Effect of enforcement of referral guidelines on patterns of orthopedic and trauma admissions to Kenyatta National Hospital, Kenya: quasi- experimental study design

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Abstract Inappropriate utilization of higher-level health facilities and ineffective management of referral processes in resource-limited settings is increasingly becoming a concern in health care management in developing countries. This is characterized by self-referral and frequent bypassing of the nearest health facilities coupled with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. On July 1, 2021, Kenyatta National Hospital (KNH) did enforce the referral guidelines that required patients have a formal referral letter to KNH to reduce the number of walk-ins and allow KNH to function as a referral facility as envisioned by Kenya 201 constitution and KNH legal statue of 1987. Study Objective: To determine the effect of referral guidelines on patterns of orthopaedic and trauma admissions to KNH. Methodology: This was a quasi – experimental design. Data abstraction was done for 459 and 446 before and after enforcement of referral guidelines. Findings enforcement of the referral guidelines reduced the proportion of walk-in admissions from 54.9% to 45.1%, while facility referrals increased from 46.6% to 53.4%. The Non-trauma orthopaedic admissions doubled from 12.0% to 22.4% after enforcement of the referral guidelines (p<0.001). The mean age was 33.8 years with mean age rising among females from 32.2 years to 38.0 years after the enforcement of the referral guidelines. There was a significant increase in the proportion of female admissions after the enforcement of the referral guidelines. The enforcement of the referral guidelines was associated with a statistically significant increase in the number of orthopaedic admissions with active insurance cover. Conclusion: the enforcement of the referral guidelines reduced the proportion of walk-ins. The enforcement of the guidelines was also associated with orthopaedic and trauma admissions with more non-trauma cases, tertiary education level, and more active insurance cover.

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