Referral Protocols Research Articles

Analysis of referrals after a synergic work between primary care and urology. Impact of joint protocol implementation and a continuing education program in our healthcare area

ObjectiveTo analyse the evolution and adequacy of referrals from primary care to urology, after the implementation of referral protocols on the most frequent urological diseases and the establishment of a continuing education program. Material and methodsA primary care-urology work group was created in 2011. Initially, performance and clinical practice protocols in prostatic pathology (BPH and PSA) were established. These were supported by training sessions for primary care physicians.After analysing the effect of the mentioned joint work, 3 more protocols (scrotal pathology, urinary tract infections and urinary incontinence) were included. We analysed and compared the referrals and their adequacy before and after the establishment of the protocols. ResultsThe most common referral causes were symptoms of the lower urinary tract due to BPH, which initially represented 22.8% of the total, and decreased to 16.9%. After the introduction of the new algorithms, we observed a decrease in referrals for scrotal pathology (13–14% to 7.8%), an increase in urinary incontinence referrals (3–10.3%) and those related to urinary tract infections remained stable. The adequacy to the protocols improved progressively: LUTS from 46% to 65.3%; PSA from 55% to 84.4% and urinary incontinence from 66.2% to 73.1%.Adequacy in scrotal pathology decreased (67.1% to 63.3%), while in UTI it stayed much the same (around 76%). ConclusionsThe joint work between Urology and Primary Care achieves an improvement in referrals adequacy regarding the most frequent urological pathologies.

Fertility preservation from the point of view of hematopoietic cell transplant specialists-a worldwide-web-based survey analysis.

With the increase in cancer survival, men and women have a chance to conceive children post-recovery. This study aims to better understand hematopoietic cell transplant (HCT) specialist practices and opinions related to fertility preservation for hematological malignancy patients. Survey requests were emailed to 586 European Society for Blood and Marrow Transplantation (EBMT) members. Respondents completed the mostly multiple-choice questionnaire on the IVF-Worldwide.com website. Results were reported as a percentage of respondents. Responses were submitted by 150 HCT specialists from 41 (of 195) countries worldwide. The survey showed that most HCT specialists (87%) are aware of and inform patients that chemotherapy, radiotherapy, and transplantation could harm fertility. Specialists referred 56% of their male patients to fertility preservation but only 36% of their female patients; many pre-pubertal or near post-menopausal patients were not referred. This indicates that barriers may be preventing specialists from referring patients for fertility preservation. Many HCT specialists do not know about or use international fertility preservation recommendations, indicating that new protocols for enhancing awareness are needed. Establishing a referral process protocol to reproductive specialists should be considered. When non-urgent treatment can be deferred for 10-20 days, patients can have a sufficient window to undergo certain fertility preservation procedures.

What Motivates Healthcare Professionals’ Referrals to Chaplains, and How to Help Them Formulate Referrals that Accurately Reflect Patients’ Spiritual Needs?

As many hospitals lack standardized referral protocols for spiritual care, healthcare professionals’ perceptions and preferences play an important role in their decisions to refer patients to chaplains. To better understand what motivates these professionals to refer patients and how they approach spiritual care, this article examines referral requests from twelve healthcare professionals to a chaplain at the Lausanne University Hospital Department of Physical and Rehabilitation Medicine. Comparative discourse analysis highlights that requests are largely driven by difficulties in patient-professional relationships. Yet, further interviews reveal that healthcare professionals construct spiritual care as a way to access patients’ sense of identity and explore the meaning they give to their lives and experiences, for the benefit of both patients and professionals. The discussion considers how chaplains could help healthcare colleagues formulate referrals that accurately reflect patients’ spiritual needs, thus improving the relevance and quality of spiritual care.

Considering patient safety in autonomous e-mental health systems \u2013 detecting risk situations and referring patients back to human care

BackgroundDigital health interventions can fill gaps in mental healthcare provision. However, autonomous e-mental health (AEMH) systems also present challenges for effective risk management. To balance autonomy and safety, AEMH systems need to detect risk situations and act on these appropriately. One option is sending automatic alerts to carers, but such ‘auto-referral’ could lead to missed cases or false alerts. Requiring users to actively self-refer offers an alternative, but this can also be risky as it relies on their motivation to do so.This study set out with two objectives. Firstly, to develop guidelines for risk detection and auto-referral systems. Secondly, to understand how persuasive techniques, mediated by a virtual agent, can facilitate self-referral.MethodsIn a formative phase, interviews with experts, alongside a literature review, were used to develop a risk detection protocol. Two referral protocols were developed – one involving auto-referral, the other motivating users to self-refer. This latter was tested via crowd-sourcing (n = 160). Participants were asked to imagine they had sleeping problems with differing severity and user stance on seeking help. They then chatted with a virtual agent, who either directly facilitated referral, tried to persuade the user, or accepted that they did not want help. After the conversation, participants rated their intention to self-refer, to chat with the agent again, and their feeling of being heard by the agent.ResultsWhether the virtual agent facilitated, persuaded or accepted, influenced all of these measures. Users who were initially negative or doubtful about self-referral could be persuaded. For users who were initially positive about seeking human care, this persuasion did not affect their intentions, indicating that a simply facilitating referral without persuasion was sufficient.ConclusionThis paper presents a protocol that elucidates the steps and decisions involved in risk detection, something that is relevant for all types of AEMH systems. In the case of self-referral, our study shows that a virtual agent can increase users’ intention to self-refer. Moreover, the strategy of the agent influenced the intentions of the user afterwards. This highlights the importance of a personalised approach to promote the user’s access to appropriate care.

Assessment of maternal referral systems used for a rural Zambian hospital: the development of setting specific protocols for the identification of complications.

In resource-limited countries, it is estimated that up to 75% of maternal deaths are preventable. Maternal referral systems are an effective measure to help prevent these deaths. The objective of this study was to delineate criteria that health care workers use to identify obstetrical emergencies and make referrals, in order to evaluate the effectiveness of the established referral system and to implement improvements to this system. Using a qualitative study design, the individuals with the highest level of formal obstetrics training at 10 health posts that refer to a rural Zambian hospital were surveyed using semi-structured interviews regarding their referral protocols. Data were analyzed through open-coding. At the conclusion of the interview, standardized referral protocols for obstetric emergencies derived from published guidelines and local practices were distributed. Identified complications resulting in referral most commonly included post-partum hemorrhage (70%), prolonged labor (70%), malpresentation (50%), antepartum hemorrhage (40%), and retained placenta (40%). While numerous reasons for referral were identified, there was little consensus on the referral protocol used for each complication. Obstacles to successful referral most commonly included cellular network disruptions (70%), distance (50%), and lack of transportation (30%).The referral protocols distributed to health posts covered only 11 of the 23 complications cited as the most common reason for referral. The referral criteria and protocols were updated to include all of the reported complications. We propose this document for others working in resource-limited settings attempting to establish or evaluate a maternal referral systems.

Evolución de las derivaciones desde Atención Primaria a Urología tras la creación de un grupo de trabajo y la instauración de protocolos y cursos de formación continuada

ObjectiveTo analyse the evolution and adequacy of referrals from Primary Care to Urology, after the implementation of referral protocols on the most frequent urological diseases and the establishment of a continuing education program. Material and methodsA Primary Care-Urology work group was created in 2011. Initially, performance and clinical practice protocols in prostatic pathology (BPH and PSA) were established. These were supported by training sessions for primary care physicians.After analysing the effect of the mentioned joint work, 3more (scrotal pathology, urinary tract infections and urinary incontinence) were included. We analysed and compared the referrals and their adequacy before and after the establishment of the protocols. ResultsThe most common referral causes were symptoms of the lower urinary tract due to BPH, which initially represented 22.8% of the total, and decreased to 16.9%. After the introduction of the new algorithms, we observed a decrease in referrals for scrotal pathology (13-14% to 7.8%), an increase in urinary incontinence referrals (3% al 10.3%) and those related to urinary tract infections remained stable. The adequacy to the protocols improved progressively: LUTS from 46% to 65.3%; PSA from 55% to 84.4% and urinary incontinence from 66.2% to 73.1%.Adequacy in scrotal pathology decreased (de 67.1% a 63.3%), while in UTI it stayed much the same (around 76%). ConclusionsThe joint work between Urology and Primary Care achieves an improvement in referrals adequacy regarding the most frequent urological pathologies.

An Ophthalmic Changes in Patients with Chronic Obstructive Pulmonary Disease: Case-Control Study

Purpose: To evaluate the prevalence of ophthalmological changes in patients with Chronic Obstructive Pulmonary Disease (COPD) cared for at the Pneumology and Ophthalmology Departments at Medical School Unifacisa-Campina Grande-Paraiba-Brazil.Materials and Methods: Twenty-two smoker patients with COPD (study group) and 22 healthy controls that underwent routine ophthalmological examination (control group) were enrolled in the investigation. They were homogeneous regarding age, gender, presence of Systemic Arterial Hypertension (SAH) and Diabetes Mellitus (DM). They were examined for the presence of cataract and Age Related Macular Disease (AMD).Results: The prevalence of ophthalmologic changes was significantly different in the two groups. Eight (36.4%)patients presented with cataract requiring surgical intervention, while one (4.5%) person in the control group had cataract (p = 0.0212). Regarding AMD, 10 (45.5%) smoker COPD patients had this disease, whereas in the control group, one (4.5%) person had this disease (p = 0.0039).Conclusion: From the results one can conclude that there is strong association between smokers diagnosed with COPD with cataract and AMD patients, reinforcing the need for a protocol for referral of these patients to the ophthalmologist.

Bottleneck Analysis to Reduce Primary Care to Specialty Care Referral Delay

Reducing delays between primary care and specialty care visits is critical to improving continuity of ambulatory care delivery. To comply with referral protocols, personnel involved in patients’ care pathways process and record pertinent information to ensure appropriate care is rendered, and missing necessary information might cause “dropping of the baton” during the patient transition. The objective of this paper is to analyze the information flow along patients’ primary care to specialty care referral pathway, and identify system bottlenecks to enhance the workflow design and workforce configuration. A semi-Markov process is introduced to describe information transition and the operations of involved personnel are modeled as capacity-constrained service queues at every stage of referral pathway. Analytical formulas are derived to evaluate the overall referral delay, and a continuous improvement method is developed to identify the most critical factor that impedes the referral process. The proposed systems approach is applied to the clinics of a large academic medical center, and the analysis stresses the importance of building a health information system that supports breaking silos and adapting providers’ workflows to the information system to facilitate smart and connected care delivery. Note to Practitioners —The ambulatory care delivery system is plagued by delays that dissatisfy patients, physicians, and other medical staff, and adversely affect patient outcomes. While many extant industrial engineering/operations research (IE/OR) articles focus on reducing physician appointment delays or waiting times during visits to a medical office, this paper seeks to address the lag between primary care visits and specialty care visits, i.e., the waiting for access to specialty care once the primary care physician has decided to refer the patient. This paper establishes a novel analytical framework to model primary care to specialty care referral processes with an emphasis on the information transition along patient pathway. The rigorous analytical model unveils the insights that might not be easily identified using qualitative approaches, and enjoys higher computational efficiency compared to simulation methods. What emerges from the study is the need to integrate health information technology into medical personnel’s workflow and redesign the process to allow effective communication, which will lead to improved care, efficiency, and satisfaction.

Pre-Natal Monitoring in the Primary Attention of the Brazilian Unified Health System

Objective: To analyze prenatal care in the primary care of the Brazilian Unified Health System. Material and Methods: This is a survey cross sectional research with inquiry-type quantitative-qualitative approach. Data collection was performed in 28 cities of the Sao Paulo state, through on- site observations and interviews with health secretaries, coordinators of primary and oral health care. The following variables were analyzed: Primary health care services for pregnant woman as educational activities, presence of care and referral protocol and the organization of oral health care. Content analysis was performed for the answers of the open questions and the quantitative treatment of the discursive data was obtained through the categorial analysis. For the answers of the closed questions a descriptive analysis was performed. Results: The total number of participants interviewed was 84 managers. It was observed that 78.6 %% of cities carried out educational activities; 42.9% do not have an active care protocol and 57.1% do not have formal referral guidelines to high-risk pregnancies. The rapid tests for HIV, Syphilis, Hepatitis B and C were confirmed by 53.6% of managers and only 39.3% reported evaluating the vaccine situation. As to dental care, 71.4% of the municipalities do not have an established guideline; 46.4% reported that access occurs through spontaneous demand; 32.1% do not consider pregnant woman a priority care group and 67.9% have instituted prenatal dental care. Conclusion: Prenatal care has guaranteed educational activities, but it has deficiencies related to the work process and to the management of services, due, for the most part, to the inexistence of assistance and organizational protocols.

Analysis of the referral system to the public endodontics service in a city within the metropolitan area of Belo Horizonte, Minas Gerais, Brazil

ABSTRACT Objective: Health services evaluation uses both general service monitoring indicators and evaluation research, with the aims of studying service performance and its enhancement through problem solving. This study aimed at analyzing the referral system between primary health care and the secondary level care in endodontics of the Dental Specialties Center in the city of Contagem, Minas Gerais, to seek enhancement of the existing referral protocol. Methods: Secondary data were collected from the municipal data systems as well as from services files, regarding all patients who were attended between 2009 and 2014. Results: Mean time between first appointment and treatment conclusion was 3.12 months. There was higher frequency of individuals from the administrative regions of cities with higher populations and more availability of primary health care units. Similar proportions of single and non-single rooted teeth were treated. High proportions of teeth reached the endodontics service of Dental Specialties Center without possible treatment. Conclusion: Data were generated to provide renovation of the service referral protocol.

Reasons for obstetric referrals from community facilities to a tertiary obstetric facility: A study from Southern Karnataka.

Context:Pregnancy-related preventable morbidity and mortality remain high in India. Safe delivery services should focus on improving neonatal and maternal outcomes while also enabling a positive childbirth experience. However, high rates of intrapartum obstetric referrals are common.Objective:To describe the timing and the reasons for obstetric referrals to a public tertiary care hospital in Bangalore and characteristics of the referring facilities.Methods:We interviewed 320 women who delivered at the tertiary care hospital within a one-month time frame prior to the interview and who originally planned to deliver elsewhere.Results:Ninety four percent of women in the study reported that the decision to transfer to the tertiary hospital was made after the onset of labour. Referrals were made for medical as well as non-medical reasons. About a third (35%) had to take loans to cover the expenses of childbirth.Conclusions:Referrals frequently occurred after the onset of labour. Our data imply that improving obstetric referral protocols will improve the birth experience and reduce the burden on tertiary care facilities and on the women themselves.

Cancer Cases Referral system in Nepal.

The burden of cancer is estimated to be increasing in Nepal, whilst the country lacks national established guidelines or protocols for referral of cancer cases. Cancer patients are presenting many different health facilities throughout the country. In rural areas almost all cancer patients have their first diagnosis when visiting a health assistant or nurse at their nearest primary health care delivery service. If cancer is suspected, health care assistants or nurses will refer the patient to a medical doctor at the primary health centre, or refer the patient directly to the cancer treatment centre or oncology department of the closest hospital. Patients from urban areas will usually be seen for the first time by a medical doctor initially and then referred to either the cancer treatment centre or oncology department of the hospital. Both in rural and urban areas the referral for treatment is determined by both the patients’ capacity to pay for treatment own healthcare, as well as their geographical location (i.e. availability and accessibility of cancer treatment services.

Recursos asistenciales en atención primaria para manejo del asma: proyecto Asmabarómetro

ObjectiveThe objective of this study was to describe the current provision of basic resources for asthma management in Primary Health Care (PHC). DesignCross-sectional study, with an ad hoc quantitative survey. Location and participantsA total of 380 primary healthcare physicians in Spain. Interventions and main measurementsAnalysis of perceptions of management and use of basic human, organisational and material resources to ensure appropriate care provision to asthma patients. ResultsSurvey respondents stated that their centre did not have a consultant doctor (64%) or nurse (62%) in respiratory disease. Almost all (92%) of the centres have spirometers, of which 70% have peak flow meters, and 93% have placebo inhalers. In the last year, respondents have received specific theoretical/practical training from the centre (46%), and by third parties (83%). More than three-quarters (78%) of the centres has educational material available for patients. There is no specific healthcare protocol in 36% of the centres, and 43% had no referral protocol. A clinical interview is conducted to monitor the patient (90%), but there are no validated questionnaires to measure therapeutic adherence (85%), or a checklist to check inhalation technique (83%). Differences are observed in the relevant variables in the analysis of each Spanish Autonomous Community. ConclusionsAccess to certain resources in the care of patients with asthma is limited in aspects of coordination between levels, varied according to Spanish Autonomous Community, and improved in most health resources in Asthma.

An Electronic Referral and Social Work Protocol to Improve Access to Mental Health Services.

The prevalence of mental health problems among adolescents in the United States is a major public health concern. However, the uptake of mental health treatment is low. Integrating behavioral health into primary care is 1 research-informed strategy to increase engagement in treatment. Facilitators of and barriers to implementation of integrated behavioral health in a pediatric primary care setting are not well delineated. We examined the effectiveness of 2 mental health quality improvement strategies: an electronic referral and a social work follow-up protocol. We analyzed the following measures: uptake rate of first mental health appointments, overall use of mental health appointments, and first and overall mental health appointment show rate. Overall use rate improved after implementation of electronic referral, with 13 consecutive points above the median. First appointment show rates improved with a special cause run occurring after adding social work students to the mental health quality improvement team. First appointment show rate improved from a monthly average of 51% (November 2014 to March 2016) to 78% (April 2016 to December 2016). Use rate improved initially with increased efforts in assisting patients with scheduling; show rate improved more slowly after an emphasis on scheduling patients exhibiting treatment readiness. Findings suggest that a number of facilitators can increase the effective use of mental health services in an integrated adolescent clinical setting. These include an electronic referral through a shared electronic health record, multidisciplinary collaboration, and care management by social workers equipped with a variety of clinical and care coordination skills.

“Ehalati”: Evaluation of the Referral System in Primary Health Care Centres in Saudi Arabia

Introduction: The burden of diseases has changed in recent years, and chronic Non-Communicable Diseases NCD have become an emerging pandemic in Saudi Arabia. At the same time, healthcare provision is shifting from free services provided directly by the state to a privatised model of healthcare delivery. An effective referral system is fundamental to manage the potential fragmentation of privatisation, and provide the integrated care needed to meet the NCD challenge. This paper evaluates the current “Ehalati” referral system; “Ehalati” is an Arabic word means “my referral”. It examines the experiences of physicians working within this referral system, from the assessment to the monitoring of referred patients. It pays particular attention to the referral processes for patients with chronic NCD in Primary Health Centres [PHCs]. Method: Semi-structured face-to-face interviews were conducted in 15 PHCs of the Ministry of Health MOH in Riyadh city, Saudi Arabia. Nineteen physicians from these PHCs were interviewed using questions drawn from the Referral System Assessment and Monitoring RSAM evaluation tool. All interviews were audio-recorded and transcribed verbatim. Results: The current referral system falls well short of ideal integrated care. Physicians reported that the feedback procedure was almost non-existent. Although referral protocols and guidelines existed, these were not available in all PHCs. The system relies on accurate knowledge of the referral network, but directories of hospitals in the network were not available in all PHCs. When we asked physicians “how do you know the type of services provided in a hospital,” their response was clearly “don’t know.” There is consistency between the referral information reported in the referral letters in all PHCs. Some physicians were unhappy about the patients’ role in the referral letter that is generated only “Upon Patient’s Request.” Data of the referrals were collected and analysed in most PHCs. Most of these analyses were sent to MOH’s “Ehalati” management. Some physicians reported that these analyses should be shared with and among physicians. There was no standard satisfaction measurement for referred patients. It found that uneven availability of training of physicians. Training for physicians on the referral guideline and system was not available for all of them. Most physicians reported that the current referral system and appointment time management limits the choices of referrals. Physicians cannot track or monitor their patients, and they do not know if patients completed the referral unless patients tell them verbally. Discussion: Physicians complained about not receiving feedback from hospitals, this aligns with previous studies that reported low feedback rate with poor quality 1. Conclusion: Improvement to the referral system is needed, particularly appointment time management, provision of up to date directory of hospitals, training to the physicians from primary care and an improved increased awareness of the significance of feedback from hospitals. Lessons learned: Involvement of patients in the evaluation of the referral system is essential. Limitations: Study was conducted only in one city and findings may not be applicable to other cities. Suggestion for future research: Future research should be focusing on feedback procedures from hospitals to PHCs.

What are the patterns of compliance with Early Warning Track and Trigger Tools: A narrative review

BackgroundEarly Warning Scores were introduced into acute hospitals in 2000. 99% of acute hospitals employ a EWS to monitor deteriorating patients with 97.9% of these linked to a referral protocol. Despite this high level of adoption, there has been little improvement in the recognition and response to deteriorating patients over the last decade. ObjectiveTo explore the patterns of compliance with Early Warning Track and Trigger Tools. DesignA narrative review. Data sourcesElectronic databases (Medline, CIHAHL, EmBase, the Cochrane library, the Centre for Reviews and Dissemination (CRD) and PROSPERO) were searched from 1 January 2000 to 5 July 2018. Titles, abstracts and full text papers were screened (two independent reviewers) against inclusion criteria and seven papers were included in the review. Data were extracted by one reviewer and checked by a second reviewer using a bespoke data collection sheet. Review methodsAll papers were quantitative in design but demonstrated clinical and methodological heterogeneity therefore a meta-analysis was not possible. A qualitative approach was undertaken to synthesise findings using a framework analysis and narrative synthesis. Themes were identified, named, defined and reported according to outcome measure. Results7/27 papers representing over 3000 patients and 963,000 data points were included in the analysis. Reported studies were conducted in the United Kingdom (n = 4), Denmark (n = 2) and Amsterdam (n = 1). Three key themes were identified, early warning score calculation accuracy, monitoring frequency and clinical response. This review identifies poor compliance with the Early Warning Score (EWS) protocol in all three themes. There is significant scoring inaccuracy with omitted EWS, missing elements of the EWS and incorrectly calculated EWS. Adherence to monitoring frequency is poor with a higher EWS being associated with reduced compliance with the escalation protocol. There is inadequate compliance with the escalation element of the EWS protocol with concerning extended delays to clinical review. There is evidence of worsening clinical response with increasing EWS. Although significant improvement is demonstrated in clinical response with the use of electronic EWS protocols, non-compliance still occurs at all EWS stages. ConclusionCompliance with EWS is poor but the cause is unidentified. Outcomes can only improve if staff complete the EWS fully, calculate the score accurately, monitor according to protocol and escalate according to clinical response. Social, environmental and professional behaviours that affect effective use of track and trigger tools should be explored to improve our understanding of suboptimal management of the deteriorating patient.

Gaps in the Substance Use Disorder Treatment Referral Process: Provider Perceptions.

The demand for substance use disorder treatment is increasing, fueled by the opioid epidemic and the Affordable Care Act mandate to treat substance use disorders. The increased demand for treatment, however, is not being met by a corresponding increase in access to or availability of treatment. This report focuses specifically on the treatment referral process, which we have identified as 1 of the key barriers to timely and effective treatment. Difficulties in referral to substance use disorder treatment are examined through the lens of providers who make referrals (ie, referral source) and individuals who work in substance use disorder facilities (ie, referral recipient). Administrative officials, emergency department physicians, addiction physicians, government officials, providers, insurance officials, and mental health advocates (n = 59) were interviewed on the referral process protocol, challenges for providers and others making referrals, and issues with substance use treatment facility intake procedures. Several main themes were identified as barriers in the process: difficulties in determining patient eligibility, lack of transparency regarding treatment capacity, referral source knowledge/understanding of options, and issues with communication between referral source and recipient. We then proposed several solutions to address specific barriers. Current gaps in the referral process cause delays to care. Improving systems would involve addressing these themes and expanding the use of appropriate treatments for the many patients in need.

Development of a pharmacy referral protocol to enhance interprofessional services in a university-affiliated dental medicine clinic

ObjectiveTo discuss the process of developing pharmacy consult services within a university-affiliated dental clinic. Secondary objectives are to describe the frequency of pharmacy consults provided when comparing the initial to the modified protocol and interventions, over time. SettingA university-affiliated student–driven dental medicine clinic in the Midwest. Practice descriptionThe dental clinic consists of third- and fourth-year dental students who provide dental services and are supervised by dental faculty. Pharmacy consults are prompted due to patient criteria met on the protocol, patient-specific factors, drug information, or other reasons. Pharmacists are present to provide consults directly with dental students or patients. Practice innovationSince October 2013, pharmacy services have been implemented into a dental clinic. A protocol is established to identify dental patients with high risk medications and medical conditions that may interfere with dental treatment. The initial protocol has been modified to include additional high-risk medications and conditions that the pharmacy team was being consulted for outside the protocol criteria. EvaluationA retrospective chart review was completed to evaluate the frequency of use of the original pharmacy protocol and the interventions provided. After the protocol was modified to include additional high-risk criteria, a second chart review was completed to assess changes in frequency of protocol use and interventions provided. ResultsPharmacists undergo extensive self-learning to understand the dental-related concerns of the high-risk criteria as well as the dental workflow. The original pharmacy protocol accounted for 42.3% (n = 113) of the overall pharmacy consults (n = 267). After protocol modifications, utilization increased to 76.4% (n = 352, total n = 461). ConclusionPharmacists are successfully integrated into a dental medicine clinic to provide services to enhance dental patient care. The approximate 30% increase in the use of the pharmacy consult protocol demonstrated that the modified version was more effective.

Evaluation of referrals for short stature: A retrospective chart review.

Referrals to paediatric endocrine clinics for short stature are common. Height velocity (HV) is an essential component of the evaluation of short stature as growth deceleration often reflects an underlying paediatric endocrine diagnosis (PED). Access to previous measurements facilitates prompt calculation of HV. To determine the availability of previous measurements at time of referral for short stature and to determine predictors of a PED. A retrospective chart review was performed on all referrals for short stature to a single paediatric endocrinologist between January 2008 and December 2014. Standard practice following receipt of a referral for short stature included repeated requests to the referring physician for previous measurements. A total of 324 charts of patients aged 11 months to 18 years were reviewed and 286 were eligible for inclusion. Previous measurements were available in 72.4%, and 44.8% of these were found to have a PED. There was a significant relation between HV<25th percentile and a PED (P<0.0001) and between height deficit (HD) and a PED (P<0.0001). Logistic regression analysis showed that a HV<25th percentile and a HD>2 standard deviations, increased the odds of PED by a factor of 5.12 (P<0.001) and 1.39 (P<0.005), respectively. HV is a significant predictor of a PED. Our higher rate of previous measurement availability is likely due to our effective referral screening protocol. The availability of these measurements, which are essential for HV calculation, are likely to reduce delays in diagnosis and management.

Managing aesthetic referrals in NHS Scotland: Outcomes from 1122 patients in the East of Scotland

The Adult Exceptional Aesthetic Referral Protocol (AEARP) encompasses a series of aesthetic procedures which, as they do not treat an underlying disease process, are not routinely available within the National Health Service. Provision of these services can only be provided on an exceptional basis.In this prospective study, we evaluated the referral process and outcomes of 1122 patients referred under the AEARP over a 3.5-year period. Referrals were screened by a vetting panel comprising of a plastic surgeon, clinical nurse specialist, and clinical psychologist. Following initial vetting, supported patients underwent psychological assessment. Patients supported by psychology were assessed in clinic, and if deemed clinically suitable, were offered surgery.Overall, 20% (225/1122) of referrals were supported for surgery. Following primary vetting, 57% (640/1,122) of referrals were supported, 40% (197/492) of referrals to clinical psychology were supported, and 65% (225/345) of the remaining cases referred for consultation were supported for surgery. Unsupported referrals included those not fulfilling the referral guidelines or those with contraindications.The AEARP is simple and effective to implement, and has been instrumental in streamlining the referral-to-outcome process in a centralised, transparent, and fair manner. It reduces a potential high number of clinic appointments where patients do not meet the aesthetic criteria and/or fail to attend – thereby helping to streamline other surgical pathways by improving clinic efficiency. Moreover, it aids referring clinicians and patient education around aesthetic issues including a holistic approach. Wide adoption of such standards may reduce waiting times, facilitate cost savings, and ultimately enhance patient outcomes.