Reducing Inappropriate Surgical Referrals Through Patient Assessment Algorithm Utilising Early Imaging: A Closed-Loop...

Emergency department (ED) referrals to specialist services are integral to patient management within the National Health Service (NHS). However, rising pressures, the lack of standardised referral protocols, incomplete assessments and time constraints often result in inappropriate referrals, compromising patient care and resource utilisation. This study evaluated the appropriateness of referrals from the ED to general surgery (GS) through a two-cycle audit with a targeted intervention, acute abdominal pain pathway, incorporating early computed tomography (CT) imaging.

A closed-loop audit was conducted at Stepping Hill Hospital, Stockport, the United Kingdom. All ED-to-GS referrals over one month in July 2020 (Cycle 1) and July 2024 (Cycle 2) were included. Data were collected on assessment completeness, investigations performed, preliminary treatment, the grade of accepting surgical doctor and alignment between ED and surgical diagnoses. Inappropriate referrals were defined as those with discordant diagnoses or requiring onward referral to another speciality post-GS assessment. Following Cycle 1, an acute abdominal pain pathway emphasising early CT use was implemented. Data were analysed using descriptive statistics, chi-square tests and effect size calculations.

In Cycle 1, 111 patients were referred to GS, 86 (77.5%) of whom had abdominal pain. Out of the 86, 34 (39.6%) lacked blood investigations, 53 (61.6%) had no basic radiology such as chest X-ray (CXR) or abdominal X-ray (AXR), 18 (21.9%) received no preliminary treatment and 24 (27.9%) were deemed inappropriate referrals. Following the intervention, Cycle 2 (n=72) showed marked improvements: referrals without blood tests decreased to five (20%) (p=0.001), those without treatment to three (4.2%) (p=0.001) and inappropriate referrals to seven (9.7%) (p=0.004), reflecting a 65.2% relative risk reduction.

The findings underscore the critical role of structured referral pathways and early imaging in improving ED-to-GS referral quality. Incorporating CT at the point of initial assessment reduced inappropriate referrals, optimised resource allocation and improved patient flow, consistent with existing literature on CT's diagnostic accuracy and impact on reducing unnecessary admissions. This intervention demonstrates a pragmatic, scalable solution to ED pressures, enhancing both clinical efficiency and patient outcomes while supporting NHS objectives of safe, cost-effective care.

The implementation of an acute abdominal pain pathway with early CT imaging significantly improved the appropriateness of surgical referrals from ED, reduced inefficiencies and enhanced overall patient management. The model is readily generalisable and has the potential for widespread adoption to address systemic challenges, ensuring high standards of care amidst increasing healthcare demands.