Inpatient Endocrinology: a comprehensive specialty service audit and Quality Improvement Project in a large tertiary care centre

Background
Endocrinology is well-established as an outpatient specialty. However, virtually
no data exist on the volume, nature, management and disposal of inpatient
referrals to inform the design and delivery of a quality-assured service.
Methods
We undertook an audit of all activity of the Inpatient Endocrine Service at
University Hospitals Birmingham NHSFT (IES@UHB) between January 2010
and December 2015. Referrals received electronically via the Patient Information
and Communication System (PICS) were collated and information was extracted
pertaining to the timing, source, reason for and disposal of each referral; as well as
to individual case outcomes (length of stay, readmission rate, mortality).
Results
A total of 2,817 actionable inpatient referrals were received over the audit period,
16% relating to readmissions. Referral volume grew at an average rate of 49.2%
year-on-year, from 127 in 2010 to 885 in 2015. Multiple referrals for the same
patient over the same episode of care made up 18.8% of the total workload. The
majority of referrals originated from medical specialty teams (37.1%), followed
by neurosurgery (20.8%); ENT (8.2%); trauma and orthopaedics (6.1%) and
others (!5%). Electrolyte derangement was by far the commonest referral
reason, principally hyponatraemia (22.3%) and hypernatraemia (3.2%). Other
common reasons included advice on hormone replacement therapy (14.6%);
disorders of calcium metabolism (10%); and post-operative review of
hypophysiectomised patients (6.4%). Median length of stay for referred cases
was 15 days and the overall mortality rate over the audit period was 24.5%, with
roughly one third of deaths occurring in hospital. Sixty-nine percent of cases with
recurrent admissions were followed up in outpatients, compared to 36.5% with
non-recurrent admissions.
Conclusions
The IES@UHB serves a high-risk patient population with a wide variety of acute
and decompensated chronic endocrine problems. Audit findings are central in
streamlining the service; as well as in developing appropriate educational
resources for staff.