The first nationwide analysis of referrals in Sierra Leone demonstrates wide variation between districts in terms of percentage bed occupancy, total number of referrals, range of referral population, referral indices and mortality rate per referral. Two locations have much higher referral indices than the national mean, Pujehun and the Western Area. Pujehun as a district has benefited from a targeted health system intervention to improve access, through ambulance service provision and improved quality of care at the district hospital.18 The Western Area high referral index is likely multifactorial; the presence of tertiary hospitals offering higher levels of care; higher density of skilled healthcare workers19; less distance and more availability of transport to access care; and a different socio-economic makeup to the national average.17 Notably, national referrals to tertiary hospitals in the Western Area were very low 71 (0·5%) and do not account for the higher referral index observed. Specific interventions to address disparities in referral numbers and service utilisation by district and to increase nationwide access and uptake of high-quality tertiary care should be considered. Our study did not demonstrate any significant relationship between bed occupancy or referral index with any of the SARA indicators reported, it may be that referral index is not a sensitive enough measure or may reflect limitations in the SARA methodology.
The high proportion of deaths in the Under 5 age category reflect national child health indicators9 and district specific reports. We did not find a statistically significant association between time to arrive at facility and poor outcome, whereas moderate associations have been found by more appropriately designed case control studies in Sierra Leone.20 The high odds ratios for mortality for adults not covered by the free healthcare scheme is likely multifactorial with adults only seeking care for severe disease due to cost barriers10 and perceptions of poor quality care at Government hospitals.21
The increasing OR for mortality as destination referral facility level increases suggests that a “triage and filter” role is being performed at the facility level with more serious and life-threatening cases being referred upwards through the health system. As expected, referrals seen within one hour by a clinician had a higher mortality, suggesting that patients are being triaged and seen according to severity at the facility level. The “triage and filter” theory is supported by a case-control study from Pujehun which found referral from primary healthcare as opposed to direct arrival at facility had an OR of 4.00 (1.98–8.43) for mortality, suggesting that less severe cases are being managed and filtered out at primary health care level.20
In our study we found no significant difference in the national number of referrals, bed occupancy or outcome by month of the year, however analysis of multiple years of data will be better placed to detect seasonal variation at the national level. However, specific hospitals especially the paediatric tertiary hospital in Freetown did experience significant seasonal variations in bed occupancy and number of referrals.
In addition to providing standardised data on patient referrals nationwide, we theorize that the NRS has benefits and impact on multiple levels of the health system, from individual, to facility, to the national level. At the patient level, the RC network provides information on service and clinic timings, to ensure patients arrive in a timely manner, as well as support in arranging transport to access care. They provide information to the patient on service costs, a major barrier for non-free healthcare population, in addition to advocating for the free healthcare population to receive entitled free care. At the facility level, they are informed in advance of incoming referrals and mobilise the receiving clinicians and services (eg. blood bank, theatres) in order to reduce facility delays in care provision, this is critical in hospitals with limited human resource, where many services are dependent on one or two key clinical staff. In locations with inadequate blood bank storage, then this pre-warning is critical to mobilise appropriate donors. RCs perform daily bed occupancy rounds, to inform hospital decision makers and improve patient flow within the facility. Through supporting onward referral processes, once the decision has been made to refer a patient, they free up limited clinicians to concentrate on the next patient. At the system level, they provide national standardised data on referrals, informing health system planning. This highlights which lower level health facilities are over or under referring, allowing decision makers to focus system improvements. They stimulate a feedback loop, informing referring clinicians of the outcome of the referred patient, important for clinical learning, as well as supporting discharges back to the primary healthcare level for ongoing care. The network provides up to date information on signal functions, as well as service availability. Regular standardised bed occupancy reports demonstrate which facilities are overburdened and which hospitals are under-utilised. Finally, in the case of system failure, closure of hospitals or disruption to service availability, they are able to redirect referrals to functioning facilities.
The NRS dataset has been used to plan the deployment of ambulance services through the National Emergency Medical System (NEMS) which was launched towards the end of 2018. The NRS dataset will prove a valuable data source to evaluate the impact of the implementation of a nationwide ambulance system in Sierra Leone. Development and dissemination of the planned National Referral Form will increase standardisation of information collected on referrals across Sierra Leone. Further analysis of referrals against the standards laid out by the BPEHS may allow classification of appropriateness of referrals.
A recent systematic review of referral systems in LMICs concluded “from a methodological perspective there is no standard approach to assessing functionality and effectiveness of referral systems”1. It is therefore difficult to make value judgements on the dataset, for example, it is unclear whether the mortality rate per referral of 4.25% detected by our study is high or low. Referral systems are obviously intricately linked to the underlying health system, so developing international comparable standards is not feasible, although some have attempted to create national benchmarks22. Further attention should be paid to developing standardised definitions, methods and indicators to assess quantity(referral index), appropriateness, timeliness and quality of referrals, this will allow comparison at the national or regional level. Monitoring of these indicators over time, or comparison of these indicators between districts or between facilities is a potential powerful method to understand health service utilisation and health system performance.