1551 Patient Safety Audit: Adherence to The ENT Referral Proforma

Medway Hospital’s ENT on-call team triages referrals according to the local ENT Emergency referral guideline. Recently, a poor referral and handover resulted in a patient with post-tonsillectomy bleeding collapsing while on an immovable trolley in ED minors. Following reflection, a referral proforma was formulated to help the on-call ENT doctor ensure safe patient management through a traffic light system. The proforma includes patient and referrer detail along with four referral outcomes or colours, depending on patient stability, each with prompts for initial management. This audit aims to measure adherence to the ENT referral proforma. We performed a retrospective cohort analysis of compliance to the new ENT referral pathway. Proformas completed between 18th October and 17th November 2020 were included. A quasi-random method of sampling was utilized, every two of three paper forms. The data was inputted on Excel. Each proforma was marked for documentation of ten aspects. Of the total seventy-seven proformas, one scored 100%. On average, proformas were 80% completed. The most documented, at 100%, was patient detail. While the least documented, at 8%, was stating if ED were informed of the plan. 5% of referrals required potential resuscitation in ED, of which none met all criteria for a safe handover. The audit shows that the referral proforma is currently not adequately completed. This provides a basis for further intervention to improve patient safety for ENT referrals. The next step would be to inform the department to discuss why adherence is poor and maximize future documentation.