The Otolaryngology, Head and Neck (ENT) Surgery Department is frequently one of the busier outpatient departments in any hospital, receiving between 9% and 20% of all referrals from primary care providers (1). In Australia there is one ENT surgeon per 47,800 inhabitants (529 ENT surgeons and 25,287,400 Australian residents) (2,3). This is in stark contrast to some European countries where there is one surgeon for every 10,000–14,000 inhabitants (Greece and Austria respectively) (4,5). It is therefore not surprising that the waiting time for an ENT outpatient appointment can be up to 12 months for non-urgent cases. Long waiting lists require additional administrative support and more concerning is the potential increased morbidity and mortality of cancer presentations associated with prolonged waiting times for an outpatient appointment (6-9).
General practitioner referral letters are invariably the only source of information available when outpatient referrals are triaged. Referrals with limited information can lead to the incorrect categorization of referrals which in turn can result in clinically inappropriate delays in the investigation and management of patients with serious pathology. Conversely non-urgent cases can occupy appointment slots that may have been of more benefit to a patient requiring an urgent review. Categorisation of referral letters is therefore an important phase of treatment, as it provides both the patient and the treating clinicians the reassurance of the condition being managed in a timely manner. In Queensland, Australia, Category 1 referrals requires the patient to be seen within 30 days of receiving the referral; Category 2 within 90 days; and Category 3 within 365 days. Currently, the ENT Department at the Ipswich Hospital (Queensland, Australia) is compliant with the requirements, and have been reviewing patients in a timely manner in accordance to their triage categories.
Effective communication between the primary care provider and the ENT Surgeon is therefore vitally important to ensure that the unfavourable effects of extensive waiting lists are negated. To improve the overall quality of general practitioner (GP) referral letters, several authors in the past have recommended the use of pro forma letters to ensure that all relevant information is included in the referral (7,10-12).
In Queensland, Australia, all hospital health districts provide guidelines, outlining the requirements for adequate referral letters (refer to Boxes 1,2). Although there are no standardized referral letters currently available in Australia, all GPs have access to pro forma letters that helps to automatically complete the details listed in Box 1, saving time for clinicians.
The aim of this study was to ascertain the quality of referrals received by the Otolaryngology, Head and Neck Surgery Department at the Ipswich Hospital (Queensland, Australia), and to consider whether the introduction of Clinical Prioritization Criteria (CPC) are truly warranted.
Each month, the Ipswich Hospital Otolaryngology, Head and Neck Surgery Department receives approximately 300 referrals from general practitioners and other medical specialists. Of the 300 referrals received in July 2018, 122 referrals were randomly selected and compared against the Ipswich Hospital referral guidelines (as listed in Boxes 1 and 2).
Referrals included in the study were limited to those received from general practitioners only. All specialist and in-hospital referrals were excluded.
The Ipswich Hospital referral requirements were divided into four separate sections: patient demographics (maximum 8 points), referring practitioner details (maximum 6 points), relevant clinical information (maximum 11 points), and condition-specific information (maximum 7 points). Each referral letter was critically assessed against their corresponding condition-specific requirements. A point was only awarded if sufficient information surrounding the criterion was provided. The maximum possible score was 32 points. The resulting score was deemed a reflection of the comprehensiveness and quality of the referral.
The referrals were received in a variety of formats: hand written, typed, and completed GP pro forma letters. Of the 122 referrals analysed, 47 were for paediatric patients and 75 for adult patients (Table 1).
The overall amount of information included within the referral letters did not compare favorably to the published standard, resulting in a mean score of 21.4 out of 32 points (66.8%) (Table 1). Both paediatric and adult referrals were of similar standards, scoring 21.7 (67.8%) and 21.2 (66.2%) points respectively (Table 1).
When considering the four sections of the referral, the referrer’s details scored the highest, with a mean of 5.5 out of a maximum of 6 points (91.7%) (Table 2).
The clinical history and condition-specific sections had low scores of 50.9% and 60% respectively (Table 2). Physical examination findings were only recorded in 40% of referrals.
The referrals were further analysed according to their specific condition. The following conditions scored the highest number of points in the specific-conditions category: otitis media with effusion (88.6%), otitis externa (87.7%), and paediatric hearing loss (85.7%) (Table 3). The following conditions all scored lower than 50% in their corresponding specific-conditions category: adult obstructive sleep apnoea (14.3%), dysphonia (40%), vertigo (40%), paediatric allergic rhinitis (42.8%), adult tympanic membrane perforation (42.8%), and paediatric epistaxis (42.8%) (Table 3).
Reassuringly, when comparing the referrals with respect to their urgency, Category 1 referrals had a higher compliance rate than Category 2 and 3 (Table 4).
Comprehensive referral letters, containing adequate relevant information, have a significant impact on specialists’ ability to accurately triage referrals (1,13). Conversely, withholding essential information in referrals increases the risk of harm to high-risk patients by potentially delaying investigation and definitive management (1,14).
Overall, there was relative paucity of information within the referrals received from general practitioners, with the mean score of 21 out of 32 (66%) when compared against the list of Ipswich Hospital requirements. It is not surprising that the section that scored highest was the general practitioner’s details (92%), as most referrals are pro formas, automatically populating the details of the general practitioner and clinic (i.e., GP name, address, telephone and fax numbers, and medical provider number).
A concerning finding was that the two lower scoring sections were: clinical history (51%) and condition-specific information (60%), which typically hold the highest yield of information when grading a referral.
The poor quality of referral information in these two sections could be the result from a combination of the time constraints, and the complexity of the referral system to name but a few.
The Clinical Prioritisation Criteria (CPC) are a set of statewide guidelines for referring practitioners, published by the Queensland Government in August 2018. It details the specific information required to be included in each referral. This was established to ensure that referrals to public specialist outpatient services are assessed according to clinical urgency. These statewide guidelines can be found on each hospital’s website for referring clinicians to review when creating a referral. The aim of these guidelines is to improve the referral and communication process between referrers and specialist outpatient services. Along with this initiative, incoming referrals are now overseen by a triage nurse who can request more information if a referral does not meet the guideline standards.
The results of this study indicate that the referral pathways in place at the time of the study required significant improvement in order to safely and accurately triage outpatient appointments. Therefore, the newly introduced CPC guidelines are welcomed and hopefully will result in more accurate triaging of referrals. We intend to evaluate the true impact of the CPC initiative by repeating the audit process in the coming months when the guidelines are well established.
A limitation of this study is the small sample size of 122 referrals, as this only represents approximately half of the referrals the Otolaryngology Department receives on a monthly basis.
It is well recognized that an inadequate referral letter can in turn result in inappropriate triaging, extended waiting times and potentially increased morbidity and even mortality rates. This study demonstrates that the key areas of improvement are the inclusion of examination findings, clinical history and condition-specific information. The implementation of a strict minimum referral criteria (through the CPC guidelines) and enabling nurses to request additional information from referring practitioners, aims to improve the overall quality of referrals received. If this system is effective it will ultimately result in more accurate triaging, improved patient care and safer outpatient services.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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Cite this article as: Sen Goh RW, Styan LE, Bond CA, Oosthuizen JC. General practitioner referral audit: are the new Clinical Prioritisation Criteria required? Aust J Otolaryngol 2019;2:29.