GUIDELINES FOR INTER-DEPARTMENTAL REFERRAL for patients

GUIDELINES FOR INTER-DEPARTMENTAL REFERRAL

(WITHIN HOSPITAL) 2024

These guidelines are expected to serve as broad guiding principles. Hospitals can implement these guidelines as per local needs and resources; they are expected to improve patient care and help develop accountability within the Institutions

FOREWARD

The referral process is a crucial component of high-quality patient care in any medical institution. Many patients who visit hospitals have multiple co-morbidities and need a multi-disciplinary approach. As an internist with experience ranging from a resident to a senior faculty member, I have observed significant variability and inconsistencies in the referral process. Problems such as poor coordination and communication, unclear procedures, non-standardized formats, and inadequate training for healthcare professionals are common. The roles of various professional levels are often undefined, resulting in gaps in patient care. To address these issues, a uniform guidance document was deemed necessary. This document aims to provide broad guiding principles that hospitals can adapt to their local needs and resources. It is expected to enhance patient care and foster accountability within institutions.

I hope these guidelines will improve patient care services, facilitate better communication between departments, enhance working relationships, and contribute to the training of residents.

May, 2024

Prof. (Dr.) Atul Goel Director General of Health Services, Ministry of Health and Family Welfare, Government of India.

GUIDELINES FOR INTER-DEPARTMENTAL REFERRAL

SECTIONS

1.Background and Introduction 2.General Principles

3.Dos and Don’t’s

4.Special Situations 5.Performas

i. For referral

ii. For Post referral advice

iii. For Record with Nursing Staff 6.Indicative List of some conditions

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BACKGROUND & INTRODUCTION

 Good Patient care services need to be comprehensive. A patient can have multiple co morbid medical conditions and a single medical condition can have multi system manifestations. For comprehensive medical care, inputs from different departments are essential, which requires a Robust referral policy.

 Inter-departmental referrals typically occur when a patient requires services or expertise beyond scope of an admitting department. This may include specialized consultations, diagnostic procedures, therapeutic interventions, or ongoing management by a different specialty. Referrals can originate from various departments within the hospital, including primary care, emergency medicine, specialty clinics, and surgical services.

 A robust and efficient referral mechanism should be an essential part of training of residents as well. After residency as they enter a healthcare setup to practice, this training will be very useful for them.

 Inter-departmental referrals also serve as opportunities for interdisciplinary collaboration and sharing of

knowledge among healthcare providers.

 By leveraging expertise and resources available across different specialties, hospitals can optimize

patient care outcomes, enhance diagnostic accuracy, and improve treatment effectiveness. Moreover, referrals enable continuity of care by promoting coordinated management of complex medical conditions and facilitating follow-up care after discharge or treatment completion.

 However, problems can arise in any inter-departmental referral process, including:

 Delays in processing/attending of referrals,

 Breakdown in communication, and

 Variations in referral practices across departments.

 To address these challenges, hospitals must implement standardized referral protocols, streamline referral workflows, and provide education and training to healthcare providers and staff involved in the referral process. Additionally, ongoing quality assurance and monitoring mechanisms are essential to evaluate the effectiveness of the referral process, thereby identifying areas for improvement, and ensuring compliance with regulatory requirements and best practices.

 Currently, with no clear guidelines in place, it has been observed that there exist heterogeneous referral mechanisms. Every department and individual have their own way of sending and attending referrals. The documentation is also variable and inconsistent. There are delays in attending to referrals which can affect patient care adversely. Mostly junior residents (first- or second-year post-graduates) see referrals where higher order inputs may actually be required. There are conflicts between departments regarding referrals which are mostly rooted in lack of communication.

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GENERAL PRINCIPLES

1. Referral for Consultant’s opinion should only be written by Consultants.

2. PG residents should not close referrals on their own without discussing with Senior Resident/Consultant.

3. Consultant on call should review the referral record of referrals attended to by his team the previous day.

(This is expected to improve patient-care and enhance learning of residents)

4. After seeing the referral, a clear need for review should be indicated by the attending team. In case of

such a need one may not wait for a formal call and see the referral on one’s own as well, in interest of

patients care.

5. Departments can prepare a roster with names of officers in various units with contact numbers &

availability of units on different days, time; place where referral needs to be sent. This should be available on website as well as well circulated within the Institution. Surgical units may also indicate availability of alternate unit(s) on OT days. These lists are a living document and should be updated periodically.

6. The case record file of patients should have a sheet listing the various referrals taken in a chronological manner for ease of review.

7. The process of referral should be clearly explained to the patient and attendants/family by the referring department.

8. After seeing a referral, the patient and family should also be explained about the advice.

9. Referral should help patient management without burdening the referring department with a huge list of investigations. Any investigation by the referral team should be completely justified from the diagnosis

offered.

10. When a team goes to see a referral, they should communicate (discuss with the doctor available/call the

concerned Consultant/SR) of the referring team and vice versa. Such clear communication will improve patient care, enhance learning, and improve working relationships.

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DO’S AND DON’TS FOR INTER-DEPARTMENTAL REFERRALS AT HOSPITALS:

Do’s:

1. Initiate referrals promptly as and when patients require specialized care, diagnostic evaluations, or consultations beyond scope of admitting department.

2. Document referrals accurately and comprehensively, including relevant clinical information, expected outcome from referral, patient preferences, and any other specific instructions.

3. Communicate clearly and effectively with receiving departments, providing necessary clinical information and patient context to facilitate appropriate evaluation and management.

4. Acknowledge receipt of referrals promptly and provide timely updates to referring providers on status of referrals and patient appointments.

5. Collaborate with receiving departments and specialists to ensure continuity of care, shared decision making and optimal treatment outcomes for patients.

6. Follow up on referrals and coordinate care transitions, ensuring that patients receive necessary follow-up appointments, treatments, and interventions.

7. Respect patient confidentiality and privacy when sharing patient information with other departments or healthcare providers.

8. Seek feedback from referring providers and receiving departments to identify areas for improvement and enhance the efficiency and effectiveness of the referral process.

9. Adhere to hospital policies, regulatory requirements, and best practices governing inter-departmental referrals to ensure compliance and patient safety.

10. Prioritize patient-centered care, considering patients’ preferences, values, and treatment goals in referral process and treatment planning.

Don’ts:

1. Don’t delay referrals unnecessarily, as this may compromise patient care and lead to adverse outcomes.

2. Don’t omit essential clinical information or documentation when initiating referrals, as this may impede

the receiving department’s ability to provide appropriate care.

3. Don’t assume that all referrals are routine or non-urgent; carefully assess each patient’s clinical

presentation and urgency to determine appropriate level of prioritization.

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4. Don’t overlook communication with patients regarding the referral process, including informing them of the reason for referral, expected next steps, and any necessary follow-up appointments.

5. Don’t rely solely on verbal communication for referrals; ensure that all referrals are documented in the patient’s medical record or electronic health record (EHR) for accuracy and accountability.

6. Don’t hesitate to escalate urgent referrals or seek assistance from senior colleagues or hospital administrators if there are delays or barriers to timely referral processing.

7. Don’t breach patient confidentiality with unauthorized individuals or departments without proper consent or authorization.

8. Don’t ignore feedback or concerns from referring providers or patients regarding the referral process; address any issues promptly and implement corrective actions as needed.

9. Don’t overlook importance of ongoing education and training for healthcare providers and staff involved in the referral process to ensure competency and adherence to best practices.

10. Don’t lose sight of patient’s overall well-being and experience throughout the referral process; prioritize patient-centered care and advocacy at every stage of care delivery.

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SPECIAL SITUATIONS

Special situations may arise during follow-up of referrals that require particular attention and handling. Here are some special situations and strategies to address them:

1. Referral Denial or Rejection:

– If a referral is denied or rejected by the specialist or receiving department, communicate the reasons for such denial to the referring department with alternative options for care.

– Providing additional information or documentation to support the referral request and address any concerns raised by the specialist.

2. Patient Non-Attendance:

– If the patient fails to attend the scheduled referral or is not on the bed, follow up with the patient/treating team to determine the reasons for non-attendance and address any barriers or concerns.

– Reschedule the visit if necessary and provide reminders and support to ensure the patient is available at rescheduled time.

3. Urgent or Emergent Referrals:

– For urgent or emergent referrals requiring immediate specialist evaluation, expedite the referral process by directly contacting the specialist or receiving department and communicating the urgency of the referral.

– Prioritize appointment scheduling and coordinate with ancillary services to ensure rapid access to necessary diagnostic tests or procedures.

5. Complex Care Coordination:

– In cases involving complex medical conditions or multidisciplinary care needs, engage in comprehensive care coordination involving multiple providers, specialties, and support services.

– Establish a multidisciplinary team approach to develop and implement a coordinated care plan that addresses the patient’s physical, psychological, and social needs.

7. Discharge Planning:

– For referrals made in the context of hospital discharge planning, ensure seamless transitions of care by coordinating post-discharge follow-up appointments, medications, and support services.

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8. Referral for Transfer from one department to another

– This situation occurs when patient from one department is transferred to another citing reason that no major active intervention is required in the referring department and/or patient primarily needs intervention in the referred department. (This leads to frequent arguments between the two departments)

– During such transfer referrals, reason for transfer needs to be clearly mentioned.

– Referring department should note down the progress of patient since admission and the notes and reports

should be arranged chronologically before transfer.

– Referring department should ensure that the patient is regularly reviewed after transfer without waiting

for a referral call (at least once a day).

– Should the patient require transfer back, that should be done without creating problems or hurdles.

– Discharge of such patients should be done in a coordinated manner by the two (or more) departments

with clear explanation to the patient regarding further course and outpatient follow-up.

9. Death of a patient

In case of death of a referred/transferred patient e.g in ICU/Dialysis Room/CCU, department where patient is in (at the time of death) should complete documentation and required paperwork required before handing over of mortal remains of patients.

10. Referral in Outpatient Department

– An EXIT counter can be set up or utilized if already present for this purpose.

– A patient referred from Dept A to Dept B should visit the designated EXIT counter to get an OPD slip of

Dept B.

– Such patient should not be made to stand in normal counters’ queue to make an OPD slip.

– This will save man-days of patient as well as associated expenses of transport and loss of wages of

another visit (OPE).

– The power of making OPD slips ONLY FOR INTERDEPARTMENTAL OPD REFERRALS during

routine OPD registration time and after the time of registration is over has to be given to the EXIT counter up to a specified extended time (9:30 AM to 1:00 PM could be an indicative time).

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PERFORMAS

REFERRAL FORM FOR INTERDEPARTMENTAL REFERRAL

Department____________________ Location of patient ______________________

Name of the patient:

Referral from:

Date of admission:

Type of Reference: Immediate/

Age and gender: UHID:

Unit:

Date and time of referral:

Bedside- Yes/No Medico-legal- Yes/No

Consultation required from:

Faculty/ Senior resident, Unit-______, Department of _________________

Admission diagnosis and procedure (if any)

Indication for Reference & Expected Outcome:

Fresh Opinion/

Follow-up opinion

Consultation required for:

/Transfer

Sent by: ________________________________( Faculty/ Senior resident) Signature/Name/Date/Time/Stamp

Reference noted by: _____________________________ Sign, Name and Stamp (Faculty/Senior resident)

Unit: Date and time:

Reminder sent on (date and time):

Noted by: Name, date and time

GUIDELINES FOR INTER-DEPARTMENTAL REFERRAL

Urgent/

Routine

Please turn over

POST REFERRAL ADVICE

Reference Seen by ____________________________ at ____________________ (date and time)

History and Examination:

Diagnosis:

Advice:

To follow up on __________________(Date) with_____________________(Name, Unit) Repeat referrals to be sent to_______________________(Details of the unit)

Signature: Name/Stamp:

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Referring Department

Receiving Department

Patient Information

Reason for Referral

Urgency

Date of Referral

Status

Completed (with time) /Pending

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Indicative List of some medical conditions classified as Immediate/Urgent/ Routine

(This is not a comprehensive list; this is just to guide the clinicians)

Medical Conditions

Immediate

(Attend within 30 minutes)

Urgent

(Attend within 6 Hours)

Routine

(Attend before next working day preferably within 12 hours)

Any hemodynamic instability

All MLC

Delirium

All in-patients

Seizures

Stroke

Respiratory failure

Organ Failure

Active bleeding

PTE/DVT

Sepsis

AKI

Any decompensated chronic condition

Clearance before elective OT* Any other

Metabolic complications-hypoglycemia, DKA, severe hyperglycemia

Obstetrical and Gynecological Conditions

Cardiogenic shock- in pregnancy

From OPD for any high risk – pregnancy – Heart disease, thyroid disorder, Gestational diabetes, Renal disorders, seizure disorders, jaundice etc

Pulmonary edema

ARDS in pregnancy

Emergency CS

Acute liver failure- AFLP

Maternal collapse

⁠Refractory seizures

⁠CVA in pregnancy

Vessel injury on OT table

⁠Bladder/ uretur injury on OT table

Gut injury on OT table

small girls with Sexual assault especially from Pediatric Surgery

⁠Urgent dialysis in pregnancy or postpartum patients

From OPD for radiology evaluation

From OPD for surgical help in complicated elective surgery From wards for same as above Psychiatry referral for postpartum depression, psychosis

⁠Urgent CTPA – suspected embolism

GUIDELINES FOR INTER-DEPARTMENTAL REFERRAL

⁠urgent NCCT CECT and USG in above conditions

⁠Purpura fulminans

⁠necrotising fasciitis

⁠cellulitis/ abscess

Orthopedic Conditions

Polytrauma associated with Head injury, Chest injury, Abdominal injury, Perineal injury, Pelvis fractures, Other visceral injuries

Injuries with Vascular Insult

Open limb injuries

Ortho cases posted for Emergency surgery

Includes Ortho cases posted for semi-emergency / Elective surgeries in next 48 hours

Cases with multiple comorbs planned for surgery in next 4-7 days

*Many references are received in emergency for clearance before elective OT which is invariably scheduled on the next working day. This should be avoided.

Orthopaedic cases admitted for Evaluation and diagnosis

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LIST OF CONTRIBUTORS

1. Dr. Atul Goel, DGHS

2. Dr. Amita Bali, DDG, Dte. GHS, New Delhi.

3. Dr. Manoj Andley, Dir. Prof. Surgery, LHMC, New Delhi.

4. Dr. LH Ghotekar, Dir. Prof. Medicine, LHMC, New Delhi.

5. Dr. Himanshu Kataria, Dir. Prof. Orthopedics, LHMC, New Delhi.

6. Dr. Anupam Prakash, Dir. Prof. Medicine, LHMC, New Delhi.

7. Dr. Srikanta Basu, Dir. Prof. Pediatrics, LHMC, New Delhi.

8. Dr. Jyotsna Suri, Professor Obs. & Gynae, VMMC, New Delhi.

9. Dr. Ratan Gupta, Professor Pediatrics, VMMC, New Delhi.

10. Dr. Vishakha Mittal, Professor Medicine, ABVIMS/RMLH, New Delhi.

11. Dr. Bijit K Kundu, CMO(SAG), ABVIMS/RMLH, New Delhi.

12. Dr. Nitin Aggarwal, Professor Surgery, ABVIMS/RMLH, New Delhi.

13. Dr. Nitin Hayaran, Professor Anesthesia, LHMC, New Delhi.

14. Dr. Manushree Gupta, Professor Psychiatry, VMMC, New Delhi.

15. Dr. Bhavuk Garg, Associate Professor Psychiatry, LHMC & Dte.GHS, New Delhi.

Note- These guidelines have been prepared to provide a framework to various hospitals. Hospitals are encouraged to develop their own Standard Operating Procedures/Policies to suit their setup.

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