This presentation contains :- 1.Levels of health care 2. Concepts of prevention 3. Level of prevention 4. Primary prevention 5. Health promotion 6. Specific protection 7. Secondary prevention 8. Tertiary prevention 9. Summary of referral system 10. Triage system 11. Reference slip 12. Referral system in India 13. Definition of referral system 14. System of referral 15. Chain of referral 16. Purpose of referral 17. Requirement for effective referral system 18. The referral units of PHC system need 19. The referral hospital at secondary and tertiary level need 20. Selection of referral case 21. Cases requiring immediate care 22. Referral form 23. Advantages of referral case 24. Key points to effective referral system 25. Nursing role in referral system

1. Presented By – Atul Yadav (RN.RM)

2. Levels of health care :-
CONCEPTS OF PREVENTION Levels of prevention In
modern day, the concept of prevention has become
broad-based.
 It has become customary to define prevention in
terms of 3 levels:
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention

3. a. Primary prevention :-
Primary prevention can be defined as "action taken
prior to the onset of disease, which removes the
possibility that a disease will ever occur".
The specific interventions are:
(a) Health promotion
(b) Specific protection

4. Health promotion
 We can prevent a number of diseases such as cholera,
typhoid fever, tuberculosis and nutritional diseases by
merely promoting the health of the individual and
community. Briefly, they include adequate nutrition,
provision of safe water supply, facilities for the safe
disposal of human excreta and other human wastes,
personal hygiene, health education, physical
education, periodic health screening and improving
the quality of life of the people.

5. Specific protection
By specific protection we mean preventing specific
diseases by specific measures. Examples include
prevention of EPI (The Expanded Program on
Immunization) diseases ( tuberculosis, diphtheria,
pertussis, tetanus, polio, and measles) by immunization;
prevention of xerophthalmia (abnormal dryness of the
conjunctiva and cornea of the eye) by administration of
vitamin A; prevention of accidents in factories and
industries by use of protective devices. Of these
immunization is the most widely used intervention in
the prevention of disease.

6. b. Secondary prevention
 Secondary prevention may be define as "action which
half's the progress of a disease at its incipient
(growing) stage and prevention complications". The
specific interventions are:
 (a) Early diagnosis (screening tests, case finding
programmes)
 (b) Adequate treatment.

7. Cont…
 We do not have vaccines to prevent all diseases. For
diseases of this category (e.g., leprosy, syphilis,
malaria) early diagnosis and treatment is the only
solution. The earlier a disease is diagnosed the better it
is from the point of view of preventing the occurrence
of further cases in the community. It is like putting out
the "spark" of fire rather than allowing it to spread and
call the fire brigade (agnishaamak dal) later.

8. c. Tertiary prevention
 When the disease process has advanced beyond its
early stages, it is still possible to accomplish
prevention by what may be called "tertiary
prevention". Tertiary prevention is defined as "all
measures available to reduce limit impairments and
disabilities, or minimise suffering caused by existing
departures from good health and to promote the
patient's adjustment to irremediable condition". The
specific interventions are:
 (a) Disability limitation
 (b) Rehabilitation

9. Cont…
 For example in leprosy we try to limit disability by
early adequate treatment and plastic surgery. This is
follows by Rehabilitation following aspects:
 (a) Functional rehabilitation – restoration of function
 (b) Vocational rehabilitation restoration of the
capacity to earn a livelihood
 (c)Social rehabilitation restoration of family and social
relationships
 (d) Psychological restoration – restore of personal
dignity and confidence.

10. Summary of referral system

11. REFERRAL SYSTEMS
A good referral system is an essential component of
health care systems. As more and more para-medical
workers are employed in the health industry, it
becomes necessary to establish a sound referral
system.

12. Triage system
 The question arises as to which sort of patients are to be
referred.
 According to the triage system, patients are grouped into 3
categories:
 Category 1: Fatal conditions ; life cannot be saved even with
treatment.
 Category 2 : Serious conditions; life can be saved but only
with immediate treatment.
 Category 3: Minor conditions; life is threatened referral can
be safely not and delayed.
 According to the above classification, patients in category 2
should receive priority.

13. Reference slips
 A reference slip should contain the following
minimum information.
 1. Patient's identification number name and address
and
 2. Present complaint
 3. Treatment given, if any
 4. Reasons for referral
 5. Name and designation of person making the referral
 6. Name of PHC making the reference
 7. Date and time of reference

15. 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.

16. DEFINITION of Referral system
Referral system is defined as a system of transferring
cases which are beyond the technical competence of one
hospital or institute .
or
Referral is the transfer of care for a patient from one
clinician or clinic to another by request. Tertiary care is
usually done by referral from primary or secondary
medical care personnel

17. • 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.
System of referral :

18. • Provision is made for by passing 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.

19. 7.SUPERSPECIALIST HOSPITAL
6. TEACHING
HOSPITAL
5. DISTRICT HOSPITAL
4. CHC
3. PHC
2. SUB CENTER
1. CHW (ANM, ASHA,VHG etc.)

20. PURPOSES
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.

21. REQUIREMENT FOR EFFECTIVE REFERRAL
SYSTEM
THE REFERRAL UNITS OF PHC 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.

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

23. THE REFERRAL HOSPITAL ATSECONDARY & 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.

24. Act as teaching center for health
professionals including community health
workers.
Cont…

25. 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.

26. CASES REQUIRING IMMEDIATE CARE
THE CASES WHO MAYREQUIRE
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.

27. • 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.

28. REFERRAL FORM

30. 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.

31. • 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.

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

33. 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.

34. • 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.

35. • 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.