An Observational Study of a National Referral System: An Analysis of 14,266 Referrals in Sierra Leone

Abstract

Background Referral systems are critical to a well-functioning health system. In 2017, a special cadre of referral coordinators were trained and deployed at every district and tertiary hospital in Sierra Leone. We analyse the referrals coordinated by the network to understand health service utilisation, referral pathways and outcomes.Methods A retrospective observational study of incoming referrals to all district and tertiary hospitals in Sierra Leone from 1st November 2017 until 31st October 2018. Multivariate analysis was performed on all referrals and a subgroup analysis of urgent referrals (n=10,865). Hospital preparedness and readiness scores were sourced from the Service Availability and Readiness Assessment 2017.Results 14,266 referrals were captured over the 12 months. Referral indices ranged from 0·51-5·97, with the highest indices found in Freetown and Pujehun. Bed occupancy ranged from 36·8-83·3%. 606 deaths were recorded, mortality rate per referral was 4.25%, with the majority of deaths, 446 (73.60%) occurring in the U5 population. Higher OR for mortality are seen from referrals originating from higher levels of the health system. The OR for mortality for a referral from the lowest level, MCHP, was 0.77, whilst from tertiary level was 2.40 (MCHP 0·77, CHP 0·90, CHC 1·40, district 2·06 and tertiary 2·40). For urgent referrals, factors associated with mortality were U5s, adult non-maternity cases and being seen by a clinician within one hour. Referrals from district hospitals to tertiary hospitals only accounted for 0·5% of all referrals. No correlation was found between referral index, bed occupancy and hospital service availability and readiness scores. The study did not detect any difference in total number of national referrals during the rainy season.Conclusions Wide variations in bed occupancy and referrals by district highlight disparities in health service utilisation. Low rates of referral from district hospitals to tertiary care should be further investigated. Referral indices and referral mortality rates are useful to monitor over time and to make inter district comparisons. Referral systems and pathways are useful indicators of health service utilisation and further research should be undertaken to standardise definitions and identify performance indicators for referral systems in low resource settings.

Improving Access to Healthcare in Sierra Leone: The Role of the Newly Developed National Emergency Medical Service

“…Data were retrieved from the national referral coordinators’ database, storing information on all incoming referrals collected at each hospital facility [ 16 ]. After initial notification of the incoming referral via telephone call from the sending PHU, patients were identified upon arrival by referral coordinators, and information regarding patient demographics, clinical condition, mode, and time of transport to the referral facility were collected through a paper report form, which was then transcribed into an Epi Info™ datasheet (Centers for Disease Control and Prevention, Atlanta, GA, USA).…”