This study was designed firstly to observe the quality of referral letters accompanying children who are referred to our pediatric ER and secondly to develop a referral education module for health care providers at different referring healthcare facilities; and thirdly to assess the impact of this intervention on the quality of referral letters.
A significant proportion (73%) of those who required admission were ‘referred’ patients, primarily from public sector teaching hospitals. A study from another teaching and tertiary care hospital has reported findings to the contrary; only 22.5% of the referred patients required admission(7). The higher admission rate among referred patients in our set up is related to multiple factors. Ours is the only tertiary level subspecialty 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.
Referral is a process in continuum; care of the patient during transport is key to good outcome. This requires fully equipped ambulance manned by HCP trained in basic and advanced life support skills. Although Government run ambulances were availed commonly in our study, the critically ill patient was unaccompanied by HCP in most situations. The fact that 4.4% of referral admissions were received in cardiopulmonary arrest draws attention to this fact that there was a complete lack of resuscitation and stabilization enroute. A recent study from our centre, showed that about 3% emergency department admissions were brought in dead. Clinical deterioration was noted in 62% children during transport, only 5 received CPR enroute(6). Another study by Bhalla et al from Delhi which looked into the care given during transport of trauma patients, found several medicolegal issues and barriers for care during referral(11).
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 status and treatment received, poses lot of problems for the referred facility. Since most patients in our setting lack knowledge or information about the treatment given, the healthcare providers at the receiving facility are highly dependent on the referring doctor’s documentation or verbal information. We found that almost all referral letters lacked the most essential information required for maintaining continuity of care. (7) 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(12–14). Referral note without adequate information was found in 69% of brought in dead referrals at a tertiary pediatric ED in India(6). 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(15).
The reasons for referral were documented in most referral letters in both phases. Our findings compare favorably, with that reported by Langalibaele et al(15) and Lachman et al(16) which was 88% and 100% respectively. But 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. Shankar et al found that almost two third of their referral letters were incomplete and lacking in crucial information (7). Majority of the referral letters were in the ‘letter format’ similar to that reported by Xiang et al (14). Lack of structured format could have been one of the reasons for the deficiency of several domains in these referral letters similar to that reported by Manis et al(17,18). 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, and referral management scheme (RMS), have been some of the measures tried to improve referral content (14). In the index study we introduced a referral education module which did make a significant impact. The proportion of poor referral letters had significantly reduced along with a corresponding significant increase in proportion of fair and good referral letters. Referral content with respect to clinical examination findings, and pre-referral stabilization and treatment during transport had improved significantly. The proportion of patients received in a physiologically decompensated state had significantly decreased in the post intervention period. Furthermore, the proportion of referrals from teaching hospitals had decreased significantly in the post intervention phase. Educational interventions thus improved the quality of referral letters, decreased overall referrals and decompensated referrals. Although we cannot definitively conclude on the causality, our findings suggest that our module has sensitized the healthcare providers in peripheral healthcare facilities, teaching hospitals about the need for timely stabilization, and good quality referral letter. It has initiated a dialogue between the referring centers and our facility and has strengthened the back-referral process i.e. sending back stabilized patients to the primary referring facility.
The strength of our study is that it is first of its kind in a setting which lacks an organized referral network. We included all consecutive referrals to achieve a sizeable sample in both phases. The information obtained in our study paves the way for development of an organized referral network which will connect tertiary facilities with the other public and corporate hospitals in the periphery.
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 wide geographical area. We had targeted our interventions on hospitals from where the maximum referrals were received during the pre-intervention phase. We feel that the intervention phase is short, considering, educational interventions may have to be sustained to achieve greater impact in changing practice. Hence, the initial sensitization achieved by our study should be further consolidated by a more sustained multifaceted outreach and continuous feedback process at policy level.
Lastly, being a before and after study design with inherent limitation of Hawthorne effect, the estimate of effect in the post intervention phase could not be completely attributed to interventional measures. The reduction in number of referrals in the post intervention phase could be attributed to a natural frequency of admission during this phase or a Hawthorne effect.