The document discusses India's referral system in healthcare. It defines referral as transferring cases beyond a facility's competence to a higher-level facility. Cases flow from village to sub-center to primary health center to community health center to district hospital and above. Immediate referral is needed for pregnancy/childbirth complications, severe diarrhea, abdominal pain, cough/fever not improving, and other serious signs/symptoms. Advantages include patients receiving effective care near home and facilities handling cases within their competence. Key factors for an effective referral system include mutual understanding, respect and cooperation between facilities. The role of community health nurses includes identifying cases needing referral, arranging transport, and following up.

1. P R E S E N T E D B Y :
H A R S H R A S T O G I ,
N U R S I N G T U T O R ,
M . S . I N S T I T U T E O F N U R S I N G ,
L U C K N O W .
Referral system in India

3. Introduction
 At each level of health care infrastructure, there is
need for support from higher level of infrastructure
and also from secondary & tertiary level hospitals to
strengthen and promote credibility of primary health
care system.

4. Definition
 “Referral system is defined as a system of
transferring cases which are beyond the technical
competence of one infrastructure to a higher level
infrastructure/institution having technical
competency and all other resources to provide
desired health services.”

5. Cont…
 The referral system is vertical in nature.
 The cases can be referred from village health post to
SC/PHC, from SC to PHC/CHC and from PHC to
CHC/secondary or tertiary level hospital and from
CHC to secondary or tertiary level hospital.

6.  Provision is made for bypassing 1 or 2 level
depending upon the nature and seriousness of cases
so that required medical and nursing care can be
given on time to the case and mortality and
morbidity can be prevented and controlled.

7. Super-speciality Hospital
Teaching Hospital
District Hospital
Community Health Centers
Primary Health Centers
Sub-Centers
Community Health Workers (ASHA,
Anganwadi)

8. Purpose
 Toprovide need based comprehensive care within the
technical competencies & resources at each level of
primary health care infrastructure efficiently and
effectively.
 Tohelp people avail specialized services available at
higher level institution which are beyond their reach.
 Tostreamline the appropriate use of PHC
infrastructure and specialized services in order to
prevent overloading of specialized institution by
direct uses.

9. Requirement of effective referral system
 The referral units of primary health care system need
to:
 Well trained required number of professionals,
medical equipment & supplies, organization
structure etc.
 Continuing training, guidance & supervision of
community health workers.
 Guidance on sanitary measures & to disseminate
information on disease control methods.

11. Cont…
 Conduct health education sessions.
 Provide logistic supports in terms of equipment &
supplies required at PHC.
 Establish liaison & functional relation with other
sectors involved in social and economic
development.
 Organize transportation facilities for cases to be
referred.

12. Cont…
 Referral hospital at secondary & tertiary level need to:
 Provide specialized clinical outpatient & inpatient
care continuously.
 Back up primary health care system by providing
primary health care messages/teaching.
 Discourage people attending OPD’s directly i.e. to
attend OPD when they have referral card/letter or a
genuine emergency.
 Act as teaching centre for health professionals
including community health workers.

14. Selection of referral cases
 The very serious patient requiring immediate
medical care & treatment.
 Patients presenting serious signs & symptoms.
 He/she may not be sick but requires immediate
referral.
 When special diagnostic procedures are required for
diagnosis.

15. Cases requiring immediate care
 The cases who may require immediate referral are as
under:
 Cases presenting any problem which cannot be
handled during pregnancy, labour and post natal
period.
 Severe diarrhoea with dehydration or not
responding to treatment.
 Pain in abdomen and vomiting with or without
presence of bowel sounds.

17. Cont…
 Heart burn, dyspepsia, dysphagia, haemetemesis and
maleana etc.
 Continuous cough with or without sputum,
haemoptysis.
 Fever with stiff neck.
 Fever not responding to treatment.
 Fever with severe joints pain, rashes, bleeding under
the skin.

18. Cont…
 Breathing difficulty while walking, sleeping, doing
physical work.
 Chest pain with/without pain in the left arm,
restlessness and vomiting.
 Jaundice, loss of appetite.
 Convulsions with fever.
 Coma, paralysis, fracture, severe injury,
haemorrhage, poison etc.

19. Advantages of referral cases
 Beneficial to patients because they receive effective
care at the primary level which is near to their
home.
 Beneficial to health workers because they are able
to take care of patients which are within their level
of competence and are not frightened to handle
difficult cases because they can refer them to
higher level centres and referral units.

20. Cont…
 Beneficial to management because it is economical
as highly trained and highly paid doctors, nurses
and other professionals take care of patients with
serious and complex problems at higher level
referral unit.
 Patients with simple and minor problems are taken
care at much low cost by health workers at lower
level.

21. Key points to effective referral system
Mutual
understanding
of each others
role
Mutual
respect
Mutual
cooperation

22. Role of Community Health Nurse
 Observe and collect information about the illness,
trauma, related situation, factors etc.
 Identifies the nature of illness/emergency and its
seriousness.
 Provides immediate treatment care within her
competence, standing orders and resources
available.
 Assures the casualty/family members/ any other
person accompanying.

23. Cont…
 Explains about the seriousness of the problem
situation and need for reference to the casualty.
 Fills up the referral form as desired and hands over
the same with related documents to be given to
health professionals in referred health centre.
 Arranges for transport of the patient according to
feasibility as soon as possible.
 May do the telephonic consultation or provide
information to referred health centre.

24. Cont…
 May accompany the casualty/patient if required
and feasible.
 Maintains the records and reports.
 Provides follow up care as per treatment and
instructions prescribed by the referral unit.

26. Gracias