Reducing Inappropriate Referrals From ED To Orthopaedic SOC

Year Submitted: 2025
Published Date: 25 March 2026

Tags: Care Process ＆ Redesign, Referral Rate, Quality Improvement, Clinical Practice Improvement, Workflow Redesign, Value Based Care, Utilisation

About this Content

Aims

To reduce the total number of referral from ED to Orthopaedic SOC by at least 5% (from 720 to 684 i.e. 36 less referrals per month) by December 2025.

Background

The Emergency Department (ED) is experiencing a significant challenge with high volume of patients referred from the ED to SOC not attending their appointment (no-show). This suggests an inefficient use of valuable specialist resources and potentially delaying care for patients who genuinely require specialist follow-up. By implementing targeted interventions to optimise the referral process, there is an opportunity to ensure ED patients receive appropriate level of care for their condition, reduce unnecessary SOC referrals and improve overall healthcare efficiency.

Methods

The project used a Plan-Do-Study-Act (PDSA) cycle approach with five main interventions:
Enhanced risk stratification guidelines and explored alternative referral options (open-date referrals for Pain/Strain/Contusions)
Regular review on inappropriate referrals with targeted feedback to 24 ED clinicians
Established new toe fracture clinical management guidelines and discharge advice
Alternative approach for subsidies eligibility (direct physiotherapy referrals under OneRehab framework)
Improved communication and created awareness in ED using AI-generated comic strips

Results

Overall reduction: Average monthly referral from ED to Orthopaedic reduced from 720 to 681 (39 less referrals per month) with median reduction of 4.6%
Pain/Strain/Contusion referrals: Reduced by 15.7% from 198 to 167 (31 less referrals per month)
Toe fracture referrals: Reduced by 50% from 30 to 15 (15 less referrals per month)
Successful implementation of open-date referrals and direct physiotherapy pathways
Maintained lower referral rates despite new medical officers joining ED

Lessons Learnt

Data-driven decision making plays a fundamental role in driving healthcare improvements. Our team could tailor strategies to address specific pain points in the referral process, monitor trends and evaluate the effectiveness of our initiatives.
Remaining flexible and innovative in healthcare delivery is vital for creating a more efficient, and patient-centred system. By implementing flexible referral pathways (eg. Open date referrals for less acute conditions and direct referral to Physiotherapy for musculoskeletal conditions), we can reduce unnecessary specialist appointments while still ensuring appropriate care provision. These strategies demonstrate the value of reimagining traditional referral pathways to better serve patient needs and optimise healthcare resources.
Scalability of successful interventions across departments can amplify hospital-wide improvements. The strategies implemented such as exploring alternative referral options and improving communication through innovative means could potentially be adapted and applied to other specialties or departments facing similar challenges with referral management.

Keywords

ED referrals, orthopaedic, no-show reduction, PDSA cycle, workflow redesign, quality improvement

Innovators' Details

Connect with this contributor!

Lim Kwee Kuang Joeann - kwee_kuang_lim@nuhs.edu.sg

Project Attachment

Reducing Inappropriate Referrals From ED To Orthopaedic SOC.pdf