Assessment of formats and completeness of paper-based referral letters among urban hospitals in Rwanda: a...

Patient referral is a process in which a healthcare provider decides to seek assistance due to the limitations of available skills, resources and services offered locally. Paper-based referrals predominantly used in low-income countries hardly follow any procedure. This causes a major gap in communication, coordination, and continuity of care between primary and specialized levels, leading to poor access, delay, duplication and unnecessary costs. The goal of this study is to assess the formats and completeness of existing paper-based referral letters in order to improve health information exchange, coordination, and continuity of care.

A retrospective exploratory research was conducted in eight public and three private healthcare facilities in the city of Kigali from May to October 2021. A purposive sampling method was used to select hospitals and referral letters from patients' files. A data capture sheet was designed according to the contents of the referral letters and the resulting responses were analyzed descriptively.

In public hospitals, five types of updated referral letters were available, in total agreement with World Health Organization (WHO) standards of which two (neonatal transfer form and patient monitoring transfer form) were not used. There was also one old format that was used by most hospitals and another format designed and used by a district hospital (DH) separately. Three formats were designed and used by private hospitals (PH) individually. A total of 2,304 referral letters were perused and the results show that "external transfer" forms were completed at 58.8%; "antenatal, delivery, and postnatal external transfer" forms at 47.5%; "internal transfer" forms at 46.6%; "Referral/counter referral" forms at 46.0%; district hospital referrals (DH2) at 73.4%. Referrals by private hospitals (PH1, PH2 and PH3) were completed at 97.7%, 70.7%, and 0.0% respectively. The major completeness deficit was observed in counter referral information for all hospitals.

We observed inconsistencies in the format of the available referral letters used by public hospitals, moreover some of them were incompatible with WHO standards. Additionally, there were deficits in the completeness of all types of paper-based referral letters in use. There is a need for standardization and to disseminate the national patient referral guideline in public hospitals with emphasis on referral feedback, referral registry, triage, archiving and a need for regular training in all organizations.