Analysis of low resource setting referral pathways to improve coordination and evidence-based services for maternal and child health in Ethiopia

Abstract

Background In low-resource settings, patient referral to a hospital is an essential part of the primary health care system. However, there is a paucity of study to explore the challenges and quality of referral coordination and communication. Objective The purpose of this research was to analyze the existing paper-based referral registration logbook for maternal and child health in general and women of reproductive age in particular, to improve referral coordination and evidence-based services in Low-Resource Settings. Methods This study analyzed the existing paper-based referral registration logbook (RRL) and card-sheet to explore the documentation of the referral management process, and the mechanism and quality of referrals between the health center (Jimma Health Center-case, Ethiopia) and the Hospital. A sample of 459 paper-based records from the referral registration logbook were digitized as part of a retrospective observational study. For data preprocessing, visualization, and analysis, we developed a python-based interactive referral clinical pathway tool. The data collection was conducted from August to October 2019. Jimma Health Center’s RRL was used to examine how the referral decision was made and what cases were referred to the next level of care. However, the RRL was incomplete and did not contain the expected referral feedback from the hospital. Hence, we defined a new protocol to investigate the quality of referral. We compared the information in the health center’s RRL with the medical records in the hospital to which the patients were referred. A total of 201 medical records of referred patients were examined. Results A total of 459 and 201 RRL records from the health center and the referred hospital, respectively, were analyzed in the study. Out of 459, 86.5% referred cases were between the age of 20 to 30 years. We found that “better patient management”, “further patient management”, and “further investigation” were the main health-center referral reasons and decisions. It accounted for 40.08%, 39.22%, and 16.34% of all 459 referrals, respectively. The leading and most common referral cases in the health center were long labor, prolonged first and second stage labor, labor or delivery complicated by fetal heart rate anomaly, preterm newborn, maternal care with breech presentation, premature rupture of membranes, malposition of the uterus, and antepartum hemorrhage. In the hospital RRL and card-sheet, the main referral-in reasons were technical examination, expert advice, further management, and evaluation. We found it overall impossible to match records from the referral logbook in the health center with the patient files in the hospital. Out of 201, only 13.9% of records were perfect matching entries between health center and referred hospital RRL. We found 84%, 14.4%, and 1.6% were appropriate, unnecessary and unknown referrals respectively. Conclusion The paper illustrates the bottlenecks encountered in the quality assessment of the referrals. We analyzed the current status of the referral pathway, existing communications, guidelines and data quality, as a first step towards an end-to-end effective referral coordination and evidence-based referral service. Accessing, monitoring, and tracking the history of referred patients and referral feedback is challenging with the present paper-based referral coordination and communication system. Overall, the referral services were inadequate, and referral feedback was not automatically delivered, causing unnecessary delays.

Public Health Center Emergency Referral Quality Analysis: Based on National Standard

“…Generally, countries with limited resources also experience the same thing. This was also experienced by developed countries 1 decade ago [8], [11], [12].…”

“…However, the quality of primary healthcare referrals in countries with limited resources is still not satisfactory as reported by various developing countries [11], [12], [13], [14]. This is a major concern, as the quality of referrals has a direct impact on patient outcomes.…”

Evaluating a clinical decision support point of care instrument in low resource setting

“…However, decision-support systems, electronic health records, the infrastructure for exchanging health information, and other similar technologies were not readily available to or used by frontline workers. During the need analysis [8,18], we studied the clinical guidelines, the patient card-sheet, and referral-out registration logbook at Jimma Health Center. Paper-based clinical guidelines, card sheets, and referral registration log sheets are the only readily available resources for assisting frontline workers and their decisions [8,18].…”

“…During the need analysis [8,18], we studied the clinical guidelines, the patient card-sheet, and referral-out registration logbook at Jimma Health Center. Paper-based clinical guidelines, card sheets, and referral registration log sheets are the only readily available resources for assisting frontline workers and their decisions [8,18]. However, none of them are automated, interactive or dynamic.…”

“…To capture the required information from the existing paper-based instrument takes much time and only contain limited information. Overall, it's challenging to "capture and summarize the required clinical data, process it in a consistent manner, construct a patient flow sheet to monitor and record the progress of care" [8,18].…”