Abstract
Background The COVID-19 pandemic called for significant
restructuring of healthcare system in the United Kingdom to overcome the
burden on emergency services and restore elective activities. This study
aims to discuss the development of a new triage system of reviewing
gynaecology e-referrals to secondary care and analyse the sustainability
of this service beyond the pandemic. The streamlining of primary care
referrals was conceptualised on the framework of Clinical Assessment
Service (CAS) as recommended by NHS Long-Term Plan.
Method CAS was implemented in our gynaecology department as a
response to COVID-19 pandemic. E-referrals triaged using CAS in phase 1
were reviewed and areas of improvement identified. A second review was
carried out in phase 2 after implementing changes to ensure improved
services. The outcomes of interest were appropriateness of referrals,
destination appointments and percentage of virtual appointments.
Results 185 e-referrals in phase 1 and 85 e-referrals in phase
2 were analysed. Training and education of relevant stakeholders and a
more efficient CAS in phase 2 resulted in significant reduction in
inappropriate referrals from 14% to 3% [RR-0.17 (95% CI -
0.04-0.72); p=0.02]. For every 9 e-referral reviewed in CAS, 1
inappropriate referral was avoided. The number of virtual appointments
increased by 16% (45% in Group 1, 61% in Group 2).
Conclusion CAS framework provides a sustainable strategy to
overcome disruptions in the provision of elective outpatient services
caused by COVID-19 pandemic. It reduces inappropriate secondary care
e-referrals, allows management of eligible patients digitally, shortens
patient care pathway and creates a dynamic link between the primary care
providers and specialist care.
Keywords Continuous quality improvement, COVID-19, General
Practice, Healthcare quality improvement, Women’s Health
Introduction
The COVID-19 pandemic has created unprecedented changes in the delivery
of gynaecological services in the United Kingdom leading to a
cancellation of outpatient and theatre appointments. Elective
gynaecological work had to be cancelled to enable capacity for sick
patients of COVID-19.1 During initial phases of the
pandemic, intensive care units, emergency departments, and medical wards
ran the risk of being overwhelmed by COVID-19 patients and much of the
disaster planning involved addressing overcrowded urgent care facilities
and decompressing these locations.2 This has led to
significant waiting lists and frustration for patients as well as
clinicians involved in elective activity. As we moved into the next
phase of the pandemic, rapid implementation of restoration and recovery
strategies to restart elective gynaecological work became a clinical
priority. Looking beyond the immediate challenge of restoring services
due to disruption in patient care as a result of the pandemic, the
learning achieved from this experience offered a unique opportunity to
focus on the required changes in healthcare structure in order to create
a better and fairer health organisation in the long term. The challenge
was to grasp this opportunity while restoring services to achieve both
recovery and renewal as the pandemic continued to plague the nation.
The approach to renewal was built on the direction set out in
the
National Health Service (NHS) Long-Term Plan.3The NHS Long-Term Plan, also known as the NHS 10-Year Plan, published
by NHS England on 7
January 2019 set out priorities for healthcare over the next 10 years
and showed how the NHS funding settlement could be
used.3 The five major changes proposed by the document
included boosting ‘out of hospital’ care, reducing pressure on emergency
services, creating a more digitally enabled outpatient care, promoting
personal health and improving population health.3 The
Clinical Assessment Service (CAS) is part of the service model
conceptualised by digital NHS to streamline and triage primary care
referrals to the most appropriate onward care
pathway.4 It is an intermediate service that allows
for greater level of clinical expertise in assessing and investigating
patients than would normally be expected of the referring clinician. It
would ensure the most cost-effective commissioning as patients are seen
in the right place at the first attempt, hence reducing cancellations
and rejected referrals.4
The objective of this single-institutional study was to analyse the
implementation of a new triage system of reviewing gynaecological
referrals for secondary care. We identified the structural and logistic
challenges to a new service, implemented recommendations and issued
action plans to reduce the number of hospital attendances without
compromising patient care.
Methods
The manuscript was written in accordance with SQUIRE
guidelines.5
The study was conducted in two phases:
Phase 1 discussed the conceptualisation of CAS framework. A
retrospective analysis of e-referrals in the first eight CAS clinics
conducted biweekly was performed. Areas of improvement were identified
from this pilot project and action plans implemented using a
Plan-Do-Study-Act approach.6 CAS framework was
implemented in our unit to expand access to secondary care during the
restoration phase of the COVID-19 pandemic. Prompt development of the
CAS protocol was proposed at the end of March 2020 during the first
lockdown. The protocol was established in May 2020. All gynaecology
e-referrals between 1 February 2020 and 30 April 2020 were reviewed in
the CAS clinic starting 20 May 2020. The results of Phase 1 were
reviewed and audited to assess the newly developed service and areas of
improvement identified.
Phase 2 involved collection of a second round of data between 12 August
2020 and 20 September 2020 to assess the same metrics as the phase 1
study, with a view to assess the change in practice by comparing the two
cohorts.
Development of CAS team
The hospital booking team received e-referrals from Primary Care
Physicians (PCP), either a General Practitioner (GP) or Advanced
Healthcare Professionals (AHP). A team was nominated to review and
triage these e-referrals. Two week wait referrals, early pregnancy
problems, and unscheduled consultations between primary care and on-call
gynaecology team were excluded from the CAS review. The team included
senior clinicians who could provide expert opinions and engage the right
stakeholders in order to ensure implementation of a change of practice
that was essential to transform elective care services in the COVID-19
context. The staff involved in streamlining the e-referrals included a
GP with special interest in Gynaecology, Clinical Director of
Gynaecology, a senior consultant gynaecologist, administrative staff
from outpatient services.
Multidisciplinary triage of e-referrals enabled team members to gain
insight into challenges and issues in primary and secondary care
domains, identify learning themes based on referrals patterns, and focus
on areas where it became apparent that there was a knowledge gap.
Overall, this enabled collaborative working pattern between primary and
secondary care clinicians and help bridge the gap between the two. The
administrative staff played a vital role in putting together CAS clinic
templates and ensuring all the information required was available to the
clinical team on electronic patient record (Cerner Millenium,
UKTM). The team met virtually on Microsoft
TeamsTM twice a week with appropriate IT support and
access to audio-visual equipment. 20-25 e-referrals were analysed in
each CAS clinic that ran for 120-150 minutes. On an average, 5-10
minutes were spent on each e-referral.
Development and Implementation of the Triage Process
Following early implementation of CAS framework, a CAS proforma was
created to capture the CAS clinical review outcomes in a uniform and
consistent manner for all patients. The proforma covered the following
aspects – indication of the e-referral, urgency of referral,
investigations required before first appointment in secondary care,
acceptance or rejection of the referral and the onward care pathway(Online supplementary material 1) . Figure 1 shows the
onward care pathway from the time the e-referral was generated. Patients
were routinely informed of the CAS process which improved patient
satisfaction and added multidisciplinary value to the clinical care they
received.
Phases of the project
Phase 1
A data collection tool was created to record details of the source of
referrals, CAS outcomes, appropriateness of referrals, destination
appointments, and proportion of virtual appointments (Online
supplementary material 2) . Analysis of data from the CAS clinics
between 20 May 2020 and 26 June 2020 was performed. Data was extracted
retrospectively from electronic patient records. A validated data input
spreadsheet (Microsoft Excel®, Microsoft Corporation,
USATM) was created for the collection of anonymised
data. The results from the first phase were presented in the gynaecology
Clinical Governance Meeting (CGM). The action plan from the project was
disseminated across primary and secondary care, with a tight schedule
for implementation of change, with a quick turnaround time. The action
plan included education and design of treatment pathways for common
gynaecological presentations, increasing uptake of advice and guidance,
educating the PCPs on the information to be included in referrals
letters and giving positive feedback on the receipt of good quality
referrals. In addition, the action plan also included training other
clinicians to perform CAS triages and virtual clinics to increase
throughput.
Phase 2
CAS clinic framework was subsequently restructured and training was
provided to more staff members in the department to conduct the reviews.
Data collection and analysis for Phase 2 was performed using the same
parameters and Excel spreadsheet. Analysis of CAS clinic outcomes
between 12 August and 20 September 2020 was performed and presented at
the gynaecology CGM. Phase 2 results were compared with those of phase
1.
Statistical Analysis
Statistical analysis was performed using SPSS (V25) (IBM Corporation)
and the magnitude of experimental effect calculated using chi square
test for significance and relative risk with confidence intervals set to
95% to reflect a significance level of 0.05.7 Data
was represented using descriptive statistics and results expressed in
absolute numbers and percentages. Tables, clustered bar chart and
stacked column charts were used when appropriate for a diagrammatic
representation of data.
Results
Data from 185 e-referrals was analysed in the first phase (Group 1) and
85 e-referrals were analysed in the second phase (Group 2). The number
of e-referrals was higher in Group 1 as the CAS clinic reviewed all
pending e-referrals from the preceding months that were deferred due to
clinic cancellations as a result of the Covid-19 pandemic and lockdown.
Source of e-referrals
Majority of the e-referrals were from General Practitioners [Group 1 -
139/185 (75%); Group 2 -76/85 (89%)]. The remaining were from
Advanced Nurse Practitioners [Group 1 - 42/185 (23%); Group 2 - 8/85
(10%)], Advanced Pharmacist Practitioners [Group 1 - 4/185 (2%);
Group 2 -1/85 (1%)] from the community who had privileges to request
secondary care referrals.
Referral indications
Referral indications for patients in Group 1 and 2 are enumerated inTable 1 . Reasons for referral encompassed a wide range of
conditions. However some of these referrals were made mainly to seek
advice for diagnostic and therapeutic interventions that would be
feasible in primary care. Some examples include advice around the
initiation, continuation, discontinuation or change of medication,
guidance on whether to perform radiological investigations and the need
for further diagnostic tests.
Appropriateness of e-referrals
76% (140/185) of e-referrals in Group 1 and 89% (76/85) in Group 2
were deemed appropriate for secondary care (Table 2) . Among the
rejected referrals, common themes were menstrual disorders and pelvic
pain that could be managed in primary care. These e-referrals were
rejected with advice on investigations or treatment that could be
initiated in primary care and secondary care referral to be considered
if they failed.
Implementation of CAS was found to reduce the inappropriateness of
e-referrals significantly from 14% in Group 1 to 3% in Group 2
[RR-0.17 (95% CI - 0.04-0.72); p=0.02]. For every 9 patients
reviewed in CAS clinic, 1 patient was found to have a reduced risk of
rejection due to an inappropriate e-referral.
Destination appointments following CAS review
Destination appointments for each accepted e-referral was organised
immediately after review in CAS clinic and the appointments were sent
out to patients. (Table 3) . Majority of the appointments were
for review in the General Gynaecology Clinic [71/140 (51%) in Group
1; 46/76 (61%) in Group 2]. The proportion of virtual appointments
was calculated after excluding referrals to hysteroscopy, colposcopy and
urogynaecology clinics that were arranged as face-to-face.
Implementation of action plan after phase 1 and training of other
clinicians was found to reduce face-to-face contact by 16% [55
%(39/71) in Group 1; 39%(18/46) in Group 2) (Figure 2) .
Discussion
This study establishes the advantages of the CAS framework. It is a
useful tool with joint ownership between primary and secondary care
clinicians, and helps to reduce inappropriate referrals, through triage
and enhances patient care. Our study showed that sharing mutually
beneficial learning themes from CAS clinics reduced inappropriate
e-referrals significantly from 14% to 3% [RR-0.17 (95% CI -
0.04-0.72); P=0.02] and for every 9 patients discussed in CAS clinics,
1 inappropriate e-referral was avoided. This has a positive impact on
healthcare through efficient utilisation of resources to deliver
patient-centred care from the outset in a multidisciplinary environment.
It would be reasonable to assume that minimising the duration of
patients’ journey by avoiding unnecessary clinical consults and
investigations would reduce the cost of secondary services provided to
patients. Experience gathered from this study also confirms that CAS
promises to enhance the quality of patient care by providing them with a
comprehensive assessment, diagnosis, and treatment in primary care and
ensures they are referred for secondary care only when there is a
definite need for hospital-based specialist services. It also provides a
means to give feedback to GPs and AHPs by educating them about
appropriate indications for referral for specialist advice, thereby
reducing inappropriate e-referrals to secondary care.
CAS was envisaged to be a collaboration initiative with joint primary
and secondary care responsibility to review, prioritise and triage
referrals to help overcome the backlog of cancelled elective
appointments during first peak of COVID-19. This fulfils the criteria
for implementation of the service model of digital NHS as recommended in
the NHS Long-Term Plan.4
Several published studies and audits8-11 have
discussed about bridging the gap between primary and secondary care but
there is a paucity of literature on implementation of a structured
triage system such as CAS to expand access to secondary care. It is well
established that the referral process and communication across primary
and secondary care interface has a potential to affect patient
care.8-11 A survey analysis conducted in England and
Wales concluded that audit activity at the primary-secondary care
interface is an enjoyable experience for a majority of
doctors.9
Quality improvement interventions like designing treatment pathways for
different gynaecological conditions, providing advice and guidance to
primary care physicians, giving feedback about missing information in
e-referrals, and applauding PCPs for a good quality e-referral in a
multidisciplinary environment helps to improve the quality of patient
care.
One of the important reasons behind successful implementation of CAS was
involvement of experienced clinicians from both primary and secondary
sectors. Advanced clinical skills are required for assessing the
information in e-referrals and making the right decision for patients.
This new service facilitated discussion of management plans for complex
patients in a multidisciplinary environment. Literature suggests that
attending these multidisciplinary clinics provide training opportunities
for GPs and career-grade trainees.12 Designing flow
charts and ‘pathways on a page’ for managing common gynaecological
conditions is an area we would like to explore through clinical
interface engagement sessions with PCPs.
Telemedicine has transformed the way healthcare service is delivered in
the NHS that is severely burdened due to COVID-19
pandemic.13 The Royal College of Obstetricians and
Gynaecologists has made recommendations that women should be managed by
remote communication in outpatient antenatal and gynaecology
appointments whenever possible.14 A systematic review
on the use of telemedicine in gynaecological practice showed remote
consultations to be promising with regards to clinical effectiveness and
gynaecological training.15 Another study on the use of
telemedicine in the management of urogynaecological conditions showed
that many first line treatments can be commenced virtually with similar
levels of patient satisfaction as face to face
appointments.16 Telemedicine is also useful when
following up post-operative patients who have had no
complications.16 This study adds further evidence that
telemedicine plays an important role in reviewing patients referred as
first attendance, provided there are robust pathways that streamline
patients to the correct consultation.16
Although there are many advantages of virtual clinics, careful planning
is sought when care is provided to vulnerable groups such as those at a
higher risk of domestic violence, depression and sexually transmitted
infections.17 Prioritising hospital appointments for
ethnic minorities should be considered as social distancing requirements
can further exacerbate an already underlying racial and minority
disparities in care and health outcomes.17 Additional
measures such as the use of 3-way telephone interpreting service may
mitigate lapses in communication but can be challenging to conduct. A
recent study conducted in Boston, USA found that differences in
telemedicine access have the potential to compound existing racial,
ethnic, and language-based disparities in chronic disease outcomes, and
careful monitoring of telemedicine use across patient demographics is
advised.18
This study has shown a reduction in face-to-face appointments from 61%
to 45% for new patient consultations by following interventions adopted
as per the action plans advocated after the first phase. One of the
interventions included training of consultants and junior doctors in
conducting tele-consultations. The general feeling among doctors was
that training and education led to an increase in confidence in
conducting these consultations. A retrospective review of 4738
gynaecology e-referrals showed that 21.4% of the referrals could be
managed by e-consult that involved writing a management plan to the
referrer.19 The increase in virtual appointments by
16% in our study is comparable to a Commonwealth Fund Review that
reported a reduction in face-to-face visits across a wide variety of
specialties by 9-51% as a result of adoption of
telemedicine.20 Another study from Canada found that
traditional consult could be avoided in 34.3% of referrals with the use
of telemedicine between GPs and gynaecologists.21
This study has many strengths. With COVID-19 expected to create barriers
in provision of elective activity in healthcare in the near future,
triage pathways and remote consultations will continue to be of
significant importance. To the best of our knowledge, this is the first
study on the use of CAS in gynaecology as recommended in the NHS
Long-Term Plan.
This study has the limitation that it is a single institution study,
Therefore the results may not be representative of practices at a
national level. This is best assessed with multi-centre studies on a
larger cohort of patients. Furthermore, while this study has
specifically validated the use of CAS in the field of gynaecology, there
is paucity of literature for evidencing implementation of a similar
framework in other specialities with equal efficacy. Cost-benefit
analysis was not performed in this study, however, it would be
reasonable to assume that CAS would help in cutting costs by reducing
inappropriate referrals and unnecessary consultations through
appropriate triage of e-referrals enabling efficient capacity and demand
management, which would automatically release efficiencies. Increase in
virtual appointments had the advantage of reducing estates and staffing
costs.
Conclusion
CAS framework provides a sustainable strategy to overcome disruptions in
provision of elective outpatient services caused by COVID-19 pandemic
and beyond. It promises a better future with enhanced access to
specialist advice and guidance for PCPs. CAS clinics reduce
inappropriate secondary care e-referrals and allow management of
eligible patients virtually avoiding unnecessary visits to the hospital.
It shortens patient care pathway and creates a dynamic link between the
primary care providers and specialist secondary care.
Declarations
Disclosure of interests
The authors declare that they have no competing interests. Completed
disclosure of interest forms are available to view online as supporting
information.
Funding
We declare that any organisation, government or university did not fund
us materially or financially.
Contribution to authorship
RR and ST were involved in the conception of the study. CT, TN and ST
were involved in triage of referrals in Phase 1 and CT, TN, ST, RR and
TV in Phase 2. RR, LF, TV and ST involved in extraction of data. RR and
MTA were involved in the analysis of the data. RR and LF were involved
in review of literature. RR wrote the manuscript with mentoring from ST,
TN. All authors were involved in the finalisation and approval of the
manuscript.
Ethical approval
The Quality Improvement Project protocol was approved by the Audit
Committee of Family and Specialty Services, Calderdale and Huddersfield
NHS Foundation Trust. Approvals to undertake phase 1 and phase 2 were
granted separately (Phase 1- CWF054; date of approval 13/05/2020 and
Phase 2- CWF069; date of approval 01/08/2020)
Acknowledgements
The authors are grateful to Dr Elizabeth Loney and Mr Ranadeb Acharyya,
Audit Committee leads of Calderdale and Huddersfield NHS Foundation
Trust, United Kingdom for the support received to undertake this
project.
Legends