A STUDY OF PRIMARY HEALTH CARE REFERRALS

DR.SHAHID BASHIR CHAUDHARY ED SPECIALIST MRS AZRA SULTANA DEPUTY NURSING DIRECTOR KING SAUD HOSPITAL UNAIZAH AL QASEEM

INTRODUCTION
King Saud Hospital Unaizah is tertiary referral hospital and second largest hospital in Qaseem region It has been nearly a decade since the implementation of the referral system in Saudi Arabia in mid-1989. Several reports have demonstrated the effectiveness of the referral system in reducing the workload on the outpatient clinics of the hospitals, while increasing the workload of the general practice clinics of the primary health care (PHC) centers. In a review article, ODonnell reported Coulters suggestion that appropriate referrals had to be necessary for the patient, timely in the course of the disease, effective in achieving its objectives and cost effective. The same study also reported that referrals were more common when the specialist hospitals were located closer to the GP practice.

METHODS
A qualitative study is carried out with the objective of studying the referral in the Hospital For:1) Looking in to the process of the referral system; 2) Determining the rate and quality of referral letters originating from the PHC/ER/OTHERS. The study of referral process was composed of several consecutive steps. All referral letters from 2-06-2010 to 08-06-2010 were collected, total number was 400.

The referrals brought in the Patient service department were photocopied and collected for the study. It was observed that the referral letters were still handwritten, making them sometimes difficult to read. It was also noticed that some patients delivered the referral letters to the OPD themselves and some of these letters were delivered in a crumpled condition, making it difficult to obtain the full information. It was also observed that referral letters were not kept for the record but returned to the patients and they were registered in computer according to the available date. No feedback reports were issued at all from the tertiary care hospital (King Saud) unless requested by the patient or the PHC doctor. The Patients who were bringing the referrals were insisting for urgent appointment, while the PHC doctor did not write until near appointment is required. All The PHC referral letters, ER, and others were evaluated for:A. presence or absence of 1- Complaint 2- Vital signs 3- Physical examination 4- Investigations 5- Referral reasons 6- Urgenency B. Corresponding Departments

RESULTS
All referral letters collected were segregated according to referral units and corresponding departments. It was observed that only 16.25% of referrals from ER were of specialist units attending the patient in Emergency Department and 7.75% of the referrals were either from School health unit or faxes from other hospitals or interior ministry, While 76% referrals were from PHC that are located in the vicinity of King Saud Hospital Unaizah .

Table1.REFERRING UNITS REFERRED FROM PHC ER OTHERS TOTAL NUMBER OF REFERRALS 304 65 31 PERCENTAGE OF REFERRALS 76% 16.25% 7.75%

350 300 250 200 150 100 50 0 T T N O AL UMB RO R F R ALS E F EE R PH C E R O HE S T R

100 80 60 40 20 0 1s Qtr 2ndQtr 3rdQtr 4thQtr t Es at W t es N orth

Figure 1 REFERRAL UNITS FOR KSH

Table 2.DEPARTMENT VISE REFER

60 50 40 30 20 10 0 NUMB ERROF REF ERRAL S PERCENTAGEOF REF ERRAL S

Denta l O rtho Derm a E T N S ery urg Neuros ery urg Gy necolog y Medicine O phtha olog lm y Ca rdio Urolog y Dia betes Ps ychia try Ches t Pedia trics R bilita eha tion hem tolog a y S peechT hera py

RALS

DEPARTMENT

NUMBERR OF REFERRALS 51 57 45 29 25 15 37 25 24 12 20 25 7 12 13 5 1 4

PERCENTAGE OF REFERRALS 12.75% 14.25% 11.25% 7.25% 6.25% 3.75% 9.25% 6.25% 6% 3% 5% 6.25% 1.75% 3% 3.25% 1.25% 0.25% 1%

Dental Ortho Derma ENT Surgery Neurosurgery Gynecology Medicine Ophthalmology Cardio Urology Diabetes Psychiatry Chest Pediatrics Rehabilitation hematology Speech Therapy

60 50 40 30 20 10 0 N UMB R O R F R ALS E R F EE R

D enta l O rtho D erm a E NT S ery urg N euros ery urg G ynecolog y Medicine O phtha olog lm y C rdio a Urolog y D betes ia Py s chia try C t hes P edia trics R bilita eha tion hem tolog a y S peechT hera py

Complaints written on referral letters are not the real complaints rather in many referrals, in the column of complaint pregnancy is written, or H/O so and so is entered. Keeping this in view we divided the complaints in to specific and non specific categories. The non specific complaint means that the complaint is not present but there is some subjective observation of the patient which he/she brought in the notice of Physician and asked for referral. Table 3: specific and non specific complaints COMPLAINTS SPECIFIC NON SPECIFIC
400 350 300 250 200 150 100 50 0 T ALNUMB R OT E

TOTAL NUMBER 33 367

PERCENTAGE 08.25% 91.75%

S CIF PE IC NO S CIF N PE IC

Table 4.vital signs, physical examination and investigations PRESENT %AGE 380 95% 12 03% 129 32.25% ABSENT 20 388 271 %AGE 05% 97% 67.75%

VITAL SIGNS PHYSICAL EXAM. INVESTIGATIONS

Indications for referral were either an unsure diagnosis or inadequate facilities for treatment or both. The findings of this study revealed that most of referrals (359) 89.75% were made for chronic conditions or for follow up consultation and 1.75 %( 7) for acute cases. While 3.75% (15) referrals are made on the request of the patients in which complaints were non specific.

RECOMENDATIONS
The results indicate the following recommendations: Special attention needs to be given to the problem of Dental /Ortho /Gaynea and Derma in Primary Health centers. Strong collaborative links between King Saud Hospitals and the surrounding primary health institutions can pave the way for better management of above cases. A system needs to be adopted to have feedback of every referral to the referring doctor so that the referring doctor will be aware of his patients condition and can manage the same problem next time in his/her area. Referral letters should be kept for the personal medical file before the date of appointment. Referral letters should not be handwritten but in the composed form. Appointments for the acute cases should be mentioned in the referral letter having a format mentioning the urgent or non urgent patient. Immediately one day workshop should be held in the hospital to give the guidelines for referral both from the ER/SCHOOL and PHCs Physicians.

REFRENCES

1.

Al-Mazrou YY, Al-Shammari SA, Siddique M, Jarallah JS. A preliminary report on

the effect of the referral system in four areas of the kingdom of Saudi Arabia. Saudi Med J 1991;11:663-8. 2. Khoja TA, Al Shari AM, Abdul-Aziz AF, Khwaja MS. Patterns of referral from health centers to hospitals in Riyadh region. East Medit Health J 1997;3:237-43. 3. http://www.biomedcentral.com/1472-6963/8/124 4. Maged S. Khattab, MD, MRCGP; Mostafa A. Abolfotouh, DrPH; Yahia M. AlKhaldi, CABFM; Mohamed Y. Khan, MD Family Practice Centre In Saudi Arabia.