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For peer review only

Referrers’ point of view on the referral process to neurosurgery and opinions on neurosurgeons: a large-scale

face-to-face regional survey in the UK.

Journal: BMJ Open

Manuscript ID bmjopen-2017-017495

Article Type: Research

Date Submitted by the Author: 27-Apr-2017

Complete List of Authors: amarouche, meriem; King's College Hospital NHS Foundation Trust, Neurosurgery Neville, Jonathan; King's College London, Medical School

Deacon, Simon; King's College London, Medical School Kalyal, Nida; King's College London, Medical School Adams, Nikita; King's College London, Medical School Cheserem, Beverly; Brighton and Sussex University Hospitals NHS Trust, Neurosurgery Curley, Daniel; King's College London, Medical School deSouza, Ruth Mary; King's College Hospital NHS Foundation Trust, Neurosurgery Hafiz, Fehmi; King's College London, Medical School Jayawardena, Tanya; King's College London, Medical School Khetani, Nishi; King's College London, Medical School Matthews, Diana; King's College London, Medical School

Mustoe, Sophie; King's College London, Medical School Okafor, Sabrina; King's College London, Medical School Padfield, Olivia; King's College London, Medical School Rao, Ishani; King's College London, Medical School Samir, Reem; King's College London, Medical School Tahir, Hyder; King's College London, Medical School Varghese, Benjamin; King's College London, Medical School Tolias, Christos; King's College Hospital NHS Foundation Trust, Neurosurgery

<b>Primary Subject Heading</b>:

Surgery

Secondary Subject Heading: Emergency medicine, Patient-centred medicine, Medical education and training

Keywords: Neurosurgery < SURGERY, NEUROSURGERY, referrals, MEDICAL EDUCATION & TRAINING

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Referrers’ point of view on the referral process to neurosurgery and opinions on

neurosurgeons: a large-scale face-to-face regional survey in the UK.

Meriem Amarouche 1, Jonathan Neville

2, Simon Deacon

2, Nida Kalyal

2, Nikita Adams

2,

Beverly Cheserem 3, Daniel Curley

2, Ruth-Mary DeSouza

1,4, Fehmi Hafiz

2, Tanya

Jayawardena 2, Nishi Khetani

2, Diana Matthews

2, Sophie Mustoe

2, Sabrina Okafor

2, Olivia

Padfield 2, Ishani Rao

2, Reem Samir

2, Hyder Tahir

2, Benjamin Varghese

2 and Christos

Michael Tolias 5

1. Neurosurgery registrar, King's College Hospital NHS Foundation Trust, London, UK

2. Medical student, King's College London, London, UK

3. Locum consultant neurosurgeon, Brighton and Sussex University Hospitals NHS

Trust, Brighton, UK

4. PhD student, University College London, London, UK

5. Consultant neurosurgeon, King's College Hospital NHS Foundation Trust, London, UK

Corresponding

author

Meriem Amarouche

Postal address King’s College Hospital NHS Foundation Trust, Denmark Hill, Brixton,

London SE5 9RS

E-mail [email protected]

Telephone 02032999000

Fax numbers None used

Key words: Neurosurgery, referrals, online referral system, opinions on neurosurgeons,

medical education.

Word count: 3932

Data sharing statement: Extra data is available by emailing [email protected]

Contributors: MA and CMT were involved in conception and design of the project. JN, SD,

NK, NA, DC, FH, TJ, NK, DM, SM, SO, OP, IR, RS, HT, and BV were involved in the acquisition

of data. MA and CMT were involved in the interpretation of data. MA, JN, SD and R-MDS

drafted the manuscript. MA, JN, SD, BC, R-MDS and CMT were involved in revising the

manuscript and approved the version published.

Funding: This study did not require any funding.

Disclosure: The authors report no financial interests or potential conflicts of interest related

to the research described in this paper.

Ethics approval: Not required.

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Abstract

Objectives: Making accurate neurosurgery referrals can be stressful hence the increased

reliance on online referral systems (ORS) across the UK. Opinions of neurosurgeons on ORS

are extensively reported but those of referrers have hardly been sought. Our study aims at

ascertaining our referring colleagues’ views on our ORS and its impact on patient care, their

opinions on neurosurgeons and how to improve our referral process.

Setting: 14 district general hospitals and one teaching hospital.

Participants: 641 healthcare professionals across a range of medical and surgical specialties

including doctors of all grades, nurses and physiotherapists were interviewed by medical

students using a smart phone application.

Results: The survey gathered the opinion of 641 healthcare professionals. Although 92%

were aware of the ORS, 74% would routinely phone the on-call registrar either before or

after making referrals online. The majority (44%) believed their call to relate to a life-

threatening emergency. 62% of referrers considered the ORS helpful in informing patients’

care and 48% had a positive opinion of their interaction with neurosurgical registrars. On

ways to improve the ORS, 50% selected email/text confirmation of response sent to

referrers and 16% to referring consultants.

Conclusion: A collaborative relationship between referring departments and neurosurgery is

paramount to delivering high quality patient care. We believe that using a universal ORS

would improve the efficiency of referrals. Additionally, given the lack of exposure to

neurosurgery during and after medical school, we recommend the implementation of an

educationally tailored approach to dealing with referrals made to neurosurgery alongside

ORS to optimise referrer satisfaction and patient care.

Strengths and limitations of this study

- Our study reports the opinions of referrers rather than that of neurosurgeons on the

use of a regional online referral system.

- Our study involved 15 referring hospitals and gathered the largest sample size of

respondents published to date on this topic.

- Our study was conducted at a regional level and only assessed opinions on a single

referral system.

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Introduction

Referrals to tertiary services are critical in ensuring that patient care is delivered according

to national standards and timeframes. Emergency departments, for example, refer 20-40%

of their patients for a specialist opinion or admission 1. Making an accurate and safe referral

can however be difficult and stressful 2-4

and requires effective and efficient communication.

It also requires an understanding of the factors in the history, examination and

investigations that are “rate determining steps” in decision making for the receiving

specialty but may not be obvious points to ask for the referring doctor. Miscommunication

and poor information sharing between healthcare professionals is one of the major causes

of preventable death or disability during hospital admissions, and a leading cause of adverse

surgical events 5 6

. Although responsibility for care is shared between medical teams, there

is a significant asymmetry in neurosurgical expertise 7 and it is therefore our duty to ensure

that the advice we provide is correctly recorded and appropriately implemented.

Traditional verbal and paper-based handover and referral systems have inherent flaws,

which can impact on patient care and lead to heightened medico-legal risk for the referring

and receiving teams. Verbal handovers have been shown to result in poor documentation,

and the significant loss and misinterpretation of information 7-9

. Similarly, paper-based

systems suffer from illegibility, inadequate paper-trails, incomplete, missing or delayed

information, and loss of patients within the system 10

. This is compounded by staff changes

from one shift to the next, which can lead to amplification of errors and also unavoidably

results in referrals being revisited by clinicians who have not seen the original patient

personally, and to whom the patient has been handed-over 11

.

Online referral systems (ORS) have been shown to be superior to traditional phone and

paper-based referrals in neurosurgery: documentation is greater, since all important

information is mandatory; the rate of duplication of information during hand-over is

reduced 10

; the response rate to referrals is higher; communications are time-stamped from

a designated individual, and phone calls to the on-call neurosurgery registrar are reduced

which improves continuity of patient encounters and time management for all parties 10 11

.

Moreover, thorough documentation of patient notes via ORS offers both referring and

receiving institutions medicolegal security during patient transfer 10

. ORS also provides a

valuable data capture tool for audit and quality improvement.

There are several ORS databases currently in use in the UK 10-12

with a steady increase in the

number of neurosurgical units changing their traditional telephone referral process to an

online one as the primary way of referring a patient for a neurosurgical opinion. This

suggests a change in attitude towards online referrals and that the logistical and

infrastructural difficulties initially encountered have been overcome 10

. There is however

very little in the literature about the experience of those referring to neurosurgery and how

these changes have affected their practice and perceptions.

The aim of this study is to ascertain the opinions that referring healthcare professionals

have of our online referral process and how they feel it impacts patient management. We

also want to gather their perceptions of the interaction with the on-call neurosurgical

registrars and investigate how our referral process can be improved.

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Methods

Our ORS was built in 2008 and was designed to receive and manage patient referrals and

transfers to the neurosurgical unit at a major teaching hospital in the UK 10

. Local referrers

are able to self-register using their General Medical Council (GMC) number and completed

referrals are instantly received by our department. Updates are visible to the referring

hospital in real time with the date and time of the updates being automatically recorded. All

relevant healthcare professionals within the neurosurgical department are able to access,

review and respond to referrals on the system. The system also highlights pending and

updated referrals. Imaging is linked and viewed separately via the Picture Archiving and

Communications System (PACS). Currently, all our referring hospitals use this ORS as the

primary way of referring a patient to our department, compared to only three hospitals

when the system was first launched in 2008 10

. Our department is increasingly reliant on this

ORS to provide neurosurgical advice, with the objective of limiting phone calls to true life-

threatening emergencies only.

We performed an audit of the number of phone calls made to the on-call neurosurgical

phone in October 2014 and again in February 2016 after changes were made to the ORS by

allowing referrers to directly fill in and submit their referral. We then conducted a face-to-

face survey using an online survey app (www.quicktapsurvey.com) in 15 hospitals who

regularly refer patients to our department over a period of five days in May 2016. A wide

range of medical and surgical specialties likely to refer patients for a neurosurgical opinion

were selected. Medical professionals included doctors of all grades (foundation year doctors

to consultant grades), nurses and physiotherapists. A 15 question survey (Table 1) was

designed by a senior neurosurgical registrar (MA) and the senior consultant who was also

involved in the creation of the ORS (CT). The survey was disseminated by medical students

and was completed on a smart phone application by respondents.

Table 1 – The 15 question survey disseminated to healthcare professionals at 15 referring hospitals. DVH –

Darent Valley Hospital; PRUH – Princess Royal University Hospital; QEQM – Queen Elizabeth the Queen

Mother Hospital; QEW – Queen Elizabeth Hospital Woolwich; TWH – Tunbridge Wells Hospital; and WHH –

William Harvey Hospital.

Results

We have noticed a dramatic decrease in the number of phone calls made to our

department’s on-call registrar from 11,683/month in October 2,014 to 2,581/month in

February 2016 achieving a total reduction of 88%. This meant referrers were no longer put

on hold for a long period of time before their call was taken. Similarly, the total number of

unanswered calls decreased from 69.7% in October 2014 to just under 9% in February 2016.

Our face-to-face survey gathered the opinion of 641 healthcare professionals from 15

referring hospitals. The average number of respondents per hospital was 43 with a range of

18 – 104 respondents. There was a good distribution across a large number of medical

specialties (n=290, 45%), accident and emergency (n=129, 20%), surgical specialties (n=117,

18%), paediatrics (n=50, 8%), ITU/anaesthetics (n=46, 7%) and other specialties (n=9, 1%).

All medical grades were represented: foundation year trainees (n=162, 25%), ST1-3 or

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equivalent (n=182, 28%), ST4-8 or equivalent (n=97, 15%), consultant (n=68, 11%) as well as

nurses (n=102, 16%) and physiotherapists (n=30, 5%).

Questions 1 to 4 were mandatory and the subsequent questions were answered by 95% of

respondents on average (range of 91% to 99%). Of the 641 total respondents, 519 (81%)

stated they refer patients to neurosurgery. The results of questions 5 to 15 will therefore be

based on those who refer to neurosurgery, excluding any non-respondents to a given

question.

Opinions of the referrers on the referral process and the online referral system

A large number of respondents were aware of our ORS (n=476, 92%). The majority (n=321,

62%) stated referring less than five patients to our neurosurgical department in the six

months preceding the survey, followed by 5 to 10 patients (n=144, 28%) and more than 10

patients referred (n=51, 10%). Whilst registrars (46%) and consultants (82%) would take the

initiative to refer patients for a neurosurgical opinion, the majority of foundation trainees

(85%), ST1-3 grades (73%), nurses (72%) and physiotherapists (86%) would first discuss with

a more senior colleague, be it a registrar or consultant.

On average, 54 % of referrers agreed or strongly agreed that our ORS is user friendly and

easy to fill in especially foundation trainees (58%) and ST1-3 grades (57%). Despite this, 74%

of the respondents would still phone the on-call neurosurgery registrar either before

making an online referral (32%) or after a referral has been submitted (43%) whilst 26%

stated they would only refer online (Figure 1). We were therefore keen to understand the

reasons behind using the phone in addition to, or instead of, referring a patient online.

Three main reasons were identified: 44% of respondents believed their call to be related to

a life-threatening emergency, 26% stated they called because no response was provided on

the ORS and 19% were merely executing seniors’ requests.

Figure 1: Grades of the 74% of referrers who continue to phone the on-call registrar before

or after making an online referral.

Just below half the referrers reported that the responses provided in our ORS were

complete (47%) whereas 45% felt the answers were incomplete or non-existent (8%). When

those results were assessed based on the grade of the referrers, three groups had

outstanding results compared to the cohort overall. The majority of referring consultants

and physiotherapists felt that the responses provided on the ORS were incomplete (41%

and 86% respectively) whereas 70% of the nurses who referred patients to neurosurgery

reported a complete response to their request. However, the small total number of

respondents in these three categories, compared to the number of junior doctors, could

potentially explain the outstanding results (junior doctors n=403, consultants n=56, nurses

n=20 and physiotherapists n=7).

To the statement “the ORS has improved handover and decreased the time spent chasing a

neurosurgical management plan”, the responses were almost evenly spread into the three

given options with a small majority either agreeing or strongly agreeing with this

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assumption (37%), whilst 33% had a neutral opinion and 31% disagreed or strongly

disagreed with the statement. The same three groups of consultants, nurses and

physiotherapists had outstanding results, providing a neutral response at 33%, 43% and 67%

respectively. Documentation on the ORS was considered helpful in informing patients’

management plan by 62 % of referrers on average, with a breakdown by medical grades as

follows: foundation year trainees (70%), ST1-3 (62%), ST4-8 (66%) and consultants (46%)

(Figure 2).

Figure 2: Opinion of referrers by grade on the effect of the ORS on patient care based on the

answers provided to the statement: “Referring my patient to neurosurgery via the online

referral system changed/informed their management plan”.

Opinions of the referrers on the interaction with the neurosurgery registrars

Just under half the respondents (48%) either agreed or strongly agreed that the

neurosurgical registrars they spoke to over the phone were polite and helpful, whilst only

21% disagreed or strongly disagreed with this statement. This held true when the results

were grouped according to the referrers’ grades. Half the number of consultants surveyed

were very satisfied with their interaction with the on-call neurosurgery registrars over the

phone. A similar percentage of registrars (52%) and more junior referring colleagues (46%)

were also pleased with their interaction with us. Our physiotherapy colleagues had a more

neutral opinion (33%), albeit without any negative responses provided. In contrast, 60% of

the surveyed nurses were satisfied with their interaction with the on-call registrars (Figure

3).

Figure 3: Opinion of referrers by grade on their interaction with our on-call neurosurgery

registrars based on the answers provided to the statement “The neurosurgery registrar I

spoke to on the phone was polite and helpful”.

Opinions of the referrers on the ways forward with the referral process and the ORS

Five options to improve our ORS were provided in our survey, with the possibility to only

choose one. Half the respondents favoured receiving an email or text message confirming

that a response to their referral has been entered on the system (n=244, 50%). The use of a

generic login, allowing other healthcare professionals to check the advice provided by

neurosurgery, received the vote of 85 respondents (17%). The proposition of sending an

email or text message to the consultant in charge of the patient’s care, notifying them of the

neurosurgical response to the referral, was the third favourite option (n=78, 16%). We also

offered to supply condition specific referral forms, such as for cauda equina syndrome or

subarachnoid haemorrhage, to guide the referrer in providing the information required to

provide an informed opinion, but this only appealed to 9% of the respondents (n=46). The

least favourite option was the possibility to access the ORS on a personal smart phone

(n=36, 7%).

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Discussion

Due to the increasing time, resource and bed pressures pervasive throughout the healthcare

system in the UK, there is focus on trying to modify referral and transfer systems to

optimise identifying and managing time sensitive referrals 13

. The introduction of the first

real time ORS in neurosurgery might have been faced with some resistance in 2008 10

but

almost a decade later, online referrals are fully integrated into the daily practice of a large

number of neurosurgical departments in the UK. The impact of using ORS on neurosurgical

registrar burden has been explored by several authors 10-12 14

but little is known about the

perceptions and opinions of the primary users of these systems: the local referrers. We

conducted the first regional survey in order to obtain an understanding of the way our

colleagues perceive the referral process and the way healthcare professionals and patients

benefit from using our ORS. We also set out to probe the opinion referring colleagues have

of their interaction with our registrars. Finally, strongly believing that the ORS is an asset to

both our neurosurgical department and the referring departments, we asked referrers their

opinion on the way to improve our existing system to allow it to better suit their needs and

render it more efficient.

Our data confirms that our colleagues are generally satisfied with the referral system we

currently have in place. The majority report that it is user friendly and that it helps inform

patient care. Nevertheless, a large number of referrers continue to phone the on-call

neurosurgery registrar either before or after making a referral online. Even though our

results show that the use of the ORS has helped significantly decrease the number of phone

calls made to the on-call registrar, this number was still dialled 89 times a day in February

2016. Our survey identified the fact that referrers tend to perceive the neurosurgical

conditions they encounter as being life-threatening emergencies as being the main reason

behind these phone calls. It also revealed that, in the majority of cases, an individual

healthcare professional refers only a very small number of patients to neurosurgery (less

than five patients in six months). Any given neurosurgical condition is, therefore, unlikely to

be encountered more than once by any single referrer, reducing their personal experience

and, potentially, their learning.

Unlike most specialties, there are no national guidelines for undergraduate neurosurgery

teaching in the UK 15

, resulting in many medical students and junior doctors not having

formal teaching from neurosurgeons and potentially no interaction with the specialty, until

they are faced with a patient with a neurosurgical condition whilst on a medical, surgical or

A&E job. A recent study, of over 350 students at nine UK medical schools, showed that one

third of final year students have difficulty in knowing when a neurosurgery referral is

required 16

. After medical school, teaching opportunities in clinical neurosurgery are also

uncommon. This highlights the need for neurosurgical educational events aimed at referring

departments, increasing awareness of available guidelines and policies such as the Society

of British Neurological Surgeons “treat and transfer” policies 17 18

and simple cost effective

strategies, for instance, the 5Cs emergency consultation model 19

.

Making an accurate and safe referral can however be difficult and stressful 2-4

and requires

effective and efficient communication. Gulsin et al 20

highlight that there is little formal

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referral guidance for referring clinicians. Bradley 21

and Lindfield 22

have piloted a training

programme to teach referral skills to medical students and newly qualified doctors,

respectively. There is however no definitive evidence yet whether using a structured referral

for time critical emergencies improves the quality of the referral 23

. Electronic referral

systems have therefore been used in an attempt to address this issue by prompting

referrers for points that are particularly important in neurosurgical decision making 10

.

Our survey showed that 20% of our colleagues are dissatisfied with the current ORS. Keen to

understand potential causes of referrer dissatisfaction in order to better address any issues,

we would like to highlight the work from Storey et al. 9. They identified inconsistent advice

and management of patients who are not accepted for transfer as the two key sources of

referrer dissatisfaction. The former relies heavily on the experience of the registrar

providing the advice and on the opinion of the on-call consultant. A given plan might be

altered after it is discussed with a more senior colleague or if on-call duties are handed over

to a new consultant. Although not specifically addressed by our data, we believe that the

use of a real time ORS is likely to decrease the incidence of inconsistent advice by ensuring

written documentation of all the conversations. This allows both referring and neurosurgical

teams to have instantaneous access to the conversation trail and avoids misinterpretation

of the advice, a problem often reported with paper-based and telephone based referrals.

Patients not accepted for transfer to a neurosurgical unit present the referring team with

ongoing clinical care for conditions they might not be familiar with. Local teams are also left

to update patients and families without, sometimes, being aware of the rationale behind a

specific management plan. They may also not have insight into why some seemingly similar

cases are accepted for transfer to a neurosurgical unit and others are not. Anecdotal

evidence from the authors suggests that a brief explanation for the rationale in cases where

the patient is not accepted for transfer goes a long way towards fostering confidence in the

referring team. This again reinforces our opinion for a more educationally tailored approach

to neurosurgical referrals. We do however acknowledge that this can be difficult to achieve

in an overstretched neurosurgical service.

With this in mind, the second aim of our survey was to understand the opinion our referring

colleagues have of their interaction with the on-call neurosurgery registrars. One paper

states that radiology, general surgery, neurosurgery and cardiology are a subset of

specialties that are negatively perceived by referrers 24

. This is not supported by our data

where half the respondents to our survey either agreed or strongly agreed that their

interaction with the neurosurgical registrars was positive. Whilst rude and dismissive

behaviour in the workplace should not be tolerated nor excused, it is important to try to

understand potential causes in order to reduce and ultimately banish this behaviour.

Factors such as poor understanding of the challenges encountered by other specialties,

physical and mental fatigue as well as lack of communication skills are the main factors

identified by our review of the literature as contributing to unprofessional behaviour in the

workplace.

To underline the importance of relationships between neurosurgery and external

departments, it is worth noting the results of a Canadian qualitative study on the perception

of neurosurgeons by patients. Whilst competence and qualifications formed part of a

positive perception, a significant component of patient confidence came from positive

referral from another clinician 25

. The opinion colleagues have of one other does not only

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influence patient perception, but it also impacts the way medical professionals interact with

each other. Individuals need to appreciate the “on the ground” challenges faced by one

another in order to be able to work together efficiently. Pressures faced by A&E

departments are well covered by the media, but less is known about pressures in acute

medical specialties for example 26

. In order to provide efficient and timely tertiary

management, a tight cooperation is required between district general and teaching

hospitals. Encouraging such cooperation can be initiated at an individual level by promoting

and encouraging events such as taster days, cross-specialty social and teaching events.

Fatigue is well known to negatively impact the safety and performance of healthcare

professionals 27-29

. What is perhaps less known, is that it can also significantly impact their

affective state 30 31

. Saadat et al. evaluated the impact of partial sleep deprivation on the

mood and the cognitive skills of 21 paediatric anaesthesiologists at a tertiary care children's

hospital during a regular non call day and following a 17 hours’ overnight shift 30

. They

demonstrated that the lack of sleep significantly affected tension, anger, fatigue, confusion,

irritability and feeling jittery, (P < 0.05). Vigour, energy, and confidence were also

significantly decreased and the paediatric anaesthesiologists were found to be less

“talkative” after a night shift (P < 0.05). It is not difficult to see how this data can be

extrapolated to the currently over stretched UK healthcare system.

Some authors have sought to find solutions to unprofessional behaviour by promoting

education and training for medical students and newly qualified doctors 21 22 32

. This training

has been reported to increase the students’ self-confidence, but there remains little

evidence that these skills can be transferred to clinical settings 32

. Since 2010, junior

neurosurgical residents in the United States start their training by attending boot camps to

enhance not only their psychomotor skills, but also their professionalism and

communication skills 33

. The published results suggest that the courses are effective and

well accepted amongst the residents 33

. The boot camp approach has more recently been

adopted in the UK 34

. In addition, other courses such as equality and diversity courses are

also available in the UK. These courses are attended by health care professionals of all

grades and backgrounds and are often mandatory during training and for revalidation 35

.

Whilst improving the above mentioned human factors is indeed of paramount importance,

it is more likely to positively and efficiently influence working conditions and patient care if

it is reinforced by the use of technology, of which ORS are the perfect example. We

increasingly rely on technology to support almost every aspect of our daily life from

communication, to shopping and transportation. It therefore seems natural that care and

communication within the healthcare system should also benefit from these advancements.

Our referring colleagues have expressed the wish of receiving an email or text confirmation

when a response to their referral is entered in the system as the main way of improving our

current referral system. We have been working on implementing this following the

completion of the survey. We are also working on a more tailored referral system offering

standardised condition-specific referral forms to help referrers with limited neurosurgical

knowledge provide relevant information to allow timely processing of their referrals.

Perhaps, the main way forward with ORS would be to use the same referral system at a

national level with an accompanying training module to increase the familiarity of referring

healthcare professionals with common and life-threatening neurosurgical conditions.

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Conclusion

We have conducted the first large-scale regional survey to assess opinions on our ORS from

the referrers’ point of view. Our results confirm that our colleagues have a positive opinion

of our ORS and feel that it positively impacts patient care. Safe and accurate referrals are

however difficult to make. They require an understanding of the factors in the history,

examination and investigations that are “rate determining steps” in decision making for the

receiving specialty, which may not be obvious details for the referring doctor given the lack

of exposure to neurosurgery during and after medical school. We believe that the way

forward to improve referrer satisfaction is to encourage an educationally tailored approach

to dealing with referrals made to neurosurgery. We do however acknowledge that this can

be difficult to achieve in an overstretched UK health service.

A positive and collaborative relationship between referring departments and neurosurgery

is paramount to delivering high quality patient care whether these patients are transferred

to a neurosurgical tertiary centre or managed at their local hospitals. As both the

neurosurgical service and the referring departments are under significant time and resource

pressures, the management of neurosurgical conditions in general, and emergencies in

particular, needs to evolve and adapt to the current resources available. The use of ORS is

one way of optimising patient and referrer satisfaction. Other suggestions for optimising

this process include increased neurosurgical teaching at medical school, condition specific

referral templates, educational liaisons between neurosurgery and the referring

department, and taking steps to mitigate the effect of adverse workplace human factors.

ORS also need to be continually improved making use of evolving technology to achieve

greater user satisfaction. The implementation of a universal referral system to neurosurgery

in the UK might be a big step towards ensuring that we achieve the common goal of

neurosurgeons and referrers alike: a high standard in patient care.

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32. Buckley S, Ambrose L, Anderson E, et al. Tools for structured team communication in

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34. RM deSouza DW. A career in neurosurgery BMJ careers2015 [Available from:

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For peer review only0 10 20 30 40 50 60 70 80 90

Physiotherapist

Nurse

F1/F2

SHO

Registrars

Consultant

Yes- Before Ireferonline

Yes- AfterI/colleaguesreferonline

No- Iusuallyreferonline

NoResponse

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For peer review only0 10 20 30 40 50 60 70 80 90 100

Physiotherapist

Nurse

F1/F2

SHO

Registrars

Consultant

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

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Questions

category

Questions Answer Options

Demographic

questions

1. Do you refer to

neurosurgery?

Yes

No

2. Which hospital are

you based at?

Canterbury

Conquest

Croydon

DVH

Guy’s

King’s

Lewisham

Maidstone

Medway

PRUH

QEQM

QEW

St Thomas’ Hospital

TWH

WHH

3. Which speciality do

you work for?

Medical specialties

(cardiology, care of

the elderly,

rehabilitation,

gastroenterology,

haematology,

general medicine,

neurology, stroke,

oncology, pain

medicine, renal,

respiratory)

Surgical specialties

(cardiothoracic

surgery, ENT,

general surgery,

maxillofacial

surgery,

ophthalmology,

urology, vascular

surgery, trauma and

orthopaedics)

Accident and

emergency

Paediatrics

(neonatology,

paediatrics,

paediatric ICU)

ITU/anaesthetics

Other specialties

(psychiatry, GP,

integrated

discharge team,

maternity,

physiotherapy)

4. What is your grade? Foundation years (FY1, FY2)

ST1 – 3 or equivalent


Consultant

Nurse

Physiotherapist

Opinions on

the referral

process and

the online

referral system

5. Are you aware of the

online referral

system?

Yes

No

6. How many patients

have you referred in

the last 6 months?

Less than 5 patients

5 – 10 patients

More than 10 patients

7. Do you refer to

neurosurgery after

discussing the case

with the…

Consultant

Registrar

I take the initiative to refer

8. The referral form is

user friendly and easy

to fill in

Strongly agree

Agree

Neither Agree nor Disagree

Disagree

Strongly Disagree

9. Do you routinely

phone the on-call

neurosurgery

registrar?

No – I usually refer online

Yes – before I refer online

Yes – after I/colleagues refer online

10. What are the reasons

for which you phone

the on-call

neurosurgery

registrar?

The referral was a life-threatening emergency

It takes too long to complete the referral form

No response was provided on the online

referral system

I was told by my senior colleague to call

I was asked by the neurosurgery registrar

to call back with more information

The local scans were not available to

review by neurosurgery registrar

11. The advice/response

received online was

Complete – I had all the information needed to

manage the patient

Incomplete – I need to follow on my referral

Non-existent

12. The online referral

system has improved

handover and

decreased the time

spent chasing a

neurosurgical

management plan

Strongly agree

Agree


Disagree

Strongly Disagree

13. Referring my patient

to neurosurgery via

the online referral

system

changed/informed

their management

plan

Strongly agree

Agree


Disagree

Strongly Disagree

Opinions on

the interaction

with the

neurosurgery

registrars

14. The neurosurgery

registrar I spoke to on

the phone was polite

and helpful

Strongly agree

Agree


Disagree

Strongly Disagree

Opinions on

the ways

forward with

the ORS

15. In my opinion, the

way forward with the

neurosurgery online

referral system, is to

Referring doctor getting email/text confirmation of a response from neurosurgery

Consultant in charge of the patient’s care getting email/text confirmation of a response

from neurosurgery

Generic login for other healthcare professionals to check the advice (e.g. nurses,

physiotherapists)

Be able to access the referral website on my smart phone

Have a condition specific referral form (e.g. cauda equine, SAH, trauma)

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Table 1 – The 15 question survey disseminated to healthcare professionals at 15 referring hospitals. DVH –

Darent Valley Hospital; PRUH – Princess Royal University Hospital; QEQM – Queen Elizabeth the Queen

Mother Hospital; QEW – Queen Elizabeth Hospital Woolwich; TWH – Tunbridge Wells Hospital; and WHH –

William Harvey Hospital.

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regional survey in the UK.

Journal: BMJ Open

Manuscript ID bmjopen-2017-017495.R1


Date Submitted by the Author: 25-Jul-2017





Surgery




BMJ Open on S



jopen.bmj.com

/B

MJ O


ovember 2017. D

ownloaded from



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neurosurgeons: a large-scale regional survey in the UK.


2, Simon Deacon

2, Nida Kalyal

2, Nikita Adams

2,



1,4, Fehmi Hafiz

2, Tanya


2, Diana Matthews

2, Sophie Mustoe

2, Sabrina Okafor

2, Olivia


2, Reem Samir

2, Hyder Tahir


2 and Christos

Michael Tolias 5




Trust, Brighton, UK



Corresponding

author

Meriem Amarouche


London SE5 9RS





medical education.

Word count: 4309











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Abstract

Objectives: There is an increased reliance on online referral systems (ORS) within

neurosurgical departments across the UK. Opinions of neurosurgeons on ORS are

extensively reported but those of referrers have hardly been sought. Our study aims at





including doctors of all grades, nurses and physiotherapists. Survey responses were

obtained by medical students using a smartphone application.

Results: Although 92% of respondents were aware of the ORS, 74% would routinely phone

the on-call registrar either before or after making referrals online. The majority (44%)

believed their call to relate to a life-threatening emergency. 62% of referrers considered the

ORS helpful in informing patients’ care and 48% had a positive opinion of their interaction

with neurosurgical registrars. On ways to improve the ORS, 50% selected email/text

confirmation of response sent to referrers and 16% to referring consultants.

Conclusion: Our results confirm that referrers feel that using our ORS positively impacts

patient care but that it remains in need of improvement in order to better suit our

colleagues’ needs when it comes to managing neurosurgical patients. We feel that the

implementation of a universal referral system to neurosurgery in the UK alongside the

promotion of neurosurgical education and mitigation of the effects of adverse workplace

human factors are likely to achieve the common goal of neurosurgeons and referrers alike: a

high standard in patient care.




- It was conducted at a regional level and only assessed opinions on a single referral

system.

- It involved 15 referring hospitals and gathered the largest sample size of


- Although the large number of responses obtained is likely to have captured an

accurate opinion of our referrers, we cannot guarantee that these are representative

of the opinions of the entire referring population.

- In retrospect, the question assessing opinions on the interaction with the

neurosurgery registrar as well as the one addressing the ways forward with the ORS

could have been more elaborate to allow a better analysis of the results.

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Introduction











surgical events 5 6















.




reduced 10




.











. There is however







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Methods

Our ORS was built in 2008 and was designed to receive and manage urgent patient referrals

and transfers to the neurosurgical unit at a major teaching hospital in the UK 10

. This system

is not used for elective referrals. It was initially designed to allow data capture and retrieval

of patient information within our department. The data was entered by the on-call

neurosurgical registrar whilst discussing the referral over the phone. This was time

consuming for both the referrer and the neurosurgical registrar. In 2015, the system was

therefore upgraded to allow referrers to have direct access locally following a self-

registration process using their professional membership number. More importantly,

referrers became able to submit a new referral online without needing to go through the

on-call neurosurgery registrar. They were also able to access the outcome of their referral

and enter updates in the journal section of the system and upload files such as pdf

documents and photographs. Submitted referrals are now instantly received by our

department. Updates are visible to the referring hospital in real time with the date and

time of the updates being automatically recorded. All relevant healthcare professionals

within the neurosurgical department are able to access, review and respond to referrals on

the system. The system also highlights pending and updated referrals. Imaging is linked and

viewed separately via the Picture Archiving and Communications System (PACS). All our

referring hospitals use this ORS as the primary way of referring patients to our department,

compared to only three hospitals when the system was first launched in 2008 10

. Our

department is increasingly reliant on this ORS to provide neurosurgical advice, with the

objective of limiting phone calls to true life-threatening emergencies only.

The first part of our study was performed in October 2014 and again in February 2016 when

we analysed the number of phone calls made to the on-call neurosurgical phone in order to

assess the impact that the above mentioned changes have had on the number of calls we

receive. For the second part of our project, we used an online app

(www.quicktapsurvey.com) to conduct a survey in 15 hospitals that regularly refer patients

to our department over a period of five days in May 2016. The survey consisted of 15

questions (Table 1) and was designed by a senior neurosurgical registrar (MA) and the

senior consultant who was also involved in the creation of the ORS (CT). Sixteen medical

students were in charge of disseminating the survey during regular working hours and out

of hours. They approached doctors of all grades (foundation year doctors to consultant

grades), nurses and physiotherapists from a wide range of medical and surgical specialties.

The respondents were selected randomly and those who confirmed being familiar with ORS

were asked to complete our survey using the app on the student’s smartphone. The medical

student conducting the survey was therefore able to answer any questions the respondents

might have instantly.

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Questions

category


Demographic

questions

1. Do you refer to

neurosurgery?

Yes

No


you based at?

Canterbury

Conquest

Croydon

DVH

Guy’s

King’s

Lewisham

Maidstone

Medway

PRUH

QEQM

QEW


TWH

WHH


you work for?

Medical specialties


the elderly,

rehabilitation,

gastroenterology,

haematology,

general medicine,

neurology, stroke,

oncology, pain

medicine, renal,

respiratory)


(cardiothoracic

surgery, ENT,

general surgery,

maxillofacial

surgery,

ophthalmology,

urology, vascular

surgery, trauma and

orthopaedics)

Accident and

emergency

Paediatrics

(neonatology,

paediatrics,

paediatric ICU)

ITU/anaesthetics

Other specialties

(psychiatry, GP,

integrated

discharge team,

maternity,

physiotherapy)




Consultant

Nurse

Physiotherapist

Opinions on

the referral

process and

the online

referral system


online referral

system?

Yes

No



the last 6 months?


5 – 10 patients


7. Do you refer to

neurosurgery after

discussing the case

with the…

Consultant

Registrar




to fill in

Strongly agree

Agree


Disagree

Strongly Disagree

9. Do you routinely

phone the on-call

neurosurgery

registrar?





for which you phone

the on-call

neurosurgery

registrar?




referral system







received online was


manage the patient


Non-existent


system has improved

handover and

decreased the time

spent chasing a

neurosurgical

management plan

Strongly agree

Agree


Disagree

Strongly Disagree


to neurosurgery via

the online referral

system

changed/informed

their management

plan

Strongly agree

Agree


Disagree

Strongly Disagree

Opinions on

the interaction

with the

neurosurgery

registrars




and helpful

Strongly agree

Agree


Disagree

Strongly Disagree

Opinions on

the ways

forward with

the ORS



neurosurgery online




from neurosurgery


physiotherapists)



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Table 1 – The 15 question survey disseminated to healthcare professionals at 15 referring

hospitals. DVH – Darent Valley Hospital; PRUH – Princess Royal University Hospital; QEQM –

Queen Elizabeth the Queen Mother Hospital; QEW – Queen Elizabeth Hospital Woolwich;

TWH – Tunbridge Wells Hospital; and WHH – William Harvey Hospital.

Results

We observed a dramatic 88% decrease in the number of phone calls made to our

department’s on-call registrar, from 11,683/month in October 2014 to 2,581/month in

February 2016 This reduced the time referrers were put on hold before their call was taken.

Similarly, the total number of unanswered calls decreased from almost 70% in October 2014

to just under 9% in February 2016.

Our survey gathered the opinion of 641 healthcare professionals from 15 referring hospitals.

The average number of respondents per hospital was 43 with a range of 18 – 104

respondents. There was a good distribution across a large number of medical specialties

(n=290, 45%), accident and emergency (n=129, 20%), surgical specialties (n=117, 18%),

paediatrics (n=50, 8%), ITU/anaesthetics (n=46, 7%) and other specialties (n=9, 1%). All

medical grades were represented: foundation year trainees (n=162, 25%), ST1-3 or







question.




months preceding the survey, followed by five to 10 patients (n=144, 28%) and more than

10 patients referred (n=51, 10%). Whilst registrars (46%) and consultants (82%) would take

the initiative to refer patients for a neurosurgical opinion, the majority of foundation

trainees (85%), ST1-3 grades (73%), nurses (72%) and physiotherapists (86%) would first

discuss with a senior colleague, be it a registrar or a consultant.

On average, 54% of referrers agreed or strongly agreed that our ORS is user friendly and




stated they would only refer online (Figure 1). Three main reasons were identified: 44% of

respondents believed their call to be related to a life-threatening emergency, 26% stated

they called because no response was provided on the ORS and 19% were merely executing

seniors’ requests.

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reported a complete response to their request.








management plan by 62 % of referrers on average, with a breakdown as follows: foundation

year trainees (70%), ST1-3 (62%), ST4-8 (66%), consultants (46%), physiotherapists (42%)

and nurses (33%) (Figure 2).



neurosurgical registrars they spoke to over the phone were polite and helpful, whilst 21%

disagreed or strongly disagreed and 31% neither agreed nor disagreed with this statement.

When the results were grouped according to the referrers’ grades, half of the number of

consultants and registrars surveyed were satisfied with their interaction with the on-call

neurosurgery registrars (50% and 52% respectively). However, more junior colleagues

seemed less pleased with their interaction with the neurosurgery registrars, with 54% of

ST1-3 and 53% of foundation year trainees either disagreeing or giving a neutral response to

this question. Physiotherapists had a more neutral opinion in general (33%), albeit without

any negative responses provided. In contrast, 60% of the surveyed nurses were satisfied

with their interaction with the on-call registrars (Figure 3).













(n=36, 7%).

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Discussion

The impact of using ORS on neurosurgical registrar burden has been explored by several

authors 10-13

but little is known about the perceptions and opinions of the primary users of

these systems: the local referrers. We have conducted the first regional survey in the UK in

order to gain a better understanding of the way referring colleagues perceive our referral

process and the way healthcare professionals and patients benefit from using our ORS. We

also set out to probe the opinion referring colleagues have of their interaction with our

registrars and discuss their opinions on the way to improve our existing ORS to allow it to

better suit their needs and render it more efficient.

Whilst our colleagues seem aware of the referral process we currently have in place, the

majority (74%) would still regularly phone the on-call neurosurgery registrar either before or

after making an online referral. Our data offers two potential explanations: (i) referrers tend

to perceive the neurosurgical conditions they encounter as being life-threatening

emergencies and/or (ii) we are not perceived as being efficient enough in providing

responses to the referrals made online.

Why are neurosurgical conditions often perceived as being life-threatening? Unlike most

specialties, there are no national guidelines for undergraduate neurosurgery teaching in the

UK 14

. Medical students and junior doctors are therefore unlikely to interact with our

specialty until they face patients with neurosurgical conditions whilst on a medical, surgical

or A&E job. Indeed, a recent study, of over 350 students at nine UK medical schools, showed

that one third of final year students have difficulty in knowing when a neurosurgery referral

is required 15

. Our data has also highlighted the fact that individual healthcare professionals

tend to refer a very small number of patients to neurosurgery (less than five patients over a

period of six months). A referrer is therefore unlikely to encounter a neurosurgical condition

more than once, thus potentially reducing their ability to independently manage similar

patients in the future as well as limiting their learning process. We therefore feel that we

need to adopt a more educationally tailored approach to neurosurgical referrals. By this we

mean that the potentially limited neurosurgical experience of our referring colleagues needs

to be taken into account when discussing a referral. We argue that guiding colleagues into

making accurate referrals by taking the time to provide additional explanation if necessary

or by increasing their awareness of available guidelines and policies, such as the Society

of British Neurological Surgeons “treat and transfer” policies 16 17 for example, is likely

to serve a triple purpose: improve the quality of the referrals we receive, promote a better

understanding of neurosurgical conditions and ultimately, improve patient care. We do

however acknowledge that this can be difficult to achieve in an overstretched neurosurgical

service and that it is likely to require a significant cultural change.

Our survey was not designed to audit our response process to the referrals we receive

online but we have nevertheless reflected on the potential factors contributing to our

referring colleagues’ dissatisfaction. Our current ORS highlights both newly submitted and

updated referrals in bold. However, the former appear at the top of the list whereas the

latter do not. Older referrals with ongoing questions from our referring colleagues are often

only reviewed and answered after a follow-up call is received. Whilst the first part of our

audit shows that we have managed to significantly decrease the number of phone calls we

receive since the modifications implemented in 2015, the on-call phone number was still

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dialled 89 times a day on average in February 2016. This is likely to divert the attention of

the on-call registrar from answering new referrals towards dealing with older ones, resulting

in further follow-up calls. The results of the present survey have made us realise the need

for better ways of highlighting unresolved referrals and we are in the process of updating

our ORS in that respect. An encouraging two thirds of respondents did however state

that the use of our ORS was helpful in informing patients’ management plan hence

reinforcing our belief in the importance of optimising our ORS to better suit the needs of

our referrers and match their expectations.

It is also worth considering the work of Storey et al. 9 when reflecting on the above. They

identified inconsistent advice and management of patients who are not accepted for

transfer as the two key sources of referrer dissatisfaction. The former relies heavily on the

experience of the registrar providing the advice and on the opinion of the on-call consultant.

A given plan might be altered after it is discussed with a more senior colleague or if on-call

duties are handed over to a new consultant. Although not specifically addressed by our

data, the use of a real time ORS is likely to contribute to decrease the incidence of

inconsistent advice by ensuring written documentation of all the conversations. This allows

both referring and neurosurgical teams to have instantaneous access to the conversation

trail and avoids misinterpretation of the advice, a problem often reported with paper-based

and telephone based referrals. It is however important that we strive to provide such

responses in a timely manner as discussed above. Moreover, we also acknowledge that the

use of an ORS is not a stand-alone solution to referrers dissatisfaction and that the human

factors discussed throughout this paper are also of paramount importance. Patients not

accepted for transfer to a neurosurgical unit present the referring team with ongoing clinical

care for conditions they might not be familiar with. Local teams are also left to update

patients and families without, sometimes, being aware of the rationale behind a specific

management plan. They may also not have insight into why some seemingly similar cases

are accepted for transfer to a neurosurgical unit and others are not. Anecdotal evidence

from the authors suggests that a brief explanation for the rationale in cases where the

patient is not accepted for transfer goes a long way towards fostering confidence in the

referring team.

This brings us to discussing the second aim of our survey: the opinion our referring

colleagues have of their interaction with the on-call neurosurgery registrars. The survey

returned mixed opinions with almost half the respondents perceiving our registrars as being

polite and helpful whereas the other half did not. Bradley et al. report that neurosurgery is

amongst the subset of specialties that are perceived negatively by referrers alongside

radiology, general surgery, and cardiology 18

. Our survey only included one question on this

subject and, in retrospect, would certainly have benefitted from a more elaborated

questionnaire to identify factors that are specific to our practice. Rude and dismissive

behaviour in the workplace should not be tolerated nor excused so, with that in mind, we

sought advice from the literature to understand potential causes and identify ways to

reduce and ultimately banish this behaviour. Factors such as lack of communication skills,

physical and mental fatigue and poor understanding of the challenges encountered by other

specialties were the recurrent themes we came across.


education and training for medical students and newly qualified doctors 19-21

. This training

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.


professionals 24-26






. They


irritability and feeling jittery (P < 0.05). Vigour, energy, and confidence were also









. The opinion colleagues have of one another does not only

influence patient perception, but it also impacts on the way medical professionals interact

with each other. Individuals need to appreciate the “on the ground” challenges faced by one







and encouraging events such as taster days, cross-specialty teaching and social events.

The final objective of our survey was to identify ways to improve our ORS. Our referring

colleagues have expressed the wish of receiving an email or text confirmation when a

response to their referral is entered in the system as the main way of improving our current

referral system. We have been working on implementing this following the completion of

the survey. In addition to the improvements discussed above, and in view of the lack of

exposure to neurosurgery during and after medical school, we are also working on a more

tailored referral system offering standardised condition-specific referral forms to help

referrers with limited neurosurgical knowledge provide relevant information to allow timely

processing of their referrals. Perhaps, the main way forward with ORS would however be to

use a universal referral system at a national level with an accompanying training module to

increase the familiarity of referring healthcare professionals with common and life-

threatening neurosurgical conditions.

Conclusion

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We have conducted the first large-scale regional survey in the UK to assess opinions on our

ORS from the referrers’ point of view. Our results confirm that referrers feel that using our

ORS positively impacts patient care but that it remains in need of improvement in order to

better suit our colleagues’ needs when it comes to managing neurosurgical patients.

Although no other studies exist to allow accurate comparison, we believe that our

experience is likely to be similar to that of other neurosurgical units across the UK. By

openly discussing both the satisfactory and the less positive results elicited by our survey,

we hope to promote a change in the way neurosurgical referrals are dealt with. The

implementation of a universal referral system to neurosurgery in the UK, the promotion of

education whilst discussing referrals with colleagues who are likely to have minimal

exposure to neurosurgery as well as taking steps to mitigate the effect of adverse workplace

human factors would be big steps towards ensuring that we achieve the common goal of

neurosurgeons and referrers alike: a high standard in patient care.









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References



10.1136/emj.2007.051631



10.1136/emj.2003.008409








informatics 2012;81(11):723-32. doi: http://dx.doi.org/10.1016/j.ijmedinf.2012.05.014








doi: 10.1308/003588407x168352



10.1136/bmjquality.u203531.w2516



10.3109/02688697.2011.566381



J Neurosurg 2016;30(2):191-4. doi: 10.3109/02688697.2016.1161171



10.3109/02688697.2011.625507



10.3109/02688697.2012.674579



2015;29(6):753-7. doi: 10.3109/02688697.2015.1054361





(2015) http://www.sbns.org.uk/index.php/download_file/view/975/87/2015 [Available

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from: http://www.sbns.org.uk/index.php/download_file/view/975/87/ accessed 02

March 2017.


https://www.nice.org.uk/guidance/cg176/chapter/1-Recommendations - transfer-from-

hospital-to-a-neuroscience-unit2014 [Available from:


hospital-to-a-neuroscience-unit2017.







10.1080/0142159X.2016.1215412







10.1016/j.jsurg.2014.06.016



march 2017 2017.





Suppl):7-18.


Sleep 1996;19(4):318-26.






1737.105715



10.3171/2015.4.JNS15113



March 2017.

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Figure 1: Grades of the 74% of referrers who continue to phone the on-call registrar before or after making an online referral.

224x110mm (72 x 72 DPI)

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Figure 2: Opinion of referrers by grade on the effect of the ORS on patient care based on the answers provided to the statement: “Referring my patient to neurosurgery via the online referral system

changed/informed their management plan”.

219x105mm (72 x 72 DPI)

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Figure 3: Opinion of referrers by grade on their interaction with our on-call neurosurgery registrars based on the answers provided to the statement “The neurosurgery registrar I spoke to on the phone was polite and

helpful”.

219x102mm (72 x 72 DPI)

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regional survey in the UK.

Journal: BMJ Open

Manuscript ID bmjopen-2017-017495.R2


Date Submitted by the Author: 11-Oct-2017





Surgery




BMJ Open on S



jopen.bmj.com

/B

MJ O


ovember 2017. D

ownloaded from



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neurosurgeons: a large-scale regional survey in the UK.


2, Simon Deacon

2, Nida Kalyal

2, Nikita Adams

2,



1,4, Fehmi Hafiz

2, Tanya


2, Diana Matthews

2, Sophie Mustoe

2, Sabrina Okafor

2, Olivia


2, Reem Samir

2, Hyder Tahir


2 and Christos

Michael Tolias 5




Trust, Brighton, UK



Corresponding

author

Meriem Amarouche


London SE5 9RS





medical education.

Word count: 3958











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Abstract

Objectives: There is an increased reliance on online referral systems (ORS) within

neurosurgical departments across the UK. Opinions of neurosurgeons on ORS are

extensively reported but those of referrers have hardly been sought. Our study aims at





including doctors of all grades, nurses and physiotherapists. Survey responses were

obtained by medical students using a smartphone application.

Results: Although 92% of respondents were aware of the ORS, 74% would routinely phone

the on-call registrar either before or after making referrals online. The majority (44%)

believed their call to relate to a life-threatening emergency. 62% of referrers considered the

ORS helpful in informing patients’ care and 48% had a positive opinion of their interaction

with neurosurgical registrars. On ways to improve the ORS, 50% selected email/text

confirmation of response sent to referrers and 16% to referring consultants.

Conclusion: Our results confirm that referrers feel that using our ORS positively impacts

patient care but that it remains in need of improvement in order to better suit our

colleagues’ needs when it comes to managing neurosurgical patients. We feel that the

promotion of neurosurgical education and mitigation of the effects of adverse workplace

human factors are likely to achieve the common goal of neurosurgeons and referrers alike: a

high standard in patient care.




- It was conducted at a regional level and only assessed opinions on a single referral

system.

- It involved 15 referring hospitals and gathered the largest sample size of


- Although the large number of responses obtained is likely to have captured an

accurate opinion of our referrers, we cannot guarantee that these are representative

of the opinions of the entire referring population. The responses were obtained

using convenience sampling. Our data can therefore suffer from selection bias and,

as mentioned above, may not be generalisable.

- In retrospect, the question assessing opinions on the interaction with the

neurosurgery registrar as well as the one addressing the ways forward with the ORS

could have been more elaborate to allow a better analysis of the results.

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Introduction











surgical events 5 6















.




reduced 10




.











. There is however







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Methods

Our ORS was built in 2008 and was designed to receive and manage urgent patient referrals

and transfers to the neurosurgical unit at a major teaching hospital in the UK 10

. This system

is not used for elective referrals. It was initially designed to allow data capture and retrieval

of patient information within our department. The data was entered by the on-call

neurosurgical registrar whilst discussing the referral over the phone. This was time

consuming for both the referrer and the neurosurgical registrar. In 2015, the system was

therefore upgraded to allow referrers to have direct access locally following a self-

registration process using their professional membership number. More importantly,

referrers became able to submit a new referral online without needing to go through the

on-call neurosurgery registrar. They were also able to access the outcome of their referral

and enter updates in the journal section of the system and upload files such as pdf

documents and photographs. Submitted referrals are now instantly received by our

department. Updates are visible to the referring hospital in real time with the date and

time of the updates being automatically recorded. All relevant healthcare professionals

within the neurosurgical department are able to access, review and respond to referrals on

the system. The system also highlights pending and updated referrals. Imaging is linked and

viewed separately via the Picture Archiving and Communications System (PACS). All our

referring hospitals use this ORS as the primary way of referring patients to our department,

compared to only three hospitals when the system was first launched in 2008 10

. Our

department is increasingly reliant on this ORS to provide neurosurgical advice, with the

objective of limiting phone calls to true life-threatening emergencies only.

The first part of our study was performed in October 2014 and again in February 2016 when

we analysed the number of phone calls made to the on-call neurosurgical phone in order to

assess the impact that the above mentioned changes have had on the number of calls we

receive. For the second part of our project, we used an online app

(www.quicktapsurvey.com) to conduct a survey in 15 hospitals that regularly refer patients

to our department over a period of five days in May 2016. The survey consisted of 15

questions (Table 1) and was designed by a senior neurosurgical registrar (MA) and the

senior consultant who was also involved in the creation of the ORS (CT). Sixteen medical

students were in charge of disseminating the survey during regular working hours and out

of hours. They approached doctors of all grades (foundation year doctors to consultant

grades), nurses and physiotherapists from a wide range of medical and surgical specialties.

The respondents were selected randomly and those who confirmed being familiar with ORS

were asked to complete our survey using the app on the student’s smartphone. The medical

student conducting the survey was therefore able to answer any questions the respondents

might have instantly.

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Questions

category


Demographic

questions

1. Do you refer to

neurosurgery?

Yes

No


you based at?

Canterbury

Conquest

Croydon

DVH

Guy’s

King’s

Lewisham

Maidstone

Medway

PRUH

QEQM

QEW


TWH

WHH


you work for?

Medical specialties


the elderly,

rehabilitation,

gastroenterology,

haematology,

general medicine,

neurology, stroke,

oncology, pain

medicine, renal,

respiratory)


(cardiothoracic

surgery, ENT,

general surgery,

maxillofacial

surgery,

ophthalmology,

urology, vascular

surgery, trauma and

orthopaedics)

Accident and

emergency

Paediatrics

(neonatology,

paediatrics,

paediatric ICU)

ITU/anaesthetics

Other specialties

(psychiatry, GP,

integrated

discharge team,

maternity,

physiotherapy)




Consultant

Nurse

Physiotherapist

Opinions on

the referral

process and

the online

referral system


online referral

system?

Yes

No



the last 6 months?


5 – 10 patients


7. Do you refer to

neurosurgery after

discussing the case

with the…

Consultant

Registrar




to fill in

Strongly agree

Agree


Disagree

Strongly Disagree

9. Do you routinely

phone the on-call

neurosurgery

registrar?





for which you phone

the on-call

neurosurgery

registrar?




referral system







received online was


manage the patient


Non-existent


system has improved

handover and

decreased the time

spent chasing a

neurosurgical

management plan

Strongly agree

Agree


Disagree

Strongly Disagree


to neurosurgery via

the online referral

system

changed/informed

their management

plan

Strongly agree

Agree


Disagree

Strongly Disagree

Opinions on

the interaction

with the

neurosurgery

registrars




and helpful

Strongly agree

Agree


Disagree

Strongly Disagree

Opinions on

the ways

forward with

the ORS



neurosurgery online




from neurosurgery


physiotherapists)



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Table 1 – The 15 question survey disseminated to healthcare professionals at 15 referring

hospitals. DVH – Darent Valley Hospital; PRUH – Princess Royal University Hospital; QEQM –

Queen Elizabeth the Queen Mother Hospital; QEW – Queen Elizabeth Hospital Woolwich;

TWH – Tunbridge Wells Hospital; and WHH – William Harvey Hospital.

Results

We observed a dramatic 88% decrease in the number of phone calls made to our

department’s on-call registrar, from 11,683/month in October 2014 to 2,581/month in

February 2016 This reduced the time referrers were put on hold before their call was taken.

Similarly, the total number of unanswered calls decreased from almost 70% in October 2014

to just under 9% in February 2016.

Our survey gathered the opinion of 641 healthcare professionals from 15 referring hospitals.

The average number of respondents per hospital was 43 with a range of 18 – 104

respondents. There was a good distribution across a large number of medical specialties

(n=290, 45%), accident and emergency (n=129, 20%), surgical specialties (n=117, 18%),

paediatrics (n=50, 8%), ITU/anaesthetics (n=46, 7%) and other specialties (n=9, 1%). All

medical grades were represented: foundation year trainees (n=162, 25%), ST1-3 or







question.




months preceding the survey, followed by five to 10 patients (n=144, 28%) and more than

10 patients referred (n=51, 10%). Whilst registrars (46%) and consultants (82%) would take

the initiative to refer patients for a neurosurgical opinion, the majority of foundation

trainees (85%), ST1-3 grades (73%), nurses (72%) and physiotherapists (86%) would first

discuss with a senior colleague, be it a registrar or a consultant.

On average, 54% of referrers agreed or strongly agreed that our ORS is user friendly and




stated they would only refer online (Figure 1). Three main reasons were identified: 44% of

respondents believed their call to be related to a life-threatening emergency, 26% stated

they called because no response was provided on the ORS and 19% were merely executing

seniors’ requests.

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reported a complete response to their request.








management plan by 62 % of referrers on average, with a breakdown as follows: foundation

year trainees (70%), ST1-3 (62%), ST4-8 (66%), consultants (46%), physiotherapists (42%)

and nurses (33%) (Figure 2).



neurosurgical registrars they spoke to over the phone were polite and helpful, whilst 21%

disagreed or strongly disagreed and 31% neither agreed nor disagreed with this statement.

When the results were grouped according to the referrers’ grades, half of the number of

consultants and registrars surveyed were satisfied with their interaction with the on-call

neurosurgery registrars (50% and 52% respectively). However, more junior colleagues

seemed less pleased with their interaction with the neurosurgery registrars, with 54% of

ST1-3 and 53% of foundation year trainees either disagreeing or giving a neutral response to

this question. Physiotherapists had a more neutral opinion in general (33%), albeit without

any negative responses provided. In contrast, 60% of the surveyed nurses were satisfied

with their interaction with the on-call registrars (Figure 3).













(n=36, 7%).

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Discussion

The impact of using ORS on neurosurgical registrar burden has been explored by several

authors 10-13

but little is known about the perceptions and opinions of the primary users of

these systems: the local referrers. We have conducted the first regional survey in the UK in

order to gain a better understanding of the way referring colleagues perceive our referral

process and the way healthcare professionals and patients benefit from using our ORS. We

also set out to probe the opinion referring colleagues have of their interaction with our

registrars and discuss their opinions on the way to improve our existing ORS to allow it to

better suit their needs and render it more efficient.

Whilst our colleagues seem aware of the referral process we currently have in place, the

majority (74%) would still regularly phone the on-call neurosurgery registrar either before or

after making an online referral. Our data offers two potential explanations: (i) referrers tend

to perceive the neurosurgical conditions they encounter as being life-threatening

emergencies and/or (ii) we are not perceived as being efficient enough in providing

responses to the referrals made online. The willingness of referrers to discuss a case and its

subtleties with another human being over the phone instead of going through an online

process is also a possible explanation for the high number of phone calls we continue to

receive. This is however beyond the scope of our study but it would benefit from further

research.

Why are neurosurgical conditions often perceived as being life-threatening? Unlike most

specialties, there are no national guidelines for undergraduate neurosurgery teaching in the

UK 14

. Medical students and junior doctors are therefore unlikely to interact with our

specialty until they face patients with neurosurgical conditions whilst on a medical, surgical

or A&E job. Indeed, a recent study, of over 350 students at nine UK medical schools, showed

that one third of final year students have difficulty in knowing when a neurosurgery referral

is required 15

. Our data has also highlighted the fact that individual healthcare professionals

tend to refer a very small number of patients to neurosurgery (less than five patients over a

period of six months). A referrer is therefore unlikely to encounter a neurosurgical condition

more than once, thus potentially reducing their ability to independently manage similar

patients in the future as well as limiting their learning process. We therefore feel that we

need to adopt a more educationally tailored approach to neurosurgical referrals. By this we

mean that the potentially limited neurosurgical experience of our referring colleagues needs

to be taken into account when discussing a referral. We argue that guiding colleagues into

making accurate referrals by taking the time to provide additional explanation if necessary

or by increasing their awareness of available guidelines and policies, such as the Society

of British Neurological Surgeons “treat and transfer” policies 16 17 for example, is likely

to serve a triple purpose: improve the quality of the referrals we receive, promote a better

understanding of neurosurgical conditions and ultimately, improve patient care. We do

however acknowledge that this can be difficult to achieve in an overstretched neurosurgical

service and that it is likely to require a significant cultural change.

Our survey was not designed to audit our response process to the referrals we receive

online but we have nevertheless reflected on the potential factors contributing to our

referring colleagues’ dissatisfaction. Our current ORS highlights both newly submitted and

updated referrals in bold. However, the former appear at the top of the list whereas the

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latter do not. Older referrals with ongoing questions from our referring colleagues are often

only reviewed and answered after a follow-up call is received. Whilst the first part of our

audit shows that we have managed to significantly decrease the number of phone calls we

receive since the modifications implemented in 2015, the on-call phone number was still

dialled 89 times a day on average in February 2016. This is likely to divert the attention of

the on-call registrar from answering new referrals towards dealing with older ones, resulting

in further follow-up calls. The results of the present survey have made us realise the need

for better ways of highlighting unresolved referrals and we are in the process of updating

our ORS in that respect. An encouraging two thirds of respondents did however state

that the use of our ORS was helpful in informing patients’ management plan hence

reinforcing our belief in the importance of optimising our ORS to better suit the needs of

our referrers and match their expectations.

It is also worth considering the work of Storey et al. 9 when reflecting on the above. They

identified inconsistent advice and management of patients who are not accepted for

transfer as the two key sources of referrer dissatisfaction. The former relies heavily on the

experience of the registrar providing the advice and on the opinion of the on-call consultant.

A given plan might be altered after it is discussed with a more senior colleague or if on-call

duties are handed over to a new consultant. Although not specifically addressed by our

data, the use of a real time ORS is likely to contribute to decrease the incidence of

inconsistent advice by ensuring written documentation of all the conversations. This allows

both referring and neurosurgical teams to have instantaneous access to the conversation

trail and avoids misinterpretation of the advice, a problem often reported with paper-based

and telephone based referrals. It is however important that we strive to provide such

responses in a timely manner as discussed above. Moreover, we also acknowledge that the

use of an ORS is not a stand-alone solution to referrers dissatisfaction and that the human

factors discussed throughout this paper are also of paramount importance. Patients not

accepted for transfer to a neurosurgical unit present the referring team with ongoing clinical

care for conditions they might not be familiar with. Local teams are also left to update

patients and families without, sometimes, being aware of the rationale behind a specific

management plan. They may also not have insight into why some seemingly similar cases

are accepted for transfer to a neurosurgical unit and others are not. Anecdotal evidence

from the authors suggests that a brief explanation for the rationale in cases where the

patient is not accepted for transfer goes a long way towards fostering confidence in the

referring team.

This brings us to discussing the second aim of our survey: the opinion our referring

colleagues have of their interaction with the on-call neurosurgery registrars. The survey

returned mixed opinions with almost half the respondents perceiving our registrars as being

polite and helpful whereas the other half did not. Bradley et al. report that neurosurgery is

amongst the subset of specialties that are perceived negatively by referrers alongside

radiology, general surgery, and cardiology 18

. Our survey only included one question on this

subject and, in retrospect, would certainly have benefitted from a more elaborated

questionnaire to identify factors that are specific to our practice. Rude and dismissive

behaviour in the workplace should not be tolerated nor excused so, with that in mind, we

sought advice from the literature to understand potential causes and identify ways to

reduce and ultimately banish this behaviour. Factors such as lack of communication skills,

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physical and mental fatigue and poor understanding of the challenges encountered by other

specialties were the recurrent themes we came across.


education and training for medical students and newly qualified doctors 19-21

. This training











.


professionals 24-26






. They


irritability and feeling jittery (P < 0.05). Vigour, energy, and confidence were also









. The opinion colleagues have of one another does not only

influence patient perception, but it also impacts on the way medical professionals interact

with each other. Individuals need to appreciate the “on the ground” challenges faced by one







and encouraging events such as taster days, cross-specialty teaching and social events.

The final objective of our survey was to identify ways to improve our ORS. Our referring

colleagues have expressed the wish of receiving an email or text confirmation when a

response to their referral is entered in the system as the main way of improving our current

referral system. We have been working on implementing this following the completion of

the survey. In addition to the improvements discussed above, and in view of the lack of

exposure to neurosurgery during and after medical school, we are also working on a more

tailored referral system offering standardised condition-specific referral forms to help

referrers with limited neurosurgical knowledge provide relevant information to allow timely

processing of their referrals. Perhaps, the main way forward with ORS would however be to

use a universal referral system at a national level with an accompanying training module to

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increase the familiarity of referring healthcare professionals with common and life-

threatening neurosurgical conditions.

Conclusion

We have conducted the first large-scale regional survey in the UK to assess opinions on our

ORS from the referrers’ point of view. Our results confirm that referrers feel that using our

ORS positively impacts patient care but that it remains in need of improvement in order to

better suit our colleagues’ needs when it comes to managing neurosurgical patients.

Although no other studies exist to allow accurate comparison, we believe that our

experience is likely to be similar to that of other neurosurgical units across the UK. By

openly discussing both the satisfactory and the less positive results elicited by our survey,

we hope to promote a change in the way neurosurgical referrals are dealt with. The

promotion of education whilst discussing referrals with colleagues who are likely to have

minimal exposure to neurosurgery as well as taking steps to mitigate the effect of adverse

workplace human factors would be big steps towards ensuring that we achieve the common

goal of neurosurgeons and referrers alike: a high standard in patient care.









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(2015) http://www.sbns.org.uk/index.php/download_file/view/975/87/2015 [Available

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Figure 1: Grades of the 74% of referrers who continue to phone the on-call registrar before or after making an online referral.

224x110mm (72 x 72 DPI)

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Figure 2: Opinion of referrers by grade on the effect of the ORS on patient care based on the answers provided to the statement: “Referring my patient to neurosurgery via the online referral system

changed/informed their management plan”.

219x105mm (72 x 72 DPI)

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Figure 3: Opinion of referrers by grade on their interaction with our on-call neurosurgery registrars based on the answers provided to the statement “The neurosurgery registrar I spoke to on the phone was polite and

helpful”.

219x102mm (72 x 72 DPI)

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