Adherence to Referral Criteria at Admission and Patient Management at a Specialized Burns Centre: The Case of the Red Cross War Memorial Children's Hospital in Cape Town, South Africa

Effect of enforcement of the national referral guidelines on patterns of orthopedic admissions to Kenyatta National Hospital, Kenya: Pre-post intervention study

BACKGROUND

Inappropriate utilization of higher-level health facilities and ineffective management of referral processes in resource-limited settings are becoming increasingly a concern in health care management in developing countries. This is characterized by self-referral and frequent bypassing of the nearest health facilities coupled with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. On July 1, 2021, Kenyatta National Hospital (KNH) enforced the Kenya Health Sector Referral Implementation Guidelines, 2014, which required patients to receive approval from the KNH referral office and a formal referral letter to be admitted at KNH to reduce the number of walk-ins and allow KNH to function as a referral facility as envisioned by the Kenya 2010 Constitution and KNH legal statue of 1987.

OBJECTIVE

To determine the effect of enforcing the national referral guidelines on patterns of orthopaedic admissions to the KNH. This was a pre-post intervention study. Data abstraction was done for 459 and 446 charts before and after the enforcement of the national referral guidelines, respectively.

RESULTS

Enforcement of the national referral guidelines reduced the proportion of walk-in admissions from 54.9% to 45.1%, while the proportion of facility referrals increased from 46.6% to 53.4% (p = 0.013). The percentage of non-trauma orthopaedic admissions doubled from 12.0% to 22.4% (p<0.001). There was also an increase in admissions through the Outpatient Clinic and Corporate Outpatient Clinic. The proportion of emergency admissions declined, while that of elective admissions increased. The increase in elective cases was mainly driven by the increase in female admissions with active insurance cover, tertiary education, non-trauma-related conditions and older age groups. However, the use of official formal written referral letters did not change despite the enforcement of the national referral guidelines.

CONCLUSION

The enforcement of the national referral guidelines reduced the proportion of walk-ins' admissions to KNH. While the enforcement of the national referral guidelines had no effect on the use of official formal written referral letters, it did limit access and utilization of inpatient orthopedic services for young male patients with no active insurance cover and in need of emergency orthopedic care.

Clinical decision-support for acute burn referral and triage at specialized centres - Contribution from routine and digital health tools

BACKGROUND

Specialized care is crucial for severe burn injuries whereas minor burns should be handled at point-of-care. Misdiagnosis is common which leads to overburdening the system and to a lack of treatment for others due to resources shortage.

OBJECTIVES

The overarching aim was to evaluate four decision-support tools for diagnosis, referral, and triage of acute burns injuries in South Africa and Sweden: referral criteria, mortality prediction scores, image-based remote consultation and automated diagnosis.

METHODS

Study I retrospectively assessed adherence to referral criteria of 1165 patients admitted to the paediatric burns centre of the Western Cape of South Africa. Study II assessed mortality prediction of 372 patients admitted to the adults burns centre by evaluating an existing score (ABSI), and by using logistic regression. In study III, an online survey was used to assess the diagnostic accuracy of burn experts' image-based estimations using their smartphone or tablet. In study IV, two deep-learning algorithms were developed using 1105 acute burn images in order to identify the burn, and to classify burn depth.

RESULTS

Adherence to referral criteria was of 93.4%, and the age and severity criteria were associated with patient care. In adults, the ABSI score was a good predictor of mortality which affected a fifth of the patients and which was associated with gender, burn size and referral status. Experts were able to diagnose burn size, and burn depth using handheld devices. Finally, both a wound identifier and a depth classifier algorithm could be developed with relatively high accuracy.

CONCLUSIONS

Altogether the findings inform on the use of four tools along the care trajectory of patients with acute burns by assisting with the diagnosis, referral and triage from point-of-care to burns centres. This will assist with reducing inequities by improving access to the most appropriate care for patients.

Adherence to Referral Criteria for Burn Patients; a Systematic Review

Introduction

Burn injuries are under-appreciated trauma, associated with substantial morbidity and mortality. It is necessary to refer patients in need of specialized care to more specialized centers for treatment and rehabilitation of burn injuries. This systematic review aimed to assess the adherence to referral criteria for burn patients.

Methods

An extensive search was conducted on Scopus, PubMed, and Web of Science online databases using the relevant keywords from the earliest to October 7, 2021. The quality of the included studies was assessed using the appraisal tool for cross-sectional studies (AXIS tool).

Results

Among a total of 7,455 burn patients included in the nine studies, 60.95% were male. The most frequently burned areas were the hands (n=3) and the face (n=2). The most and least common burn mechanisms were scalds (62.76%) and electrical or chemical (2.88%), respectively. 51.88% of burn patients had met ≥ 1 referral criteria. The overall adherence to the referral criteria for burn patients was 58.28% (17.37 to 93.39%). The highest and lowest adherence rates were related to Western Cape Provincial (WCP) (26.70%) and National Burn Care Review (NBCR) (4.97%) criteria, respectively.

Conclusion

The overall adherence to the referral criteria for burn patients was relatively desirable. Therefore, well-designed future studies are suggested in order to uncover approaches to improve adherence to referral criteria for burn patients.

Adherence to the emergency management of severe burns referral criteria in burn patients admitted to a hospital with or without a specialized burn center

BACKGROUND

The primary aim was to determine to what extent referral and admission of burn patients to a hospital with or without a burn center was in line with the EMSB referral criteria.

METHODS

This was a retrospective, multicenter cohort study. Burn patients admitted from 2014 to 2018 to a hospital in the Southwest Netherland trauma region and Network Emergency Care Brabant were included in this study. Outcome measures were the adherence to the EMSB referral criteria.

RESULTS

A total of 1790 patients were included, of whom 951 patients were primarily presented to a non-burn center. Of these patients, 666 (70.0%) were managed according to the referral criteria; 263 (27.7%) were appropriately not referred, 403 (42.4%) were appropriately referred. Twenty (2.1%) were overtransferred, and 265 (27.9%) undertransferred. In 1213 patients treated at a burn center 1119 (92.3%) met the referral criteria. Adherence was lowest for electrical (N = 4; 14.3%) and chemical burns (N = 16; 42.1%), and was highest in 'children ≥5% total body surface area (TBSA) burned' (N = 109; 83.2%).

CONCLUSION

The overall adherence to the referral criteria of patients presented to a non-burn center was fairly high. However, approximately 25% was not transferred to a burn center while meeting the criteria. Most improvement for individual criteria can be achieved in patients with electrical and chemical burns.

A third of referrals are unnecessary: Critical review of burn outpatient clinic data

OBJECTIVES

The purpose of this study was to establish patterns in types of burns referred to the Outpatient Clinic (OP) at Vancouver General Hospital (VGH).

METHODS

A 2-year retrospective chart review was conducted of patients presenting to the OP Clinic from June 1, 2016 - June 1, 2018. Data collected included: patient demographics, depth of burn, Total Body Surface Area (TBSA), anatomical location of burn, geographical location of referral, and operative versus non-operative management.

RESULTS

The OP Clinic served 470 patients for burn injuries with a total of 1852 visits. Of these, 20% were follow-up visits post-admission, and 73.6% were primary referrals from the emergency department (ED) or elsewhere. The vast majority (69.6%) of burns were less than 5% TBSA. Half involved the hands (50.9%), and half were superficial dermal in depth (45.1%). A third of patients attended only one appointment with the OP Clinic before discharge and 15% did not receive any treatment.

CONCLUSIONS

The results of our study demonstrate gaps in current provincial referral guidelines leading to a significant number of "unnecessary referrals." Further research could correlate the results to current provincial referral guidelines to estimate their current efficacy in practical use.