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.