Fibre-optic laryngoscopy is still widely used in daily clinical practice; however, high-definition laryngoscopy using narrow band imaging could be more reliable in characterising pharyngeal and laryngeal lesions.

Endoscopic videos were assessed in a tertiary referral hospital by 12 observers with different levels of clinical experience. Thirty pairs of high-definition laryngoscopy with narrow band imaging and fibre-optic laryngoscopy videos were judged twice, with an interval of two to four weeks, in a random order. Inter- and intra-observer reliability, sensitivity and specificity were calculated in terms of detecting a malignant lesion and a specific histological entity, for beginners, trained observers and experts.

Using high-definition laryngoscopy with narrow band imaging, inter-observer reliability for detecting malignant lesions increased from moderate to substantial in trained observers and experts (high-definition laryngoscopy with narrow band imaging κ = 0.66 and κ = 0.77 vs fibre-optic laryngoscopy κ = 0.51 and κ = 0.56, for trained observers and experts respectively) and sensitivity increased by 16 per cent.

Inter-observer reliability increased with the level of clinical experience, especially when using high-definition laryngoscopy with narrow band imaging.

The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland’s (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care.

The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation.

Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide.

The C4 has played an integral role in the State of Maryland’s pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.

This study aimed to investigate the use of the head and neck cancer risk calculator version 2 in a primary care setting and to evaluate the impact of the risk calculator on the number of referrals stratified by urgency and cancer yield.

Referrals between April 2019 and August 2019, April 2020 and July 2020 (pre-risk calculator) and August 2020 and July 2021 (post-risk calculator) were analysed. Referral urgency, head and neck cancer risk calculator version 2 score, cancer diagnosis, cancer type and further investigations were recorded.

The 2023 patient encounters were analysed; there were 1110 (55 per cent) referrals before head and neck cancer risk calculator version 2 use and 913 (45 per cent) after head and neck cancer risk calculator version 2 use. A higher proportion of older (p < 0.001) and male (p < 0.013) patients were seen post-head and neck cancer risk calculator version 2 use. All cancer cases were seen on the urgent suspicion of cancer pathway post-head and neck cancer risk calculator version 2 use; however, a higher proportion of patients were seen as urgent suspicion of cancer (51.1 vs 83.5 per cent; p < 0.001). Overall, the cancer diagnosis rate increased from 2.7 to 4.1 per cent.

The head and neck cancer risk calculator version 2 had high sensitivity in cancer diagnosis. More studies are required to optimise the predicted versus actual cancer probability gap.

There is limited understanding of treatment pathways for paediatric sleep-disordered breathing. This study explored current UK pathways and what is important to well-being for parents and children.

The study comprised in-depth qualitative interviews (n = 22) with parents of children (2–9 years) with symptoms of sleep-disordered breathing referred to a regional ENT clinic (n = 11), general practitioners who might refer these children to ENT (n = 5) and hospital doctors involved in treating these children (n = 6). Interviews were audio recorded, transcribed verbatim, anonymised and analysed thematically.

General practitioners rarely identify seeing children with sleep-disordered breathing; conversely hospital doctors identify unsuspected issues. Parents are worried their child will stop breathing, but routes to referral and diagnosis are not straightforward. Modern technology can aid investigation and diagnosis. Patient weight is an issue for general practitioners and hospital doctors. Adenotonsillectomy is the treatment of choice, and information on paediatric sleep-disordered breathing is needed.

Guidelines for the management of paediatric sleep-disordered breathing are needed.

Dementia is a progressive illness with a complex biopsychosocial constellation of symptoms faced by millions of individuals and families worldwide. Palliative care teams have specialized in symptom management and end-of-life care for decades; however, the role of palliative care in dementia management is not yet well elucidated. The aim of this systematic review was to understand the impact of palliative care in dementia management.

This systematic review was conducted using a prospective study protocol. Medline and PubMed were searched from January 1, 1998 to October 2017. Eligible studies included single-blind cluster, two-arm parallel cluster, or unblinded randomized controlled trials (RCTs), observational studies, retrospective cohort studies, cross-sectional studies, concurrent mixed methods study, qualitative study, and Delphi studies.

Four key themes were identified in this review: goals of care and end-of-life conversations, symptom management, emergency room visits, and prescribing behavior. In each domain, palliative care consultation either showed benefit or was postulated to have benefit if implemented.

Although the literature to support or refute thematic conclusions is not large, there was a trend toward patient care benefit across several domains. Large RCTs with longer follow-up across different settings should be undertaken to solidify the themes and trends outlined in this review. Understanding the views of healthcare providers including referral sources (i.e., general practitioners and specialists) through qualitative research could optimize palliative care referrals, implement palliative care recommendations, and improve a targeted palliative care education curriculum.

To describe the behavioural and psychiatric problems found in nursing home psychiatric referrals in the Dublin South city area.

We undertook two consecutive surveys of nursing home referrals to the St James’s Hospital psychiatry of old age service over a 2-year period. During the second survey a new clinical nurse specialist was specifically appointed to manage the seven nursing homes included in the study.

The most common reason for referral during survey one was uncooperative/aggressive behaviour (22%). For survey two, patients were most commonly referred for low mood (31%) or agitation (29%). During survey one, the majority of patients assessed were diagnosed with behavioural and psychological symptoms of dementia (41%). This was also a prevalent diagnosis during survey two, affecting 27% of those referred. Only 7% of patients were considered to be delirious during survey one. This rose to 31% the following year making it the most common diagnosis during survey two. Over the 2-year study period, 7% of referred patients were diagnosed with depression. In terms of prescribing practices, the discontinuation rate of antipsychotic mediation following psychiatric input was 13% in survey one. By survey two, this had risen to 47%.

Delirium is often undetected and untreated in nursing homes. Residents presenting with psychiatric symptoms should undergo routine bloods and urinalysis prior to psychiatric referral. Dedicated input from trained psychiatric nursing staff can lead to both an improvement in the recognition of delirium and reduced prescribing rates of antipsychotic medication.

To investigate general practitioners’ (GPs’) desire and perceived added value of point-of-care (POC) troponin, its effect on referral decisions, and test requirements.

Excluding acute coronary syndrome (ACS) in primary care remains a diagnostic challenges for GPs. Consequently, referral rates of chest pain patients are high, while the incidence of a cardiovascular problem is only 8–15%. Previous studies have shown that GPs are interested in a POC troponin test. This test could enhance rapid exclusion of ACS, thereby preventing unnecessary patient distress, without compromising safety and while reducing costs. However, using this test is not recommended in current guidelines due to uncertainty in the test’s potential added value, and the lower sensitivity early after symptom onset as compared with troponin tests in a regular laboratory.

An online survey containing 34 questions was distributed among 837 Dutch GPs in June 2015.

A total of 126 GPs (15.1%) completed at least 75% of the questions. 67.1% of GPs believe that POC troponin tests have moderate to very high added value. Although the availability of a POC test is expected to increase the frequency at which troponin tests are used, it likely decreases (immediate) referral rates. Of the responding GPs, 78.3% only accept 10 min as the maximum test duration, 78.1% think reimbursement of the POC device is required for implementation, and 68.9% consider it necessary that it can be performed with a finger prick blood sample. In conclusion, according to GPs, the POC troponin test can be of added value to exclude ACS early on. Actual test implementation will depend on test characteristics, including test duration, type of blood sample required, and reimbursement of the analyzer.

Improving the informational quality of referrals from primary to secondary care and appropriately re-directing referrals is an important goal of clinical commissioning groups in England. Based on the available empirical evidence, a referral management and booking service that combined referral guidelines, online referral templates and administrative and clinical triage, was developed by a primary care trust in southeast London.

A pilot study of 13 out of 46 practices in the trust was conducted using a mixed methods approach. Referral numbers were investigated by analysing changes in practices’ rates of first outpatient attendances in secondary care. Informational referral quality was assessed by analysing triage outcomes. Semi-structured interviews were used to inquire about practices’ evaluation of the new system. Structured telephone interviews were conducted to assess patients’ satisfaction.

Overall rates of first outpatient attendances declined more strongly for pilot practices than controls. The number of referrals challenged for being incomplete or having insufficient clinical information decreased. The rate of referrals challenged by clinical triage for not conforming to referral guidelines was well below the rate of inappropriate referrals published in the literature. Interviews with practices revealed a number of themes and a broad range of attitudes. Patients were highly satisfied.

Findings provided favourable evidence for the effectiveness of the new referral management system. They were, however, preliminary. If referrals into secondary care continued to be reduced on a long-term basis, the system would be cost effective despite the time and effort required for clinical triage.

To analyse trends in two-week rule referrals for head and neck cancer over 10 years.

Data from two-week referrals received by the Wirral University Hospital NHS Trust between 1 January and 30 June 2012 were compared with similar data from 2002.

A total of 357 referrals were received during the 6-month audit period, compared with 149 during the whole of 2002. Cancer pick-up rates were 9 per cent and 5 per cent in the first and second cycles, respectively.

The annual number of two-week referrals made to our department increased by over 450 per cent in 10 years, but the resulting cancer pick-up rate fell by nearly 50 per cent. Whilst cancer patients need to be seen quickly, the current system is inefficient in parts. Modifications to the treatment pathway should be considered to improve patient care quality and reduce pressure on ENT departments.

To define the important elements of an emergency department (ED) consultation request and to develop a simple model of the process.

From March to September 2010, 61 physicians (21 emergency medicine [EM], 20 general surgery [GS], 20 internal medicine [IM]; 31 residents, 30 attending staff) were questioned about how junior learners should be taught about ED consultation. Two investigators independently reviewed focus group and interview transcripts using grounded theory to generate an index of themes until saturation was reached. Disagreements were resolved by consensus, yielding an inventory of themes and subthemes. All transcripts were coded using this index of themes; 30% of transcripts were coded in duplicate to determine the agreement.

A total of 245 themes and subthemes were identified. The agreement between reviewers was 77%. Important themes in the process were as follows: initial preparation and review of investigations by EM physician (overall endorsement 87% [range 70–100% in different groups]); identification of involved parties (patient and involved physicians) (100%); hypothesis of patient's diagnosis (75% [range 62–83%]) or question for the consulting physician (70% [range 55–95%]); urgency (100%) and stability (74% [range 62–80%]); questions from the consultant (100%); discussion/communication (98% [range 95–100%]); and feedback (98% [range 95–100%]). These components were reorganized into a simple framework (PIQUED). Each clinical specialty significantly contributed to the model (χ2 = 7.9; p value = 0.019). Each group contributed uniquely to the final list of important elements (percent contributions: EM, 57%; GS, 41%; IM, 64%).

We define important elements of an ED consultation with input from emergency and consulting physicians. We propose a model that organizes these elements into a simple framework (PIQUED) that may be valuable for junior learners.

To establish the safety and effectiveness of nurse-led triage of otolaryngology out-patient referrals.

One hundred consecutive general practitioner referrals were reviewed by two consultants, two specialist registrars, two foundation year two senior house officers and two otolaryngology nurses. One of the nurses had received triage training. All referrals were triaged as ‘urgent’, ‘soon’ or ‘routine’ by each rater.

The triage-trained nurse's results demonstrated good agreement with those of the senior consultant (80 per cent). This agreement was similar to that with the other consultant (77 per cent) and the specialist registrars (79 and 82 per cent). Weighted κ statistics (correcting for chance agreement) showed that the triage-trained nurse had the second closest agreement to the senior consultant (0.66). After the actual out-patient appointments, retrospective review of the patients' case notes revealed that none had been triaged inappropriately by the trained nurse, and no urgent cases had been missed.

Triage of out-patient referrals by trained ENT nurses is safe and effective, and is an acceptable alternative to traditional consultant vetting of referrals.

Colorectal cancer is the third most common cancer in the UK. Referral guidance can help general practitioners (GPs) identify predictive symptoms of colorectal cancer at an earlier stage in primary care. The objectives of this study were to test the feasibility of a paper-based assessment tool incorporating the CAPER score, a clinical prediction rule for patients presenting to primary care with lower gastrointestinal (GI) symptoms. Three different recruitment methods and GP compliance with completing the CAPER score were assessed.

Patients aged 45 years and above consulting for bowel-related symptoms were recruited in 25 general practices in five regions in the UK. Two recruitment methods were carried out by practice receptionists and one by the GP (GP-prompted). The assessment tool prompted GPs to calculate a score using CAPER; a score of 35 points or over indicated a study referral. Three audits assessed recruitment success, compliance with the assessment tool and clinical outcomes.

In total, 122 patients were recruited into the trial. Although overall recruitment was low, GP-prompted recruitment was more successful than the other two methods. Most GPs completed a clinical examination (92.6%) as directed by the assessment tool; however, only 64% of GPs completed a rectal examination. GPs did not comply well with carrying out haemoglobin (48%) and faecal occult blood (FOB) tests (38%). Only 55% of the final CAPER scores were calculated correctly by GPs. Four patients were diagnosed with colorectal cancer; all met the referral criteria for the CAPER score; however, only three met the NICE referral criteria.

Overall, recruitment into the study was lower than expected. GP-prompted recruitment was the most effective. Assessment tool compliance was low, which indicates that in future trials a more user-friendly design should be developed.

The 1998 National Health Service White Paper stated that anyone suspected of having a cancer would be seen by a specialist within two weeks. The ‘trigger symptoms’ prompting such referral have been nationally agreed by the National Institute for Health and Clinical Excellence. This study aimed to quantify the diagnostic yield of urgent referrals for suspected head and neck malignancy, and to identify reasons why patients ultimately diagnosed with malignancy may not have been referred via this pathway.

All patients referred to the trust with suspected head and neck malignancy in 2005 were included in the study. Data were obtained on date of referral, date of appointment, reason for referral and which National Institute for Health and Clinical Excellence guideline heading the referral fell under, clinical findings, and final diagnosis. Concurrently, all patients in the trust with a histological diagnosis of head and neck malignancy were identified using the computer records of the pathology department.

One hundred and seventy-seven patients were referred with suspected head and neck malignancy over the one-year study period. Of these, 169 were seen within two weeks. The commonest causes of referral were hoarseness and neck lumps. Of these patients, 22 (12 per cent) were ultimately diagnosed with malignancy. During the one-year study period, 39 patients were diagnosed hospital-wide with head and neck malignancy, 17 of whom had not been referred via the urgent referral pathway. No unifying theme was identified to explain why these patients had not been referred via this pathway.

In a group of patients with symptoms suggestive of head and neck malignancy, only 12 per cent were ultimately diagnosed with cancer. Of all the patients within the trust diagnosed with head and neck cancer, 44 per cent had come from outside the urgent referral pathway.