A study of the paediatric referral system between primary health care facilities (Urban Health Centres) and the referral hospital, University Teaching Hospital, Lusaka

Abstract

The Paediatric referral system is an important aspect of Health care service to sick children and their parents/guardians. It is the link between the Lusaka Urban Health Centres and UTH. When functioning effectively it is of the utmost importance in the ultimate morbidity and mortality of the patients. The referral system existed before but was strengthened in 1996 when it was noted to be working with a decrease in the number of patients at UTH and an increase at the Health Centres. However, effectiveness of the Paediatric referral system in Lusaka, Zambia has not been evaluated. This study is a descriptive cross-sectional study carried out by use of two standardised structural questionnaires to assess the effectiveness of the referral system and the capacity of the clinics. It was carried out in the Department of Paediatrics and Child Health, UTH and 4 clinics of the 23 Urban Health Centres under LUDHMT. Patients who had an appropriate referral, arrived within 2 hours of referral from the clinic, had 48 hours or more duration of treatment before death, and for the discharged patients who were either followed up at the UTH or referred back to the referring clinic were considered as having had an effective referral. Additionally, Parents or guardians of the referred patients should have had communication with the health workers both at the clinic and hospital concerning the disease condition and should have been satisfied with the medical care given both at the clinic and hospital. 272 (93%) of the patients arriving at the UTH Outpatients Department of Paediatrics were referred from the urban clinics. At the time of study, IMCI guidelines were in use for referral. However, there was no consistent use of IMCI guidelines for referral nor did there appear to be consistent use of other smaller protocols for referral that had been in use before IMCI like Control for Diarrhoeal Diseases and Acute Respiratory Tract Infection protocols. There did not appear to be any prioritizing in the referrals probably because the IMCI guidelines were not used consistently. Each referring officer referred as he thought necessary and this was dictated by various factors in the different clinics e.g. lack of bed space, lack of staff, sheer patient overload and possibly even lack of adequate knowledge to treat a disease condition. Of the 272 patients referred only 70 ( 25.7%) were found to be effective referrals whilst 202 (74.3%>) were ineffective due to non fulfilment of one or several of the above factors. The commonest causes of referral ineffectiveness were duration of treatment of less than 48 hours before death in the UTH - 13 of 29 patients that died (44.8%), and a time lag between clinic and hospital of greater than 2 hours - 135 (50.2%). Other causes of ineffectiveness were lack of a planned follow up of a patient or referral back to the urban clinic - 99 (39.6%), lack of communication between health worker and patients' parents or guardians-80 (30.5%)) and dissatisfaction of the parent or guardian with the medical care given either at the clinic or hospital - 96 (35.3%o). On arrival at the UTH 175 (65.4%)) of the patients were being seen within 30 minutes whilst 237 (87.1%)) were being seen within 1 hour, thus delay at UTH was not a major contributory factor to ineffective referral at the time of the study. Transportation of patients from the clinics to the hospital was disappointing with only 29 (10.7%) accessing ambulance service even with a severe disease condition. 181 (66.5%)) of the referred patients used public transport (minibuses). Of the 29 critically ill patients that died, 22 (75.9%) used public transport to get to the UTH whilst only 3(10.3%)) used an ambulance. The lack of a reliable efficient and available transport system therefore contributed highly to the ineffectiveness of the referral system. The most common disease conditions for which the patients were being referred were acute respiratory tract infection (ARI) -70 (25.7%), Malaria -66 (24.3%), PEM -29 (10.7%o), ADD -25 (9.2%)) and Septicaemia -22 (8.1%). Mortality of admitted referred patients was 11.6%o (29 of 250 admitted). PEM caused the highest mortality 9 (31%o) followed by Pneumonia 6 (20.7%)), Malaria 4 (13.7%o) and Septicaemia 3 (10.3%)). Proportion of children dying of a particular disease within a disease was highest amongst the children with PEM 9 of 29 (31%o), FTT 1 of 4 (25%o) Anaemia 1 of 7 (14.3%)) and Septicaemia 3 of 22 (13.6%)). It appeared children with relatively chronic illnesses presented late to hospital and had higher mortality within the first 24 to 48 hours. This too caused the referral system to be ineffective due to late referral because of delay either at home or the clinic. The findings in this study indicate that the referral system is working. However most referrals fall short of the criteria of an effective referral thus rendering the referral system mostly ineffective.