The document discusses the referral system in the Indian healthcare infrastructure. It defines referral as transferring cases beyond a facility's competence to a higher facility. Cases flow vertically from village to primary healthcare centers to community health centers and then to district hospitals. Bypassing levels is allowed for serious cases. The purposes are to provide comprehensive care, access to specialized services, and prevent overloading specialized facilities. Effective referral requires trained staff, continuing education, guidance, transportation, and mutual understanding between facilities. Nurses play a key role by observing patients, identifying needs, providing initial care, arranging transport, and following up.

1. REFERRAL SYSTEM
Dr. Kailash Nagar
Assistant Professor
Dept. Community health

2. 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.

3. 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”.

4. • 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.

5. • 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.

6. SUPERSPECIALIST HOSP
TEACHING
HOSPITAL
DISTRICT
HOSPITAL
CHC
PHC
SUB CENTER
CHW (ANM, ASHA,VHG etc.)

9. PURPOSES
1. To provide need based comprehensive care within
the technical competencies & resources at each level
of primary health care infrastructure efficiently and
effectively.
2. To help people avail specialized services available at
higher level institution which are beyond their
reach.
3. To streamline the appropriate use of PHC
infrastructure and specialized services in order to
prevent overloading of specialized institution by
direct uses.

10. REQUIREMENT FOR EFFECTIVE REFERRAL
SYSTEM
THE REFERRAL UNITS OF PHC SYSTEM NEED TO:
1. Well trained required number of professionals,
medical equipment & supplies, organization
structure etc.
2. Continuing training, guidance & supervision of
community health workers.
3. Guidance on sanitary measures & to
disseminate information on disease control
methods.

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

12. THE REFERRAL HOSPITAL AT SECONDARY & TERTIARY LEVEL
NEED TO:
• Provide specialized clinical outpatient & inpatient
care continuously.
• Back up primary health care system by providing
PH 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 center for health professionals
including community health workers.

13. 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.

14. CASES REQUIRING IMMEDIATE CARE
THE CASES WHO MAY REQUIRE IMMEDIATE
REFERRAL ARE AS UNDER:
• Cases presenting any problem which cannot be
handled during pregnancy, labor and post natal
period.
• Severe diarrhea with dehydration or not responding
to treatment.
• Pain in abdomen and vomiting with or without
presence of bowel sounds.
• Heart burn, dyspepsia, dysphagia, haemetemesis and
maleana etc.
• Continuous cough with or without sputum,
haemoptysis.

15. • Fever with stiff neck.
• Fever not responding to treatment.
• Fever with severe joints pain, rashes, bleeding
under the skin.
• 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,
hemorrhage, poison etc.

16. REFERRAL FORM

18. 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 centers
and referral units.

19. • 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 and
patients with simple and minor problems are
taken care at much low cost by health workers
at lower level.

20. KEY POINTS TO EFFECTIVE REFERRAL
SYSTEM
1.
• Mutual understanding of each
others role.
2.
• Mutual respect
3.
• Mutual cooperation

21. NURSE’S ROLE IN REFERRAL SYSTEM
• 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.

22. • Assures the casualty/family members/ any other
person accompanying.
• 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 center.
• Arranges for transport of the patient according to
feasibility as soon as possible.
• May do the telephonic consultation or provide
information to referred health center.

23. • 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.