Inappropriate utilization of higher-level health facilities and ineffective management of referral processes in resource-limited settings is increasingly becoming 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) did enforce the referral guidelines that required patients have a formal referral letter to KNH to reduce the number of walk-ins and allow KNH to function as a referral facility as envisioned by Kenya 201 constitution and KNH legal statue of 1987. Study Objective: To determine the effect of referral guidelines on patterns of orthopaedic and trauma admissions to KNH. Methodology: This was a quasi – experimental design. Data abstraction was done for 459 and 446 before and after enforcement of referral guidelines. Findings enforcement of the referral guidelines reduced the proportion of walk-in admissions from 54.9% to 45.1%, while facility referrals increased from 46.6% to 53.4%. The Non-trauma orthopaedic admissions doubled from 12.0% to 22.4% after enforcement of the referral guidelines (p<0.001). The mean age was 33.8 years with mean age rising among females from 32.2 years to 38.0 years after the enforcement of the referral guidelines. There was a significant increase in the proportion of female admissions after the enforcement of the referral guidelines. The enforcement of the referral guidelines was associated with a statistically significant increase in the number of orthopaedic admissions with active insurance cover. Conclusion: the enforcement of the referral guidelines reduced the proportion of walk-ins. The enforcement of the guidelines was also associated with orthopaedic and trauma admissions with more non-trauma cases, tertiary education level, and more active insurance cover.

Tertiary hospitals in resource-limited countries should treat referred patients but in reality, are the first level of care for the vast majority of patients. As a result, the tertiary facility effectively functions as a primary health care facility. The urban phenomenon of widespread self-referral is associated with low rates of formal referral from peripheral health facilities. The study objective was to determine the patterns of orthopaedic and trauma admissions to Kenyatta National Hospital. This was descriptive study design. 905 patient charts were reviewed in 2021. The mean age was 33.8 years (SD 16.5) with range of 1–93 years. Majority 66.3% were between 25–64 years with those above 65 years being 40 (4.4%). Children 0–14 years comprised 10.9% of the admissions. Of the 905 admissions, 80.7% were accident and trauma-related admissions while 17.1% were non-trauma related admissions. About 50.1% were facility referrals while 49.9% were walk-ins. Majority of admissions were through Accident and Emergency Department 78.1%, Corporate Outpatient Care 14.9% and orthopedic Clinic 7.0%. About 78.7% were emergency admissions while 20.8% were elective admissions. Approximately 48.5% were due to Road Traffic Accidents and 20.9% due to falls. Close to 44.8% were casual workers and 20.2% unemployed. About 34.0% attained primary education and 35.0% secondary education. About 33.2% of female admissions were due to non-trauma conditions as compared to male admissions (12.8%) (p<0.001). Admissions for those aged 25–64 years were 3.5 more likely to have emergency admission as compared to those aged 0–14 years. Male were 65.1% less likely to have elective admissions compared to female (p<0.001). Whereas lower limb injuries and non-trauma related conditions were the most commonly admitted conditions, Lower limb injury and spine cases were mostly facility referred while non-trauma conditions were walk-in patients. Vast majority (89.2%) of admissions were from Nairobi Metropolitan region.