Article Text

Download PDFPDF

E-referrals: improving the routine interspecialty inpatient referral system
  1. Emma Shephard,
  2. Claire Stockdale,
  3. Felix May,
  4. Alistair Brown,
  5. Hannah Lewis,
  6. Sara Jabri,
  7. Daniel Robertson,
  8. Victoria Moss,
  9. Rob Bethune
  1. Royal Devon and Exeter Hospital, Exeter, UK
  1. Correspondence to Dr Emma Shephard; emmashephard{at}


Interspecialty referrals are an essential part of most inpatient stays. With over 130 referrals occurring per week at the Royal Devon and Exeter Hospital, the process must be efficient and safe. The current paper-based ’white card' system was felt to be inefficient, and a Trust incident highlighted patient safety concerns. Questionnaires reinforced the need for improvement, with concerns such as a lack of referral traceability and delays in the referral delivery due to workload. The aims of the project were to improve patient safety and junior doctor efficiency in the referral process. Through appreciative enquiry and the PDSA (Plan-Do-Study-Act) model, an electronic referral system was developed, piloted within two specialties and later expanded to others with improvements made along the way based on user feedback. The system includes novel features including specialties ’acknowledging' a referral to allow referral progress to be tracked. The system stores all referrals, creating a fully auditable inpatient referral pathway. Qualitative data indicated improvement to patient safety and user experience (n=31). Timings for referrals were measured over a 6-month period; referrals became faster with the electronic system, with average time from decision to refer to referral submission improving from 2.1 hours to 1.9 hours, with a noted statistically significant improvement in timings on a statistical process control chart. An unexpected benefit was that patients were also reviewed faster by specialties. Measuring these changes presented a significant challenge due to the complexity of the referral process, and this was a big limitation. Overall, the re-design of a paper-based referral system into an electronic system has been proven to be more efficient and felt to be safer for patients. This is a sustainable change which is being rolled out Trust-wide. We hope that the reporting of this project will help others considering reviewing their inpatient referral pathways.

  • quality improvement
  • patient safety
  • patient care
  • referral and consultation
  • inpatients

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Contributors The group was mentored by RB who provided an aid in QI methodology and helped with engaging key stakeholders and Trust management. ES, CS, FM, AB, HL, SJ, DR and VM planned the project and all collected quantitative data onto a shared spreadsheet set up by DR. ES then translated these data across to the Life QI system for aid with run chart formation and data analysis. SJ and HL wrote the questionnaires which were both handed out by ES, CS, FM, AB, HL, SJ and VM, and electronically distributed by ES. CS, ES and FM worked with the IT team to produce and adapt the electronic system. ES and CS worked with each specialty individually to implement the system. ES and CS wrote the project for submission, with inputs from RB.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Approval from the ethics board was not sought on the basis that this was a local quality improvement project and not a study on human subjects.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.