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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.
RESUMO
PURPOSE: To report mortality, after a longer interval, in a cohort of patients with drug-resistant epilepsy treated by temporal lobe surgery between 1975 and 1995. A previous audit of these patients ending December 1, 1997 observed a standardized mortality ratio (SMR) of 4.5. METHODS: We analyzed mortality in a cohort of 306 patients with temporal lobe epilepsy (TLE) who underwent temporal lobe resections between December 1, 1975 and December 1, 1995. Deaths occurring after December 1,1997 and until December 1, 2009 were evaluated. Medical records, death certificates, postmortem examination reports, coroner officer's reports, and coroner's inquest reports were sought, and causes of death were ascertained. Sudden unexpected death in epilepsy (SUDEP) cases were identified. KEY FINDINGS: In 3,569 person-years of follow-up 19 deaths occurred, [SMR 2.00, 95% confidence interval (CI) 1.27-3.13], 14 men (SMR 2.01, 95% CI 1.19-3.39) and 5 women (SMR 1.68, 95% CI 0.70-4.03). On analysis of subgroups, SMRs were significantly elevated in patients with mesial temporal sclerosis (MTS) (SMR 2.50, 95% CI 1.38-4.51), men with MTS (SMR 3.12, 95% CI 1.56-6.25), men with nonspecific lesions (SMR 2.68, 95% CI 1.00-7.09), and right-sided resections in MTS (SMR 3.33, 95% CI 1.39-8.00). During follow-up, six SUDEP cases were observed with a rate of 1/595 person-years. SIGNIFICANCE: In this cohort, the risk for premature death in patients undergoing TLE surgery decreased over time but remained above the standard population. Men had a slightly higher risk than women, as did right-sided resections in MTS, confirming this observation in the original cohort. Although lower, the risk of SUDEP remained. Without up-to-date information on seizure outcome, we were unable to directly relate this to mortality.
