Electronic referrals to Endourology MDT: A Quality Improvement Project
BAUS ePoster online library. Bradley C. 11/10/20; 304273; PCU-5 Disclosure(s): nil
Caroline Bradley
Caroline Bradley
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Electronic referrals to Endourology MDT: A Quality Improvement Project
Bradley C 1, Kerr L 2, Jones G 1
1 Glasgow Royal Infirmary, United Kingdom
2 Queen Elizabeth University Hospital, Glasgow

Introduction
Urolithiasis is a common presentation to urology, with a prevalence of 1-20% depending on geographical location, and is noted to be increasing over recent years (1).
Approximately 100 referrals, not including primary care referrals are received by this tertiary endourology centre monthly, and there is no standardised referral pathway. Referrals can vary from email, fax, letters and copies of immediate discharge letters, and telephone discussions, with varying amounts of clinical information and necessary investigations being performed prior to referrals.
Due to this variability in referrals, there is limited clinical information and incomplete investigations which prolongs the patients management pathway, and prolongs time spent by senior clinicians needing to vet the referrals and gather information about the case prior to discussion at MDT. In some cases, delays to initial management plans occur due to outstanding investigations which should have been undertaken by the referrer needing to be arranged prior to MDT discussion.
Standardisation of referrals is key to improving the quality of referrals, however attempts locally have previously have included distributing a document/guide to endourology MDT referrals which outlined the necessary tests and information to be included in referrals, but there was no significant improvement.
There is a limited amount of published literature surrounding the use of electronic referrals, particularly in urology. A study conducted in London to introduce a new electronic system for all inpatient referrals in urology highlighted the potential improvement in services, as well as quantifying the workload burden of urolithiasis, which made up the largest proportion of referrals (Batura, 2016). A further study found that less than half of urology inpatient referrals resulted in intervention, and less then half were followed up in the community, again suggesting that a more structure electronic referral system may be of benefit in optimising referrals (Sullivan, 2013).
In other specialities, studies have shown that electronic referral process can increase the volume of referrals to a service, which can be of benefit in services which are underutilised (Pirruccello, 2017, Doumouras, 2017), and have shown standardised referral proformas or checklists can aid referrals, and reduce time spent by clinicians collecting further information (Eskeland, 2018). A pilot study in ophthalmology in Fife, Scotland suggested the setting up of electronic referral processes was 'feasible, fast, safe, and obviated the need for outpatient appointments in 128 (37%) patients with a high patient satisfaction' (Khan, 2015).
Aims
This project aims to improve the quality and content of referrals to endourology by introducing a standardised electronic referral system.
The electronic form requires specific patient data and investigations prior to submission, in order to improve the quality of referrals
In doing so, this project aims to improve efficiency of endourology services overall by reducing the need for investigations that should have been performed prior to referral, reducing the time spent by senior clinicals (registrars or consultants) vetting referrals and gathering information for discussion at MDT.
Measures & Changes
The referral quality was measured by its completeness, specifically by the inclusion of the relevant information as decided by the endourology team in order to aid decision making and management planning in patient care.
The data points required/requested in the referral form included:
1. Information about the patients presentation
Presenting with pain, presenting with infection, date of CTKUB, XR KUB, urine culture, isotope renogram, for active treatment or follow up, is this the first episode, has the patient been stented
2. Patient information
Previous cardio/respiratory history, hypertension, diabetes, recent GA, pacemaker or defibrillator in place, anticoagulant or antiplatelet agents, any other comorbidities
Methods
In consultation with hospital IT services, and the endourology clinical team, an electronic referral form was designed, with specific patient information required prior to submission. The form was advertised and promoted at hospital induction in order to inform clinicians of the new referral process for stone disease.
Additionally, the urology middle grades and registrars were given information regarding this in order to be able to submit forms for patients they had reviewed, and advise clinicians who we were referring to submit the form for follow up.
The electronic referral pathway to the endourology MDT was implemented in August 2019, information was provided at hospital inductions. Referrals were reviewed for June and September 2019.
Several data points including CT KUB, xray and patient history were identified, and the referrals analysed for completeness.

Results
There was a significant improvement in the quality and completeness of the referrals, with an increase from 34.37% complete, to 93.92% complete, from June to September.
Figure 1 shows the individual results for each of the data points and the comparison between June and September.

Action & Re-assessment
Analysis and comparison between referrals received before and after the introduction of the system showed an improvement. The improvement in information allowed referrals to be vetted in advance of MDT, allowing more time for discussion of complex cases. This provides a more efficient and safer patient journey.
The process has highlighted further refinement required including the need to include specific blood tests (stone screen) into the referral for, and to further advertise the process to educate clinicians about the referral process.
Summary
This quality improvement project illustrates the benefits to the introduction of a standardised referral pathway to the endourology MDT, and has become a permanent fixture in the service in this area.
Locally the project has been successful, and given this, it is likely this process could be applied elsewhere to standardise referrals and improve patient care.
Going forward, it has highlighted further refinement of the process such as the need to include specific blood tests into the referral form to further improve the service.

References:Batura, D. Hashemzehi, T. Lee, T. Mahbubani, K. Ally, M. Figaszewska, MJ. Kavia, R. 2016. Beneath the tip of the iceberg: using electronic referrals to map the unquantified burden of clinical activity in a urology service. International Urology and Nephrology. 48(11), p 1751-1755.
Doumouras, AG. Anvari, S. Breau, R. Anvari, M. Hong, D. Gmora, S. 2017. The effect of an online referral system on referrals to bariatric surgery. Surgical Endoscopy. 31, p 5127-5134.
Eskeland, SL. Rueegg, CS. Brunborg, C. Aabakken, L. de Lange, T. 2018. Electronic checklists improve referral letters in gastroenterology: a randomized vignette survey. International Journal for Quality in Health Care. 1;30(6), p 450-456.
Khan, AA. Mustafa, MZ. Sanders, R. 2015. Improving patient access to prevent sight loss: ophthalmic electronic referrals and communication (Scotland). Public Health. 129(2), p 117-123.
Pirruccello, JP. Traynor, KC. Natarajan, P. Brown, C. Hidrue, MK. Rosenfield, KA. Kathiresan S. Wasfy JH. 2017. An electronic cardiac rehabilitation referral system increases cardiac rehabilitation referrals. Coronary Artery Disease. 28(4), p 342-345.
Sullivan, JF. Forde, JC. Creagh, TA. Donovan, MG. Eng, MP. Hickey, DP. Mohan, P. Power, RE. Smyth, GP. Little, DM. 2013. A review of inpatient urology consultations in an Irish tertiary referral centre. Surgeon. 11(6), p 300-303
Electronic referrals to Endourology MDT: A Quality Improvement Project
Bradley C 1, Kerr L 2, Jones G 1
1 Glasgow Royal Infirmary, United Kingdom
2 Queen Elizabeth University Hospital, Glasgow

Introduction
Urolithiasis is a common presentation to urology, with a prevalence of 1-20% depending on geographical location, and is noted to be increasing over recent years (1).
Approximately 100 referrals, not including primary care referrals are received by this tertiary endourology centre monthly, and there is no standardised referral pathway. Referrals can vary from email, fax, letters and copies of immediate discharge letters, and telephone discussions, with varying amounts of clinical information and necessary investigations being performed prior to referrals.
Due to this variability in referrals, there is limited clinical information and incomplete investigations which prolongs the patients management pathway, and prolongs time spent by senior clinicians needing to vet the referrals and gather information about the case prior to discussion at MDT. In some cases, delays to initial management plans occur due to outstanding investigations which should have been undertaken by the referrer needing to be arranged prior to MDT discussion.
Standardisation of referrals is key to improving the quality of referrals, however attempts locally have previously have included distributing a document/guide to endourology MDT referrals which outlined the necessary tests and information to be included in referrals, but there was no significant improvement.
There is a limited amount of published literature surrounding the use of electronic referrals, particularly in urology. A study conducted in London to introduce a new electronic system for all inpatient referrals in urology highlighted the potential improvement in services, as well as quantifying the workload burden of urolithiasis, which made up the largest proportion of referrals (Batura, 2016). A further study found that less than half of urology inpatient referrals resulted in intervention, and less then half were followed up in the community, again suggesting that a more structure electronic referral system may be of benefit in optimising referrals (Sullivan, 2013).
In other specialities, studies have shown that electronic referral process can increase the volume of referrals to a service, which can be of benefit in services which are underutilised (Pirruccello, 2017, Doumouras, 2017), and have shown standardised referral proformas or checklists can aid referrals, and reduce time spent by clinicians collecting further information (Eskeland, 2018). A pilot study in ophthalmology in Fife, Scotland suggested the setting up of electronic referral processes was 'feasible, fast, safe, and obviated the need for outpatient appointments in 128 (37%) patients with a high patient satisfaction' (Khan, 2015).
Aims
This project aims to improve the quality and content of referrals to endourology by introducing a standardised electronic referral system.
The electronic form requires specific patient data and investigations prior to submission, in order to improve the quality of referrals
In doing so, this project aims to improve efficiency of endourology services overall by reducing the need for investigations that should have been performed prior to referral, reducing the time spent by senior clinicals (registrars or consultants) vetting referrals and gathering information for discussion at MDT.
Measures & Changes
The referral quality was measured by its completeness, specifically by the inclusion of the relevant information as decided by the endourology team in order to aid decision making and management planning in patient care.
The data points required/requested in the referral form included:
1. Information about the patients presentation
Presenting with pain, presenting with infection, date of CTKUB, XR KUB, urine culture, isotope renogram, for active treatment or follow up, is this the first episode, has the patient been stented
2. Patient information
Previous cardio/respiratory history, hypertension, diabetes, recent GA, pacemaker or defibrillator in place, anticoagulant or antiplatelet agents, any other comorbidities
Methods
In consultation with hospital IT services, and the endourology clinical team, an electronic referral form was designed, with specific patient information required prior to submission. The form was advertised and promoted at hospital induction in order to inform clinicians of the new referral process for stone disease.
Additionally, the urology middle grades and registrars were given information regarding this in order to be able to submit forms for patients they had reviewed, and advise clinicians who we were referring to submit the form for follow up.
The electronic referral pathway to the endourology MDT was implemented in August 2019, information was provided at hospital inductions. Referrals were reviewed for June and September 2019.
Several data points including CT KUB, xray and patient history were identified, and the referrals analysed for completeness.

Results
There was a significant improvement in the quality and completeness of the referrals, with an increase from 34.37% complete, to 93.92% complete, from June to September.
Figure 1 shows the individual results for each of the data points and the comparison between June and September.

Action & Re-assessment
Analysis and comparison between referrals received before and after the introduction of the system showed an improvement. The improvement in information allowed referrals to be vetted in advance of MDT, allowing more time for discussion of complex cases. This provides a more efficient and safer patient journey.
The process has highlighted further refinement required including the need to include specific blood tests (stone screen) into the referral for, and to further advertise the process to educate clinicians about the referral process.
Summary
This quality improvement project illustrates the benefits to the introduction of a standardised referral pathway to the endourology MDT, and has become a permanent fixture in the service in this area.
Locally the project has been successful, and given this, it is likely this process could be applied elsewhere to standardise referrals and improve patient care.
Going forward, it has highlighted further refinement of the process such as the need to include specific blood tests into the referral form to further improve the service.

References:Batura, D. Hashemzehi, T. Lee, T. Mahbubani, K. Ally, M. Figaszewska, MJ. Kavia, R. 2016. Beneath the tip of the iceberg: using electronic referrals to map the unquantified burden of clinical activity in a urology service. International Urology and Nephrology. 48(11), p 1751-1755.
Doumouras, AG. Anvari, S. Breau, R. Anvari, M. Hong, D. Gmora, S. 2017. The effect of an online referral system on referrals to bariatric surgery. Surgical Endoscopy. 31, p 5127-5134.
Eskeland, SL. Rueegg, CS. Brunborg, C. Aabakken, L. de Lange, T. 2018. Electronic checklists improve referral letters in gastroenterology: a randomized vignette survey. International Journal for Quality in Health Care. 1;30(6), p 450-456.
Khan, AA. Mustafa, MZ. Sanders, R. 2015. Improving patient access to prevent sight loss: ophthalmic electronic referrals and communication (Scotland). Public Health. 129(2), p 117-123.
Pirruccello, JP. Traynor, KC. Natarajan, P. Brown, C. Hidrue, MK. Rosenfield, KA. Kathiresan S. Wasfy JH. 2017. An electronic cardiac rehabilitation referral system increases cardiac rehabilitation referrals. Coronary Artery Disease. 28(4), p 342-345.
Sullivan, JF. Forde, JC. Creagh, TA. Donovan, MG. Eng, MP. Hickey, DP. Mohan, P. Power, RE. Smyth, GP. Little, DM. 2013. A review of inpatient urology consultations in an Irish tertiary referral centre. Surgeon. 11(6), p 300-303
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