Referral is mostly a myth

A patient with a surgical disease has first to refer himself to you, and if you cannot care for him, you have to refer him to someone else. Referral onwards from a community health worker (CHW) takes place at all the five steps in Figure 1-5. Although surgery is done in other parts of this system, we are concerned with the district hospital, and the critical referral steps from C to D and from D to E.

Although ''referral systems' exist in all health services, the difficulties they put in a patient's way are often insurmountable. Unfortunately, for many patients referral is a myth. In many developing countries the possibilities for referral appear to have got worse during the last decade rather than better, due to their declining economies. Too often, there is just no petrol for the hospital's ambulance to take a patient to a referral hospital, or no money to buy it. Alas, in many countries the future does not seem any more hopeful.

Only too often a patient reaches a referral hospital with great difficulty, only to return no better then he went. Because there are so many uncertainties, assess the chances for each patient individually. Try to find out what happens to each of the patients you send. Just what cases is it useful to refer, how, when, and to whom? If there are referral services, be sure to use them, both to refer patients and to learn from yourself.

In the pages that follow we often suggest that you ''refer the patient', but we realize that this is often impossible. So we have done our best to tell you what to do if it is impossible. The urgency, or lack of it with which a patient needs to be referred is critical, and varies with each condition, so we have indicated just how urgent referral is in each case.

Some surgeons working in referral hospitals have a false idea of the practicalities of referral. They see only the tip of the iceberg[md]the patients who reach them successfully. So they may think that referral is easier than it is. There are however certain cases which referral hospitals should accept without question, and district hospitals should know what they are. They include the closure of intestinal fistulae (9.14), and difficult ankle fractures (82.3).

Referral hospitals have their problems: (1) They may be overcrowded with simple cases that you could care for in your district hospital. One of the purposes of these manuals is to make sure that any surgery that can be done in a district hospital is done there, so that referral hospitals can fulfil their proper function. (2) When the time comes to discharge a referred patient who cannot go home unaided, they may be unable to send him there because they cannot contact his rural relatives.

Here is an account of what one patient went through successfully to get himself treated at a referral hospital. It is from the Chairman's address to the 1980 Annual Conference of the Association of Surgeons of East Africa. Fortunately for the patient, he was in the Chairman's care.

Jellis JE, ''Chairman's Address', Proceedings of the Association of Surgeons of East Africa 1981;4:53-56. PATSON BANDA (49 years) was in a LandRover when it rolled over in deep sand, causing an open fracture of his right humerus and injuring his radial nerve. He was still able to walk, so he eventually reached a district hospital, where his wound was carefully toileted, and left open for delayed primary suture. His radial nerve injury was recognized, his arm was put in a collar- and-cuff sling, and he was asked to return in 48 hours. His wound was clean so it was closed. So far he had received ideal treatment.

It was decided to refer him to the provincial hospital 40 km away, across a river and a flood plain, 20 minutes by air, a day by boat, or two days by LandRover. There was no radio, and the telephone was not working, so there was no way of telling the provincial surgeon that he was coming. He was able to get a seat on a barge and was in the provincial capital 24 hours later. It was dark but he was able to find a relative with whom he could stay the night. The next day he sat in the outpatient queue and handed his slip to the medical assistant. Unfortunately, the provincial surgeon had left the previous day to attend a planning meeting at the Ministry of Health. He would not be back for two days. The provincial surgeon returned and saw him, but decided that his training had not prepared him for posterior exploration of the humerus, plating the fracture and perhaps secondary suture of the radial nerve. Also, he had no 6/0 monofilament. So Patson was given a bus warrant, and a note to the orthopaedic surgeon in the teaching hospital in the capital city.

Unfortunately, he had no money, no food, and no clean clothes for the journey, so he went home. His LandRover had been partly dismantled by thieves, but his partner had towed the wreck back to his village, and hired a lad to help him with the fishing. The family were already deeply in debt. They debated whether he should go 800 km to the capital, but his limp wrist decided them. He started on his long journey with a pack of food, a few clean clothes, and a bus warrant, but very little money.

Four days later he arrived at the orthopaedic clinic on a Friday. He had no appointment, and the surgeon to whom the note was addressed had held his clinic on the previous day. The harassed sister, busy with another clinic, found that he had no relatives in the city, and no money, so she sent him to the orthopaedic ward in the hope that they might have a bed for him over the weekend. They did.

On Monday the surgeon saw him. His wound had healed and he was fit for surgery, and the necessary screws, plates, adhesive drapes, and sutures were in stock. But there was a three months waiting list, so he had to wait 10 days, even for operation as a semi-emergency. A silent cheer went up from the hospital staphylococci, as they began to colonize the skin of this provincial patient.

His radial nerve was freed from compression in its spiral groove, and his fractured humerus was successfully plated. Two weeks later he returned to the provincial hospital with suggestions for physiotherapy (a two day journey for each session) and instructions to return in a year for removal of the plate.

He was lucky. He was one of the minority for whom the referral system worked. His radial nerve palsy recovered. The state paid for nearly 4 weeks in a teaching hospital, and 1600 km in transport. He was in debt, and his family were hungry, but he did not have to sell his boat, or the remains of his LandRover. It could have been much worse.]] TOPNO (41 years) fractured his ankle in a bus accident. The very competent doctor who saw him had learnt that difficult ankle fractures should be referred (82.3). He could manipulate fractures, but he thought that an expert would do better, so he sent the patient with a letter to the referral hospital 70 km away. After a long journey, the patient arrived too late at the fracture clinic. He was able to reach the next fracture clinic in time, only to find that the surgeon was away at a conference. So he hung around hopefully for some days, but in the end he was advised to return to his original hospital. Meanwhile, he had had no treatment except the original ''first aid' plaster. When he eventually returned to the doctor who first saw him, his fracture had partly united in a very bad position. It was now too late to manipulate him, so he now has a stiff painful ankle and is waiting to have it fused. LESSON A patient may be better in your hands, if you learn those of the expert's procedures that you can reasonably do. ASSESS EACH PATIENT'S CHANCES OF EFFECTIVE REFERRAL

REFERRAL SHOULD YOU SEND HIM? The chances of being able to refer a patient vary greatly, and are apt to change. They depend on the answers to these questions.

(1) Is it worth sending him anyway? He may not have a disease for which the referral hospital has any effective treatment. Even if he does reach it, he may not be sure of any better treatment than yours.

(2) Is he prepared to leave his family and his fields or his job?

(3) Can he get himself to the referral centre? In some districts, for example, the roads and airstrips are closed for weeks at a time during the rainy season.

(4) Has he or the hospital got money for transport and for lodging when he gets there? Often, neither of them have.

(5) If he does arrive, will he find his way to the right clinic, wait in the right queue and be seen and admitted? Will there be an empty bed? Will the surgeon you send him to actually be there when he arrives, or will he have gone on holiday, or to a conference in Europe.

AT THE REFERRAL HOSPITAL a patient you refer will be in competition with ordinary local cases, so try to feed him into its administrative system. Tell him exactly where to go and whom to see. Try to send him personally to a surgeon you know, and who you know will treat a case of this kind. Find out on which days the surgeon has his clinics.

Inform the surgeon that the patient is coming. Make sure that the patient knows exactly what to do, and where to go when he arrives.

Investigate him first, and state the procedure that you think he needs. If a biopsy is necessary, do it, and refer him with his report. Often a biopsy takes time and may have to be sent to the referral hospital. If referral is urgent, don't wait for the report. Send a careful letter with him, including all necessary information.

If there are any particularly good referral facilities, such as those for artificial limbs, for example, be sure to use them.

Finally, don't refer patients unnecessarily. No surgeon likes to be sent ganglions (27.11)!

Fig. 1-5 THE REFERRAL SYSTEM. Each of these steps in the referral chain has its difficulties. A, from the patient's home to a community health worker. B, from the community health worker to the health centre. C, from the health centre to the district hospital. D, from the district to the provincial hospital. E, from the provincial to the teaching hospital. The histogram shows the number of major and minor operations combined at each stage in the referral chain in Kenya. Note the overwhelming aggregate importance of district hospital surgery. It is assumed that no surgery is done at home, or by the community health workers, and very little at health centres, for which no data were available. Data are from the Central Province of Kenya in 1983 extrapolated to the whole country. It is also assumed that the Central Province is typical. Kenya's 7 provinces are assumed to have one provincial hospital and 16 district hospitals each. The 6 district hospitals from which data were obtained averaged 2325 operations annually, ranging from 636 in Nyandarong to to 5708 in Muranga. Nyeri provincial hospital did 2,,,,944 operations, and the Kenyatta National Hospital 15,,,,333.