The most crowded places in the valley of Kashmir are the healthcare institutions. Be they sub-centres of PHCs, PHCs, CHCs, Sub-district or district hospitals. It can be an indicator of both health consciousness and wellness essential for living a fulfilling life, hypochondria or ailments and diseases. But as stories unfold across these multitudes are due to ailments and diseases which are on rise since some recent past constraining for remedial measures.
In this scenario the tertiary care hospitals in Srinagar are hit hard with excessive load on account of referral cases as thousands of patients from different district hospitals are referred to these hospitals. After referrals from the providers of primary and the secondary care, tertiary care is a level third medical management where all kinds of super specialties like I.C.U, C.C.U, MRI. dialysis, blood banks, sophisticated ventilators support etc. are supposed to exist.
Germane to mention that at tertiary hospitals doctors are sometimes engaged with collateral referrals, cross referrals, interval referrals and split referrals. Referrals are justified, unjustified and bad too. The obvious result of this gigantic number is the loss of golden hour- a crucial hour after the emergency erupts where extempore & right diagnosis and life saving treatment are required instantly especially for trauma and severe medical emergencies which get delayed due to the referral process as someone has to be second.
Being aware of this precarious situation, medical fraternity and health services officials have also given vent to their concerns and stressed the need for plugging the loopholes with urgent measures to rationalise the referral issue. According to news paper reports (GK.20/10/2023) quoting officials at least 50,000 referral cases from various district hospitals were received annually at the tertiary hospitals in Srinagar burdening them beyond time, space, equipment and manpower.
The intensity of the position can be gauged from the figures which showed that in Sheri-e-Kashmir Institute of Medical Sciences Soura (SKIMS) alone 18,000 referral cases were received per year. Lalla Ded Maternity hospital dealt with 10,000 referral cases annually. Likewise SMHS. Hospital had to entertain about 3,500 cases. In Bone & Joint (B&J) hospital 18 percent of its patients were referrals and 70 percent of the 850 to 900 cases in the OPD at the Chest Disease hospital also come from different districts. Out of 800 monthly emergency cases at SKIMS Soura 600 were referral cases. Similarly of 5,000 monthly OPD cases at SKIMS Soura 3,000 were the referred ones. In B &J hospital half the number of referrals were said to be unjustified and half justified. Maximum number of cases were received from the districts of Anantnag in south Kashmir and Baramulla in north Kashmir.
Why do patients from far-flung areas skip their district hospitals and rush to more far away premier institutes in Srinagar is not unfounded. The exodus is a forced one else nobody would like to tread out of his/her courtyard as a natural propensity. This is due to fear of lack of diagnostic and treatment facilities which may be the result of some administrative reasons, executive problems, logistics compulsions and centralization of utilities briefly described as follows:-
a) Administrative reasons may include management of healthcare infrastructure, human resource development & utilization, posting of requisite medicos & paramedical staff, allocation of duties, accountability, transparency, maintaining calendar of postings and transfers, application of roaster duty schedule, smooth and full flow of timely supplies of medicines, drugs, surgical equipments and other medical paraphernalia, regular surprise inspection of subordinate hospitals to ensure effective presence of officials, conducting referral audit of referrals made in previous month etc. Referral audit though somewhat difficult for the referral practice depends on the referral habit of a doctor yet can give a valuable insight into clinical practice and may lead to course correction.
b) Executive problems are relating to shortage of faculty and staff, absence (due to any reasons) of posted faculty and staff, personnel who are present merely but not constructively, inadequate or un-matching indoor and outdoor accommodation, retiring room facility, lack of relevant faculty and staff, generous dedication towards profession, sympathy and empathy with patients, difficulty in making diagnosis, need of specialist opinion, non-availability of ailment apposite medicament etc. In absence of expert supervision and guidance by senior doctors especially in the evening or night hours junior doctors feel compelled to prefer to refer the cases to tertiary hospitals concerned in Srinagar to walk safe harbours
c) Logistic compulsions play an invincible role in hurrying the patients to gallop to tertiary hospitals in Srinagar. It is quite understandable and reasonable too that patients who reside in the outskirts of their districts whose boundaries are nearer to tertiary hospitals than their district hospitals should race to Srinagar. This saves their time, expenses besides expecting better cure and care. For instance patients from Bhagat Kanipora that falls in the district of Budgam, Mirgund falling in the district of Baramulla and Dangerpora falling in the district of Bandipore will naturally prefer Srinagar rather than moving backward to their district hospitals far away from them.
d) Centralisation of utilities like Bone & Joint hospital, Children hospital, Psychiatry hospital, Chest Disease hospital, Dental College & hospital which are the sole facilities of their kind centered in Srinagar is another factor which draws patients to tertiary hospitals at Srinagar from other districts. In absence of an alternative it is an inevitability that has to be endured till such facilitates are decentralized to district level.
Now Government Medical Colleges have been established one each in every district that will change the name & style of the erstwhile district hospitals to Government Medical College & Hospital followed by the name of the district concerned. There will be up-gradation to the tertiary level that demands and presupposes associated facilities at district level. Expansion and decentralization of tertiary facilities to district level will definitely enable to arrest the rising trend of referrals to a great extent.
Medical service officials too are to meet expected standard of behavior as they are not working gratuitously but in exchange of a consideration particularly for doctors which is too handsome to be complained against or feel dissatisfied. Every level should try its utmost to cure morbidity and prevent mortality. Referral whether emergency or non-emergency being transfer of care from one clinician or clinic to another by request cannot be avoided and diagnosis or treatment denied.
The profession of doctors being without borders and medicines sans frontiers patients are to be attended to even if foreigners. But unjustified referrals are to be stopped else it means either incompetency or dereliction of duties or under utilization or non-utilisation of resources, denial of relief and prolonging pain to patient through waste of time. Remedying the reasons will reduce the colossal referrals automatically.
However, Srinagar being the capital city there shall/should invariably be an edge over others in having and providing services to cure diseases as is precedent in other states and countries of the world. Hence hospitals at Srinagar may continue to have some referrals though rarely for that faculty and the institutions should feel proud to shoulder engagement.
The author is a former Sr. Audit Officer and Consultant in the A.G’s Office Srinagar.
Unnecessary Referrals Burdens Tertiary Care Hospitals
10
0
19.12.2023
The most crowded places in the valley of Kashmir are the healthcare institutions. Be they sub-centres of PHCs, PHCs, CHCs, Sub-district or district hospitals. It can be an indicator of both health consciousness and wellness essential for living a fulfilling life, hypochondria or ailments and diseases. But as stories unfold across these multitudes are due to ailments and diseases which are on rise since some recent past constraining for remedial measures.
In this scenario the tertiary care hospitals in Srinagar are hit hard with excessive load on account of referral cases as thousands of patients from different district hospitals are referred to these hospitals. After referrals from the providers of primary and the secondary care, tertiary care is a level third medical management where all kinds of super specialties like I.C.U, C.C.U, MRI. dialysis, blood banks, sophisticated ventilators support etc. are supposed to exist.
Germane to mention that at tertiary hospitals doctors are sometimes engaged with collateral referrals, cross referrals, interval referrals and split referrals. Referrals are justified, unjustified and bad too. The obvious result of this gigantic number is the loss of golden hour- a crucial hour after the emergency erupts where extempore & right diagnosis and life saving treatment are required instantly especially for trauma and severe medical emergencies which get delayed due to the referral process as someone has to be second.
Being aware of this precarious situation, medical fraternity and health services officials have also given vent to their concerns and stressed the need for plugging the loopholes with urgent measures to rationalise the referral issue. According to news paper reports (GK.20/10/2023) quoting officials at least 50,000 referral cases from various district hospitals were received annually at the tertiary hospitals in Srinagar burdening them beyond time, space, equipment and........
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