The organisation of an ophthalmological service for diabetics in a teaching hospital

A new system of ophthalmological evaluation of diabetic patients in a teaching hospital has been devised. All the patients attending the diabetic clinic were screened by ophthalmologists. Any patient with a problem was then referred to a diabetic ophthalmology clinic where a full evaluation was done and treatment given where necessary. In an 18-month period 1,015 new ophthalmological diabetic patients were screened. Of these patients 13.6% had background retinopathy, 8.4% pre-proliferative retinopathy and 3.4% proliferative retinopathy, while 8.6% had maculopathy. These results show that even in a teaching hospital a significant percentage of patients already have pre-proliferative or even proliferative retinopathy when seen by an ophthalmologist for the first time. The importance of organising an ophthalmological service for the diabetic patient is stressed.     

A survey of the need for psychological input in a follow-up service for adult burn-injured patients

Increasingly, burns services are incorporating clinical psychologists as members of their acute care and rehabilitation teams. This study aimed to provide evidence for the necessity of psychological input in a follow-up service for victims of burn injuries in Manchester. Psychological morbidity and need of consecutive burn-injured patients (n=68) attending an outpatient clinic was surveyed in comparison to a sample of consecutive plastics and trauma patients attending the same clinic (n=44). Significantly more burn-injured patients reported emotional difficulties as measured by the hospital anxiety and depression scale and the impact of events scale due to their condition than the plastics and trauma patients. Burn-injured individuals reported a lack of psychological support and made suggestions for support services that may have been beneficial. The findings supported the need for a comprehensive follow-up service that would make specialist physical and psychological support more accessible to burn-injured patients post-hospitalisation. The accuracy of medical staff in identifying psychological difficulties during a routine follow-up consultation was examined in a sub-group of burns victims (n=21). Medical staff was able to correctly identify the presence of psychological difficulties in 58% of cases. Implications regarding referral routes to psychological services were highlighted.     

A Direct Booking Hernia Service - A shorter wait and a satisfied patient

Introduction

Patients requiring routine operations often have lengthy waits for outpatient appointments and surgery. Our aim was to reduce this wait by offering patients a Direct Booking Hernia Service and to assess its efficacy and its acceptability to patients.

Methods

Two groups of patients referred for treatment of an inguinal hernia were compared. Group 1 were those referred to a single named consultant and all those referred without specifying a consultant's name during the same period. Group 2 were those referred to any other named consultant at the same hospital during the same period. For those in Group 1, the referral letter was triaged by a single surgeon and sent directly to the Day Surgery Unit (DSU). The patient's first appointment was for nurse led pre-assessment in the DSU. At the same visit the duty DSU surgeon checked the hernia to confirm the diagnosis. If medically fit, patients were offered a date for operation within 4 weeks of their pre-assessment. If unfit for DSU, the nurses would discuss the patient with the DSU lead anaesthetist and could book them directly onto an inpatient list or refer them to the outpatient clinic. Group 2 patients followed the traditional pathway of outpatient clinic, then booking for surgery. Group 1 patients were invited to complete a patient satisfaction questionnaire following their treatment.

Results

There were 74 patients in Group 1 and 147 in Group 2 during the study period. In Group 1 3/74 (4.1%) did not have hernias at pre-assessment. The mean total waiting time from referral to surgery was 70 days. In Group 2 the mean wait for an out-patient appointment was 77 days, and the wait from outpatient appointment to surgery was 84 days, giving a total average waiting time of 161 days. The proportion of patients treated as day cases was 88.7% in Group 1 and 70% in Group 2. 43% of Group 1 patients responded to the questionnaire. 94% of these would recommend the service to a friend.

Conclusion

The Direct Booking Hernia Service provides an efficient way of treating patients requiring inguinal hernia repair that is acceptable to patients. It significantly reduces waiting times and reduces the load on outpatient appointments.     

Maximizing use of a surgical clinic for referrals of patients having back problems.

OBJECTIVE: To determine ways to improve the delivery of service in a surgical clinic, based on the outcome of surgical consultations for back pain. DESIGN: A prospective outcome study. SETTING: A university teaching hospital providing secondary and tertiary care. PATIENTS: One hundred and forty-two consecutive patients who presented to surgical clinics for assessment of a back problem between Apr. 14 and May 30, 1996. INTERVENTIONS: Surgeons determined the diagnosis and visit outcome; data were tabulated objectively by a third-party researcher. OUTCOME MEASURES: Waiting time for consultation, presence of referral letter, third-party interests, diagnosis and visit outcome. RESULTS: Twenty-five percent of patients had chronic pain not amenable to surgery, 19% of patients were surgical candidates and were offered an operation, 13% were symptomatically improved to the point of not wanting an operation, 11% wanted a second opinion only, 10% had mechanical back pain appropriate for referral to physiotherapy, 9% had not undergone an adequate trial of nonoperative treatment when seen in the clinic and were given follow-up appointments, 5% were "no shows," 3.5% were seen for a medicolegal assessment, 3.5% wanted confirmation from a specialist that they did not need surgery and 1% had symptoms due to a vascular rather than a spinal cause and were referred to a vascular surgeon. CONCLUSION: Delivery of service could be improved by more rigorous screening to reassign appointment times of patients who have not had an adequate trial of nonoperative treatment, are improved or do not intend to keep their appointment.     

A prospective audit of referral patterns to a dedicated Foot and Ankle surgical service

Introduction

In order to ensure we provided an appropriate patient focused service we undertook a prospective audit of referrals to our surgical foot and ankle department in a large District General Hospital/Treatment centre.

Methodology

An audit was conducted over a 12 month period to establish the initial referral patterns to a dedicated foot and ankle service. This was undertaken by completion of a dedicated audit form, with departmentally agreed terms and domains following the International coding of diseases (ICD) system. The form was completed by the attending clinician for each new patient contact and the information gathered included referral source; attending clinician; diagnosis; investigations; treatment; and ongoing referral patterns.

Results

1133 referrals were received over a 12-month period. Of these 974 [86%] were referred from their general practitioner. 118 patients had a secondary concern and 12 had a third complaint. For ease, the presenting complaints were clustered under six sub-headings; first ray {426}; lesser rays {324}; rear-foot {111}; tendonopathy/ligament/soft tissue {288}; mid-foot {72}; systemic/general {158}.775 investigations were requested. These were subdivided into their specific modalities. Treatment included surgery for {65%}; steroid injection {12%}; Orthoses {17.4%}; Advice {13%}; Physiotherapy {3.4%}.

Conclusion

Only 65% of GP referrals to this surgical service were deemed appropriate as they progressed directly to surgery. However, it is important to establish what constitutes ‘appropriate’ since within the remaining 35% of referrals only 66 (5.8%) required no intervention at all. Of the residual group who required ‘treatment’ approximately 17% required steroid injection or orthoses and 143 (13%) received advice and went away to contemplate the consultation. Referral pathways could be improved by greater communication between GP and foot and ankle service with the construction and implementation of referral guidelines which would enhance the referral and treatment pathway to the service.     

Diagnostic Biopsy of Lymph Nodes of the Neck,Axilla and Groin: Rhyme,Reason or Chance?

INTRODUCTION

Improving patient pathways of care is becoming increasingly important in the delivery of timely, appropriate surgical care. With this aim, we analysed the referral and management pathway of patients undergoing diagnostic superficial lymph node biopsy.

PATIENTS AND METHODS

A retrospective review of case notes of patients undergoing diagnostic superficial lymph node biopsy over 3 years, 1998–2000 at the Bradford Hospitals NHS Trust. Indication for surgical biopsy was based on clinical suspicion following assessment in the out-patient clinic for the majority, and arrangement of investigations as deemed appropriate. There were no clinical algorithms in use during the study period.

RESULTS

There was no evidence for the use of explicit protocols for referral or management. Biopsy was often delayed. Of 268 patients referred from primary care, referral was made to any of 14 hospital departments with 39% (105 of 268) attending more than one outpatient appointment, and 155 (41 of 268) attending more than one department. Eighteen percent (47 of 268) of patients were informed of their diagnosis within 6 weeks of referral and 42% (113 of 268) within 3 months of referral. Nine percent (24 of 268) underwent pre-operative fine needle aspiration cytology. Of patients with enlarged neck nodes, 29% (52/180) had examination of the upper aero-digestive tract.

CONCLUSIONS

The study supports the introduction of co-ordinated problem-based referral and management pathways for the management of patients with enlarged superficial lymph nodes supported by regular audits of practice.     

The fourteen-day rule and colorectal cancer

OBJECTIVE: To examine the effect of the fourteen-day rule on the colorectal service of a district general hospital. METHODS: Prospective audit of all patients referred by general practitioners to the colorectal service of a district general hospital serving a population of approximately 300,000 people. The main outcome measures were: (i) mean interval in days from referral to first clinic appointment; (ii) first clinic appointment to diagnosis; and (iii) overall interval from referral to diagnosis. RESULTS: There was a change in the referral pattern with greater numbers of 'fourteen-day rule' and urgent referrals than expected (P < 0.001). The mean time interval from referral to diagnosis was reduced (P < 0.01). This was due to a reduction in the wait for a first clinic appointment (P < 0.01). The wait between first appointment and diagnosis was unchanged (P < 0.05). Waiting times for patients referred as 'routine' or whose GPs did not specify a priority also improved. CONCLUSIONS: The 'fourteen-day rule' with respect to colorectal cancer has reduced waiting times for a first appointment to see a specialist. Further improvements will require additional resources to reduce the delay for investigations. The effect on long-term survival remains to be seen.     

The South Tyneside FASTRAK service: evaluation of a new model for day surgery

Objective: To evaluate a service (FASTRAK) offering general practitioners direct access to day surgery operative waiting lists, based on explicit guidelines regarding patient suitability for surgery and anaesthesia. Design: Notes abstraction for a cohort of patients referred via FASTRAK and a cohort referred via conventional day surgery routes; postal questionnaire survey of patient satisfaction amongst FASTRAK patients and matched controls referred via conventional routes; postal survey of professional satisfaction. Setting: One district general hospital in the north east of England, and all general practices in that district. Subjects: 1278 patients (1100 conventional day case patients; 178 FASTRAK patients) for notes abstraction; 70 patients for patient satisfaction survey 83 general practitioners for professional satisfaction survey. Main outcome measures: interval from referral to operation, and appropriateness of referral; patient experience and satisfaction with hospital and post-discharge care, especially with respect to information provision, for patient survey; overall rating of service, perceived benefits and disadvantages and future intentions for professional satisfaction survey. Results: The interval from referral to operation was significantly shorter for FASTRAK patients by a median of 91 days. Out of a total of 178 FASTRAK referrals, only seven (4%) were inappropriate whilst diagnosis was wrong in three (2%) cases. Patients referred via FASTRAK were much more likely to have received written information prior to admission (83 vs. 37%: χ²=12.25. P=0.0019). General practitioners (GPs) had positive views of the service; 94% rated it as ‘fair' to ‘very good'. GPs, 90%, perceived the main benefit to patients to be a shorter waiting time for operation; 40% felt that the availability of clear information for patients benefited doctors. Increased general practitioner workload was recognised as a disadvantage (61%) and the main barrier to use of the service was lack of eligible patients under the current guidelines (69%). Conclusions: When diagnosis, indication for surgery and fitness for anaesthesia are not in doubt, general practitioners, given appropriate guidance, are able to provide all the necessary pre-operative services that are usually provided in the general surgical outpatient clinic, without prejudicing the quality of care or decreasing patient satisfaction.     

Direct Access Minor Surgery service--patient satisfaction and effectiveness

INTRODUCTION: Waiting lists for surgical out-patients and elective operations are a major concern of the National Health Service. A Direct Access Minor Surgery programme in an ambulatory minor theatre area has been introduced to expedite patient treatment. The response of patients to this service has been assessed. PATIENTS AND METHODS: A postal questionnaire was offered to all patients attending for the Direct Access Minor Surgery over a period of 20 months (January 2002 to August 2003). Patients were asked about direct attendance for surgery without a prior out-patient appointment, about waiting time before operation on the day of surgery and the adequacy of pre-operative information. Overall satisfaction was assessed using a scoring system. The incidence of inappropriate referrals was analysed. The influence of the service on waiting lists and resources was assessed. RESULTS: A total of 221 patients were operated on, 257 lesions being excised. Response rate to the postal questionnaire was 55%. Of respondents, 75% thought that it was appropriate to attend the hospital directly without an out-patient clinic appointment. To 83% the waiting time was acceptable. Of patients, 90% were happy with the pre-operative information. Overall, 91% of respondents were very satisfied with the service. Inappropriate referrals were 4%. The new service reduced waiting time for minor surgery from 53 to 10 weeks. It also released approximately 140 new out-patient slots per annum. CONCLUSION: Direct Access Minor Surgery is a safe and favoured service with high patient satisfaction.     

Urogynecology triage clinic: a model of healthcare delivery

Introduction and hypothesis  To establish whether a nurse-led urogynecology triage clinic (UTC) is effective in terms of patient journey (from primary referral to first hospital contact until discharge), diagnosis, management, and outcomes. Methods  The case notes of 300 patients attending the UTC in a university hospital between January 2006 and November 2007 were randomly selected for review. Results  The mean interval from referral to first visit improved from 15.6 weeks (range = 12–32 weeks) to 4.6 weeks (range = 1–11 weeks, SD = 1.97) after UTC. Compared to pre-UTC, the mean period from first visit to final outcome improved from 11 months (range = 3.0–23.0 months) to 8.8 weeks (range = <1–60 weeks, SD = 11.15). Fifty-nine percent were discharged from the UTC without being seen by a specialist. Conclusions  By service redesigning, the UTC has reduced the number of clinic visits and patient journey time and has also shown that the majority of women with incontinence can be adequately managed by a specialist nurse.     

Effective management of severe traumatic brain injury in a district hospital

Abstract The authors investigated how effectively adults with severe traumatic brain injury (TBI) can be managed in a district general hospital intensive care unit offering intracranial pressure monitoring (ICPM) receiving advice from a neurosurgical unit. A single-centre case series with retrospective review of prospectively collected information was undertaken of 44 consecutive patients presenting over seven years from January 2003 to January 2010 with severe traumatic brain injury to a single district general hospital intensive care unit serving a population of 500,000 adults. A prospectively entered clinical database was used to obtain information including patient demographics, Glasgow Coma Score (GCS) on admission, ICPM insertion, ICPM-related complications, inpatient mortality and neurosurgical advice. Case notes were used to ratify information and obtain neurorehabilitation clinic functional outcome scores. Forty-four patients were identified (40 male, age range 16-77 years). Mortality in intensive care was 30%. Twenty-eight patients received frontal twist drill ICPM following neurosurgical advice. ICPM had 2 (7%) device malfunctions but no other complications. Twelve additional patients were transferred to tertiary centres. Patients (23 of 31) who survived ICU stay (74%) were referred to neurorehabilitation. Mean clinic follow-up was 14 months. All patients had a Glasgow Outcome Score (GOS) of 3 or 4 at initial clinic assessment. Twenty-two improved to GOS to 4 or 5 at clinic discharge. One patient died prior to clinic discharge. Carefully selected patients with severe TBI can be managed safely and effectively in a district general hospital offering ICPM insertion if transfer to a neurosurgical centre is not possible. Neurosurgical advice regarding patient selection and on-going management is fundamental to provid a good service. Protocol driven therapies provide a useful systematic approach to doctors who do not deal with severe TBI on a routine basis.     

Design of appointment systems for preanesthesia evaluation clinics to minimize patient waiting times: a review of computer simulation and patient survey studies.

Anesthesiologists can use the science of clinic scheduling to design appointment systems for preanesthesia evaluation clinics. The principal reasons reported for inappropriately [or arguably unethically] long patient waiting times are provider tardiness, lack of patient punctuality, patient no-shows, and improperly designed appointment systems. However, the fundamental reason why anesthesia clinics have such long patient waiting times is because of their relatively long mean (and consequently standard deviation) of consultation times. If commonly applied valuations of provider idle time to patient waiting time are used in anesthesia clinics, appointment intervals will be sufficiently brief that the mean patient waiting time will be at least the mean consultation time or half an hour. Patients will be dissatisfied with this level of service. Therefore, efforts to decrease the mean patient waiting time in anesthesia clinics should focus foremost on minimizing the mean consultation time and its variability, which can most likely be achieved by assuring that providers have rapid access to relevant clinical information, including external medical records, surgical dictations, etc. Anesthesiologists managing anesthesia clinics may find it valuable to apply other interventions to decrease patient waiting times. Scheduling of preanesthesia evaluation and surgical clinics should be coordinated to assure patient punctuality. Providers should be on time for the start of their sessions. If an add-on patient cannot be seen during a scheduled clinic session, because all appointment times have been assigned to other patients, the add-on patient should be seen by a different provider or at the end of the regularly scheduled clinic session. Mean consultation times should be measured accurately for each provider. Substantial provider idle time should be expected. Appropriate values for breaks, appointment intervals, and percentage no-shows should be determined by computer simulation, using parameters appropriate for each provider and anesthesia clinic. Finally, traditional efforts at making waiting for a consultation tolerable should be made.     

Direct optometrist referral of cataract patients into a pilot 'one-stop' cataract surgery facility

OBJECTIVES: To determine the feasibility of a) direct optometrist referral of patients with cataract, and b) combined assessment with same day cataract surgery ('one stop' cataract surgery). METHODS: Evaluation of 169 patients referred directly by optometrists into a pilot 'one stop' cataract surgery facility. RESULTS: Of 169 referrals, 160 patients (94.7%) were given confirmed appointments for the 'one stop' cataract service and 9 patients (5.3%) were appointed conventionally. Of 160 patients attending the 'one stop' cataract service, 154 patients (96.3%) underwent cataract surgery at the same visit, in 4 patients (2.5%) cataract surgery was indicated but deferred and in 2 patients (1.3%) cataract surgery was not indicated. The referral was supplemented with information regarding the patient's medical history forwarded by the general practitioner for 3 patients (1.8%). There were no systemic or sight-threatening complications. 151 patients (98.1%) achieved a visual acuity of 6/12 or better at a mean of 31 days post-operatively. CONCLUSION: Optometrists can accurately predict the need for cataract surgery and refer directly into a pilot 'one stop' cataract surgery facility, without the need for general practitioner involvement. 'One stop' cataract surgery is feasible; benefits to the patient include the abolition of the need to visit the general practitioner for consultation and referral, and the hospital for pre-assessment.     

The socio-economical impact of paediatric fracture clinic appointments

The aim of our study was to quantify the indirect cost of a paediatric fracture clinic appointment on society. Our study took place in a paediatric outpatients department using two questionnaires, completed at the time of attendance. The primary measures were days off work and pay lost for the carer and time out from education of the patient. One hundred consecutive patients were asked to complete a after their appointment. Seventy-one were completed. A second clinic evaluation sheet was completed by the surgeons seeing the patients, to assess the appropriateness of the attendance. The results showed that for every 100 appointments 25 working days were lost and 18 people lost pay. Fifty-four days of school were missed as a direct result of attending clinic for review. We showed that 93% of the clinic attendances were thought to be appropriate from the perspective of the surgeon seeing the patient. Streamlining the aftercare of fractures can relieve this considerable socioeconomic burden.     

Audit of Two-Week Rule Referrals for Suspected Testicular Cancer in Cornwall, 2003–2005

INTRODUCTION

The objective was to evaluate the two-week wait referral system for suspected testicular cancer and to compare waiting times from referral to treatment before and after the introduction of the two-week wait process.

PATIENTS AND METHODS

We reviewed 241 case notes for patients referred under the two-week wait system with suspected testicular tumour during a complete 3-year period (2003–2005) and recorded information from the referral letter, findings in the urology clinic, results of ultrasound and final outcomes. We also identified 42 cases of testicular tumour treated during a complete 3-year period (1997–1999) just before the two-week wait system was introduced. The journey from referral to treatment for tumour cases was compared during these two periods.

RESULTS

Testicular cancer was only found in 8% of patients referred by the two-week wait system. We judged the referral to be inappropriate in 48% of cases. Of referred cases, 78% required no surgical treatment. There was a significant improvement of 9 days in the average time from general practitioner (GP) referral to urology clinic attendance but all other journey intervals remained the same.

CONCLUSIONS

The performance of GPs in examining scrotal swellings and applying the two-week wait guidelines was very poor, resulting in many unnecessary urgent clinic visits. The referral system speeds up the visit to a urology clinic but the overall effect is probably not of clinical significance. We suggest that it would be much more cost-effective for all these patients to have an ultrasound scan within 2 weeks instead of a urology clinic appointment.     

Prospective evaluation of a novel one-stop testicular clinic

INTRODUCTION

In 2003, the waiting time for routine scrotal assessment approached 6 months in our hospital. The patients'' diagnostic pathway was not uniform and involved several delays between general practitioner, radiologist and urologist. If malignancy was suspected, patients were seen and assessed within 2 weeks. However, it was possible for patients with unsuspected malignancy to have their diagnosis delayed.

PATIENTS AND METHODS

Funding was provided by the NHS Modernisation Agency''s Action On Urology project. Men who were referred by their general practitioner (GP) with a testicular or scrotal condition would be reviewed in a one-stop joint sonographer and urology nurse specialist clinic provided entirely within the urology department with rapid open access. Data were prospectively collected for 2 years. Source of referral, suspected diagnosis, findings and outcome were recorded.

RESULTS

A total of 1017 patients attended the clinic over this period; of these, 203 (4%) were referred under the ‘2-week wait’ criteria. Of patients attending the clinic, 79% were discharged to GP care, 8% were added to the waiting list for a surgical procedure and 20% were referred with ‘testicular lump’. Eleven patients were suspected to have testicular tumour on ultrasound and proceeded to orchidectomy in this period. One patient (0.1%) was found to have an unsuspected seminoma. The waiting time for all scrotal ultrasound examinations has fallen from 22 to 2 weeks. The waiting times for intravenous urography and general ultrasound were also significantly reduced following the introduction of this service (P = 0.005).

CONCLUSIONS

The majority of patients passing through this clinic are the ‘worried-well’ with benign scrotal pathology. They can now be seen within 2 weeks regardless of whether their GP suspects testicular tumour. This reduces anxiety in this large group of patients freeing capacity elsewhere in the diagnostic imaging department.     

Resource implications of outpatient referrals to a general urological service.

The effects of new outpatient referrals on the dynamics of global provision in a surgical service has not previously been defined. Because of managerial pressure to reduce the time interval between general practitioner referral and first specialist assessment, many services are now faced with additional outpatient loads without any clear idea of the effect that this additional burden will have on overall practice. In an attempt to define the logistic implications of a new outpatient load, 293 patients, referred from primary care to a general urological service, were followed for a further two interactions with the secondary care team. 'One-stop' visits with in-clinic investigation and an active discharge policy were employed to assist with efficient patient management. Of the original patients, 28% required investigations not available in the clinic, with cost and logistic implications for support services. In all, 32% of the patients needed further follow-up appointments, despite the active discharge policy. This necessitated 95 people being seen in additional clinic time. Of the patients referred, 37% needed inpatient treatment; 46% being day case procedures, the remainder constituting a variable case mix. This work necessitated 7.1 operating sessions and an additional 75 inpatient bed days for every 100 new patients referred. A model for determining the resource requirements for a surgical outpatient load is proposed.     

The use of a spirit-level to improve radiograph quality in ring fixators

The use of ring fixators in lower limb reconstruction and deformity correction both for trauma and elective procedures is now widespread. The long course of treatment requires regular outpatient review with frequent radiological imaging to assess the progression of treatment and plan correctional adjustment.Following publication of a technique using a frame mounted spirit-level to aid radiographers in accurately aligning the limb for optimal imaging we implemented a similar technique in our department and carried out a two part prospective comparative study to assess the impact on radiograph quality.Comparison was made of radiograph quality, X-rays taken, patient trips to the radiology department and X-ray exposure before and after implementation of the spirit-level guide technique in patients attending an out-patient clinic for routine follow up following ring fixator application.26 patients were included in the control arm and 33 in the intervention group. On review, 42.3% of patients in the control group were deemed to have had suboptimal imaging compared with only 9.1% of those imaged using the spirit-level guide, a statistically significant improvement. When comparing total numbers of images taken for each group to achieve the requested number of adequate views there was less statistical significance, nor was there a statistically significant difference in radiation dose between the groups.A significant reduction in the number of inadequate images being taken, with a subsequent reduction in patients requiring return to the radiology department for re-imaging and then re-review in clinic, has clear implications for patients, clinicians and hospital efficiency. The patient journey time is reduced, less time and fewer resources are used in the radiology department and patients in clinic are seen more efficiently and with less wasted time.We conclude that the implementation of a simple frame mounted spirit-level as a guide for radiographers in the outpatient clinic significantly reduces the number of suboptimal and wasted images taken in the assessment of patients being treated by ring fixator.     

Triaging referral to a specialist breast clinic

BACKGROUND: The aim of this study was to determine the effectiveness of a triage system in predicting patients with malignancy among those referred to a specialist breast clinic. METHODS: A retrospective study of all referrals seen at the specialist breast clinic from January 2002 to June 2002 was conducted. The triage system allocated an urgent appointment if (i) urgent referral was requested by the referring physicians or (ii) 'non-urgent referral' was made and any one of the following 'high-risk' criteria were present: aged more than 50 years when presenting with breast lump, lump larger than 3 cm, bloody nipple discharge or physical signs suggestive of malignancy. Routine appointment was given if these conditions were not met. The outcomes of individual groups were assessed. RESULTS: Three hundred and sixty-three referrals were analysed and 44 cancers (13.2%) were diagnosed. The mean waiting time for urgent and routine appointments was 19 and 154 days, respectively. There were 108 urgent referrals and 21 (19.4%) cancers were diagnosed. Ninety-two patients were given an urgent appointment because of the presence of high-risk criteria, and 21 cancers were detected (22.8%). After the two-stage triage, breast cancer was subsequently diagnosed in only 2 out of the remaining 163 patients (1.2%) given a routine appointment. CONCLUSION: Most of the patients with cancer (96%) were given an urgent appointment through the triage system. In addition to the assessment by referring physicians, certain high-risk criteria are helpful to select patients who should be seen urgently.     

Patterns of referral to Red Cross War Memorial Children's Hospital, Cape Town

Patterns of referral to Red Cross War Memorial Children's Hospital were studied to assess the appropriateness of referrals. From 1 July to 31 December 1987 all 9,288 referral letters presented to the hospital were collected and a sample (4,662 letters) analysed. It emerged that the patients were similar to those attending the outpatient department without referral, except that relatively fewer referred patients were black. The private sector, i.e. general practitioners, was the largest referral agency, followed by day hospitals. Most patients were referred to the outpatient department without an appointment. Of the specialist clinics, the surgical clinics (i.e. ophthalmology and ear, nose and throat) had the highest number of referrals. The majority of patients (84.9%) were not admitted. Only in 30.3% of referred cases did the hospital make contact with referral agents. Referral rates were highest from the predominantly coloured areas of the Cape Peninsula. The hospital cannot isolate itself from the community it serves and needs to support and guide referral agents in order to improve the utilisation of the hospital. Training of health professionals in order to increase expertise is a priority. A study of the total patient population would facilitate the understanding of hospital utilisation. Similar studies could be beneficial at other hospitals.