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.
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.
['Ezhumalai|Gopalakrishnan|G|', 'Jayashree|Muralidharan|M|http://orcid.org/0000-0002-6149-1355', 'Nallasamy|Karthi|K|', 'Bansal|Arun|A|', 'Bharti|Bhavneet|B|']
D002648:Child D002675:Child, Preschool D004636:Emergency Service, Hospital D005260:Female D006282:Health Personnel D006302:Health Services Research D006784:Hospitals, Teaching D006801:Humans D007223:Infant D008297:Male D011446:Prospective Studies D058996:Quality Improvement D012017:Referral and Consultation D063128:Tertiary Healthcare
Pediatric emergency Quality of referral Referral letter Triage