Referrals to a pediatric emergency department of a tertiary care teaching hospital before and after introduction of a referral education module - a quality improvement study

Abstract

Background: Provision of timely care to critically ill children is essential for good outcome. Referral from smaller peripheral hospitals to higher centers for intensive care is common. However, lack of an organized referral and feedback system compromises optimal care. We studied the quality of referral letters coming to our Emergency Department (ED) with respect to their demography, association with severity of illness and mortality before and after referral education. Methods: Our study was completed in three phases in the Pediatric ED; Pre-intervention, Intervention and Post intervention phases. Quality of referral letter was matched with a quality checklist proforma and graded as 'good', 'fair' and 'poor' if it scored > 7, 5-7 and < 5 points respectively. A peer reviewed referral education module was prepared using case studies, expert opinions, and lacunae observed in the first phase and administered to health care providers (HCP's) of referring hospitals. Quality of referral letter was compared between pre and post intervention phases. Results: Most referrals belonged to the neighboring states of Punjab (48.2%) and Haryana (22.4%). Major referring hospitals were from public sector (80.9%), of which the teaching hospitals topped the list (53.6%). Government run ambulance services (85.5%) was commonest mode of transport used and need for a PICU bed and/or mechanical ventilation (50.4%) was the commonest reason for referral. The post intervention phase saw a significant decline in the proportion of poor (93.2 vs.78.2%; p = 0.001) and a significant increase in the proportion of fair (6.1 vs 18%; p = 0.001) and good referral letters (0.7 vs 18%; p = 0.001). The proportion of children with physiological decompensation at triage had reduced significantly in the post intervention phase [513 out of 1403 (36.5%) vs. 310 out of 957 (32.3%); p = 0.001].

A Qualitative Exploration of the Referral Process of Children with Common Infections from Private Low-Level Health Facilities in Western Uganda

“…Another challenge mentioned by the HWs in LLPHFs was inadequate communication between the private facility staff and those in referral facilities. This is an area for more research, as we did not find any studies describing this phenomenon in Uganda; however, it has been described by researchers in the United States and India [43,44]. Lack of communication leads to frustration as the HWs who refer never get to know how the patient is faring.…”

“…Research has shown that children referred from lower health facilities are more critically ill and have poorer outcomes [30] and that referral notes and explaining the reasons for referral to caretakers facilitate adherence to referral advice [39]. Further, research shows that apart from facilitating adherence to referral advice, wellwritten referral letters lead to patients presenting in less critical condition [39,44]. Delayed referrals or noncompliance to referral may result in poor outcomes as the children may present in a more critical condition or even die before receiving appropriate care, as was found in previous study in Uganda [17,38].…”

Facilidades e entraves da referência em unidade de pronto atendimento

“…As dificuldades no processo de transferência dos pacientes para o hospital, desde o contato com os profissionais da referência à efetiva transferência, são marcadas por consequências: atraso do atendimento no local adequado com possíveis prejuízos no estado de saúde do paciente; comprometimento do cuidado às pessoas que aguardam atendimento na UPA; alteração no processo de trabalho; estresse e frustração nos profissionais da UPA. Na Índia, a falta de um sistema de referência organizado compromete o atendimento ideal às crianças gravemente doentes, o que estimulou o desenvolvimento de uma intervenção educativa acerca de encaminhamentos para os hospitais, realizada com os profissionais de saúde em diferentes unidades de saúde, intervenção que melhorou a qualidade das cartas de referência 22 .…”

Assessing Facilitators and Barriers to Referral of Children Under the Age of Five Years at Ndirande Health Centre in Blantyre, Malawi

“…This finding resonates with previous studies conducted in Malawi, Uganda, and Nigeria that revealed that mothers delayed in seeking medical attention for their infants because they had to wait for permission and financial support from their partners. 26 , 47 , 48 We recommend continued counseling on immediate uptake of referral protocols for Malawi to sustain the gains in the reduction of infant mortality rates. Our findings that mothers were able to recognize when a child is sick are different from another Malawian study that showed that guardians were unable to quickly recognize symptoms or they had perceived the illness as not severe.…”

“…15,16,25 Furthermore, education on referral optimizes the quality of referral letters that health care works send out. 26 Caregivers compliance to the referral procedures also facilitates referral and results in a significant reduction in child morbidity and mortality. 17 An effective referral system is a key component in the management of pediatric cases in Malawi.…”