An Exploratory Analysis of Referrals to a major Emergency Department in a developing country

Background: Hospital crowding, ED waiting times and high demand for unscheduled care all place significant burdens on secondary care services. This impacts on patient care, staff morale and overall functioning of the whole healthcare system. Patient referrals from other healthcare providers often is a result of limited access to resources, specialists or because of acuity. However, some referrals may be more suitable for lower acuity settings, with the benefit of better overall patient experience. In addition, duplication of contacts with a healthcare professional may not result in additional benefit to patients, but may necessarily add to the patient journey and contribute to crowding. Objectives: We aimed to determine the originator of referrals to the ED. We also aimed to determine the proportion of referred patients who received any meaningful intervention at the ED. Finally, we aimed to estimate the proportion of patients referred who may have been suitable for direct inpatient referral or management in a lower acuity setting. Methods: We conducted a prospective evaluation of all referrals to the ED of a large urban hospital over 7 days. Routine anonymised demographic, diagnosis and intervention data were collected and simple descriptive analysis was undertaken using Microsoft Excel®. A validated algorithm was applied to determine suitability for lower acuity settings, and contextual secondary analysis was applied to determine choice of altResults: There were 168 formal referrals during the period evaluated (mean 24/day), of which data was available for 151. Most referrals were on Monday and Thursday. 39.7% were referred from the four regional District Health Facilities (DHF). 12 % were referred by specialists. There were significantly higher referrals from Local Health Centres located more than 5km of the hospital compared with those closer, although this could have been due to greater numbers outside the 5 km radius. 5.5% were thought suitable for primary care management and 31% could have been referred directly to an inpatient team if this were available. The majority (51.3%) of referred patients received no significant intervention in the ED, with almost 1 in 7 suitable for outpatient management. Conclusions: A significant number of patients referred to the ED may have been more appropriately directed. Direct special admission, access to outpatient referral slots or telephone advice from senior ED or specialty clinicians may prevent up to a half of referrals being seen by an ED clinician. This may reduce unnecessary transport, improve time and resource utilization and decongest the ED and hospital. Further large scale evaluation is warranted to investigate the predictors of referral, control for seniority, and make more robust recommendations for improving the patient journey ernate pathways.

Pathways to care and ethnicity. 2: Source of referral and help-seeking

BACKGROUND: Previous research has found that African–Caribbean and Black African patients are likely to come into contact with mental health services via more negative routes, when compared with White patients. We sought to investigate pathways to mental health care and ethnicityin a sample of patients with a first episode of psychosis drawn from two UK centres. METHOD: We included all White British, other White, African–Caribbean and Black African patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas. Clinical, socio-demographic and pathways to care data were collected from patients, relatives and case notes. RESULTS: Compared with White British patients, general practitioner referral was less frequent for both African–Caribbean and Black African patients and referral by a criminal justice agency was more common. With the exception of criminal justice referrals for Black African patients, these findings remained significant after adjusting for potential confounders. CONCLUSIONS: These findings suggest that factors are operating during a first episode of psychosis to increase the risk that the pathway to care for Black patients will involve non-health professionals.

Social class and pathways to care among psychiatric clinic referrals at the University Hospital of the West Indies [abstract]

OBJECTIVE: To determine the effects of social class on the pathways to outpatient psychiatric care at the University Hospital of the West Indies. METHODS: This was a prospective cohort study of patients attending the psychiatric screening clinic of the University Hospital of the West Indies. Demographic, clinical and outcome variables were collected over the period February to July 2001. RESULTS: The cohort consisted of 306 patients of whom 150 were male, 156 were female and 85.4 percent were from social classes III to V. Most of the patients came from urban St.Andrew (57 percent). More than half (51 percent) took the bus, 61 percent were brought by family members, 31.8 percent came alone. More than three-quarters (76.4 percent) were seen in the emergency outpatient department prior to being referred. Most (66.4 percent) patients presented within six months of onset symptoms. Once seen, 47.3 percent (142) were referred the government community mental health service while an equal number was distributed within the psychiatric service of the hospital. There was a statistically significant relationship between social class and method of transportation (p= 0.001). No association was found with social class and any other variable. CONCLUSIONS: For the majority of these patients, with the exception of the method of transportation to the clinic, there is no effect of social class on all the variables studied. The transporattion variable, which was significant, was not related to the services offered. (AU)

Utilization of liaison psychiatric services in a general hospital in Jamaica [abstract]

OBJECTIVE: To identify the pattern and characteristics of Liaison Psychiatry refferals in the University Hospital of the West Indies over a six-month period. METHOD: A prospective cohort analysis was conducted on patients referred to the Liaison Psychiatry service between November 28, 2000 and May 28, 2001. Clinical and sociodemographic data were gathered by individual interviews and mental status examination and a DSM IV diagnosis made. RESULTS: Fifty-nine patients were referred with 28 (47.5 percent) males, and with a mean ñ Standard Deviation age of 39.42 ñ 15.92 years. Significantly more patients were referred from the medical wards (37, 62.5 percent) than from the surgical wards (14, 23.7 percent) or the gynaecological wards (8, 13.6 percent) (x2= 16.803, 2df, p<0.005). The main reason for referral was "strange behaviour" (31, 52.5 percent) and depression (13, 22 percent). There was no statistically significant difference between the referring wards and the reason for referral or diagnostic pattern. An equal number of patients were diagnosed with a psychotic disorder and unipolar depressive disorder (33.9 percent each). CONCLUSION: The medical wards of the University Hospital of the West Indies are the main agents of referral to the Liaison Psychiatric service with the majority of patients presenting with the majority of patients unipolar depressive or psychotic disorders. (AU)

Perceptions about mental illness among pre-clinical medical students in Trinidad and Tobago

Perceptions about mental illness among medical practitioners are likely to determine their capacity to recognise, treat appropriately and refer patients who have mental health problems. It is therefore important that training of medical students in psychiatry is undertaken with knowledge of their attitudes to mental health disorders. We determined the perceptions of 108 pre-clinical medical students (69 males, 39 females; mean age 22 years) toward mental illness in Trinidad and Tobago by analysing their responses to a questionnaire based on a case vignette of a young man with a paranoid psychotic illness. 88 percent felt that medical treatment in hospital was the best means of treating the illness and 86 percent suggested that discharge should be conditional on regular visits to a doctor. 89 percent however opposed the patient's marrying into their families and 85 percent to his teaching their children. This was associated significantly with having a personal relationship with someone having a mental illnes (p < 0.03). Surprisingly, 25 percent believed that mental illness could be caused by supernatural forces, particularly females who were almost twice as likely as males to express this belief.(AU)

Neurological and neurosurgical referrals overseas from the Queen Elizabeth Hospital, Barbados, 1987-1996

This paper reports on neurological and neurosurgical referrals overseas from the Queen Elizabeth Hospital (QEH) for the period November 1987 to November 1996, and is a follow up to an earlier report for the period January 1984 to November 1987. It outlines the pattern of referral, diagnoses, referral centres and costs based on examination of the files of all QEH patients transferred overseas under a government aided scheme. There were 203 transfers of 191 patients (69 males, 122 females) including 10 patients who were transferred twice and one patient who was transferred three times. Patients ages ranged from 1 to 80 years (mean 37 years). Twenty overseas centres were used during the period but most patients were transferred to Brooklyn Hospital, New York in 1988, Mount Sinai Medical Center, New York, between 1989 and 1994, and Hospital de Clinicas Caracas, Venezuela (1992 to 1996). 65 percent of the referrals were for neurosurgery and 25 percent were for magnetic resonance imaging scans for diagnosis. The largest diagnostic categories were central nervous system tumors (40 percent) and subarachnoid haemorrhage (25 percent). Estimated costs reached almost BDS$11 million, but the mean actual cost was BDS$63,916 based on information from 123 patient transfers. Thus, the actual total government expenditure was probably closer to BDS$13 million. This study demonstrates the urgent need to establish a neurosurgical service at the QEH and the cost effectiveness of doing so.(AU)

Neurological/neurosurgical referrals overseas from the Queen Elizabeth Hospital, Barbados, 1987 - 1996

In 1988, we reported on the neurological/neurosurgical referrals overseas in the period January 1984 to November 1987. The present study is a follow-up of the previous one and reviews overseas referrals over a 9 years period from November 1987 to November 1996. The pattern of referral, diagnoses, referral centres and costs were studied. All Queen Elizabeth Hospital patients transferred overseas between November 1987 and November 1996 under a government-aided scheme for neurological investigation or neurosurgical treatment were include. The Department of Social Services files were reviewed. No patients were transferred in November and December 1987 but 203 patient-transfers were arranged for neurological investigation and/or treatment overseas between January 1988 and November 1996. This includes 10 patients who were transferred twice and one patient three times. 191 patients, 69 males and 122 females, were included, with ages ranging from 1 to 80 (mean 37) years. Most patients were referred to Brooklyn Hospital, New York in 1988, Mount Sinai Medical Center (1989 - 94), and Hospital de Clinicas Caracas, Venezuela (1992 - 96). Twenty overseas centres were used during the study period. Sixty-five percent were referred for neurological management while 48 (25 percent) had MRI scans for diagnosis. The largest diagnostic category was central nervous system tumours (40 percent) followed by subarachnoid haemorrhage (25 percent). Through the government-aided scheme more than ten million BDS dollars were pledged during the study period. Actual costs were determined in only 38 percent of cases but there was a suggestion that the mean actual cost per patient of overseas neurosurgical management and investigation had shown little change over the nine years of the study, remaining at about Bds. $60,000.00(AU)

A prospective study of ward referrals for renal disease at a Jamaican and a United Kingdom Hospital

Seventy ward referrals for renal disease were prospectively studied at each of two tertiary hospitals: University Hospital of the West Indies (UHWI), Kingston, Jamaica and Nottingham City Hospital (NCH), England. At UHWI, the referral population was significantly younger, 89 percent being less than 60 years of age compared to 40 percent at NCH (p<0.05). The leading cause of acute renal failure (ARF) at UHWI was systemic lupus erythematosus (SLE) followed by acute tubular necrosis (ATN). The leading causes of ARF at NCH were ATN and obstructive uropathy. Primary renal disease and diabetes mellitus were the major causes of end-stage renal disease (ESRD) at both centres, followed by SLE and hypertension at UHWI than at NCH but the numbers were small (p<0.05). Mortality rates were similar among patients with ARF and nephrotic syndrome at both centres, but were higher for patients with chronic renal failure (CRF) at UHWI than at NCH (p<0.05). Continuous ambulatory peritoneal dialysis (CAPD) was a frequent mode of renal replacement therapy at NCH (76 percent v 19 percent on haemodialysis). At UHWI, CAPD was not available and 45 percent of patients with ESRD were not offered maintenance dialysis because of inadequate facilities. The major difference in management and outcome between the two centres occurred in cases with CRF, suggesting that survival in patients with CRF in Jamaica could be improved if this therapeutic modality was available. (AU)

Referrals in family practice: a retrospective study of referrals - abstract

This study took a retrospective look at referrals from a primary care physician to secondary and tertiary institutions during three years of post-graduate training, July 1988 to September 1991. The aims were to assess the types of referrals made, their outcome and the degree of communication that existed between the specialities. Of the 151 referrals made, 41 (27.15 percent) were males and 110 (72.85 percent) were females; a male : female ratio of 1 : 2.7. The age of referral followed the population distribution with the majority 37.77 per cent in the reproductive age group 15 - 44 years. Most of the referrals went to the departments of Surgery, Accident and Emergency, Opthalmology and to the Nutritionist. The surgical disciplines received 37.75 per cent of the referrals while 5.96 per cent went to the medical disciplines. Compliance with referrals was found to be 78.15 per cent, with 13.25 per cent of the patients requiring admission to hospital at the time of referral. Emergency management on referral was required in 19.21 per cent of cases, whilst 63.58 per cent of the patients had an out patient follow-up appointment. Resolution of the problem occurred in 42.38 per cent of patients. Ninety-five per cent [95.36] of the patients returned to the primary care setting after referral, although communication from the specialties was documented in only 11.92 per cent of the referrals. The remainder of information on referral outcome was verbal in 69.54 per cent while in 18.54 per cent of cases there was no documentation on referral outcome (AU)

Analysis of referrals from the Marigot primary health care district to secondary care in Dominica - abstract

As part of a series on the Primary Health Care Services in the Marigot Health District, referrals from the district to secondary care were analyzed for patterns of morbidity and actual utilization of the services offered. From 1st October, 1991 to 30th September, 1992, 560 referrals were registered. Of these, 260 were directly admitted to the wards of the central Princess Margaret Hospital (PMH), 68 were referred to the Casualty Department of the PMH and 232 to specialist outpatient clinics. Surgical cases, especially fractures and acute abdomen, are the most common reason for referral to the wards. Simple fractures are seen and treated at the Casualty Department. Reasons for referral to the outpatient departments are also mainly surgical, especialy phimosis, hernias and thyroid lumps. Few referral notes arrived back in the district. Half of the records of patients referred to the outpatient departments could not be traced. Twenty-two patients were known not to have kept their appointment, and it is most likely that a substantial number of the remainder did not keep theirs either. Other patients discontinued their visits on their own initiative. Some patients may discontinue follow-up because they misjudge the seriousness of their condition and may develop subsequent secondary complications of their condition because of this. Further expansion of the district outreach programme with outpatient clinics in the district may improve quality of compliance and care, especially for the elderly population, and improce communication between primary and secondary care (AU)

Profile of two child guidance clinics looking at referral patterns, family characteristics and diagnoses

A retrospective study was conducted which comprised 212 patients who attended the Comprehensive Health Center Child Guidance Clinic and 107 who attended the University of the West Indies Child Guidance Clinic. Both clinics were similar in most areas. The mean age was 10.5 ñ 3 with 48.3 percent in the age group 11-15 years. 62. 4 percent of the patients were male and 87.1 percent were from the Kingston Metropolitan area. 37.5 percent of the patients were attending primary schools. 20.4 percent of the patients were from two-parent families. The most common diagnosis was conduct disorder (32.3 percent). The most common presenting complaints were stealing (36.4 percent), learning problems (32.6 percent) and aggressive behaviour (26.6 percent). Psychotheraphy was the favored mode of therapy. The attrition rate was greater than 70 percent. One major difference between the clinics was that there were more referrals (31.1 percent vs. 9.3 percent) from family members and less referrals (25.0 vs 44.9 percent) from health professionals at the Comprehensive Clinic in comparison to the University Clinic. Another difference was that some findings at the Comprehensive Clinic were statistically significant while similar findings at the University Clinic were not. There was a significantly higher percentage of patients receiving individual (61.8 percent vs 39.3 percent), group psychotheraphy (21.8 percent vs 11.2 percent) as well as laboratory investigations (8.5 percent vs 2.8 percent) at the Comprehensive Clinic and referrals to other agencies (15.0 percent vs 6.6 percent) at the University Clinic. There was a higher prevalence (10.4 percent vs 0 percent) of sexual abuse at the Comprehensive Clinic. These findings of high attrition rates and high percentage of conduct disorder indicate the important need for a major study of the Child Guidance Clinics in the island looking at clinic utilization, especially at outcome of patients diagnosed with conduct disorder and the factors affecting attrition from the clinics. It is recommended that a community survey assessing prevalence rates of psychiatric disorders in children should be done to give a picture of the mental health needs of children in Jamaica.(AU)

Referrals in family practice: a retrospective study of referrals

This study took a retrospective look at referrals from a primary care physician to secondary and tertiary institutions during three years of post graduate training: July 1988 to September 1991. The aims were to assess the type of referrals made, their outcome and the degree of communication that existed between the specialities. Of the 151 patients referred, 41 (27.2 percent) were males and 110 (72.8 percent) were females, a male: female ratio 1:2.7. The patients' records were found to have documentation on the referral outcome in 64.9 percent of the cases. Of the remaining 35.1 percent, information was obtained by telephone enquiring about the referral. However in 6.6 percent of the cases no contact was possible. The age of the referrals followed that of the population distribution with the majority (37.8 percent) in the reproductive age group (15-44 years). Of the total referrals, 37.8 percent were distributed to the surgical disciplines whereas 6.0 percent went to the medical. Most of the referrals went to General Surgery, Accident and Emergency, Opthalmology and to the Dietician (Nutritionist). Compliance with referrals was found to be 78.2 percent with 13.3 percent of the patients requiring admission to the hospital at the time of referral. Of the patients referred, 63.6 percent had an outpatient follow-up appointment and 19.2 percent required emergency management. Resolution of the problem occurred in 42.4 percent of patients. What was interesting is that, 95.4 percent of the patients returned to the primary care setting after referral. Communication between the specialities and the primary care occurred in 11.9 percent of the referrals. Most information on referral outcome was by patient's "word of mouth" in 69.5 percent of cases, while in 18.5 percent of the referrals there was no information on the outcome. On review of the referrals, the author felt that in 11.3 percent of cases referral was untimely. (AU)

The pattern of in-patient psychiatric referrals in a general hospital

All patients referred for a psychiatric consultation from the adult wards of a General Hospital over a 10-month period were examined. The referral rate was 1.4 percent. Twice as many female patients were referred as male pateints. Parasuicide accounted for 68 percent of referrals. The most common psychiatric diagnoses were adjustment reaction (41 percent), depression (23 percent), alcohol dependence (5 percent). In 30 percent of referrals, no psychiatric treatment was necessary; 26 percent were transferred to the psychiatric unit and 17 percent were discharged to the out-patients' psychiatric clinic. Explanations are offered for the "hidden" psychiatric morbidity in General Hospitals and the high percentage of referrals who did not need psychiatric follow-up. Suggestions are made for a better liaison between physicians and psychiatrists (AU)

Further comparisons of teacher and parent ratings of behavior and emotional problems in Jamaican children

As a sequel to comparisons between parent and teacher reports on behavioral/emotional problems in clinic-referred Jamaican 6-11 year-old youngster were compared. Similar to clinic-refered findings,low to moderate correlations emerged for parent and teacher reports on nonreferred children. Correlations were also significantly higher for ratings of undercontrolled (eg., disobedience, stealing, fighting) than ratings of overcontrolled (eg., shyness, depression, fearfulness) behavior, suggesting that some findings may be robust across cultures and referral status. However, correlation coefficients varied across referral status for ratings of overcontrolled problems in boys. Overall, the findings suggest that the study of child behavior requires attention to the reporter of the behavior and the context in which such behavior occurs (AU)

Service needs of children with disabilities in Jamaica

We investigated the service needs of children attending a medical assessment as part of a two stage survey of 2 to 9-year-old children in mid and south Clarendon, Jamaica. Parents were asked about symptoms relating to six different disabilities: visual, hearing, speech, motor, cognitive and fits. Following medical and psychological assessment, a diagnosis of mild, moderate, severe or no disability was made. For children with disabilities, the frequencies of five possible types of intervention recommended by the physician were analysed and related to the prevalence of the six disabilities in the parish. To estimate the needs of the Jamaican child population the figures were extrapolated based on an estimate of 1 million children under the age of 15 years. These needs were then compared with places in existing services. Of the disabled children, 62 percent needed special education, 29.5 percent needed community-based services, 21 percent needed spectacles, 21 percent needed specialist referral, and 6 percent required medical treatment. Although the vast majority of these needs are not met, many more could be met in the community if existing health and education personnel are trained in basic techniques of screening and assessment. (AU)

A survey of patients' attitudes towards inpatient psychiatric ward rounds

Attitudes towards the multidisciplinary ward round were assessed in fifty psychiatric inpatients, from two wards, using a semi-structures interview. About three quarters of them had at least a moderately favourable impression of the ward round but more than half would still prefer not to be interviewed in this way. Levels of anxiety and perceived helpfulness were positively correlated. Afro-Caribbeans found the interview significantly less helpful, less understandable and less memorable. Men found it less helpful than women and there were differences found between the two wards. Possible explanations for these findings are discussed. (AU)

Over and undercontrolled clinic referral problems of Jamaican and American children and adolescents: the culture general and the culture specific

Child behaviour problems and corresponding clinic referral patterns may be significantly influenced by cultural factors. Prevailing values and childrearing practices within a culture may discourage development of some child problems while fostering others. We explored this possibility, focusing on clinic referral problems of two different societies: (a) Jamaica, where the Afro-British culture discourages child aggression and other undercontrolled behavior and possibly inhibition and other overcontrolled behavior, and (b) the United States, where undercontrolled child is seemingly more generally accepted. We coded clinic-referred problems listed by parents of Jamaican and American youngsters (N=720). Cross-cultural differences were striking: Overcontrolled problems were noted more often for Jamaican than American youngsters, whereas the the converse was true for undercontrolled problems. These and other findings suggest that factors such as culture and sex may be linked to substantial differences in the problems for which youngsters of different countries are treated in clinics.

Severe mental disorder in Afro-Caribbean patients: some social, demographic and service factors

Forty-two consecutively identified Afro-Caribbean patients with a first episode of psychosis were compared with a similar group of non-Caribbean patients. A number of differences emerged, although the same portion of patients in each group had symptoms for 6 months or more prior to psychiatric contact. Afro-Caribbean patients showed greater delay in seeking help, more `disturbance' later in the course of their illness and were more likely to be admitted compulsorily. The social geography of the two groups suggests that the high rates of schizophrenia and related psychoses that we previously reported cannot be explained simply by differences in area of residence at the time of presentation. (AU)

Characteristics of a rural area community mental health programme County Caroni

The paper describes characteristics and trends in a rural area Community Mental Health programme. Research done by the mental health team supports some of the previously held notions on alcoholism and dispels some myths about parasuicide and suicide. Education at all levels continues to be an important preventative measure in the fight against drug abuse. The effort to set up an Alcohol and Referral Center is partly thwarted by poor community resources. The mental health team has had to enlist the support of service organisations in their educationl programmes. More work needs to be done in the area of psychogeriatrics, rehabilitation and family life. The need for closer links between governmental agencies and the community is emphasized. (AU)

Neurological/neurosurgical referrals from Queen Elizabeth Hospital, Barbados - abstract

Neurological/neurosurgical cases (NNC) requiring overseas investigation and treatment have become an increasingly difficult problem for Barbados in recent years. All overseas referrals from Queen Elizabeth Hospital (QEH) between January 1, 1984 and November 1, 1987 have been reviewed. Ninety one NNCs were referred; there were 48 males and 43 females, aged 32ñ7 years (meanñSD, range 4 months to 69 years). Only five were older than 60 years. Eleven centres were used. In 1984 referrals to the University Hospital of the West Indies (UHWI), Jamaica, ceased; for the next two years, most NNCs were sent to Port-of-Spain, Trinidad. Several factors, chiefly bureaucratic delays in approval for transfer, forced new lines of referral, outside of the Caribbean. In 1986 and 1987, 63 percent of new cases were referred to North America, chiefly to Mount Sinai Hospital New York. This was made possible by a Government aid scheme. During 1984 - 1986, there were non-surgical than surgical cases. In January 1987, a CAT Scan was installed at QEH and there was a marked fall (by over 60 percent) in referrals in 1987. Each of the 13 NNCs referred in this year was correctly diagnosed as needing surgery. This represents a huge savings in non-surgical referrals for investigation. Lack of neurological/neurosurgical facilities for investigation and treatment has placed an inordinate burden on finances, social services and internists, as well as severely compromising the outcome of NNCs (AU)