General practitioners have a pivotal role in providing medical care for the NHS - acute referrals to various hospital specialties are often arranged by them. But inappropriate referrals can cause unnecessary inconvenience for the patients and affect the target times for care provision in A&E.
GPs have been the pillars for provision of medical care ever since systematic and institutionalised care came into existence. They form the basic link between the patients and the secondary and tertiary specialist units.
They often refer patients to the casualty department for acute orthopaedic illnesses. These referrals stretch the resources of the casualty department. Most hospitals ask GPs to refer patients directly to the orthopaedic senior house officer to avoid this. If used inappropriately, access to this facility may result in unnecessary referrals to the orthopaedic SHO. The orthopaedic SHO is expected to deal with GP referrals as promptly as possible by the casualty department. This situation frequently puts significant pressure on the orthopaedic SHO and may cause unnecessary inconvenience to the patients.
A prospective study of this area was carried out from August 2005 to January 2006 at the Royal Gwent Hospital, Newport. The study included all the patients referred from the GPs directly to the SHO or the registrars.
This purpose of our study was to identify patterns of referrals from GPs, the appropriateness of these referrals, the promptness of speciality response, waiting times of the referred patients, and overall outcomes for the referred patients.
On accepting referral, patients were asked to attend the emergency department and were registered as 'orthopaedics expected patients'. A detailed proforma was filled in for each GP-referred patient seen. In addition, patient case notes and the A&E database were used to gather information on the diagnosis, management and timing of various events during care.
Reasons behind delays for patients who had to wait in emergency for more than the 4 hour target times were determined. The proportion of the patients that needed to be admitted and those who were discharged with or without an out-patients appointment was also noted.
A total of 297 patients were referred to the on-call orthopaedic SHO by GPs over the six months. The average number of patients referred each day was 1.6 (range 0 to 7). Approximately 24 per cent of all patients were referred on Mondays, while only 6 per cent were referred to our specialty on the weekends.
The diagnosis made by GPs and the orthopaedic SHO or registrar matched in only 37 per cent of patients. A total of 38 patients or 12.7 per cent breached the 'four hour waiting targets', even when the patients were seen directly by orthopaedic SHOs. Out of these, 26 patients or 69 per cent waited too long because of non-availability of beds. Seven patients or 18 per cent waited too long while investigations were completed to allow a diagnosis. The target was breached in the remaining five cases, or 14 per cent, because the orthopaedic SHO was busy seeing other patients.
Eighty three percent of the patients required some investigations before a diagnosis could be arrived at. The commonest investigations were blood tests and x-rays. The mean time to obtain the results of those investigations in the emergency department for those patients was 67 minutes, with a range of 26 to 109 minutes.
Out of the 297 patients, 137 patients or 46 per cent were admitted for further investigations or management. One hundred and sixty or 54 per cent were well enough to be sent home safely.
The most common referrals were for septic arthritis - 63 patients - and back pain with cauda equina syndrome - 54 patients.
A total of 99 patients were referred for uncontrolled back pain. Fifty four out of 99 patients were perceived by the GP to have cauda equine syndrome. Of the 54 patients referred as suspected cauda equina compression, only 15 were significant enough to warrant an urgent review by the specialist registrar.
Upon clinical evaluation, specialist registrars ruled out the diagnosis of cauda equina in a further 11 patients. Eventually, four out of 54 patients were admitted for an urgent MRI scan, the results of which were not suggestive of cauda equina. A total of 52 patients out of 99 were admitted for control of back pain or further investigations, and the rest were discharged.
Sixty three patients were referred for septic arthritis of various joints. As a part of orthopaedic directorate protocol, all patients referred for this had blood investigations along with systematic clinical examination. Out of these, 16 patients required aspiration of the knee joint to facilitate the diagnosis. Only one required arthroscopic washout of his knee in theatre.
In their article General practice adrift, Nina Bojlen and Dorte Gannik showed that the general practitioner as a gatekeeper occupies a central and much needed role in health care. Increasing specialisation, consumerism and liberalisation threaten to eliminate the generalist role in healthcare, precisely at a time when it is most acutely needed.
In the era of target-driven healthcare and provision both in acute and outpatient setting, the appropriateness of referrals to specialties is of utmost importance. GP referrals to secondary care are key factors in the cost of running the NHS.
Our data suggests that most of the patients were dealt with expeditiously. The most important reason for delay in managing GP referrals was administrative problems like lack of beds and delay in obtaining results of the investigations. This is a clear reflection of the limited resources in the A&E department and the hospital in general.
There was a mismatch of diagnosis between the GP and junior orthopaedic doctors in a significant proportion of the cases. As a considerable number of patients required investigations, it would be worthwhile to give GPs urgent access to these so that the referrals could be more appropriate and precise. This would save resources for the hospital and prevent undue inconvenience to the patients.
The study shows that a junior doctor was able to make clear decisions about patient and felt confident to discharge 54 per cent of the patients back to the community. This was by simply adhering to the standard protocols for managing patients in casualty.
In other words, 160 referrals to the on-call SHO were completely unnecessary. These protocols could be distributed to the GP, which would help them formulate a management plan for the patient from the outset.
Pain management has a great impact on GP's day to day activities and on health economy in general. Studies have shown that many decisions on referrals are influenced more by the social context than information about the patient's condition. A major proportion of this constitutes back pain and related issues, many of which are referred as cauda equina syndrome.
In 2001, NICE formulated guidelines to encourage appropriate referrals from general to specialist services. NICE advises emergency referrals to be made only if the 'red flags' are present. A high index of suspicion is necessary to diagnose cauda equina, yet with appropriate training and systematic objective clinical examination, the rate of over-diagnosis amongst the GP fraternity could be brought down.
Establishment of rapid access back pain clinics would give a more acceptable option, both to the GPs and the patients. Studies have proved that urgent specialist referrals to outpatient clinics prevent several inappropriate hospital admissions. Further studies have shown direct access to physiotherapy by primary care providers is more cost effective than consultant access physiotherapy models.
Orthopaedic training often forms a relatively small part of the undergraduate and post graduate training for most GPs. Formal training in orthopaedics improves patient management in primary care and helps GPs to identify those patients who need to be referred for a specialist orthopaedic opinion.
Refresher courses for GPs have been proven in studies to alter the referring behaviour. In view of the changing investigations, treatment tools and hospital protocols, keeping abreast with the current best practice is of utmost importance to the doctors working in the community.
Ashish Khurana is a clinical research fellow in orthopaedics, Sujit Kadambande a specialist registrar in orthopaedics, and Rohit Kulkarni a consultant orthopaedic surgeon at Royal Gwent Hospital,