Using Network and Complexity Theories to Understand the Functionality of Referral Systems for Surgical Patients in Resource-Limited Settings, the Case of Malawi

Background: A functionally effective referral system that links district level hospitals (DLHs) with referral hospitals (RHs) facilitates surgical patients getting timely access to specialist surgical expertise not available locally. Most published studies from low- and middle-income countries have examined only selected aspects of such referral systems, which are often fragmented. Inadequate understanding of their functionality leads to missed opportunities for improvements. This research aimed to investigate the functionality of the referral system for surgical patients in Malawi, a low-income country. Methods: This study, conducted in 2017-2019, integrated principles from two theories. We used network theory to explore interprofessional relationships between DLHs and RHs at referral network, member (hospital) and community levels; and used principles from complex adaptive systems theory to unpack the mechanisms of network dynamics. The study employed mixed-methods, specifically surveys (n=22 DLHs), interviews with clinicians (n=20), and a database of incoming referrals at two sentinel RHs over a six-month period. Results: Obstacles to referral system functionality in Malawi included weaknesses in formal coordination structures, notably: unclear scope of practice of district surgical teams; lack of referral protocols; lack of referral communication standards; and misaligned organisational practices. Deficiencies in informal relationships included mistrust and uncollaborative operating environments, undermining coordination between DLHs and RHs. Poor system functionality adversely impacted the quality, efficiency and safety of patient referral-related care. Respondents identified aspects of the district-referral hospital relationships, which could be leveraged to build more collaborative and productive inter-professional relationships in the future. Conclusion: Multi-level interventions are needed to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of how to build more functional systems to optimise the continuum and quality of surgical care for rural populations in similar settings.

The Importance of Telemedicine in a Post COVID World

Telemedicine has found immense popularity, especially in a COVID-19 affected world. Its application shall improve the quality of health care provided to patients and help in time management as it help facilitates optimized referral systems which are based on the immediate/follow up needs of the patient, decision-making, reduction in patient’s waiting time as well as consultation time. This review is an effort to shed light on the main practical applications of teledentistry for emphasizing potentialities, problems, and applications of this relatively new branch in medicine. The paper also highlighted highlight the various aspects of telemedicine in relation to the healthcare sector, its advantages/disadvantages in a post COVID-19 world.

Challenges Affecting Health Referral Systems in Low-And Middle-Income Countries: A Systematic Literature Review

Aims: Low and middle-income countries are still facing challenges of dysfunctional referral systems which have impaired health service provision. This review aimed at investigating these challenges to understand their nature, cause, and the impacts they have on health service provision. Methods: Database search was made in Google scholar, ACM Library, PubMed health, and BMC public health, and a total of 123 papers were generated. Only 14 fitted the inclusion criteria. Inclusion criteria included studies that were both quantitative and qualitative addressing challenges facing referral systems or health referral systems, studies describing the barriers to effective referral systems, and studies describing factors that affect referral systems. The review only included studies conducted in LMICs and included literature between January 2010 and February 2021. Findings: Results revealed that human resource and financial constraints, non-compliance, and communication are the key challenges affecting referral systems in LMICs. Recommendation: Countries that are facing these challenges need to overhaul the system and improve end-to-end communication between hospitals, improve capacity specifically in referral and emergency units, and sensitizing patients on the adherence to emergency protocols.

Unlocking Trust in Community Health Systems: Lessons from the Lymphatic Filariasis Morbidity Management and Disability Prevention Pilot Project in Luangwa District, Zambia

Background: Surgery for hydrocele is commonly promoted as part of morbidity management and disability prevention (MMDP) services for lymphatic filariasis (LF). However, uptake of these surgeries has been suboptimal owing to several community level barriers that have triggered mistrust in such services. This study aimed at documenting mechanisms of unlocking trust in community health systems (CHS) in the context of a LF hydrocele management project that was implemented in Luangwa District, Zambia. Methods: Qualitative data was collected through in-depth interviews and focus group discussions (n=45) in February 2020 in Luangwa District. Thirty-one in-depth interviews were conducted with hydrocele patients, CHWs, health workers, traditional leaders and traditional healers. Two focus group discussions were also conducted with CHWs who had been involved in project implementation with seven participants per group. Data was analyzed using a thematic analysis approach. Results: The use of locally appropriate communication strategies, development of community driven referral systems, working with credible community intermediaries as well as strengthening health systems capacity through providing technical and logistical support enhanced trust in surgery for hydrocele and uptake of the surgeries. Conclusion: Implementation of community led communication and referral systems as well as strengthening health services are vital in unlocking trust in health systems as such mechanisms trigger authentic partnerships, including mutual respect and recognition in the CHS. The mechanisms also enhance confidence in health services among community members.

Critical comparative analysis of data sources toward understanding referral during pregnancy and childbirth: three perspectives from Nigeria

Background The highest risk of maternal and perinatal deaths occurs during and shortly after childbirth and is preventable if functional referral systems enable women to reach appropriate health services when obstetric complications occur. Rising numbers of deliveries in health facilities, including in high mortality settings like Nigeria, require formalised coordination across the health system to ensure that women and newborns get to the right level of care, at the right time. This study describes and critically assesses the extent to which referral and its components can be captured using three different data sources from Nigeria, examining issues of data quality, validity, and usefulness for improving and monitoring obstetric care systems. Methods The study included three data sources on referral for childbirth care in Nigeria: a nationally representative household survey, patient records from multiple facilities in a state, and patient records from the apex referral facility in a city. We conducted descriptive analyses of the extent to which referral status and components were captured across the three sources. We also iteratively developed a visual conceptual framework to guide our critical comparative analysis. Results We found large differences in the proportion of women referred, and this reflected the different denominators and timings of the referral in each data source. Between 16 and 34% of referrals in the three sources originated in government hospitals, and lateral referrals (origin and destination facility of the same level) were observed in all three data sources. We found large gaps in the coverage of key components of referral as well as data gaps where this information was not routinely captured in facility-based sources. Conclusions Our analyses illustrated different perspectives from the national- to facility-level in the capture of the extent and components of obstetric referral. By triangulating across multiple data sources, we revealed the strengths and gaps within each approach in building a more complete picture of obstetric referral. We see our visual framework as assisting further research efforts to ensure all referral pathways are captured in order to better monitor and improve referral systems for women and newborns.

258 Are Electronic Algorithmic Referral Systems the Future of Triage? Evaluating the Use of The Oxford Acute Referrals System (OARS) For Plastic Surgery

Introduction A traditional referral involves transfer of information over a telephone call and is typically documented in an unstructured format on paper notes, producing poor continuity of referrals between shifts, increasing the risk of error, and compromising patient safety. The Oxford Acute Referrals System (OARS) is an electronic platform that keeps a complete record of referrals, whilst providing the referring clinician with step-by-step specialist advice according to inbuilt BSSH guidelines. This audit demonstrates our experience of its’ use in a tertiary centre Plastics department. Method One week of referrals in 2019, prior to the implementation of OARS, were compared with the equivalent week in 2020 once OARS was established. Data was collected retrospectively using electronic patient records. Results In one week in 2019, 120 cases were reviewed in the emergency clinic compared with 155 OARS referrals for the equivalent week in 2020. Following OARS implementation, 69% of referred cases did not footfall in the emergency clinic. 46% were managed locally with specialist advice from Plastic Surgery. 10% were brought directly into a theatre list, of which 7% were subsequently treated conservatively. A Plastic surgery consultant reviewing OARS referrals taken by juniors, changed the decision of how or where to manage the patient in 6% of cases. Conclusions OARS is an effective triage system that has considerably reduced footfall in the emergency clinic, whilst simultaneously expediting patient care down the correct treatment pathway. Its use led to safe management of patients remotely, which has important implications during a pandemic.

320 The Initial Impact Of COVID-19 On Paediatric Spinal Services Across Scotland

Background The COVID-19 pandemic has meant a significant decline in the activities of the paediatric spinal services in Scotland. Method All referrals to the Scottish paediatrics spinal service from 1st January 2020 to 30th June 2020 were analysed. Comparison was made to the same period in 2019. All orthotist initial consultations and all paediatrics spinal theatre activity in Scotland from 1st March 2020 to 30th June 2020 was analysed and compared to the previous year. Results There was a 64.3% decline in referrals during the first wave of the pandemic in Scotland to the paediatric spinal service. The mean wait time to be seen in 1st clinic for a new referral was 6.56 weeks in 2020 compared to 10.94 in 2019. There were however 60 patients still waiting to be seen. The number of paediatric spinal operations declined by 34% during March to June 2020 when compared to the same months in 2019 There was a reduction of 50% of new paediatric patients seen by orthotists from March – June 2020 when compared to 2019 Conclusions COVID-19 has had a significant effect on paediatric spinal services in Scotland. This is likely due to a combination of service delivery factors and patient factors. This is likely to result in delays to children getting the care they require for their spinal condition. There will also be a back-log of patients requiring to be seen when services start to re-establish themselves. There are several options available to department to optimise efficiency, such as video consultants and streamlining referral systems.

Palliative care model in Thailand

Background: Thailand has few hospices and a limited range of palliative care services. Aims: To explore palliative care models in Thailand. Methods: A convergent mixed-methods study design using purposive sampling to select three levels of healthcare services and one religious organisation. Findings: The quantitative data revealed that the structures of palliative care accessibility, referral systems, and continuity of care were in place at all levels of healthcare services. The qualitative data revealed the themes of the structure of palliative care, processes and outcomes. Conclusion: The variety of palliative care structures identified in Thailand are suitable for the context in which palliative care is provided. The problems that need solving are referral systems, patient access to opioids, inequitites in care distribution and medicine dispensing and palliative care outcome evaluation.

Assessing the functionality of an emergency obstetric referral system and continuum of care among public healthcare facilities in a low resource setting: an application of process mapping approach

Background Weak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, particularly for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. The objective of this study is to establish process details of emergency obstetric referral systems across different levels of public healthcare facilities to deepen understanding of systemic barriers and preliminary solutions in an urban district, using Ablekuma in Accra, Ghana as a case study. Methods The study is an analytical cross-sectional study. Nine [1] targeted interviews were carried out for a three-week period in June and July 2019 after informed written consent with two [2] Obstetrics & Gynaecology consultants, two [2] Residents, one family physician, and four [3] Midwives managing emergency obstetric referral across different levels of facilities. Purposeful sampling technique was used to collect data that included a narration of the referral process, and challenges experienced with each step. Qualitative data was transcribed, coded by topics and thematically analysed. Transcribed narratives were used to draft a process map and analyze the defects within the emergency obstetric referral system. Results Out of the 34 main activities in the referral process within the facilities, the study identified that 24 (70%) had a range of barriers in relation to communication, transport system, resources (space, equipment and physical structures), staffing (numbers and attitude), Healthcare providers (HCP) knowledge and compliance to referral policy and guideline, and financing for referral. These findings have implication on delay in accessing care. HCP suggested that strengthening communication and coordination, reviewing referral policy, training of all stakeholders and provision of essential resources would be beneficial. Conclusion Our findings clearly establish that the emergency obstetric referral system between a typical teaching hospital in an urban district of Accra-Ghana and peripheral referral facilities, is functioning far below optimum levels. This suggests that the formulation and implementation of policies should be focused around structural and process improvement interventions, strengthening collaborations, communication and transport along the referral pathway. These suggestions are likely to ensure that women receive timely and quality care.