Referral means transferring a patient’s care either some part or all to another facility that has the special needs of the patient. The needs in this regard may include specialist consultation, investigation, care and/or treatment that may not be met by the referring institution usually from a primary (lower) to secondary or tertiary facility. In some cases and in most organized health service systems, referral from higher (secondary or tertiary) to lower facility may be necessary for continuity of care. The essence of referral therefore is to preserve life by all means possible.
A referral not properly done is as bad as denying the patient care. The decision to make a referral and the time at which the decision is made is the most important determinant of the patient’s life or quality of life thereafter. Haven observed some referrals in Ghana, two things come to mind.
First is delayed referral
Some primary facilities overly delay in making a decision to refer patients. Both in-patient and out-patients are affected. Some patients are referred at the tail end when conditions become very critical and exceedingly deteriorating. It appears at some point that some facilities refer because of the fear of recording mortality and so you see patient arrive at the receiving end as Brought-In-Dead (BID). What a shame!!
The second is unnecessary referrals
Unnecessary referrals which I called the “patient dumping syndrome” is also on the increase. Most facilities refer patients without any special reasons but reasons that cannot be written on the referral form. Some group of service providers are specially faulted in this arena but for some reasons specifications cannot be made.
Some referrals are simply for the purposes of patient unable to pay for medical bills, troublesome patient, fear of recording mortality and in some cases patients requiring end of life care which has nothing to do with specialist care or consultation.
I recount my ordeal on one referral when the patient couldn’t make it on our way to the referring institution. This young lady in tears looked into my eyes and asked “you people knew my mum was going to die, you referred a dead body for what, why didn’t you tell us, at least our mum would have had a peaceful transition, why must it happen in an ambulance”. All my words dissipated as I nearly joined her in tears.
The consequence of this is that the few secondary/tertiary facilities get overburdened and those who actually require specialist management will fail to access the service for reasons of the common slogan ‘no bed space’ and actually it’s not just a slogan but a reality.
We all have the responsibility to make our referral system more robust, efficient and friendly to the patients and their relatives. In doing so, let’s do referrals in timely manner, patients who require to be stabilize before referral should be stabilized before doing so. A patient with unstable and dwindling vitals pushed in the taxi to a referring facility is no different from pushing him into a morgue.
Explaining patient’s prognosis to relatives is also vital as it can reduce referrals of inevitable death cases and also give relatives an opportunity to prepare instead of making a goose chase.
Arrangements must be properly made with the receiving facility about the patient before dispatch for patients who are critically ill. This will avoid the ambush situation at the receiving ends and the ambush situation of no bed. (You may never appreciate this until you become a “referral at large nurse” in the corridors of Accra secondary/tertiary hospitals). All referral letters should be properly addressed. It saves a lot of time and energy. Above all critically ill patients should at all times be dispatched in well-resourced ambulances.
Together We Serve Gh
Awiagah Sherrif Kwame