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Published on: January 18, 2018
Prioritisation of vascular outpatient appointments cannot be based on referral letters alone
N N B Patel1, J D'Souza, M Rocker
1Royal Glamorgan Hospital, Llantrisant, Ynysmaerdy, Rhondda Cynon.
Insights
Referral letters for lower limb ischaemia often lack crucial details, hindering timely patient prioritization. Improving documentation in general practitioner (GP) referrals is essential for effective vascular care.
Area of Science:
- Vascular Surgery
- General Practice
- Health Services Research
Background:
- General practitioners (GPs) refer a high volume of patients with diverse vascular conditions weekly.
- Effective prioritization of vascular referrals is crucial for timely patient management.
- Conditions range from cosmetic varicose veins to critical limb ischaemia and aneurysms.
Purpose of the Study:
- To prospectively evaluate vascular referral letters for their adequacy in enabling patient prioritization.
- To assess the quality of information provided in GP referral letters to vascular units.
Main Methods:
- A prospective review of GP referral letters to two vascular units over four months.
- Inclusion criteria focused on patients with lower limb ischaemic symptoms.
- Data collected included documented urgency, claudication distance, rest pain, risk factors, and clinical signs.
Main Results:
- 83% of 174 referrals were for peripheral vascular disease; 72% cited claudication.
- Key details like claudication distance (37%) and rest pain (13%) were often missing.
- Urgency was not stated in 66% of letters, correlating with only 3% seen within four weeks versus 22% when urgency was stated.
- 90% failed to document critical ischaemic signs; 6% required immediate admission upon review.
- Significant regional variation in documenting urgency was observed (57% vs. 23%, p < 0.0001).
Conclusions:
- Referral letters frequently lack essential details on symptoms, risk factors, and clinical signs.
- The stated degree of urgency in referrals is often insufficient for effective prioritization.
- Development of standardized referral protocols is recommended to improve vascular patient management.
Background:
Vascular referrals include patients with conditions varying from varicose veins of cosmetic nuisance to patients with critical ischaemia, transient ischaemic attacks and abdominal aortic aneurysms. A large number of such referrals are received each week from general practitioners. It is important to prioritise patients with conditions that need to be dealt with quickly.
Objective:
We prospectively reviewed referral letters to two vascular units, one in South Wales and one in the Oxford region to assess whether prioritisation can be made on the basis of referral letters.
Material And Methods:
All GP referral letters were studied for four months. Only patients with lower limb ischaemic symptoms were included. Degree of urgency requested by the GP was also noted.
Results:
Of 174 referrals for potential lower limb ischaemia analysed, 145 (83%) proved to be due to peripheral vascular disease. Of these 145 referrals, 72% were referred for claudication. Only 37% and 13% respectively mentioned claudication distance and/or rest pain. Risk factors with reference to diabetes, hypertension, hyperlipidaemia, ischaemic heart disease, atrial fibrillation, cerebrovascular disease and smoking were made in 19%, 43%, 23%, 23%, 10%, 14%, 31% of letters respectively. Clinical signs were poorly documented, with 90% of referrals failing to mention presence or absence of critical ischaemic signs. The GP's own assessment of urgency was not stated in 66% of letters, without which only 3% of patients were seen in the clinic within four weeks, compared with 22% in those in whom urgency was stated. Six per cent of patients when reviewed in outpatients were found to have sufficiently severe symptoms to warrant immediate admission. Regional variation was observed with 57% of Royal Glamorgan Hospital referral letters documenting degree of urgency compared with only 23% of Royal Berkshire Hospital letters (p = < 0.0001).
Conclusion:
Most referral letters were poorly documented with regard to key symptoms, risk factors and clinical signs. The degree of urgency was often not stated. The creation of referral protocols is now being considered.
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