Impact of Referral Guideline Enforcement on Orthopedic and Trauma Admissions at Kenyatta National Teaching and Referral Hospital, Kenya: A Pre-Post Test Design

Abstract

Background: The suboptimal utilization of tertiary health facilities and inadequate management of referral systems in low- and middle-income countries pose challenges to health system administration, characterized by frequent self-referrals and bypassing of lower-tier health facilities. On July 1, 2021, Kenyatta National Hospital (KNH) implemented referral guidelines, mandating that all admitted patients be referred from lower-tier health facilities, aligning with the KNH legal statute of 1987. This study aimed to evaluate the impact of enforcing referral guidelines on the spatial distribution of orthopedic and trauma admissions at KNH.

Methodology: A pre-posttest study design was employed, reviewing a total of 459 and 446 charts in 2021 before and after the enforcement of referral guidelines. Measures of central tendencies and Chi-squared tests were applied, and density plots were generated using Geographic Information System (QGIS 2.18.19) to illustrate the spatial distribution of admissions.

Results:  of KNH admissions, 85.3% and 79.3% originated from Nairobi County and its environs. Admissions were geographically diverse, with a notable concentration from Nairobi County and its environs. Enforcement of referral guidelines led to a significant decrease in admissions from Nairobi County, dropping from 64.3% to 56.9% (p=0.019). Declines were particularly observed in Kamukunji, Embakasi, and Ruaraka sub-counties, serving as the catchment population for Mama Lucy Kibaki Referral Hospital. Conversely, admissions from Kibra and most of Kajiado County were notable. There was a concurrent increase in admissions from other parts of the country (p = 0.003).

Conclusion: Over four-fifths of KNH admissions are from Nairobi County and its environs. The enforcement of referral guidelines resulted in decreased local admissions and an uptick in admissions from other regions in the country.