A Comparative Analysis of Patterns and Types of Orthopaedic and Trauma Admissions to Kenyatta National Hospital and the Associated Factors: Before and After Enforcement of Referral Guidelines

Abstract

Inappropriate utilization of higher-level health facilities and ineffective management of the referral processes in resource-limited settings is increasingly becoming a concern in health care management in developing countries. This is characterized by self-referrals and frequent bypassing by patients of nearest health facilities with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. On 1st July 2021, Kenyatta National Hospital (KNH) enforced the referral guidelines that required patients to have a formal referral letter to KNH to reduce the number of walk-ins and allow KNH to function as a referral facility as envisioned by KNH legal statue of 1987. Study Objective: To determine the patterns and types of orthopaedic and trauma admissions to KNH and the associated factors before and after the enforcement of the referral guidelines. Methodology: This was a descriptive analytical study design. The study was conducted amongst the orthopaedic admission caseload for 2021 with a sample size of 459 and 446 before and after enforcement of referral guidelines. Quantitative data was analysed using SPSS version 21 and qualitative data using NVivo version 12. Findings The enforcement of the referral guidelines reduced the proportion of walk-ins’ admissions from 54.9% to 45.1% (p=0.013) and was associated with decline of admissions through A&E from 84.1% and 72.0% (p < 0.001). There was an increase in admissions through COC from 10.5% to 19.5% (p=0.011). Emergency admissions declined from 84.7% to 73.4% and elective admissions increased from 15.3% to 26.6% (p=0.001). The Non-trauma admissions doubled (p=<0.001). Admissions with active insurance cover increased from 24.7% to 37.8% (p < 0.001). Most of the admissions were from Nairobi County and its environs. Majority of the admissions had lower limb injury followed by upper limb injuries with least admissions due to acetabular injuries before and after the enforcement of the referral guidelines. The major factors associated with admissions to KNH were inadequate human resource capacity and availability, patient’s preference, financial constraints, inadequate orthopaedic equipment’s and implants availability and health facility infrastructure. Conclusions: the enforcement of the referral guidelines reduced the proportion of walk-ins. The majority of the admissions were from Nairobi County and its environs. Lower limb and upper limb injuries were the most common. Inadequate human resource capacity and availability, patient’s preference, financial constraints, and inadequate orthopaedic equipment’s and implants availability from peripheral health facilities were associated with referrals to KNH.