Giving ourselves a head start: improving the quality of documentation of referrals to neurosurgery

Referrals to neurosurgical units are regularly made by doctors in the emergency department (ED), intensive care and acute medicine, following brain injuries sustained by both traumatic and non-traumatic processes. Although some centres accept electronic referrals, many still rely on telephone conversations with a specialist registrar. The flaw in this style of communication is that only information volunteered or requested is relayed. Furthermore, documentation of these dialogues is often incomplete, omitting specific and vital details. Inconsistent advice from referral centres on the management of such brain injury cases had been highlighted, prompting a review of practices at local level in order to improve quality of patient care. The aim of this project was to identify the current level of documentation and improve this through departmental education and implementation of a referral proforma. National guidelines and a literature review were used to formulate the gold standard for high quality documentation. ED patient notes were retrospectively reviewed over a three month period, assessing adequacy of referral documentation to a neurosurgical centre against the parameters previously set. Initial audit results and specific case studies were presented to ED team members at an educational meeting. A “record of telephone referral to neurosurgery” (RTRN) form was also introduced. Re-audit against the same set of standards was conducted to assess any change in level of documentation and use of the form itself. The results of this project have shown that, although departmental education improves clinical practice, following the introduction and use of a protocol such as the RTRN there was a significant improvement in the level, and therefore quality of, documentation.