Pre-referral Management Research Articles

Frequency of Errors in Colorectal Lesion Description and Management Prior to Referral to A Tertiary Center

Background and AimsAccurate reporting of polyp characteristics is crucial for effective resource allocation in endoscopic resection referrals. We present our experience with pre-referral management of challenging colorectal lesions. MethodsWe reviewed a prospectively collected database of consecutive referrals for endoscopic resection of challenging colorectal lesions. The database included details of prior colonoscopies. We assessed pre-referral management using established guidelines. ResultsAmong 1,826 referred lesions in 1826 patients, size estimates were missing for 421 (24%) lesions; 56 (3.2%) were found twice as large as previously estimated, while 65 (3.7%) were half the previous estimate. Morphological descriptions were absent for 376 (22%) polyps. Tattooing was performed for 822 (47%) lesions, with 247 (30%) placed correctly. Of the 1,103 (77%) polyps biopsied, only 11 (1.1%) were classified as high-risk by the referring endoscopist. ConclusionsErrors in pre-referral management of challenging colorectal lesions are frequent. Improved adherence to national guidelines could enhance practice.

Pre-referral management of preeclampsia with severity features in a low-income country—characteristics and challenges in a Sub-Saharan setting: a mixed method study

Background: Preeclampsia continues to be a major cause of maternal and perinatal mortality and morbidity, globally. Although pre-referral treatment constitutes a bigger part of the management package for preeclampsia with severity features in low-income settings, little is known regarding the characteristics and challenges of preeclampsia pre-referral and referral management in the Sub-Saharan setting. ObjectiveTo determine the characteristics and challenges of pre-referral and referral management of preeclampsia with severity features Study design: We conducted a mixed method study on the pre-referral management of pregnant women who complicated by preeclampsia with severity features in Ethiopia. We prospectively collected data on clinical characteristics, management outcomes, and pre-referral characteristics of pregnant women who complicated by preeclampsia with severity features. Data were collected using a structured questionnaire. For the qualitative part of our study, we conducted 20-30 minutes, semi-structured, qualitative face-face in depth-interview with 14 health professionals. Quantitative data were analyzed using SPSS version 23 and simple descriptive statistics was employed. We used thematic analysis on Open Code 4.03 software to analyze the qualitative data. - ResultsA total of 261 pregnant women who had preeclampsia with severity features were included in the study and 14 care providers were interviewed on existing challenges with pre-referral management for patients with preeclampsia with severity features. The mean systolic and diastolic blood pressures were 154.3mmHg and 100.3mmHg, respectively. The total perinatal mortality was 6.5% (17/261). Three mothers (1.1%) complicated by intra-cranial hemorrhage and other three (1.1%) other women developed pulmonary edema. Out of 261 patients, only 41 patients (15.7%) received magnesium sulphate. Similarly, antihypertensive was given only to 35 patients constituting 13.4%. Eight mothers convulsed (3.1%) during referral. Two mothers (0.8%) developed pulmonary edema when they arrived at recipient health institutions after referral. Likewise, another two (0.8%) women developed disseminated intravascular coagulation (DIC) by the time of arrival from referring health institution. Up on qualitative data analysis, three overarching themes were recognized: (i) challenges related Patient and family resistance, (ii) Challenges related to healthcare providers’ knowledge, skill and confidence, and (iii) health system related challenges. Low utilization of magnesium sulphate and ant-hypertensive drugs, patient misperceptions regarding reasons for referral, providers lack of knowledge on the pre-referral management, inadequate communication between referring and recipient health institution, and non-existence of uniform pre-eclampsia pre-referral and referral management protocols among the referring institutions were the identified gaps. ConclusionWe found a significant gap in pre-referral management for patients with preeclampsia with severity features. Preeclampsia management policy reforms should include introduction of adequate patients counselling platforms, increasing community awareness creation, providing in-service training on pre-referral management of preeclampsia for health personnel, ensuring constant availability of anti-convulsant and antihypertensive drugs and uniform implementation of preeclampsia pre-referral management protocols across health institutions.

Acceptability of pre-referral rectal artesunate for severe malaria in children under 5 years by health workers and caregivers in the Democratic Republic of the Congo, Nigeria and Uganda

BackgroundFor children below 6 years with suspected severe malaria attending a health care provider unable to provide parenteral malaria treatment, pre-referral rectal artesunate (RAS) is recommended by the World Health Organization to prevent death and disability. A number of African countries are in the process of rolling out quality-assured RAS for pre-referral treatment of severe malaria at community-level. The success of RAS depends, among other factors, on the acceptability of RAS in the communities where it is being rolled-out. Yet to date, there is limited literature on RAS acceptability. This study aimed to determine the acceptability of RAS by health care providers and child caregivers in communities where quality assured RAS was rolled out. This study was nested within the comprehensive multi-country observational research project Community Access to Rectal Artesunate for Malaria (CARAMAL), implemented in the Democratic Republic of the Congo (DRC), Nigeria, and Uganda between 2018 and 2020. Data from three different sources were analysed to understand RAS acceptability: interviews with health workers during three health care provider surveys (N = 341 community health workers and 467 primary health facility workers), with caregivers of children < 5 years of age during three household surveys (N = 9332 caregivers), and with caregivers of children < 5 years of age who were treated with RAS and enrolled in the CARAMAL Patient Surveillance System (N = 3645 caregivers).ResultsRAS acceptability was high among all interviewed stakeholders in the three countries. After the roll-out of RAS, 97–100% heath care providers in DRC, 98–100% in Nigeria and 93–100% in Uganda considered RAS as very good or good. Majority of caregivers whose children had received RAS for pre-referral management of severe malaria indicated that they would want to get the medication again, if their child had the same illness (99.8% of caregivers in DRC, 100% in Nigeria and 99.9% in Uganda). In three household surveys, 67–80% of caregivers whose children had not previously received RAS considered the medication as useful.ConclusionRAS was well accepted by health workers and child caregivers in DRC, Nigeria and Uganda. Acceptability is unlikely to be an obstacle to the large-scale roll-out of RAS in the studied settings.

Impact of the national sarcoma guidelines on the prevalence and outcome of inadvertent excisions of soft tissue sarcomas: An observational study from a UK tertiary referral centre

ObjectivesThis study aims to investigate the impact of the national guideline on the prevalence and outcome in patients with soft-tissue sarcoma (STS) who had undergone inadvertent excisions. MethodsA total of 2336 patients were referred to a tertiary sarcoma centre from six regions (North East, North West, East Midlands, West Midlands, Wales, and South West) in the United Kingdom with a diagnosis of STS between 1996 and 2016, of whom 561 patients (24.0%) had undergone inadvertent excisions. Patients were categorised into two groups of 10-year periods pre and post the National Institute for Health and Clinical Excellence (NICE) guideline implementation in 2006. ResultsThe proportion of inadvertent excisions decreased after the NICE guideline implementation: 27.2% (pre-NICE) versus 19.8% (post-NICE) (p = 0.001). A substantial regional variation (17.4%–34.5%) in the proportion of inadvertent excisions in the pre-NICE era was reduced in the post-NICE era (14.3%–22.4%). The 5-year disease-specific survival was 77.7% (pre-NICE) versus 75.6% (post-NICE) (p = 0.961) and there was a trend toward lower incidence of local recurrence in the post-NICE era; 13.5% (pre-NICE) versus 10.5% (post-NICE) (p = 0.522). Multivariate analyses revealed that residual tumours in re-resection specimens were independently associated with an increased risk of disease-specific mortality (HR, 3.35; p < 0.001) and local recurrence (HR, 1.99; p = 0.017), which was significantly reduced after the NICE guideline implementation (53.2% versus 42.0%; p = 0.022). ConclusionsThe NICE guideline implementation reduced the proportion of patients with STS who had undergone inadvertent excisions and residual tumour in re-resection specimens, indicating an improved pre-referral management of STSs.

Feasibility of task-sharing with community health workers for the identification, emergency management and referral of women with pre-eclampsia, in Mozambique

BackgroundMaternal mortality is an important public health problem in low-income countries. Delays in reaching health facilities and insufficient health care professionals call for innovative community-level solutions. There is limited evidence on the role of community health workers in the management of pregnancy complications. This study aimed to describe the feasibility of task-sharing the initial screening and initiation of obstetric emergency care for pre-eclampsia/eclampsia from the primary healthcare providers to community health workers in Mozambique and document healthcare facility preparedness to respond to referrals.MethodThe study took place in Maputo and Gaza Provinces in southern Mozambique and aimed to inform the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial. This was a mixed-methods study. The quantitative data was collected through self-administered questionnaires completed by community health workers and a health facility survey; this data was analysed using Stata v13. The qualitative data was collected through focus group discussions and in-depth interviews with various community groups, health care providers, and policymakers. All discussions were audio-recorded and transcribed verbatim prior to thematic analysis using QSR NVivo 10. Data collection was complemented by reviewing existing documents regarding maternal health and community health worker policies, guidelines, reports and manuals.ResultsCommunity health workers in Mozambique were trained to identify the basic danger signs of pregnancy; however, they have not been trained to manage obstetric emergencies. Furthermore, barriers at health facilities were identified, including lack of equipment, shortage of supervisors, and irregular drug availability. All primary and the majority of secondary-level facilities (57%) do not provide blood transfusions or have surgical capacity, and thus such cases must be referred to the tertiary-level. Although most healthcare facilities (96%) had access to an ambulance for referrals, no transport was available from the community to the healthcare facility.ConclusionsThis study showed that task-sharing for screening and pre-referral management of pre-eclampsia and eclampsia were deemed feasible and acceptable at the community-level, but an effort should be in place to address challenges at the health system level.

Management of Low-Grade Appendiceal Mucinous Neoplasms (LAMN): An International Survey of Surgeons Performing CRS and HIPEC.

Low-grade appendiceal mucinous neoplasms (LAMN) are commonly managed by community surgeons at diagnosis. There is variability in the treatment of LAMN, both by community and specialist providers. We assessed current management practices for LAMN across surgeons with expertise in peritoneal surface malignancies (PSM). An online survey was sent to 106 international surgeons specializing in PSM. The survey assessed demographics, favored pre-referral management, and definitive management practices for LAMN. The response rate was 40% (67% USA, 33% international). Respondents had performed a median of 18 (interquartile range [IQR] 7.75-29) HIPEC cases in the last year, of which 10 (IQR 4-20) were for LAMN. Ninety-three percent reported more than half of LAMN referrals had already undergone surgery-an estimated 50% appendectomy and 20% right hemicolectomy (RH). No surgeon respondents supported performing right hemicolectomy before referral. For LAMN confined to the appendix, 86% of respondents would definitively treat with appendectomy. In the presence of mucinous implants, 24% would observe after appendectomy and 76% would proceed with HIPEC. All would perform HIPEC if implants contained tumor cells. When LAMN involved the appendiceal base, 67% of respondents would proceed with partial cecectomy, while 33% favored RH. Pre-referral management of LAMN is not standardized and 20% of patients were referred to a surgeon who performs CRS/HIPEC after a right hemicolectomy that would not have been recommended. Management of LAMN by surgeons who treat PSM is also variable. Long-term data and identification of prognostic features are necessary to generate consensus on the optimal management of these complex patients.

Is pre-referral management of anterior urethral strictures prior to urethroplasty appropriate?

To evaluate whether the management of anterior urethral strictures prior to definitive urethroplasty is appropriate. Of a total of 419 men diagnosed with anterior urethral strictures at hospitals across Japan and thereafter referred to our institution for definitive urethroplasty between 2004 and 2019, the medical records of 371, for whom data on stricture characteristics at the initial diagnosis and pre-referral management were available, were retrospectively reviewed. A pre-referral single transurethral procedure, such as direct vision internal urethrotomy or urethral dilation, was considered appropriate only for favorable stricture, defined as a single nontraumatic untreated bulbar urethral stricture ≤2cm in size, and repeat transurethral procedures were considered inappropriate in any circumstances. The association between the appropriateness of the pre-referral management strategy and patient and clinical characteristics was analyzed. A total of 242 patients (65.2%) had a pre-referral history of at least one transurethral procedure, and performing the procedure was considered inappropriate for 221 patients (59.6%). On multivariate logistic regression analysis, location of the patient's residence far from our institution (outside of the Kanto area; odds ratio 3.35, 95% confidence interval 1.86-6.04; P<0.0001), voiding with intermittent dilation (odds ratio 2.38, 95% confidence interval 1.38-4.12; P=0.002), iatrogenic stricture (odds ratio 11.18, 95% confidence interval 5.30-23.61; P<0.0001), and stricture longer than 20mm (odds ratio 3.05, 95% confidence interval 1.47-6.38; P=0.003) were the independent predictors of inappropriate use of transurethral procedures. Transurethral procedures are often inappropriately used. There is a clear need to promote appropriate management strategies for urethral strictures among general urologists.

Pre-referral management of patients with severe preeclampsia and eclampsia in a district hospital, Southeast Sulawesi, Indonesia

Objective: This study aims to determine the enforcement of diagnosis, management and description of the referral system of PEB and eclampsia patients at Level I Health Facilities and South Konawe Hospital in January-December 2017Materials and Methods: This study used an observational descriptive design, carried out in the Maternity Room of South Konawe Hospital on 1 January-31 December 2017. There were 47 cases of PEB/Eclampsia from 420 total cases. Most cases of PEB/Eclampsia in Konsel Hospital suffered by pregnant women aged&gt; 35 years, as many as 27 cases (59%). age 21- 34 years, 15 (31%) and the lowest among women aged &lt;20 years, as many as 5 cases (10%). Multigravida, which is 38 cases (81%) and 9 cases 19%) in primigravida. Pregnancy&gt; 34 weeks is 46 cases (98%) and 1 case (2%) at &lt;34 weeks gestation. There were 39 referral cases (83%) all of which were counseled and 8 non-referral cases (17%), where completeness of the tools, medicines and referral letters obtained 39 cases (100%) incomplete.Results: The administration of antihypertensive drugs was given to 89% of cases, and MgSO4 was not given to 100% of cases of PEB/Eclampsia referred to RSUD Konawe Selatan due to fear of officers in providing such therapy to PEB/Eclampsia patients. Examination of urine protein as a support for PEB/Eclampsia cases was recorded in 69% of referral cases at the Konawe Selatan General Hospital.Conclusion: From the whole data, it was found that the pre-requisite conditions had not been fulfilled properly. Referral should be well prepared in order to achieve patient safety and decrease in MMR.

Lessons learned from the development and implementation of an electronic paediatric emergency and acute care database in Lilongwe, Malawi

As the field of global child health increasingly focuses on inpatient and emergency care, there is broad recognition of the need for comprehensive, accurate data to guide decision-making at both...

Cyclic vomiting syndrome in children: a single-center experience

Background Cyclic vomiting syndrome (CVS) is a functional disorder characterized by recurrent episodes of intractable vomiting separated by symptom-free periods. The onset starts at any age from infancy to adulthood. Little is known about its etiology. The diagnosis is based on the fulfillment of Rome IV criteria. CVS is usually a misrecognized disorder, and delayed diagnosis is very common. Aim The purpose was to evaluate the prevalence, clinical characteristics, prereferral management, and response to treatment among children with proved CVS in our institution. Patients and methods This was a retrospective study that included all children with CVS attending the Gastroenterology Clinic at Alexandria University Children’s Hospital between January 2016 and the end of June 2019. All patients were followed up for at least 6 months. The diagnosis is based on the fulfillment of Rome IV criteria. The following data were retrieved from the medical records including demographic information, evaluation steps performed for diagnosis, analysis of CVS characteristics, prereferral management, and finally, the treatment algorithm and response to treatment during follow-up. Results The study included 79 patients, and two-thirds of them were females. They constituted 2–5% of the cases referred yearly to our clinic. Evaluation for possible organic cause was indicated in 22.7%. No abnormalities were found in the barium studies. Other investigations including gastroscopies were not diagnostic for other organic causes. The mean age at onset of symptoms was 6±3.3 years. Overall, 25.3% of patients reported specific triggers, and 62.5% reported recognizable prodromes. The episodes were stereotypic among all patients. Overall, 52% experienced the start of the episodes at night. The interval between episodes was 2.5±1.8 months. The mean duration of each episode was 2.4±2 days. Listlessness and pallor were the commonest during the vomiting phase. The vomiting was bilious in 65.8%and contained blood in 50.8%. Personal history of migraine was positive in 9%. Family history of migraine and motion sickness was positive in two-thirds. The mean duration before referral of the patients was 12.5+8 months. Overall, 78% of the episodes were interpreted as episodes of gastroenteritis, food poisoning, or acid peptic disorders. Moreover, 54.4% were admitted at least once. The overall response to the first-line prophylactic therapy is 89.3%, with no significant adverse effects. Conclusion The prevalence and clinical characteristics were similar to other similar reports. Barium studies are not necessary in most of the patients. CVS is prevalent yet an underdiagnosed health problem. Propranolol is effective and safe and may be considered as a first-line prophylaxis in patients older than 5 years of age.

Study of functional constipation among children attending the Gastroenterology Clinic at Alexandria University Children’s Hospital

Background Functional constipation is a common health problem in the pediatric age group. Delayed management leads to a significant childhood morbidity. Aim The purpose of this study is to evaluate the prevalence, precipitating factors, and clinical characteristics and management of children with functional constipation in our community. Patients and methods This work was performed as a prospective study that included all children aged 1–15 years with functional constipation who presented to the Pediatric Gastroenterology Clinic at Alexandria University Children’s Hospital between August 2015 and January 2016. Demographic data, precipitating factors, clinical characteristics, and prereferral management were recorded. All patients were treated and followed up for at least 4 months. Results During the study period, 86 patients were enrolled. They constituted the most important cause for referral to the Gastroenterology Clinic during the study period. Most of the patients were living in low to middle socioeconomic status and were belonging to mothers of low to intermediate level of education. Low-fiber diet, diminished fluid intake, and urge postponing when present at public places were the commonest risk factors for developing constipation. Family history of constipation was positive in 32.6% of patients. The mean duration of complaints before presentation to our clinic was 19.22±22 months. Chronic abdominal pain was the most common presenting symptom (77.9%). Only 28% of the parents were aware that their children are constipated. The passage of hard painful stools was the most common character of stool in the studied group (98.8 and 95.3%) followed by infrequent evacuations ( Conclusion Functional constipation is a very common, yet underestimated, underdiagnosed, and maltreated health problem our community.

Shared care: a quality improvement initiative to optimize primary care management of constipation.

Pediatric constipation is commonly managed in the primary care setting, where there is much variability in management and specialty referral use. Shared Care is a collaborative quality improvement initiative between Boston Children's Hospital and the Pediatric Physician's Organization at Children's (PPOC), through which subspecialists provide primary care providers with education, decision-support tools, pre-referral management recommendations, and access to advice. We investigated whether Shared Care reduces referrals and improves adherence to established clinical guidelines. We reviewed the primary care management of patients 1 to 18 years old seen by a Boston Children's Hospital gastroenterologist and diagnosed with constipation who were referred from PPOC practices in the 6 months before and after implementation of Shared Care. Charts were assessed for patient factors and key components of management. We also tracked referral rates for all PPOC patients for 29 months before implementation and 19 months after implementation. Fewer active patients in the sample were referred after implementation (61/27,365 [0.22%] vs 90/27,792 [0.36%], P = .003). The duration of pre-referral management increased, and the rate of fecal impaction decreased after implementation. No differences were observed in documentation of key management recommendations. Analysis of medical claims showed no statistically significant change in referrals. A multifaceted initiative to support primary care management of constipation can alter clinical care, but changes in referral behavior and pre-referral management may be difficult to detect and sustain. Future efforts may benefit from novel approaches to provider engagement and systems integration.

Can guidelines improve referral to elective surgical specialties for adults? A systematic review

AimTo assess effectiveness of guidelines for referral for elective surgical assessment.MethodSystematic review with descriptive synthesis.Data sourcesMedline, EMBASE, CINAHL and Cochrane database up to 2008. Hand searches of journals and websites.Selection...

Analysis of referral letters to a department of old age psychiatry.

There is a paucity of literature on the content of referral letters to psychiatric services and few relating specifically to referrals to a department of old age psychiatry. There has been a significant increase in referrals over the last five years to this service, which may reflect the ageing population and a greater awareness of the service. Our objective was to evaluate the quality and legibility of information received, clarity of reason for referral and details of pre-referral management. The clinical records of the first 100 referrals in 2002 to this department were analysed. The referral letters were examined for the documentation of a number of demographic variables, reason for referral, interventions to date and level of urgency. The clinical records of nine patients did not have an identifiable referral letter at the time of this analysis. Of the remaining 91 analysed, 59% were referred by their GP, 33% were inpatient liaison referrals and 8% from outpatient departments. In the majority, patients' details were given, however, only 30% included a phone number. Next-of-kin was mentioned in 29%. GP's name was included in 71% of referrals from OPD and 7% of liaison referrals. The level of urgency was stated in 19%. Whether a domiciliary or OPD visit would be more appropriate was stated in 22%. The reason for referral was clear in 75%, with 43% including some aspect of Mental State Examination, 7% had included a MMSE score, 1% mentioned level of suicide risk. Thirty-one per cent had pre-referral investigations and 45% had pre-referral treatment documented. The letters were clearly legible in 73%. The information in the referral letter in many cases was insufficient to prioritise and expedite appropriate assessment. It is planned to introduce a proforma referral form, specific to old age psychiatry, which would include the information which is required and which would, hopefully, lead to a more efficient service.

Late referral of end-stage renal failure.

We studied all new patients accepted for renal replacement therapy (RRT) in one unit from 1/1/96 to 31/12/97 (n = 198), to establish time from nephrology referral to RRT, evidence of renal disease prior to referral and the adequacy of renal management prior to referral. Sixty four (32.3%, late referral group) required RRT within 12 weeks of referral. Fifty-nine (29.8%) had recognizable signs of chronic renal failure > 26 weeks prior to referral. Patients starting RRT soon after referral were hospitalized for significantly longer on starting RRT (RRT within 12 weeks of referral, median hospitalization 25.0 days (n = 64); RRT > 12 weeks after referral, median 9.7 days (n = 126), (p < 0.001)). Observed survival at 1 year was 68.3% overall, with 1-year survival of the late referral and early referral groups being 60.5% and 72.5%, respectively (p = NS). Hypertension was found in 159 patients (80.3%): 46 (28.9%) were started on antihypertensive medication following referral, while a further 28 (17.6%) were started on additional antihypertensives. Of the diabetic population (n = 78), only 26 (33.3%) were on an angiotensin-converting-enzyme inhibitor (ACEI) at referral. Many patients are referred late for dialysis despite early signs of renal failure, and the pre-referral management of many of the patients, as evidenced by the treatment of hypertension and use of ACEI in diabetics, is less than optimal.