A closed loop audit on in-patient neurology referral system at St. Hellier Hospital, Sutton, Carshalton

<h3></h3> St. Hellier Hospital provides consultant-driven neurology in-patient referrals(NRs) review during working- hours. St. George’s Hospital(SGH), South-London, covers urgent out-of-hours service. Our goal was to assess and improve NRs service. In an 8-week audit from 1/10/2022, data on demographics, referral contents, and documentation were collected. Following improvements, an 8-week re-audit occurred from 1/2/2023. Analysis of 178 NRs(55% males, mean-age 71, new-referrals:re-referrals 3:1) revealed 62% duplications in 45/178 re-referrals, mainly due to team changes(78%). Out-of-hours NRs(53%) resulted in 39.4% requiring urgent SGH opinions at night, causing delays. Clinical information was suboptimal in 107(80%), and 66(37.1%) had unclear referral reasons. Discrepant contact information (43%) stemmed from night-to-morning team transfers. Consultant replies using ‘neurology-in- patient-referral-acknowledgement’ were present in 68%. In the re-audit, 159 NRs(51% males, mean-age 69, new-referrals:re-referrals 9:1) showed significantly reduced duplicate re-referrals (2/20,p&lt;0.001). Urgent out-of-hours NRs decreased (28/71,p:&lt;0.01), with only 4 (p:&lt;0.01) requiring urgent SGH opinions. Suboptimal clinical information was found in 26(18%) NRs, and 38(23.9%) had unclear referral reasons. Contact information discrepancy reduced to 19/133 (13%,p&lt;0.01). Replies using ‘neurology-in-patient-referral- acknowledgement’ improved (94.9%,p&lt;0.01). Improvements of referral form, junior doctor education, and ‘neurology-in-patient-referral- acknowledgement’ enforcement improved referral quality, pathway adherence, reduced delays, and mitigated potential medicolegal consequences. Ongoing industrial actions posed limitations for the re-audit.