Appropriateness of Emergency Referrals Made by Primary Care Clinicians

Objectives: To evaluate the appropriateness of emergency referrals made by primary care clinicians and determine factors contributing to inappropriate referrals. Methods: A cross sectional study, based on referral notes review. Patients referred to Khawla Hospital emergency department by a primary care clinician in Muscat governorate were randomly selected. Referral notes were reviewed by five family physicians. Appropriateness of referrals were evaluated according to primary care referral protocol. Any referral document that deviated from the protocol was classified as inappropriate. The prevalence and characteristics of inappropriate referrals were identified. Factors contributing to inappropriate referral were determined using multivariable logistic regression. Results: A total of 591 referrals were reviewed. 354 (59.9%) were classified as inappropriate. The reason for inappropriate classification was due to inadequate medical notes 291 (82.2%), lack of provisional diagnosis 176 (49.7%), misdirected to a non-concerned emergency 30 (8.4%), misclassification of urgency in which 107 (30.2%) were urgent and 45 (12.7%) were routine. After adjusting for multiple variables, insufficient clinical notes, unavailability of referral guidelines, and lack of expertise were strong determinants of inappropriate referral with odds ratio 62.52 (95% CI: 32.04 - 121.96), 2.88 (95% CI: 1.40 – 5.92), and 9.37 (95% CI: 4.09 – 21.43), respectively. Conclusion: While most referrals made by primary care clinicians required emergency management, the majority were identified as inappropriate and that was mainly due to insufficient clinical documentation. Inadequate clinical notes, lack of national guidelines and expertise were found to be strong predictors for inappropriate emergency referrals. Keywords: Referral and consultation, hospital referral; emergency; primary care; physicians; documentation; records; guidelines.