Challenges at either end of the referral process

The trust was presented with challenges at both ends of the district nurse referral process—from acute staff making the referral to community nursing teams accepting, prioritising and delivering the requested care.

Requesting a district nurse referral was a time-consuming and disjointed process for staff within the trust’s acute hospital. Referrals were completed outside of its core EPR system and would involve accessing a form on their local PC or downloaded from the intranet. Valuable time would be wasted coming out of the EPR to access the form, inputting clinical data already recorded in the EPR to complete the referral and then emailing to the district nursing team from the user’s email account.

Several teams were good at saving the forms in shared locations so other members of staff had easy access. However, in some cases, this process wasn’t consistently followed, and it caused issues if a team member needed to locate and/or update the form and check that it had been submitted to the community team. Since there was no way to tell if the referral had been sent if the sender was not on duty, this led to confusion for staff and, in some instances, teams would have to duplicate work and restart the process to avoid delays in patient care. In parallel, community teams may have received more than one referral for the same patient.

For community-district nursing teams that still use paper processes to manage referrals, the main issue was forms missing key information, such as a patient’s address, precise reason for referral, wound care information, patient discharge date, visit dates. Stacey Leigh, Digital Matron and Digital Clinical Safety Officer at Bolton NHS Foundation Trust, explained the impact this had on nursing teams: “We did some time and motion studies and calculated that they were spending approximately two hours a day ringing the wards to compile missing information so we could triage the referrals correctly. The teams would also run into the same issue when contacting the wards if members of staff who completed the form weren’t on shift and the information couldn’t be located.”

End-to-end referral management

The trust decided that in order to mitigate the issues and optimise the process, the district nurse referrals should be requested within the central Sunrise EPR. The trust’s digital team and Altera completed the implementation within 12 months, of which a significant amount of time was spent ensuring the process complied with complex transcribing and medication policies to maintain patient safety across care settings. The configuration of the referral form included mandatory elements, embedded guidance and pop-up messages, and conditional logic to ensure the forms were accurately completed and could only be submitted if all required data was entered. This has meant that there are now fewer inappropriate referrals received and the district nurses receive all crucial data elements that help them assess, prioritise and schedule ongoing care without having to attempt to get more information from ward staff.

With the district nurse referrals built into the EPR, clinicians can access the form as part of their regular workflows and without having to look for a separate form elsewhere. On creating new referrals, relevant information automatically feeds in from the patient’s record saving staff re-keying information already documented. For example, if a patient has a wound and has been seen by tissue viability during their time at hospital, it will also automatically pull through the key information to the referral form, along with relevant medication information so that the district nurses are aware of the patient’s status at discharge. This is true also for the current treatment so they can select the appropriate dressings and equipment to take with them when they make the initial home visit.

All community triage nurses and district nurse managers now have read access to the Sunrise EPR system, enabling them to review the patient’s clinical course through any previous visits. The referrals are no longer received via email but directly to a specific list in Sunrise. This provides the recipient with a direct link into the patient’s full EPR record. From there, the district nursing teams can accept or decline the referral and acute staff can monitor that it’s been received and accepted.

The go-live went smoothly and teams across both care settings quickly adjusted to the improved process. Within the first full month of being live, more than 230 referrals were processed.

Meaningful impact to patients and staff

Streamlining the district nurse referral process across Bolton has improved patient safety, clinical care and patient experience by enabling:

• A reduction in patient incidents.
• A joined-up care record across secondary and community care.
• More reliable and accurate information sharing between teams to inform care, saving clinical time and closing communication gaps.
• Full compliance with medication policies across care settings.
• Paper processes replaced with safer digital workflows with a full audit trail.
• Ability to quantify and report on referrals and metrics that previously required manual calculation.

Time savings are being gained at various points during the referral process, including:

• The ability for acute teams to complete the whole referral process from within the Sunrise EPR system. Nurses can create the referral form directly in the EPR, at which point patient data is automatically fed into the form and on completion the form can be shared with community teams from within the EPR.
• Fewer instances of referral forms being misplaced after shift changes, preventing duplication of work.
• Fewer instances of inappropriate referrals due to embedded guidance within the referral form.
• Fewer instances of duplicated referrals due to limitations for ward staff to check if referral was sent.
• Less time required by nursing and administration teams to triage forms by calling wards to clarify patient information, owing to referral forms containing more accurate mandatory information.
• Increased monitoring and reporting capabilities because all referral data is stored and accessible within the EPR, making the process more efficient.

"The district nurse referral within Sunrise has been so valuable for the acute and district nursing teams. Now with one single source of truth, the teams no longer have to duplicate work or spend time investigating if a referral has been completed. This single process allows for one route to referral. This will be enhanced further when the community teams go live on Sunrise later this year and can continue to document in the patient records as a seamless entry from acute to community,”

said Zoe Fitzsimmons,
Chief X Information Officer at Bolton NHS Foundation Trust.

Sarah Hewinson, District Nursing Matron at Bolton NHS Foundation Trust, added: “Fully digitising district nurse referrals and integrating into the Sunrise™ EPR has been a game changer for staff in terms of releasing time to care. The flow of information from acute teams is more streamlined and communication between care settings is much better. On the rare occasion that information is missing while we’re triaging requests, we can access Sunrise and fill the gap ourselves, which is a massive improvement from spending time calling the relevant ward. We can promptly triage and ensure the patient’s care is delivered without any delay.”

Reflecting overall on the implementation and process improvements, Stacey Leigh, said: “Implementing an electronic district nurse referral within our EPR has promoted joined up working across our acute and community teams, streamlining patient care and making it more reliable. It has not only reduced the amount of time it takes to complete the referral but made the content more accurate, therefore freeing up nurses’ time and enabling a positive patient experience.”

Stacey concluded by sharing what’s next on the digital horizon: “In the summer, we’ll be enhancing the referral process by rolling out district nursing read/write access to Sunrise EPR as part of a wider roll out of the EPR across acute and community. Typically, secondary and community use different EPR systems so we’re really excited to progress to this ground-breaking stage of our digital strategy and scale up similar efficiency benefits across other services. The potential for that is huge!”