A Study of Primary Health Care Referrals in Qaseem Region Saudi Arab

8/2/2019 A Study of Primary Health Care Referrals in Qaseem Region Saudi Arab

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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 itsobjectives 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.


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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 tothe 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 werefrom PHC that are located in the vicinity of King Saud Hospital Unaizah .


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Table1.REFERRING UNITS

REFERRED

FROM

TOTAL NUMBER OF

REFERRALS

PERCENTAGE OF

REFERRALS

PHC 304 76%ER 65 16.25%

OTHERS 31 7.75%

0

50

100

150

200

250

300

350

TOTAL NUMBER OF REFERRALS

PHC

ER

OTHERS

0

20

40

60

80

100

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

East

West

North

Figure 1 REFERRAL UNITS FOR KSH


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Table 2.DEPARTMENT VISE REFER

0

10

20

30

40

50

60

NUMBERR OF

REFERRALS

PERCENTAGE OF

REFERRALS

Denta

Ortho

Derma

ENT

Surger

Neuro

Gynec

Medic

Ophth

Cardio

Urolog

Diabet

Psych

Chest

Pediat

Rehabhemat

Speec

RALS


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0

10

20

30

40

50

60

NUMBERR OF REFERRALS

DentalOrthoDermaENT

SurgeryNeurosurgeryGynecologyMedicineOphthalmologyCardioUrologyDiabetesPsychiatryChestPediatricsRehabilitationhematologySpeech Therapy

DEPARTMENT NUMBERR

OF

REFERRALS

PERCENTAGE

OF

REFERRALS

Dental 51 12.75%

Ortho 57 14.25%

Derma 45 11.25%

ENT 29 7.25%

Surgery 25 6.25%

Neurosurgery 15 3.75%

Gynecology 37 9.25%

Medicine 25 6.25%

Ophthalmology 24 6%

Cardio 12 3%

Urology 20 5%

Diabetes 25 6.25%

Psychiatry 7 1.75%

Chest 12 3%

Pediatrics 13 3.25%Rehabilitation 5 1.25%

hematology 1 0.25%

Speech Therapy 4 1%


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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 TOTAL NUMBER PERCENTAGE

SPECIFIC 33 08.25%

NON SPECIFIC 367 91.75%

0

50

100

150

200

250

300

350

400

TOTAL NUMBER

SPECIFIC

NON SPECIFIC


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Table 4.vital signs, physical examination and investigations

PRESENT %AGE ABSENT %AGE

VITAL SIGNS 380 95% 20 05%

PHYSICAL EXAM. 12 03% 388 97%

INVESTIGATIONS 129 32.25% 271 67.75%

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 aformat 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


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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/1472-6963/8/1244. Maged S. Khattab, MD, MRCGP; Mostafa A. Abolfotouh, DrPH; Yahia M. Al-

Khaldi, CABFM; Mohamed Y. Khan, MD Family Practice Centre In Saudi Arabia.
http://www.biomedcentral.com/1472-6963/8/124http://www.biomedcentral.com/1472-6963/8/124

A Study of Primary Health Care Referrals in Qaseem Region Saudi Arab

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