How do we intervene? Addressing on-call neurology registrar service demands and reviewing referral quality

<h3></h3> Despite the learning opportunities afforded by on-call experiences, high associated workloads often contribute to trainee dissatisfaction. High workloads can also result in delayed decision-making, affecting quality of experience and costs to service users and providers. Neurology services are increasingly challenged by supply-demand imbalances, however exploring local contextual factors resulting in service inefficiencies remains essential. In a University Hospital-based quality improvement project, we retrospectively analysed 2 months of referral data qualitatively and quantitatively. We identified the acute neurology registrar (on-call from 0900–2100, and servicing acute stroke out- of-hours), had a mean of 31.3 contacts (online + bleep) per day, with higher levels on Friday-Sunday (36.2) then Monday-Thursday (27.7). Weekday bleeps peaked between 1500–1700. Mean time-to- review of inpatient referrals (17.3 hours) varied daily (Tuesday 13.6 hours, Friday 22.3 hours), correlated with referral time (in-hours versus out-of-hours), and was associated with priorly unresolved referral numbers, particularly post-weekends. Of inpatient referrals: 10.9% were admitted as Neurology inpatients, 79.3% were physically reviewed, 88% were deemed ‘wise’, and 65% had referee-to-referrer agreement on review type required. Our systematic assessment identified contextualised improvement targets, facilitating the provision of extra registrar-level acute stroke out-of-hours cover, and reshaping of on-call neurology consultant duties to address demand for afternoon inpatient reviews.