Vertical Integration for strengthening referral linkages

1. UTTAR PRADESH
TECHNICAL SUPPORT UNIT
MINI SKILL LAB in Uttar Pradesh, India
Strengthening Referral linkages Between CEmONC and BEmONC Facilities
25th
February 2025 Lucknow
REFERRAL STRENGTHENING
VERTICAL INTEGRATION MEETING

2. To create a platform for CHCs & DH to discuss referred Maternal & New-born cases
OBJECTIVES
To seek solutions for minimizing delays
To resolve challenges in establishing effective referral management and complication tracking system
To resolve systemic challenges in good quality referral

3. Complication tracking and Referral system strengthening GO

4. Complication tracking and Referral system strengthening GO

5. 01
02
03
DELAY IN
REACHING THE FACILITY
Time taken in reaching
the facility from home
and in inter facility
transfer
Care provided by EMT in
the ambulance
DELAY IN DECISION
TO SEEK CARE
Condition of mother at
the time of admission
Antenatal care history
.
DELAY IN RECEIVING
ADEQUATE HEALTHCARE
Prior information that a
patient has been referred
and is expected to arrive.
Facility readiness for
managing referred-in
complications.
Logistics and drug
availability
3 DELAYS MODEL AND RIGHTS OF REFERRAL
 Right Centre
 Right Pre-Referral Management
 Right Documentation
 Right Follow Up
 Right Linkages

6. Two initiatives - Vertical Integration and WhatsApp Groups
STRATEGY
VI MEETING
6-Feedback
from referral
facility
7-Discussion
of good
practices for
improved
outcomes
8-Suggest
action to fill
gaps
9-Follow up of
the action
recommended
1-
Immediate
communicati
on (Phone
and
WhatsApp)
2- Ensure
prompt
transport
and optimum
care in
ambulance
3-Provide
adequate pre
referral
management
4-Strengthen
referral
document
5-Follow up
of
complication
The Referral WhatsApp Groups facilitate
share real-time data of complications
referred across facilities

7. Referral group – Feedback mechanism

8. • What has been done in 1st
referring facility (whether the complication was timely recognized)
• Was Pre referral management by the referring facility-complete or incomplete (Diagnosis, Reason for
referral, Vitals, Treatment).
• Complete documentation of pre referral management and condition of patient at the time of referral,
documented in the referral slip provided in the case sheet.
• Mode of transport & promptness – Time taken (102/108 or private)
• Pre informed to referred facility or not (Dedicated phone number in DWH and posting of completely filled
case in referral group)
• Referral slip to be given to the relative of the client. (EMT??)
• Refer in and Refer out registers (Time – important)
• Feedback by referral facility on the case
• Day 3 follow up by the referring facility (to be documented in refer out register)
• Discussion on Way forward (good practices/ shortcomings of referring to higher facility & actionable points
to improve further referral)
Main points for discussion

9. CASE 1
Maternal Complication- PPH Case referred from CHC Sarojini Nagar to Lokbandhu Sri Raj
Narayan Combined Hospital, Lucknow

10.  G3P2L2A0 mother arrived on 18-01-2025 at 09:20 PM with complaints of Labour Pain.
 Vitals: BP – 130/80 mm of Hg, Pulse rate – 82bpm, FHS: 146 & Temperature: 36.8 Degree Celsius.
 Hb: 10.6 gm/dl ; HIV & Syphilis :NR
 Term labour: 38 Weeks .
 Final Diagnosis in referral slip : Uncontrolled PPH
 Patient referred to Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow on 18.01.2025 at 11:44 PM. Case
was posted in referral group.
Case 1: At CHC Sarojini Nagar

11. Case Sheets at CHC Sarojini Nagar

12. Treatment given at CHC Sarojini Nagar

13. Referral slip received at Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow
from the CHC

14. Referral out register-CHC Sarojini Nagar

15. Referral in register- Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow

16. Patient received on 19.01.2025 at ? to Emergency,
Lokbandhu Sri Raj Narayan Combined Hospital,
Lucknow .
Patient admitted on 19.01.2025 at 12:56 AM
Indication for admission: PPH
Case 1: At Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow

17. Treatment given at Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow

18. Discharge of patient from Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow
PPH Managed and Patient discharged from Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow on
20.01.2025.
Patient condition at discharge: Stable.
 Treatment Advised at the time of discharge: Antibiotics for 5 days.

19. Case 1 - Process
ambulance
• Term Pregnancy
• Complication identified
from CHC-PPH
Pre referral management : Injection Oxytocin
• Ambulance services
informed.
• No information shared
with higher facility.
• Referral slip has been
posted in the
WhatsApp referral
group.
• Referral slip filled.
• Data entered in the referral
out register.
• Referred at 11:44 PM on
18-01-2025
• Case received at ? on 19-01-2025.
• Data entered in Refer in register.
• Diagnosis : G3P2L2A0 with PPH.
• Outcome : Patient Stable.
• Follow up not done
from CHC to DWH
and not updated
the outcome in
Referral out
register.
• Communication to
CHC from DWH not
done
G321L2A0 mother
arrived on 18-01-2025 at
09.20 PM with
complaints of Labour
Pain.

20. • Time mentioned in refer out register – 18.01.2025; 11:44 PM
• Time mentioned in referral slip – 11:44 PM
• Call received to 108 ambulance at ?
• Ambulance reached CHC Sarojini Nagar at ? (Response time : ?)
• Ambulance left CHC Sarojini Nagar at ?
• Reached Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow at ?
• Client handover to the Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow Emergency on 19.01.2025 at ?.
• Time of admission in Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow as mentioned in case sheet – 19.01.2025 at 12:56 AM.
Refer out – Transportation – Refer in (Source: Ambulance records)

21. • Case was recorded in Referral out register of CHC Sarojini Nagar at the time of referrals and also
in Referral in register of Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow at the time
of admission.
• Referral slip was posted in the what's app referral group of Lucknow.
• Client was referred in a timely manner from CHC Sarojini Nagar.
• Case was successfully managed at Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow.
Positive Practices

22. • No Ambulance record available at CHC Sarojini Nagar.
• Referral Follow up has not been done from CHC and updated the outcome in the referral out
register.
• No updation from the Lokbandhu Sri Raj Narayan Combined Hospital, Lucknow to CHC Sarojini
Nagar regarding the status and outcome of patient.
Gaps in Referral Linkages

23. Drug Warehouse Active stock Quarantine stock Pipeline stock
Inj Magnesium Sulphate Lucknow Drug Warehouse
(TP Nagar 1 UPMSCL)
Inj Oxytocin Lucknow Drug Warehouse
(TP Nagar 1 UPMSCL)
Inj Dexamethasone Lucknow Drug Warehouse
(TP Nagar 1 UPMSCL)
Inj Iron Sucrose Lucknow Drug Warehouse
(TP Nagar 1 UPMSCL)
Inj Calcium Gluconate Lucknow Drug Warehouse
(TP Nagar 1 UPMSCL)
Tab Misoprostol Lucknow Drug Warehouse
(TP Nagar 1 UPMSCL)
24
Warehouse Drug Stock – DVDMS Portal data – 19.02.2025

24. Facilities Inj Magnesium
Sulphate
Inj Oxytocin Inj
Dexamethasone
Inj Iron
Sucrose
Inj Calcium
Gluconate
Tablet
Misoprostol
BCHC Sarojni Nagar
BCHC Bkt
DH Jhalkari Bai
Mahila Hospital
DH Awanti Bai
Mahila Hospital
DH Lokbandhu Raj
Narain
BCHC Chinhat
BCHC Kakori
BCHC Mall
BCHC
Mohanlalganj
BCHC Gosaiganj
BCHC Malhabad
25
Facility Drug Stock – DVDMS Portal data – 19.02.2025

25. CASE 2
New born complication – Birth Asphyxia Case referred from CHC Kakori to SNCU,
Veerangana Avanti Bai Women Hospital Lucknow

26. G3P2L2A0 mother delivered at Ambulance on 25.01.2025 at 08:45 PM. Admitted at 09:00 PM on
25-01-2025.
Hb: 10g/dl & Temperature: Not recorded.
Preterm (28Weeks) Normal Vaginal Delivery on 25.01.2025 at 08:45 PM.
Weight of the baby: 970 gms.
 Delayed Cry, Poor Sucking & Extremely Low Birth Weight
Referred to SNCU, Veerangana Avanti Bai Women Hospital Lucknow on 25.01.2025 at 10:00 PM.
Case 2 : At CHC level (CHC Kakori)

27. Case Sheets at CHC Kakori

28. Treatment given at CHC Kakori

29. Referral out register from CHC Kakori

30. • Time mentioned in refer out register – 25.01.2025; 10:00 PM
• Time mentioned in referral slip – ? AM
• Call received to 108 ambulance at ? AM
• Ambulance reached CHC Kakori at ? AM (Response time : ?)
• Ambulance left CHC Kakori at ? AM
• Reached Veerangana Avanti Bai Women Hospital Lucknow at ? PM
• Client handover to the Veerangana Avanti Bai Women Hospital Lucknow Emergency on ? at ? PM
Refer out – Transportation – Refer in (Source: Ambulance records)

31. SNCU Medical College What's App Referral Group, Lucknow

32. At Veerangana Avanti Bai Women Hospital Lucknow
 Baby reached at Veerangana Avanti Bai Women Hospital but bed not available .
 Baby further referred to Medical College.

33. At Medical College, Lucknow
 Baby reached at Medical College but bed not available .
 Baby went to Private Hospital.

34. At Private Hospital Lucknow
 Baby got Expired.

35. • Case was recorded in Referral out register of CHC Kakori at the time of referrals.
• Referral slip was posted in the what's app referral group of Lucknow.
• Baby was referred in a timely manner from CHC Kakori.
Positive Practices

36. • No bed availability has been asked at SNCU, Veerangana Awanti Bai Women Hospital
before referral.
• No bed availability has been asked at SNCU, Medical College before referral.
Gaps in Referral Linkages

37. 1. All referral cases should be sent only in referral slips instead of OPD slips.
2. Referral slip should be complete with all the required information in it.
3. Referral should be done through the doctor on duty (Specialist/MO) with his/her
signature & name in the referral slip.
4. Bed availability should be ensured before referring the babies in both DWH/DCH
& Medical Colleges.
Actionable points

38. 5. Some referred cases are not posted in the referral group; Explain the significance
of posting the referral slip in the what's app group to all the staff nurses in the
Labour room and NBSU in CHC.
6. Referral out & Referral in registers should be filled properly and appropriately.
7. Follow up of referred cases should be carried out and the outcome needs to be
updated in the referral out register on a timely manner.
Actionable points

39. Uttar Pradesh Technical Support Unit
India Health Action Trust
404, 4th
Floor Ratan Square
No 20A, Vidhan Sabha Marg,
Lucknow, 226001
Uttar Pradesh, India
 +91-522-4922350 / 4931777
 www.ihat.in
Thank You
Dr. Sriram Chandramohan
sriram.chandramohan@ihat.in