Introduction Since the publication of the controversial “Safe and Sustainable Standards for Specialist Surgical Centres” in 2012, care of patients with congenital heart disease has come under extreme scrutiny, with focus on the provision of safe and effective care locally where possible and centralised in specialist centres where necessary. Three years after this process began, we analysed the quality of new patient referrals with suspected congenital heart disease to outpatient services at a paediatric cardiology specialist centre.
Method We reviewed referral and outcome data for all new referrals to Rapid Access and Consultant Outpatient clinics from January to March 2015 at Evelina London Children’s Hospital. Patients with pre-existing diagnoses of congenital heart disease including those referred for assessment prior to anaesthesia were excluded. Data were analysed for referral appropriateness and completeness in accordance with standards identified from available literature and local referral guidelines.
Results 257 referrals (71 Rapid Access Service, 186 Consultant Outpatient Service) were analysed; 144 male (56%), 113 (44%) female. The median age range for the Rapid Access Service was 0–4 weeks and 5–12 years for the Consultant Outpatient Service. 102 referrals (40%) were received from primary care services and 155 (60%) from secondary care. Of 241 referral documents available only 81% contained a documented medical history, 55% a drug history and 47% commented on family history. For physical examination 23% documented the resting heart rate, 20% noted a blood pressure (children <1 year of age were excluded from this standard), and only 59% documented cardiac auscultation. 14% of referrals commented on palpation of femoral pulses, and 14% noted the oxygen saturations. An electrocardiogram was sent with 34% of referrals (referrals from primary care were excluded from this standard). 24% of referrals suggested a potential diagnosis and 88% asked a specific clinical question. Out of the 257 referrals received, congenital heart disease was newly diagnosed in only 44 (17%) of the cases. Septal defects were the most commonly diagnosed pathology (43%) and 10 patients (23%) had more complex pathology. No children in the sample were diagnosed with critical heart disease despite the fact that the Rapid Access Service is designed to identify patients with congenital heart disease requiring urgent triage and assessment.
Conclusion New patient referrals with suspected congenital heart disease are not compliant with referral guidance, contributing to low diagnostic yields. In a cash strapped NHS, referrals to tertiary services should be considered carefully. At present, no import is given to such concerns by NHS trusts as each referral (regardless of the quality or outcome) earns income for the hospital trust. The quality of the referrals was extremely poor; affecting the ability to appropriately triage patients with subsequent implications for patient safety. Monitoring of referral standards needs to be considered centrally in order to discourage unnecessary referrals.
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