Abstract:

Background: Delayed referrals and inappropriate pre-referral care in primary health care facilities contribute to poor patients’ outcomes in secondary and tertiary referral health care facilities. This calls for a need to analyze the status of referrals seen at tertiary health care facility in order to come up with recommendations for patients care improvement at all levels of health care system.

Objective: To determine the proportion, appropriateness and immediate outcome of referrals in pediatric wards at Bugando Medical Centre (BMC).
Methods: A hospital based cross sectional study enrolling all acutely referred children aged 1-59 months admitted in BMC pediatric wards. Referral forms were reviewed, detailed history and thorough physical examination were done. Children were viewed after 48 hours to determine the immediate outcome. Data were analyzed using STATA.

Results: A total of 300children were enrolled. Only 2% (6) had appropriately filled-in referral forms and only 3.3 (10) used ambulance as a means of transport. The proportion of referral was 55.1% (332/602), appropriateness was 16.7% (50), partially appropriate 39% (117) and inappropriate 44.3% (133). Death occurred in 34 (11.3%) [95% CI 8.2% - 15.5%]. In appropriate referrals were not associated with mortality at tertiary referral health care facilities. Other factors associated with mortality were, lower chest in drawing (OR: 4.9; 95% CI: 1.7 – 13.8; p=0.003), lower limb swelling (OR: 3.6; 95% CI: 1.3 – 10.2; p=0.013), convulsion (OR: 8.1; 95% CI: 2.2 – 29.9; p=0.008), shock (OR: 9.7 95% CI: 1.8 – 52.6; p=0.008), age>2 years (OR: 5.2; 95% CI: 1.7 – 16.2; p=0.004), and inability breastfeed or drink (OR: 7.3; 95% CI: 2.2 – 23.7; p=0.001).

Conclusion and recommendations: There is low proportion of referrals accompanied by large inappropriateness of referral. There is relatively low mortality which is linked to serious ill children (chest in drawing, convulsion, shock and inability to breastfeed or drink). The inappropriateness of referral is not associated with mortality. A clear guideline for referral is needed from the Ministry of Health to improve referral system along with improving their capacity of facilities at all levels. A specialized hospitals/clinics to refer children direct to tertiary hospitals to prevent unnecessary delay.