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Ezhumalai G, Jayashree M, Nallasamy K, et al. Referrals to a pediatric emergency department of a tertiary care teaching hospital before and after introduction of a referral education module - a quality improvement study. BMC Health Serv Res. 2020;20(1):761doi: 10.1186/s12913-020-05649-w.
Ezhumalai, G., Jayashree, M., Nallasamy, K., Bansal, A., & Bharti, B. (2020). Referrals to a pediatric emergency department of a tertiary care teaching hospital before and after introduction of a referral education module - a quality improvement study. BMC health services research, 20(1), 761. https://doi.org/10.1186/s12913-020-05649-w
Ezhumalai, Gopalakrishnan, et al. "Referrals to a pediatric emergency department of a tertiary care teaching hospital before and after introduction of a referral education module - a quality improvement study." BMC health services research vol. 20,1 (2020): 761. doi: https://doi.org/10.1186/s12913-020-05649-w
Ezhumalai G, Jayashree M, Nallasamy K, Bansal A, Bharti B. Referrals to a pediatric emergency department of a tertiary care teaching hospital before and after introduction of a referral education module - a quality improvement study. BMC Health Serv Res. 2020 Aug 17;20(1):761. doi: 10.1186/s12913-020-05649-w. PMID: 32807142; PMCID: PMC7430091.
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BMC Health Serv Res. 2020 Aug 17;20(1):761. doi: 10.1186/s12913-020-05649-w.

Referrals to a pediatric emergency department of a tertiary care teaching hospital before and after introduction of a referral education module - a quality improvement study.

BMC health services research

Gopalakrishnan Ezhumalai, Muralidharan Jayashree, Karthi Nallasamy, Arun Bansal, Bhavneet Bharti

Affiliations

  1. Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
  2. Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. [email protected].

PMID: 32807142 PMCID: PMC7430091 DOI: 10.1186/s12913-020-05649-w

Abstract

BACKGROUND: Provision of timely care to critically ill children is essential for good outcome. Referral from smaller peripheral hospitals to higher centers for intensive care is common. However, lack of an organized referral and feedback system compromises optimal care. We studied the quality of referral letters coming to our Emergency Department (ED) with respect to their demography, association with severity of illness and mortality before and after referral education.

METHODS: Our study was completed in three phases in the Pediatric ED; Pre-intervention, Intervention and Post intervention phases. Quality of referral letter was matched with a quality checklist proforma and graded as 'good', 'fair' and 'poor' if it scored > 7, 5-7 and < 5 points respectively. A peer reviewed referral education module was prepared using case studies, expert opinions, and lacunae observed in the first phase and administered to health care providers (HCP's) of referring hospitals. Quality of referral letter was compared between pre and post intervention phases.

RESULTS: Most referrals belonged to the neighboring states of Punjab (48.2%) and Haryana (22.4%). Major referring hospitals were from public sector (80.9%), of which the teaching hospitals topped the list (53.6%). Government run ambulance services (85.5%) was commonest mode of transport used and need for a PICU bed and/or mechanical ventilation (50.4%) was the commonest reason for referral. The post intervention phase saw a significant decline in the proportion of poor (93.2 vs.78.2%; p = 0.001) and a significant increase in the proportion of fair (6.1 vs 18%; p = 0.001) and good referral letters (0.7 vs 18%; p = 0.001). The proportion of children with physiological decompensation at triage had reduced significantly in the post intervention phase [513 out of 1403 (36.5%) vs. 310 out of 957 (32.3%); p = 0.001].

CONCLUSION: Referral education had significantly improved the quality of referral letters. Proportion of children with physiological decompensation at triage had decreased significantly after referral module. This change suggests sensitization of the peripheral hospitals towards a better referral process. Continued multifaceted approach will be required for sustained and increased benefits.

Keywords: Pediatric emergency; Quality of referral; Referral letter; Triage

References

  1. Ratcliffe J. Provision of intensive care for children. BMJ. 1998;316(7144):1547–8. - PubMed
  2. Newbrander W, Ickx P, Werner R, Mujadidi F. Compliance with referral of sick children: a survey in five districts of Afghanistan. BMC Pediatr. 2012;12:46. - PubMed
  3. Loudon I. The principle of referral: the gatekeeping role of the GP. Br J Gen Pract. 2008;58(547):128–30. - PubMed
  4. Kliegman R. Nelson Textbook of Pediatrics.2 -volume set. Edition 21. Philadelphia: Elsevier Health Sciences; 2020. - PubMed
  5. Santhanam I, Pai M, Kasturi K, Radhamani MP. Mortality after admission in the pediatric emergency department: a prospective study from a referral children’s hospital in southern India. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc. 2002;3(4):358–63. - PubMed
  6. Praveen K, Nallasamy K, Jayashree M, Kumar P. Brought in dead cases to a tertiary referral paediatric emergency department in India: a prospective qualitative study. BMJ Paediatr Open. 2020;4(1):e000606. - PubMed
  7. Sankar J, Singh A, Narsaria P, Dev N, Singh P, Dubey N. Prehospital transport practices prevalent among patients presenting to the pediatric emergency of a tertiary care hospital. Indian J Crit Care Med Peer-Rev Off Publ Indian Soc Crit Care Med. 2015;19(8):474–8. - PubMed
  8. Jayashree M, Singhi SC. Initial assessment and triage in ER. Indian J Pediatr. 2011;78(9):1100–8. - PubMed
  9. WHO | IMCI information package. WHO. [cited 2019 May 13]. Available from: https://www.who.int/maternal_child_adolescent/documents/chs_cah_98_1a/en/ . - PubMed
  10. Census of India Website : Office of the Registrar General & Census Commissioner, India. [cited 2020 Jun 30]. Available from: https://censusindia.gov.in/2011-common/censusdata2011.html . - PubMed
  11. Bhalla K, Sriram V, Arora R, Ahuja R, Varghese M, Agrawal G, et al. The care and transport of trauma victims by layperson emergency medical systems: a qualitative study in Delhi. India BMJ Glob Health. 2019;4(6):e001963. - PubMed
  12. Font F, Quinto L, Masanja H, Nathan R, Ascaso C, Menendez C, et al. Paediatric referrals in rural Tanzania: the Kilombero District study - a case series. BMC Int Health Hum Rights. 2002;2(1):4. - PubMed
  13. Kloos H. Utilization of selected hospitals, health centres and health stations in central, southern and western Ethiopia. Soc Sci Med 1982. 1990;31(2):101–14. - PubMed
  14. Xiang A, Smith H, Hine P, Mason K, Lanza S, Cave A, et al. Impact of a referral management “gateway” on the quality of referral letters; a retrospective time series cross sectional review. BMC Health Serv Res. 2013;13:310. - PubMed
  15. Langalibalele M, Benjamin L-M. Quality of general practitioner referral letters to a south African tertiary hospital: determinants of quality content and good practice. J Public Health Epidemiol. 2011;3(11):482–8. - PubMed
  16. Lachman PI, Stander IA. The referral letter--a problem of communication. South Afr Med J Suid-Afr Tydskr Vir Geneeskd. 1991;79(2):98–100. - PubMed
  17. Manias E, Geddes F, Watson B, Jones D, Della P. Perspectives of clinical handover processes: a multi-site survey across different health professionals. J Clin Nurs. 2016;25(1–2):80–91. - PubMed
  18. Westerman RF, Hull FM, Bezemer PD, Gort G. A study of communication between general practitioners and specialists. Br J Gen Pract. 1990;40(340):445–9. - PubMed

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