Journal Article

3-006 Optimising chest pain referrals: a cross-sector and multidisciplinary QIP to reduce inappropriate referrals to a chest pain clinic

Jocson, Khelvin

2025

Overview

Background and Local ProblemA six-month audit at a Rapid Access Chest Pain Clinic in Southeast England found that 20% of referrals were inappropriate, contributing to inefficiencies in service delivery. Given the burden of coronary artery disease in the UK, a Quality Improvement Project (QIP) aimed to reduce inappropriate referrals below 10%, decrease total referrals by 10%, and maintain service capacity to review patients within two weeks.Methods and InterventionStakeholder engagement played a central role, facilitating collaboration across a multidisciplinary action group integrating primary and secondary care. This alignment supported consistency in referral pathways and clinical decision-making. A Root Cause Analysis identified key issues, while a Pareto Analysis prioritised the most significant factors, including referrals for non-anginal chest pain, incomplete information, alternative diagnoses, and patients already under cardiology care. A driver diagram mapped cause-and-effect relationships, and a QIP Decision Matrix determined that updating the referral form was the most feasible and impactful solution. A structured family of measures guided data collection to monitor progress.The Plan-Do-Study-Act (PDSA) framework was used to iteratively test and refine interventions. PDSA-1 applied qualitative data analysis to develop a new referral form, which was subsequently approved. PDSA-2 introduced the form in the Emergency Department over eight weeks, assessing its impact on inappropriate referrals. PDSA-3 expanded implementation across all referral sources, including primary care, over ten weeks. Collaboration between hospital specialists, GPs, and referral coordinators facilitated clear communication and the integration of updated referral criteria into routine practice.ResultsPDSA-1 led to referral form approval. PDSA-2 in ED achieved a 91% reduction in inappropriate referrals but did not lower overall referral volume.Abstract 3-006 Figure 1The new RACPC form[Figure omitted. See PDF]PDSA-3 reduced inappropriate referrals by 66.5%, lowering the baseline rate from 20.6% to 6.9%. Total referrals decreased by 10%. The reduction applied across all targeted causes, most notably eliminating non-anginal pain referrals. Coordination between primary and secondary care enhanced triage processes, contributing to success. Measurement of waiting times was discontinued due to external service changes affecting accuracy.Abstract 3-006 Figure 2PDSA-3 outcomes[Figure omitted. See PDF]ConclusionThe new referral form significantly reduced inappropriate referrals and overall referral volume to the RACPC. The intervention was assessed as sustainable using the five measures of the Sustainability in Quality Improvement (2023) framework. This QIP highlights the value of effective stakeholder engagement, multidisciplinary collaboration, and cross-organisational integration, demonstrating how structured quality improvement methodologies can optimise referral processes and improve service efficiency.

• Publisher: BMJ Publishing Group LTD
• Subject: Collaboration / Pain / Quality improvement