Graydon Sara L, Thompson Andrew E
Department of Medicine, Division of Rheumatology, University of Western Ontario, London, Ontario, Canada.
J Rheumatol. 2008 Jul;35(7):1378-83. Epub 2008 May 15.
Rheumatologists triage referrals in order to assess those patients who may benefit from early intervention. Success of triage strategies requires accurate transfer of clinical information between the primary caregiver and rheumatologist. We describe a prototype triage system and formally evaluate the quality of referral content to a rheumatologist's practice.
All new referrals were reviewed by a rheumatologist and, based on the information conferred, assigned a grade using a prototype triage system. This grade reflected each case's suspected urgency and guided the timing of consultation. After the initial rheumatologic consultation a post hoc grade was assigned to each case based on the clinical information gathered. Agreement between referral and consultation grades was assessed. All cases graded as urgent at the time of consultation, and thus felt to be truly urgent, were examined for the quality of content of their referral letters.
Two hundred six referrals were evaluated. Ninety-six cases (47%) experienced a grade change between referral and consultation. Thirty-five cases (17%) were upgraded to urgent status after consultation, reflecting inappropriately triaged truly urgent patients. Analysis of referral letters for truly urgent cases revealed the absence of a presumptive diagnosis, symptom duration, and documentation of involved joints in over 30% of referrals.
The absence of basic historical, examination, and laboratory markers accounted for inappropriate triage of urgent cases. Our study recognizes dysfunction within the current model of care and questions the development of standardized referral tools as a solution. Other models of care should be investigated for this patient population.
风湿病专家对转诊进行分类，以评估那些可能从早期干预中获益的患者。分类策略的成功需要在初级护理人员和风湿病专家之间准确传递临床信息。我们描述了一个原型分类系统，并正式评估了转诊至风湿病专家诊所的内容质量。
所有新的转诊病例均由一名风湿病专家进行审查，并根据所提供的信息，使用原型分类系统进行分级。该分级反映了每个病例的疑似紧急程度，并指导会诊时间。在首次风湿病会诊后，根据收集到的临床信息为每个病例分配一个事后分级。评估转诊分级与会诊分级之间的一致性。对所有在会诊时被评为紧急的病例（因此被认为是真正紧急的），检查其转诊信的内容质量。
共评估了206例转诊病例。96例（47%）在转诊与会诊之间出现了分级变化。35例（17%）在会诊后被升级为紧急状态，这反映了对真正紧急患者的分类不当。对真正紧急病例的转诊信分析显示，超过30%的转诊信中没有初步诊断、症状持续时间以及受累关节的记录。
缺乏基本的病史、检查和实验室指标导致了紧急病例的分类不当。我们的研究认识到当前护理模式存在功能障碍，并对开发标准化转诊工具作为解决方案提出质疑。对于这一患者群体，应研究其他护理模式。
