Improving the likelihood of neurology patients being examined using patient feedback

Abstract

We aimed to establish whether recall of elements of the neurological examination can be improved by use of a simple patient assessment score.In a previous study we demonstrated that in-patients referred to neurology at two United Kingdom (UK) hospitals were not fully examined prior to referral; we therefore designed a larger quality improvement report with 80% power to detect a 10% increase in tendon hammer or ophthalmoscope use following an educational intervention.In-patients referred to neurology over a four month period (in hospitals in the UK (10), Jordan (1), Sweden (2), and the United Arab Emirates (1)) were asked whether they recalled being examined with a tendon hammer (T), ophthalmoscope (O), and stethoscope (S) since admission. The results were disseminated to local medical teams using various techniques (including Grand Round presentations, email, posters, discounted equipment). Data were then collected for a further four month period post-intervention.Pre-intervention and post-intervention data were available for 11 centres with 407 & 391 patients in each arm respectively. Median age of patients was 51 (range 13-100) and 49 (range 16-95) years respectively, with 44.72% and 44.76% being male in each group. 264 patients (64.86%) recalled being examined with a tendon hammer in the pre-intervention arm, which significantly improved to 298 (76.21%) (p<0.001). Only 119 patients (29.24%) recollected examination with an ophthalmoscope pre-intervention, which significantly improved to 149 (38.11%)(p=0.009). The majority of patients (321 (78.87%)) pre-intervention recalled examination with a stethoscope, which significantly improved to 330 (84.4%) to a lesser extent (p=0.045).Results indicate that most patients are not fully examined prior to neurology referral yet a simple assessment score and educational intervention can improve recall of elements of the neurological examination and thus the likelihood of patients being examined neurologically. This is the largest and - to our knowledge - only study to assess this issue. This has implications for national neurological educators.

Testing the reflexes

“…In general practice testing the reflexes can be helpful in deciding if neurological, neurosurgical, or orthopaedic referral is needed—despite this, there is evidence that most patients in the United Kingdom are not fully examined before referral 7. For specific circumstances where tendon reflex testing is essential, see box 1.…”

Highlights from this issue

“…“Fundoscopy—discs not seen”, “ophthalmoscope not available”, or simply a blank space where the ophthalmoscopy findings should appear, are commonly seen in the notes of patients admitted with neurological problems across the world. One recent study found that only 30% of such patients recalled being examined with an ophthalmoscope 1. This unsatisfactory situation must be putting patients at risk.…”