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INTRODUCTION: In the current financial climate faced by the NHS, it is important that we reduce the amount of inappropriate referrals made to secondary care specialties. ENT Emergency Clinics are one-stop clinics provided by many UK ENT departments to allow more rapid access to ENT services from primary care. However, many referrals to these clinics were considered to be inappropriate, overloading the clinic and delaying referrals to more specialist clinics. We conducted a service improvement project through introduction of referral guidelines and liaising with local GPs. METHODS: We carried out an initial audit of ENT referrals over a one-month period, which suggested that 31% (69/225) of referrals were inappropriate. We developed a guideline referral proforma that included six specific conditions and details of subspecialist clinics available. This was circulated among GPs and A&E doctors and backed up by hospital teaching sessions. Two months later we repeated the audit. RESULTS: Following introduction of guidelines there was a significant reduction in inappropriate referrals from 31% (69/225) to 16% (28/179), p<0.01. Despite significant improvements overall, the proportion of inappropriate referrals from GPs remained higher than those from the local A&E department in both Cycle 1 (42% vs.24%, p<0.01) and Cycle 2 (23% vs. 5%, p<0.01). DISCUSSION AND CONCLUSION: Devising and circulating guideline proformas in conjunction with local education for referring doctors may help reduce the number of inappropriate ENT referrals. This simple and cheap intervention could be used more widely and developed in primary care departments in partnership with local hospitals. Our study also highlights the challenges encountered when introducing new guidelines that affect referrals from doctors in the community. Increasing opportunities for GP trainees to gain some exposure to common conditions presenting to primary care might reduce inappropriate ENT referrals in the future.
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Penetrating neck injuries (PNIs) are uncommon in the UK. The majority of guidelines are from the USA or South Africa. No UK national guidelines exist. Increasing urban violence in the UK has lead to an increase in PNIs. There is a need to develop a PNI guideline that reflects the pathology and experience in the UK. A retrospective review of all PNIs managed at St George's Hospital over an 18 month period was undertaken. Data collected included patient demographics, mechanism of injury, investigations, multidisciplinary team involvement and management. Clinical activity data was correlated to current worldwide literature and a flow-chart style clinical guideline was produced. 25 neck wounds were managed over an 18 month period. 68 % were male, 32 % female with a mean age of 36 years. The mechanism of injury included deliberate self-harm (48 %), stab wounds (32 %), gunshot wounds (4 %), shotgun wounds (4 %) and other accidental causes (12 %). 52 % of wounds were superficial to platysma. 58 % of deep wounds had CT. 42 % of patients with deep wounds also had panendoscopy. Interventional radiology was used in one case (8 %) and a single case was managed jointly with the vascular team (8 %). UK ENT surgeons have limited exposure to neck trauma and dedicated head and neck out-of-hours cover is uncommon. There is a need for UK PNI guidelines that reflect local pathology and experience. The St George's PNI guideline can be used to facilitate assessment, documentation and management of a relatively infrequent emergency presentation.