, 1976 (79.9%) were TB uninfected, 724 (26.7%) had an immune correlate of TB infection and 10 (0.4%) TB disease. Reasons for referral were: positive or increasing skin test results in routine screening (992, 36.6%), screening before admission to a health care institution (501, 18.5%) and TB contact (457, 16.9%). DT was positive in 11.7% (308/2625) and TST in 63.1% (467/740) (Kappa 0.08, 95% CI:0.013-0.14). A positive DT was associated with older age (OR 1.16 (95% CI: 1.13-1.19) per year). Among TB contacts DT positivity was associated with contagiousness: highest proportion of positivity of 12.0% was observed when the index case was smear positive. In a setting with universal BCG vaccination and regular screening with TST, DT was used to rule out TB infection as TST was commonly positive. We found an association of DT positivity and contagiousness of the index case in children contacts. These observations may suggest improved specificity and sensitivity of DT compared to TST.

Unveiling referral's impact on asphyxiated newborns: a cross-sectional study

Background: Birth asphyxia also known as perinatal asphyxia, refers to the lack of oxygen during the childbirth. The asphyxiated newborns require a comprehensive care and many special newborns care units have established in Gujarat for the sick newborns. This study mainly focuses on understanding the reasons for referral, the average travel time to tertiary care institutions, and identifying gaps to minimize unnecessary referrals among patients. Methods: The cross-sectional study was conducted over a period of one year, and out-born asphyxiated newborns were selected based on the inclusion criteria. A pretested, semi-structured questionnaire was used to collect the data, which was later analyzed using Microsoft excel and statistical package for the social sciences (SPSS) 26. Results: Out of the 131 newborns, 31% had moderate-severe asphyxia. Approximately 9% of the patients had to travel for more than 2hours to reach the final health facility. Among the patients, risk of mortality was significantly higher among the those who were referred from the private health facility. Lack of availability of bed, ventilator and economic burden were among the common reason for referral. Conclusions: There is a necessity to prevent unnecessary multiple and delayed referrals, and to provide essential care during transport to improve the outcomes.

TRANSITION TO THE SPECIAL NEEDS REPORT FOR CHILDREN (SNRC): AN ANALYSIS OF REFERRALS TO CHILD AND ADOLESCENT PSYCHIATRY OVER THE LAST THREE YEARS

Objective: Following the enactment of the Special Needs Report for Children (SNRC) regulation on February 20, 2019, several changes were made to the reporting system. The field of child psychiatry is among the leading specialties issuing SNRC reports. This study aimed to evaluate the psychiatric and other medical diagnoses of cases referred to pediatric and adolescent psychiatry for SNRC, determine their level of needs, and discuss the new regulation in the context of existing literature. Material and Methods: Demographic and clinical characteristics, as well as levels of needs and relevant areas, were retrospectively analyzed for cases aged 0-18 who presented to a university hospital's pediatric and adolescent psychiatry clinic between January 2021 and January 2024. Results: A total of 986 children and adolescents, comprising 331 (33.6%) females and 655 (66.4%) males, with a mean age of 10.27±3.77 years, were included in the study. The most common reason for SNRC referral in the 0-4 age group was speech delay (n=32, 45.1%) while learning difficulties were predominant in other age groups. Analysis of psychiatric diagnoses under SNRC revealed delayed milestone diagnosis as the most common at 45.7% (n=451), followed by specific learning disorder (n=312, 31.6%) and autism spectrum disorder (n=154, 15.6%). Non-psychiatric diagnoses showed that 28.8% (n=284) of cases had at least one accompanying medical disease, including cerebral palsy (n=65, 6.5%), sensorineural hearing loss (n=47, 4.8%), epilepsy (n=37, 3.8%), and Down syndrome (n=21, 2.1%). Additionally, 20% (n=198) of cases exhibited special needs in at least one non-psychiatric area, with motor development being the most common domain (n=125, 63.1%). Conclusion: These findings highlight the diversity of needs among children and adolescents receiving SNRC reports. Accurate evaluation and reporting of special needs in child and adolescent psychiatry are crucial for enhancing individuals' quality of life and providing necessary support.

Trends and Reasons of Referral of Benign Breast Disease Patients in a Tertiary Hospital in India

Trends and Reasons of Referral of Benign Breast Disease Patients in a Tertiary Hospital in India

Impact of 5 waves of COVID-19 on pediatric ophthalmology

ObjectiveTo characterize the impact of multiple waves of COVID-19 on pediatric ophthalmology at a tertiary care hospital. MethodsMedical records were reviewed from pediatric patients seen for ophthalmic emergencies at the Montreal Children's Hospital (Montreal, Canada) from 5 COVID-19 periods: March 13 to May 31, 2020; September 20, 2020, to February 21, 2021; March 21 to May 31, 2021; August 17 to November 5, 2021; and December 19, 2021, to January 25, 2022, as well as 2 pre-COVID time periods: March 13 to May 31, in 2018 and 2019). ResultsThere was a significant reduction in ophthalmic consultations when comparing pre-COVID to all 5 COVID waves (p < 0.0001). There was an increase in the average number of daily urgent (p = 0.01) ophthalmic consultations from waves 1 to 4. Mean household income of patients was not significantly different pre-COVID compared to during the 5 COVID waves (p = 0.96). The most common referral reason was ocular trauma (38.0% of cases). There was a non-significant trend demonstrating more infectious disease presentations during waves 3 to 5 (p = 0.07). There was no difference in symptom duration prior to presentation (p = 0.54); however, there was a difference in the time between emergency room and ophthalmology assessment in waves 3 and 4 compared with wave 5 (p = 0.003). ConclusionThe number of pediatric ophthalmology consultations was less during the 5 COVID waves than pre-COVID. An increase in urgent pediatric ophthalmology consultations occurred as COVID-19 infection rates in Quebec decreased. Access to health care and time to care were preserved across waves compared with pre-pandemic.

Home-video EEG monitoring in a pediatric setting

IntroductionPediatric video-EEG monitoring is a standard procedure in epilepsy clinics, typically conducted in in-hospital settings.However, hospitalizationis sometimesunnecessary and imposes a burden on children and their families. In response to the rise of telehealth, home video-EEG monitoring has emerged, utilizing portable EEG equipment and video-cameras. ObjectiveThe aim of this study was to assess the feasibility of home video-EEGin a pediatric population. MethodsWe conducteda prospective pilot study of twentyhome video-EEG tests in children. We evaluated the quality of EEG and video recordings using a 5-point scale.Demographic, clinical and quality data were comparedto a similar group undergoing in-hospital video-EEG monitoring. ResultsTwenty children aged 2.1–17.2 years (mean 9.57 ± 1.01), 12 females (60 %), underwent home video-EEG. A higher proportion of children with intellectual disability/autism were observed in the home-EEG group compared to the in-hospital group: 12 patients (60 %) vs. 5 (25 %) (p < 0.05*, Fisher exact test). In the ambulatory group patients with developmental and epileptic encephalopathy were overrepresented (7 i.e., 35 % vs. 0), while those withself-limited childhood epilepsy were more prevalent in the in-hospital group (5 i.e., 25 % vs 0) (p < 0.05*, Chi square). In the ambulatory group the reasons for referral were seizure localization/classification in 11 patients (55 %), paroxysmal event classification in 5 (25 %) and quantification of sleep epileptic activity in 4(20 %),similar to the in-hospital group (40 %, 40 % and 20 % respectively, p > 0.05, Chi square). The quality of the EEG recording was higher compared to in-hospital tests: median 5 [IQR 3.25–5] vs 4[IQR 3–4] (p < 0.05*, Mann-Whitney U test), while the quality of video recording was lower compared to in-hospital recordings: median 3[IQR 2.25–4] vs 5[IQR4-5] (p < 0.01**, Mann-Whitney U test). ConclusionsHome video-EEG monitoring is apromising option forlong-termpediatric EEG monitoring, particularlyfor children with special needs.

Normal Development of Tibiofemoral Angle in Healthy South-Eastern Nigerian Children: A Clinical Study on 3147 Children.

Angular deformities of the lower extremities are common in children and are a frequent reason for orthopaedic referral. These deformities, which are usually encountered when children start to walk are typically measured using the tibiofemoral angle (TFA), which represents the angle formed by the intersection of the anatomical axis of the femur with the anatomical axis of the tibia. This study aimed to determine the TFA in healthy South-Eastern Nigerian children, and to determine the effect of gender and age on this angle. This cross-sectional study was done in Enugu metropolis with 3147 school children and adolescents aged 3-17 years. It was found that the majority of the subjects (97.6%) had valgus TFA. The maximum knee valgus angle from the study was 6.8° ± 0.80° at 4 years. Thereafter, the knee valgus angle declined to a mean of 2° at 17 years. There were physiological changes in TFAs noted, which vary with regards to both age and gender of the subject.

Current Quality Level of Referral Letters and Feedback Reports in the First Health Cluster in Riyadh Health Cluster Primary Healthcare Centers

Background: Effective communication between primary healthcare centers (PHCCs) and referral hospitals is critical for ensuring the continuity and quality of patient care. Referral letters and feedback reports are essential for this communication, yet their quality is often inconsistent, potentially impacting patient outcomes. Study Aim: To assess the standard of feedback reports from referral hospitals and the quality of referral letters from PHCCs within the first health cluster in Riyadh. Methodology: This cross-sectional study randomly selected 360 referral letters and feedback reports from nine PHCCs in the first health cluster in Riyadh. Systematic sampling was employed to select approximately 55 documents from each center. Each document was evaluated based on 16 key components as per the Quality Assurance Manual of the Ministry of Health, using an author-developed scoring system. Results: The study included 360 referral letters and feedback reports, with an average quality score of 13.2 ± 1.5 out of 16. A majority of the documents (253, 70.3%) scored 13 or higher. Key components such as general information and patient file numbers were present in all documents (100%). Vital signs were documented in 351 cases (97.5%), and the reason for referral in 327 cases (90.8%). However, investigation results and current treatment details were included in only 142 (39.4%) and 150 (41.7%) of the documents, respectively. Clear handwriting was observed in 262 reports (72.8%), while 98 (27.2%) had legibility issues. Conclusion: The overall quality of referral letters and feedback reports in the first health cluster in Riyadh is relatively high. However, significant gaps were identified in the documentation of investigation results, current treatment details, and clinical examination findings. Addressing these gaps through targeted training, standardized documentation practices, and the adoption of electronic health records can enhance the quality of patient referrals and improve care continuity and outcomes.

Hospitalists' perception of their communication with primary care providers - survey results from six hospitals in Central Switzerland.

Due to the increasing complexity of the healthcare system, effective communication and data exchange between hospitalists (in-hospital physicians) and primary care physicians (PCPs) is both central and challenging. In Switzerland, little is known about hospitalists' perception of their communication with PCPs. The primary objective was to assess hospitalists' satisfaction with their communication with PCPs. Secondary objectives addressed all information about the referral process and communication with PCPs during and after the hospital encounter. Lastly, the results of a previous survey among PCPs were juxtaposed to compare their responses to similar questions. This study surveyed hospitalists in six hospitals in the Central Switzerland region. The survey was sent via email to hospitalists from November 2021 to February 2022. The questionnaire contained 17 questions with single- and multiple-choice answers and the option of free-text entry. Exploratory multivariable logistic regression was used to analyse independent associations. In total, 276 of 1134 hospitalists responded (response rate 24.3%): (1) the majority of hospitalists are satisfied with the general communication (n = 162, 58.7%) as well as with referral letters (n = 145, 52.5%), (2)preferred information channels for referral letters are email (n = 212, 76.8%) and electronic portals (n = 181, 65.5%), (3)the three most important items of information in referrals are: medication list, diagnoses and reason for referral. In multivariable regression, compared to other clinicians, internists independently favoured informing PCPs of emergency admissions of their patients in a timely manner (OR 2.04; 95%CI 1.21-3.49). Comparing responses from PCPs (n = 109), the most prominent discrepancy was that 67% (n = 184) of hospitalists claimed to "always" inform after an encounter, whereas only 7% (n = 8) of PCPs agreed. Most hospitalists are satisfied with the communication with PCPs and prefer electronic communication channels. Room for improvement was found around timely transmission of patient information before and after hospital encounters.

Pre-referral management of preeclampsia with severity features in a low-income country—characteristics and challenges in a Sub-Saharan setting: a mixed method study

Background: Preeclampsia continues to be a major cause of maternal and perinatal mortality and morbidity, globally. Although pre-referral treatment constitutes a bigger part of the management package for preeclampsia with severity features in low-income settings, little is known regarding the characteristics and challenges of preeclampsia pre-referral and referral management in the Sub-Saharan setting. ObjectiveTo determine the characteristics and challenges of pre-referral and referral management of preeclampsia with severity features Study design: We conducted a mixed method study on the pre-referral management of pregnant women who complicated by preeclampsia with severity features in Ethiopia. We prospectively collected data on clinical characteristics, management outcomes, and pre-referral characteristics of pregnant women who complicated by preeclampsia with severity features. Data were collected using a structured questionnaire. For the qualitative part of our study, we conducted 20-30 minutes, semi-structured, qualitative face-face in depth-interview with 14 health professionals. Quantitative data were analyzed using SPSS version 23 and simple descriptive statistics was employed. We used thematic analysis on Open Code 4.03 software to analyze the qualitative data. - ResultsA total of 261 pregnant women who had preeclampsia with severity features were included in the study and 14 care providers were interviewed on existing challenges with pre-referral management for patients with preeclampsia with severity features. The mean systolic and diastolic blood pressures were 154.3mmHg and 100.3mmHg, respectively. The total perinatal mortality was 6.5% (17/261). Three mothers (1.1%) complicated by intra-cranial hemorrhage and other three (1.1%) other women developed pulmonary edema. Out of 261 patients, only 41 patients (15.7%) received magnesium sulphate. Similarly, antihypertensive was given only to 35 patients constituting 13.4%. Eight mothers convulsed (3.1%) during referral. Two mothers (0.8%) developed pulmonary edema when they arrived at recipient health institutions after referral. Likewise, another two (0.8%) women developed disseminated intravascular coagulation (DIC) by the time of arrival from referring health institution. Up on qualitative data analysis, three overarching themes were recognized: (i) challenges related Patient and family resistance, (ii) Challenges related to healthcare providers’ knowledge, skill and confidence, and (iii) health system related challenges. Low utilization of magnesium sulphate and ant-hypertensive drugs, patient misperceptions regarding reasons for referral, providers lack of knowledge on the pre-referral management, inadequate communication between referring and recipient health institution, and non-existence of uniform pre-eclampsia pre-referral and referral management protocols among the referring institutions were the identified gaps. ConclusionWe found a significant gap in pre-referral management for patients with preeclampsia with severity features. Preeclampsia management policy reforms should include introduction of adequate patients counselling platforms, increasing community awareness creation, providing in-service training on pre-referral management of preeclampsia for health personnel, ensuring constant availability of anti-convulsant and antihypertensive drugs and uniform implementation of preeclampsia pre-referral management protocols across health institutions.

765 Enhancing the Quality of Referrals to Vascular Surgery at a District General Hospital: A Closed-Loop Quality Improvement Project

Abstract This quality improvement project aimed to improve the completeness of referrals to vascular surgery from in-patient wards and the Sameday Emergency Care unit at a UK district general hospital. We implemented a comprehensive vascular surgery proforma to enhance the quality of referrals to the department. Referrals made between 01/01/23 and 01/03/23 were assessed according to Professional Record Standards Body (PRSB) guidelines, which outlines the necessary information to be included in clinical referrals. The new proforma was introduced to all hospital clinicians, enabling them to email completed referrals to a dedicated vascular surgery inbox. To evaluate the impact of the new system, referrals were re-audited between 12/05/23 and 13/07/2023 using the same PRSB criteria. Significant improvements were observed in the completeness of referrals, as indicated by the percentage of fulfilled PRSB criteria: patient demographics (60% vs. 100%), referrer details (51% vs. 100%), reason for referral (93% vs. 100%), relevant clinical risk factors (60% vs. 95%), medication history (60% vs. 100%), family history (40% vs. 84%), social history (47% vs. 93%), patient ideas concerns and expectations (40% vs. 81%), examination findings (60% vs. 93%), and investigation findings (63% vs. 91%). The median number of fulfilled criteria per referral increased from 2.5 to 9 (out of 10), demonstrating a substantial improvement (p &amp;lt; 0.0001). Our dedicated vascular surgery referrals proforma had a significant positive impact on the completeness of referrals to the department. This change has the potential to enhance continuity of care, improve clinical prioritisation, promote patient safety, and enhance the overall efficiency of our service.

Referral Patterns to an Ophthalmic Outpatient Clinic in a Tertiary Eye Care Center in Iraq

Purpose: We aim to conduct a comprehensive review of outpatients at a tertiary ophthalmology clinic to evaluate various aspects including the spectrum of eye disorders, referral patterns, reasons for referral, and patient self-assessment, with a particular focus on self-referrals. Study Design: A cross-sectional study. Place and Duration of Study: Ibn Al-Haitham Teaching Eye Hospital from April to May, 2023. Methods: Referral letters were grouped into the primary health center (PHC), secondary hospital, internal referral and private clinic. Referral letter quality was assessed based on clinical information and particular request. Results: A total of 1367 individuals aged 40.8 ± 22.17 years were eligible for study. There were 19.2% referrals form PHC, 18.4% from secondary hospitals, 10.7% from private clinics, 3.3% were internal referrals, 37.2% were self-referred and 11.3% had medical or surgical follow-up. Blurred vision was the predominant complaint of 677 (51.6%) patients. Out of 659 referral letters, 25% scored two essential information items, 5.2% scored three, and only 0.8% scored four items. The majority (97.2%) of letters provided specific requests. Among all, 26.3% of PHC, 38.2% of hospitals, 34.9% of private clinics, 21.7% self-referred and 51.1% of internally referred patients considered their situations difficult. Conclusion: Majority of cases seen in ophthalmology tertiary centers consist of common conditions that could be effectively managed by PHCs and general hospitals. Improved referral standards for specialized medical institutions may reduce tertiary hospital over population.