The TOS study: can we use our patients to help improve clinical assessment?

We believe that there is a need to increase awareness, particularly among foundation year doctors, of the importance of performing a full neurological examination, including ophthalmoscopy, in medical inpatients. Following a serious unexpected incident (missed papilloedema), we implemented a multifaceted intervention, including ensuring greater availability of equipment for neurological/ ophthalmological assessment, education and curriculum redesign in two large teaching hospitals in the UK.

Following the results of our initial intervention, we introduced a patient assessment scoring system to evaluate patient recollection of the completeness of neurological examination by medical staff in the two Trusts over a four-month period.

Of the 93 patients referred to neurology during this period, 33% could not recollect being examined with a tendon hammer and 48% said they had not been examined with an ophthalmoscope. In contrast, the majority (95.7%) remembered the use of a stethoscope in their examination. The data were fed back to medical staff which resulted in greater awareness of the importance of a complete neurological examination. No further adverse incidents of missed papilloedema were reported in the following 12 months, although it would be premature to state that this situation has been resolved.

A patient assessment score can be used by medical staff to raise awareness of the importance of a complete neurological examination from referring physicians.