Audit

 
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Dr Laura Reynolds & Dr Kenny Strain

Audit to assess the Accuracy and Appropriateness of Two Week Wait Referrals to an OMFS unit at a District General Hospital

Introduction

As part of the hospital’s quality improvement process Laura and I carried out an audit to assess the “quality” of the referrals that the OMFS department was receiving from GMPs and GDPs. We wanted to look at the information supplied by the referring practitioner and then the appropriateness of the referral in terms of the 2 week wait pathway. 

According to NICE guidance (NICE, 2017), a Head & Neck Cancer pathway referral, or “Two Week Wait” (2WW) referral should be considered in patients with:

  • Unexplained ulceration in the oral cavity lasting more than 3 weeks
  • Persistent or unexplained lump(s) in the neck
  • A lump on the lip and or oral cavity
  • A red or red and white patch in the oral cavity

At Rotherham District General Hospital (RDGH) a referral pro forma has been distributed to GMPs. GDPs however, write written referral letters.

Aims

The aims of this audit were to assess the accuracy and appropriateness of the 2WW referrals received at RDGH over a year. Accuracy was determined by how well the pro forma was completed and whether written referrals provided the same information. Appropriateness was based on whether the clinical findings met the NICE Standards.

Methods

Data was collected retrospectively. 298 referrals were received between 01/09/16-31/09/17. 30 sets of notes were randomly selected, 20 from GMPs and 10 from GDPs in proportion to the referral rates. The data was collected by examining the pro formas and the medical notes.

Results

30% of GMP referrals had correctly filled in all required fields on the pro forma. 0% of GDP referrals had provided all of the equivalent information in their letters (Table 1)

GDP

GMP

Discussed the possibility of cancer

10%

45%

Recorded the smoking status

50%

90%

Recorded the alcohol status

20%

75%

Relevant medical history

70%

95%

Drug history

30%

100%

Pro-forma fully completed / Referral letter gave all required information

0%

30%

Average % of required information provided

77%

89%

Table 1: Results of referral accuracy

10% of referrals (3 cases) were diagnosed as Squamous Cell Carcinoma (SCC). 2 of these cases were GDP referrals and 1 case was a GMP referral.

Based on the NICE referral criteria, 85% of referrals were appropriate. 10% of GMP referrals were inappropriate compared to 20% of GDPs.

GMPs referred a much wider greater variety of lesions in comparison to GDPs, as can be seen in Figure 2.

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Figure 1: Bar chart showing the definitive diagnoses demonstrating a wider range of lesions being referred by GMPs.

10% of cases were SCCs, this corresponds to another similar published audit which found that 8% of 2WW referrals were SCC (Pigott, 2015). The average time for a 2WW referral to be seen in the OMFS Department was 10 days.

Conclusions

The results showed that using a referral proforma drastically improved the accuracy of the referral. We therefore found that GMP referrals tended to be more accurate than GDP referrals, which were most often in a hand-written letter format. As a result of this, we are planning to distribute the pro forma to GDPs and we recommend contacting your nearest OMFS department to see if there is a pro forma in place that your practice could use. The use of such a form will ensure that you are providing the information required by the department and will also reduce the administrative and surgery time needed to complete a referral.

References

Nice Guidelines: Suspected Cancer: Recognition and referral. 2017. URL available at: www.nice.org.uk/guidance/ng12/chapter/1-Recommendations-organised-by-site-of-cancer#head-and-neck-cancers

Pigott L. 2015. Comparison of the diagnostic yield of medical and dental referrals at an oral and maxillofacial 2 weeks rule clinic. Natl J Oral Maxillofac Surg 6(1): 52-54.