Adherence to national healthcare referral guidelines and outcomes of children managed at Moi Teaching and Referral Hospital Eldoret Kenya

Abstract

Background: Referral guidelines are meant to ensure coordination and continuity across all levels of health care. In Kenya, primary health care is supposed to be the first point of entry into the referral system yet patients bypass lower level health facilities to tertiary hospitals leading to congestion and limited access by the larger population. This could result in increased morbidity and mortality among the patients who are denied access. Objective: To determine adherence to the National Referral Guidelines and immediate outcomes of children seen at Moi Teaching and Referral Hospital (MTRH), Eldoret. Methods: Prospective study done at the Pediatric emergency department of MTRH from February to June 2016. A total of 422 children aged 14 years and below were recruited using a systematic sampling technique. Socio-demographic data (age, gender, residence of the child as well as parental level of education andemployment status) were collected and clinical data was collected using interviewer administered questionnaires. Clinical charts were reviewed to determine chief complaint, investigations done prior to referral, diagnosis at the referring facility, management and treatment outcomes post referral.Information on adherence to transfer guidelines was collected by examining ambulances using a check list. The results were presented as frequencies, percentages, mean and corresponding standard deviation in the form of charts and tables. Pearson chi-square test and odds ratios were used to test for association between independent and dependent variables at a 95% confidence interval. Results: Out of the enrolled participants, 234 (55.5%) were male while 217 (51.4%) were aged between 5 to 14 years. Hospital referrals accounted for 67 (15.9%) of all the participants with the rest being self-referrals. There was no counter referrals observed. Adherence to the four transfer guidelines requirements was observed in 31(46.3%) of the 67hospital referrals seen. The referral facility (MTRH) was called prior to the referral of 32 (47.8%) of the hospital referrals, 56 (83.6%) had a referral document; 43 (64.2%) were transferred in ambulances and 46 (68.7%) were accompanied by health care workers. Admissions were reported among 59 (88.1%) of the facilities were admitted while223(62.8%)of self-referrals were treated and discharged. Lower level of parental education (p= 0.025), residing outside Uasin Gishu County (p<0.001) and a child being older than five years (p = 0.015) were significantly associated with hospital referral to MTRH. Children who were referred were nearly three times (AOR = 2.932; 95% CI: 2.422 – 3.550; p<0.001) more likely to be admitted compared to those who were self-referred. Conclusions: The overall adherence to referral guidelines was low and less than a quarter of the children seeking care at MTRH were referrals from other facilities. Majority of the participants were self-referrals and no counter-referral was observed. Less than half of the hospital referrals were transferred as per the transfer process guidelines. Most of the self-referrals were treated and discharged while nearly all the hospital-referred children were admitted. Recommendation: Further qualitative studies determining reasons for self-referrals and lack of adherence to transfer guidelines should be conducted.