Spotlight on local innovation – redesigning the acute care hot clinic referral pathway

When I first rotated onto the acute care unit (ACU) at the Countess of Chester Hospital, it didn’t take long to realise that our hot clinic – designed to provide rapid ambulatory follow-up for patients discharged with urgent investigations – wasn’t functioning as well as it needed to. The clinic is a lifeline for patients with suspected venous thromboembolism or unresolved diagnostic questions, yet behind the scenes we were struggling with long waiting lists, inconsistent referrals and an inefficient, largely manual system.

In 2023, the waiting list peaked at 850 patients. Referrals came through in varying formats and with variable quality. We relied on email chains and a hand-built spreadsheet to track progress – a system that was as fragile as it was time-consuming. It was clear we needed a better, safer and more sustainable pathway.

Working closely with information governance colleagues and the electronic patient record team, I led a project to rebuild the hot clinic referral process from the ground up. We wanted a pathway that was transparent, auditable and easy for clinicians to use, while reducing unnecessary workload for the ACU team.

The new digital referral system:

• allows all referrals to be tracked and audited in real time
• automatically generates inclusion and exclusion criteria to guide safe referrals
• provides immediate feedback to referrers when a case is accepted or rejected
• has significantly reduced inappropriate or incomplete referrals. 

The impact was immediate. Our rejection rate fell from 50% to 4% and patient safety improved because documentation was clearer, and decisions were consistently recorded.

One of the most satisfying outcomes was hearing resident doctors say that they now felt more confident discharging patients. Knowing that there was a reliable, efficient and well-governed mechanism for urgent follow-up changed the way we approached risk, especially in borderline cases where admission might previously have felt like the only safe option.

The project sparked a wider discussion in our team about the role of acute medicine in managing the ‘gaps’ between emergency and specialty care. Hot clinics can act as a kind of ‘side door’ – a space where patients who don’t require admission can still receive timely review. However, they only work well when:

• inclusion and exclusion criteria are explicit and consistently applied
• specialty teams don’t use them as a substitute for appropriate follow-up
• there is clear agreement on which patients the clinic is and is not designed for. 

Without that clarity, hot clinics risk being overwhelmed or misused.

One challenge that came through strongly in discussions was the balance between efficiency and patient experience. While ambulatory care is far preferable to unnecessary admission, we heard examples of patients waiting long hours in uncomfortable environments – often due to delays in cannulation or scanning capacity.

It’s a reminder that hot clinics don’t just need good processes – they need:

• adequate space
• appropriate nursing support
• reliable access to diagnostics. 

Sharing this project with colleagues was a privilege. Many resident doctors told me how valuable it was to see peers leading improvement work, and how important rotation is in exposing us to different models of ambulatory and hot clinic care. It’s clear that there is appetite for national guidance on the scope and purpose of acute medical hot clinics – something that could bring much-needed consistency across trusts.

For me, this project reinforced a simple truth: quality improvement isn’t an add-on for IMT doctors – it’s a powerful way to understand our services, make things safer and build confidence as clinicians. Reworking the ACU hot clinic has been challenging but seeing both patient care and resident doctor experience improve makes every bit of effort worthwhile.