This study was designed firstly to observe the quality of referrals coming to a pediatric Emergency Room of a tertiary care multispecialty teaching hospital and secondly to develop a referral education module for health care providers at different referring healthcare facilities; and thirdly to assess the difference in the quality of referrals between both the phases.
A total of 12,490 patients visited our ER during the pre and post intervention phases combined. Majority were ‘referred’ patients, primarily from public sector teaching hospitals. Furthermore, most referred patients required admission. A study from another teaching and tertiary hospital has reported findings to the contrary; only 22.5% of referred patients required admission(7). The higher admission rate of referred patients in our set up is probably related to multiple factors. Ours is the only tertiary level super-specialty public sector hospital catering to 5 neighboring states. Lack of organized emergency and intensive care services and expertise in the peripheral hospitals, causes our hospital to bear the brunt of large number of referrals and admissions.
Accurate transfer of patient information in the form of a well-documented referral letter is crucial for maintaining continuity of care especially in sick children. Lack of vital information with respect to clinical examination findings and treatment received, poses lot of problems for the referred facility. Since most patients in our set up are also ignorant about the treatment given, the healthcare providers at the receiving facility are highly dependent on the referring doctors documentation or verbal information. We found that almost all referral letters lacked the most essential information required for maintaining continuity of care. The referral letters in the pre-intervention phase had missing information related to illness, clinical examination, treatment given, investigations, procedures and pre-referral stabilization. Studies have shown that nearly one third of specialist referrals from general practitioner (GP) lack essential clinical information and are often inadequate(8–10).Similarly another study evaluating the quality of GP referrals to a South African tertiary care hospital, reported that certain important components related to pre referral treatment (6.3%), laboratory tests (8.3%) and special tests (4%) were mentioned in very few referral letters only(11).
On the other hand, nearly half of the referral letters in both phases contained reasons for referral. Though much lower than that reported by Langalibaele et al (11) and Leonard et al(12) which was 88% and 100% respectively. Although indications were mentioned, pre-referral communication with the referred center was absent. In a resource limited setting like ours, absence of prior information results in poor preparedness at the tertiary level, the case in example being need of a ventilator.
We observed that all the referral letters were hand written and unstructured. Majority of the referral letters were in the ‘letter format’ similar to that reported by Xiang et al (13). Lack of structured format could have been one of the reasons for the poor quality and deficiency of several domains in these referral letters similar to that reported by Manis et al(14,15). A structured format is preferable as it ensures completeness of information by forcing the health care provider to fill all the columns and check all the required boxes.
Various methods have been tried worldwide to improve the incorporation of relevant information in referral letters. Referral guidelines, structured performa, peer or specialist feedback, risk factor checklist, referral management scheme (RMS), have been some of the measures tried to improve referral content (10). In the index study introduction of a referral education module did make a significant impact. The proportion of poor referrals had significantly reduced along with a corresponding significant increase in proportion of fair and good referrals. Referral content with respect to clinical examination findings, and pre-referral and during transport treatment details had improved significantly. The proportion of patients received in a physiologically decompensated state had significantly decreased in the post intervention period. Although we cannot definitively conclude on the causality, our findings suggest that our module had helped sensitize the healthcare providers in peripheral healthcare facilities about the need for timely stabilization, and good quality referral. It has enhanced communication between the referring centers and our facility and strengthened the back-referral process i.e. sending back stabilized patients to the primary referring facility.
This study paves the way for development of an organized referral network which connects tertiary care facilities with the other public and corporate hospitals in the periphery. The initial sensitization achieved by our study should be further consolidated by a more sustained multifaceted outreach and continuous feedback process. These interventions will also help reduce the unnecessary referrals and consequent overcrowding of a tertiary care facility. The major limitation of our study was that we could not cover all the health care facilities that were referring to us as they were distributed over a widely geographical area. We had targeted our interventions on hospitals from where maximum referrals were received during the pre-intervention phase. Secondly this being a before and after study design, there could have been Hawthorne effect in the post intervention phase.